Determination of a Low Skeletal Muscle Mass Index Using the Mass of the Gluteus Medius in Older Patients With Hip Fractures

This study evaluated the relationship between the muscle mass of the gluteus medius (GM) and skeletal muscle mass index (SMI) measured in patients with hip fractures. In this study, 141 patients with hip fractures were divided into those with high or low SMI. The GM index (GMI) was calculated by dividing the GM by the square of the height in meters. The correlation between GMI and SMI was subsequently analyzed, and cutoff values for determining the loss of skeletal muscle mass were calculated using the receiver operating characteristic curve. GMI and SMI showed a positive correlation for both sexes (male: r = .890, female: r = .626, p < .001). The GMI cutoff values were 19.460 cm2/m2 for males and 17.850 cm2/m2 for females. Skeletal muscle mass evaluation of the GM could contribute to hip fracture recovery by improving mobility and facilitating the early diagnosis of loss of SMM.

Early Wearing of Knee-Ankle-Foot Orthosis Improves Functional Prognosis in Patients after Stroke

OBJECTIVES

Knee-ankle-foot orthosis (KAFO) is sometimes used for gait training in stroke patients. The impact of the time of wearing KAFO on activities of daily living (ADL) recovery has not been clarified. This study aimed to examine the relationship between the days from onset to KAFO wearing and functional prognosis in patients after stroke.

MATERIALS AND METHODS

This retrospective, observational study was conducted with stroke patients who were prescribed a KAFO. Patients were divided into early and delayed groups according to the median days from onset to KAFO wearing. Baseline characteristics were evaluated at the initiation of KAFO wearing. The primary outcome was the Functional Independence Measure (FIM) gain, which was scored by the nurse at baseline and discharge.

RESULTS

112 participants (mean age 67.9 ± 14.0 years, 51.8% male) were included. The time period measure from day of onset to KAFO wearing for the early group was significantly shorter than the delayed group (35.8 ± 6.6 days vs. 73.5 ± 28.9 days). The early group had a higher FIM at discharge (84.9 ± 28.0% vs. 65.1 ± 29.0%, P < 0.001) and higher FIM gain (36.9 ± 19.8% vs. 26.8 ± 22.3, P = 0.013) than did the delayed group. Multiple regression analysis showed that the early group was associated with FIM gain (coefficient = 8.607, P = 0.032).

CONCLUSIONS

Early wearing of KAFO, irrespective of the difference in ADL at the time of KAFO wearing, may have a positive impact on the improvement of ADL in patients after stroke.

Delayed Dysphagia May Be Sarcopenic Dysphagia in Patients After Stroke

OBJECTIVE

In many cases, swallowing function is impaired after the onset of stroke and gradually improves. However, delayed dysphagia has been reported in some post-stroke patients. Recently, several studies have reported that low muscle strength and decreased muscle mass cause dysphagia. This study aimed to investigate whether these conditions are associated with delayed dysphagia after stroke.

DESIGN

A multicenter prospective observational cohort study.

SETTING AND PARTICIPANTS

Participants included 165 patients with post-stroke dysphagia (mean age 79.1 ± 8.0 years, 53.3% women) admitted to rehabilitation wards for post-stroke rehabilitation.

METHODS

Swallowing function was assessed using the Functional Oral Intake Scale. Delayed dysphagia was defined as dysphagia that occurred more than 7 days after stroke onset. We used logistic regression to examine the independent association between low muscle strength and decreased muscle mass and delayed dysphagia development. Furthermore, we examined the relationship between improvement in dysphagia and delayed dysphagia.

RESULTS

Delayed dysphagia was observed in 18 (10.9%) patients. The combination of severely low muscle strength and decreased muscle mass was independently associated with the development of delayed dysphagia (adjusted odds ratio: 4.423, 95% confidence interval: 1.400-13.974, P = .011). Delayed dysphagia had an adverse effect on the improvement of dysphagia during in-hospital rehabilitation (adjusted odds ratio: 0.278, 95% confidence interval: 0.078-0.986, P = .047).

CONCLUSIONS AND IMPLICATIONS

The development of delayed dysphagia was influenced by a combination of severely low muscle strength and decreased muscle mass. Furthermore, delayed dysphagia adversely affects the improvement of dysphagia in patients with stroke and needs to be identified early. Identifying delayed dysphagia using the methods proposed in this study and incorporating early intervention may prevent or delay dependency conditions in this population.

The functional assessment for control of trunk (FACT): An assessment tool for trunk function in stroke patients

BACKGROUND

The Functional Assessment for Control of Trunk (FACT) was developed to evaluate trunk function after stroke. However, only a few studies used FACT to show functional outcome.

OBJECTIVE

This study aimed to validate the FACT predictive ability for functional outcome following stroke and create an English version of the FACT.

METHODS

This retrospective, observational study was conducted with patients aged≥65 years with stroke. Patients were divided into two groups according to the median FACT score at admission: trunk impairment or high trunk function group. Multiple regression analysis was performed for Functional Independence Measure (FIM) gain and FIM efficiency to examine the relationship between trunk function assessed by FACT at admission and functional prognosis.

RESULTS

105 participants (mean age, 80.2±7.6, 57.1%were men) were included. Of these, 48 (45.7%) and 57 (54.3%) were categorized to the trunk impairment group and high trunk function group, respectively. FACT score at admission was associated with FIM gain (coefficient = 0.875, P = 0.001) and FIM efficiency (coefficient = 0.015, P = 0.016) after adjusting for confounders.

CONCLUSIONS

Trunk impairment at admission assessed by FACT could predict functional prognosis. The English version of FACT was created and further demonstrated the validity of FACT.

Low tongue strength is associated with oral and cough-related abnormalities in older inpatients

OBJECTIVES

Sarcopenic dysphagia is partly characterized by a decline in the strength of the swallowing muscles. However, its associated characteristics and symptoms are unclear. The aim of this study was to clarify the characteristics and symptoms of swallowing ability associated with low tongue muscle strength, which is one of the swallowing muscles in older adults.

METHODS

This was a cross-sectional study of 197 older patients admitted to the hospital for orthopedic conditions. We measured the maximum tongue pressure (MTP) against the palate. Swallowing-related characteristics were assessed with the Mann assessment of swallowing ability. Sarcopenia was diagnosed using the 2019 Asian Working Group for Sarcopenia.

RESULTS

The mean age of patients was 81.3 ± 7.6 y, and 80.2% of patients were women. Forty-two patients (21.3%) showed low MTP, defined as <20 kPa. Approximately 50% of participants had sarcopenia. Patients in the low MTP group had a significantly higher incidence of sarcopenia compared with the normal MTP group (71.4% vs. 48.4%; P = .008). After adjusting for potential confounders in the multivariate analyses, low MTP was found to be independently associated with abnormalities in tongue coordination (odds ratio [OR]: 5.251; 95% confidence interval [CI], 2.336-11.807; P < .001), oral transit (OR: 5.248; 95% CI, 1.424-19.345; P = .013), cough reflex (OR: 2.709; 95% CI, 1.280-5.733; P = .009), and voluntary cough (OR: 7.786; 95% CI, 3.329-18.208; P < .001).

CONCLUSIONS

Patients with low tongue strength are characterized by abnormal oral and cough-related characteristics.

Effects of Physical Rehabilitation and Nutritional Intake Management on Improvement in Tongue Strength in Sarcopenic Patients

The study aimed to investigate the impact of physical intervention and the amount of nutritional intake on the increase in tongue strength and swallowing function in older adults with sarcopenia. From November 2018 and May 2019, older patients with sarcopenia who were admitted for rehabilitation were analyzed. The intervention employed in the study was the usual physical and occupational therapy for two months. Tongue strength was measured before and after two months of treatment. Data on tongue strength, the amount of energy and protein intake, intervention time, and swallowing function were examined. A total of 95 sarcopenic older patients were included (mean age 83.4 ± 6.5 years). The mean tongue strength after the intervention was significantly increased from 25.4 ± 8.9 kPa to 30.5 ± 7.6 kPa as a result of the treatment (p < 0.001). After adjusting the confounding factors in the multivariable models, an energy intake of ≥30 kcal/kg/day and a protein intake of ≥1.2 g/kg/day based on the ideal body weight had a significant impact on the increase in tongue strength after the treatment (p = 0.011 and p = 0.020, respectively). Swallowing function assessed using the Mann Assessment of Swallowing Ability was significantly increased after the treatment (mean difference between pairs: 1.12 [0.53-1.70]; p < 0.001). Physical intervention and strict nutritional management for older inpatients with sarcopenia could be effective to improve tongue strength and swallowing function.

Estimating appendicular muscle mass in older adults with consideration on paralysis

AIM

This study aimed to develop appendicular skeletal muscle mass (ASM) estimating formulas that also consider the presence of paralysis for older adults and people with disabilities.

METHODS

This retrospective study analyzed 315 consecutive patients, post-stroke, aged ≥65 years, in a rehabilitation hospital. Six different ASM estimating formulas were developed using a five-fold cross-validation method and compared with the measured ASM obtained from bioelectrical impedance analysis. These formulas included age, gender, height, weight, arm circumference, triceps skinfold, calf circumference and presence of paralysis. Using Pearson's correlation coefficients (r) and intraclass correlation coefficient (ICC), we examined the correlation between the formulas and the measured ASM. The accuracy of the ASM estimating formula for detecting decreased muscle mass was evaluated using the F-value and Matthew's correlation coefficient.

RESULTS

Patients' mean ± SD age was 79.0 ± 8.1 years, and 51.4% of them were men. The mean ± SD bioelectrical impedance analysis-measured ASM was 13.7 ± 4.3 kg. Furthermore, 241 (76.5%) patients had decreased measured ASM. The mean adjusted R² of the developed six formulas was 0.861-0.871. In all formulas, the r and ICC of the estimated ASM for the measured ASM were strong (r = 0.936-0.930 and ICC = 0.928-0.934). These formulas revealed excellent sensitivity (86.0-88.2%), specificity (72.5-81.1%), accuracy (0.838-0.870), F-value (0.899-0.918) and Matthew's correlation coefficient (0.509-0.612) for measured ASM depletion.

CONCLUSIONS

We successfully developed ASM estimating formulas using anthropometric measurements considering the presence of paralysis. Thus, these formulas are beneficial for diagnosing sarcopenia in older adults, without requiring any special equipment. Geriatr Gerontol Int 2020; 20: 1145-1150.

Association of Sarcopenic Dysphagia with Underlying Sarcopenia Following Hip Fracture Surgery in Older Women

This study aimed to investigate the association between the development of dysphagia in patients with underlying sarcopenia and the prevalence of sarcopenic dysphagia in older patients following surgical treatment for hip fracture. Older female patients with hip fractures (n = 89) were studied. The data of skeletal muscle mass, hand-grip strength, and nutritional status were examined. The development of dysphagia postoperatively was graded using the Food Oral Intake Scale by a certified nurse in dysphagia nursing. The patients’ mean age was 85.9 ± 6.5 years. The prevalence of sarcopenia was 76.4% at baseline. Of the 89 patients, 11 (12.3%) and 12 (13.5%) had dysphagia by day 7 of hospitalization and at discharge, respectively. All patients who developed dysphagia had underlying sarcopenia. Lower skeletal muscle mass index (SMI) (<4.7 kg/m²) and grip strength (<8 kg) at baseline indicated a higher incidence of dysphagia on day 7 (p = 0.003 and Phi = 0.391) and at discharge (p = 0.001 and Phi = 0.448). Dysphagia developed after hip fracture surgery could be sarcopenic dysphagia, and worsening sarcopenia was a risk factor for dysphagia following hip fracture surgery. Clinicians and medical coworkers should become more aware of the risks of sarcopenic dysphagia. Early detection and preventive interventions for dysphagia should be emphasized.

Genetic variants of DNA repair-related genes predict efficacy of TAS-102 in patients with refractory metastatic colorectal cancer

Background

Tri-phosphorylated trifluridine (FTD) incorporation into DNA is TAS-102's main anti-tumor action. We tested whether genetic polymorphisms in homologous recombination (HR) and cell cycle checkpoint pathway for DNA repair is associated with outcomes in refractory metastatic colorectal cancer (mCRC) patients treated with TAS-102.

Patients and methods

We analyzed genomic DNA extracted from 233 samples of three cohorts: an evaluation cohort of 52 patients receiving TAS-102, a validation cohort of 129 patients receiving TAS-102 and a control cohort of 52 patients receiving regorafenib. Single nucleotide polymorphisms of genes involved in HR (ATM, BRCA1, BRCA2, XRCC3, FANCD2, H2AX, RAD51) and cell cycle checkpoint (ATR, CHEK1, CHEK2, CDKN1A, TP53, CHE1, PIN1, PCNA) were analyzed by PCR-based direct sequencing.

Results

In univariate analysis for the evaluation cohort, patients with any G allele in ATM rs609429 had longer overall survival (OS) than those with the C/C variant (8.7 vs. 4.4 months, HR 0.37, 95% CI: 0.14-0.99, P = 0.022). Patients carrying any A allele in XRCC3 rs861539 had significantly longer progression-free survival (PFS) (3.8 vs. 2.3 months, HR 0.44, 95% CI: 0.21-0.92, P = 0.024) and OS (15.6 vs. 6.3 months, HR 0.25, 95% CI: 0.08-0.79, P = 0.012) than those with the G/G variant. In multivariable analysis, ATM rs609429 remained significant for OS (P = 0.020). In the validation cohort, patients having ATM rs609429 with any G allele showed longer OS and PFS; the G/A variant in XRCC3 rs861539 showed longer OS, though without statistical significance.

Conclusion

Genetic variants in the HR pathway may predict clinical outcome in mCRC patients receiving TAS-102.

Evaluation of tuberculosis contact investigations in Japan

SETTING

Although monitoring and evaluation using standardised indicators is an important aspect of tuberculosis (TB) contact investigation, no attempts have been made to systematically evaluate contact investigations in Japan.

OBJECTIVE

To evaluate TB contact investigations conducted in public health centres (PHCs) by estimating the scores of selected indicators.

DESIGN

A cross-sectional study was conducted in 2012 to estimate six selected indicator scores for contact tracing, contact evaluation and contact treatment at 11 PHCs using the TB registry and relevant contact investigation records of all forms of newly notified active TB cases. Indicator scores were compared across PHCs using median and interquartile range (IQR).

RESULTS

A total of 2527 contacts of 313 index TB cases were identified; of these, 1874 were evaluated using the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Of 187 contacts who were TST/IGRA-positive, 15 were diagnosed with active TB. Consistently higher medians and lower IQRs were obtained for indicators of contact tracing and contact evaluation than those of contact treatment.

CONCLUSION

Our study is the first to evaluate the performance of TB contact investigations in Japan using standardised indicators; the study indicated performance gaps, especially in the treatment for latent tuberculous infection among contacts.

Impact of genetic variations in the MAPK signaling pathway on outcome in metastatic colorectal cancer patients treated with first-line FOLFIRI and bevacizumab: data from FIRE-3 and TRIBE trials

BACKGROUND

The MAPK-interacting kinase 1 (MKNK1) is localized downstream of the RAS/RAF/ERK and the MAP3K1/MKK/p38 signaling pathway. Through phosphorylation MKNK1 regulates the function of eukaryotic translation initiation factor 4E, a key player in translational control, whose expression is often upregulated in metastatic colorectal cancer patients (mCRC). Preclinical data suggest that MKNK1 increases angiogenesis by upregulating angiogenic factors. We therefore hypothesize that variations in the MKNK1 gene predict outcome in mCRC patients treated with first-line FOLFIRI and bevacizumab (bev).

PATIENTS AND METHODS

A total of 567 patients with KRAS wild-type mCRC in the randomized phase III FIRE-3 and TRIBE trials treated with first-line FOLFIRI/bev (discovery and validation cohorts) or FOLFIRI and cetuximab (cet) (control cohort) were included in this study. Five single-nucleotide polymorphisms in the MAPK signaling pathway were analyzed.

RESULTS

AA genotype carriers of the MKNK1 rs8602 single-nucleotide polymorphism treated with FOLFIRI/bev in the discovery cohort (FIRE-3) had a shorter progression-free survival (PFS) than those harboring any C (7.9 versus 10.3 months, Hazard ratio (HR) 1.73, P = 0.038). This association could be confirmed in the validation cohort (TRIBE) in multivariable analysis (PFS 9.0 versus 11.0 months, HR 3.04, P = 0.029). Furthermore, AA carriers in the validation cohort had a decreased overall response rate (25% versus 66%, P = 0.049). Conversely, AA genotype carriers in the control group receiving FOLFIRI/cet did not show a shorter PFS. By combining both FOLFIRI/bev cohorts the worse outcome among AA carriers became more significant (PFS 9.0 versus 10.5 months) in univariable (HR 1.74, P = 0.015) and multivariable analysis (HR 1.76, P = 0.022). Accordingly, AA carriers did also exhibit an inferior overall response rate compared with those harboring any C (36% versus 65%, P = 0.005).

CONCLUSION

MKNK1 polymorphism rs8602 might serve as a predictive marker in KRAS wild-type mCRC patients treated with FOLFIRI/bev in the first-line setting. Additionally, MKNK1 might be a promising target for drug development.

Clinical relevance of EMT and stem-like gene expression in circulating tumor cells of metastatic colorectal cancer patients

Using approved methods, circulating tumor cells (CTCs) are only isolated from blood in 30%-50% of metastatic colorectal cancer (mCRC) patients. We previously validated a technique to isolate circulating tumor cells (CTCs) in a cohort of mCRC patients by combining immunomagnetic enrichment of EpCAM⁺/CD45^- cells with qRT-PCR amplification of CK20 and survivin expression. Here, we examined the prognostic utility of CTC epithelial-mesenchymal transition (EMT) and stem cell gene expression. An 8 ml blood sample was collected from 78 consecutive mCRC patients before treatment with investigational and standard chemotherapeutics. The mRNA expression of EMT (PI3Kα, Akt-2, Twist1) and stem cell (ALDH1) markers was measured. Associations between CTC gene expression and progression-free survival (PFS) and overall survival (OS) were determined using Cox regression models. Among patients without CK20 or survivin-expressing CTCs (n=17), 55% had expression of ALDH1, PI3Kα and/or Akt-2. Patients with positive CTC Akt-2 expression had a significantly shorter median PFS (3.0 versus 4.0 months) compared with those without CTC Akt-2 expression in univariable (hazard ratio (HR)=1.61; log-rank P=0.034) and multivariable analyses (HR=1.70; adjusted P=0.041). In univariable analysis, CTC ALDH1 expression was associated with shorter OS (10.0 versus 38.6 months; HR=2.04, P=0.021). Patients with CTCs expressing ALDH1, PI3Kα and/or Akt-2 had a significantly inferior PFS (3.0 versus 7.7 months; HR=1.88, P=0.015) and OS (10.0 versus 26.8+ months; HR=2.25, P=0.050) in univariable, but not multivariable, analysis.

CONCLUSIONS

CTC Akt-2 expression may serve as a clinically useful prognostic marker in mCRC patients and warrants further evaluation in prospective trials.

Effects of 8-residue β sheet breaker peptides on aged Aβ40-induced memory impairment and Aβ40 expression in rat brain and serum following intraamygdaloid injection

Amyloidβ-protein (Aβ) assembly into toxic fibrillar structures is seminal in development of senile plaques, the pathological hallmark of Alzheimer's disease. Blocking this process could have a therapeutic value. β-sheet breaker peptides (βSBP) decrease Aβ fibrillogenesis and neurotoxicity by preventing or dissolving misfolded Aβ aggregates. The present study investigated the effects of βSBPs on Aβ40-related neuropathology, memory impairment in 8-armed radial maze and expression of Aβ40 in brain and serum. Aβ40 was injected into amygdaloid nucleus followed 8 days later by octapeptideβSBPs 15-22, 16-23 and 17-24. Aβ40 was detected not only in amygdala, but also in serum. Aβ40 induced cellular changes in amygdala and additionally in hippocampus. Aβ40 decreased correct choices, whereas increased errors (both number of arms revisited and total number of revisits) and latency of completing the maze test. The βSBPs decreased Aβ40-induced pathological changes, memory impairment and Aβ40 expression in serum. The βSBP15-22 distinctively decreased the total errors on day 14. The present results show that octapeptide βSBPs corrected Aβ40-induced memory impairment, and support investigation of βSBPs as a promising treatment of diseases characterized by neurodegeneration and memory impairment such as Alzheimer's disease.

Superconductivity of La(2-x)BaxCuO4

Superconductivity near 30 K in the La-Ba-Cu-O system, first observed by Bednorz and Müller [1], was soon found to be attributable to the K2NiF4-type (at room temperature) compound La(2-x)BxxCuO4 [2]. Substitution of Sr and Ca for Ba yielded superconducting systems, also with high superconducting transition temperature Tc. Replacement of La by Y led to the discovery of the 90 K superconductors.

Optimal use of antihypertensive agents in management of bevacizumab-associated hypertension

614

Background: Hypertension (HT) is the most common toxicity associated with bevacizumab (BV). Angiotensin converting enzyme inhibitors, calcium channel blockers (CCB), beta-blockers or diuretics are frequently chosen to control BV-associated HT. However, optimal use of these antihypertensive (AHT) agents for each grade of HT remains to be determined. Furthermore, the AHT agent to be used must be carefully chosen to avoid increasing risk for BV-associated cardiovascular adverse events.

Methods: Seventy-five consecutive patients with metastatic colorectal cancer who received first-line FOLFOX4 plus BV 5 mg/kg were included in the study. Treatment continued until progression of disease or unmanageable toxicity occurred. Blood pressure was measured prior to treatment in each cycle and graded using the NCI–CTC, version 3.0. The management protocol was as follows: 8-12 mg candesartan cilexetil (an angiotensin II receptor antagonist) as the first choice for grade 2 HT; 2.5 mg ≤ additional amlodipine besylate (a CCB) when grade 3 HT occurred; BV was discontinued if HT remained uncontrolled with use of both these agents. Stable blood pressure < 150/100mmHg during treatment was defined as manageable.

Results: Twenty patients (26.7%) had a history of HT. Grades 2-3 HT developed in 53 patients (70.7%) and grade 3 in 24 (32%). Median number of treatment cycles until onset of grades 2 and 3 HT was 3 and 4.5, respectively. Comparing patients with a history of HT to those without, the incidence of grade 3 was greater in the former (85 vs. 12.7%, respectively), and the median number of treatment cycles until onset of grade 3 was shorter (4 vs. 12 cycles, respectively); blood pressure was considered manageable in both groups (90 vs. 91%, respectively), and no difference in total duration of chemotherapy was observed. No AHT approach-related severe adverse events were observed.

Conclusions: Grade 3 HT was manageable during BV treatment, regardless of prior hypertensive history. However, to ensure improved survival, especially in patients with a history of HT, appropriate management is needed in BV-associated grade 3 HT. These data suggest that use of AHT agents is an effective and safe strategy in the management of BV-associated HT.

No significant financial relationships to disclose.

Use of circulating tumor cells to predict response to chemotherapy in patients with advanced gastric cancer

43

Background: The purpose of this study was to quantify circulating tumor cells (CTCs) in advanced gastric cancer (AGC) patients, and to demonstrate the role of CTCs in cancer therapy. The purpose of this study was to identify CTC threshold proposal for determining response to chemotherapy in AGC.

Methods: From November 2007 to June 2009, fifty-two patients with AGC were enrolled into a prospective study. All patients were enrolled using institutional review board-approved protocols at the Cancer Institute Hospital and provided informed consent. The study population consisted of patients of aged 18 years or older with histologically proven AGC. Other inclusion criteria were Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 2; adequate organ function. The subjects were five patients treated with S-1 (40 mg/m2, twice daily, days 1-28, repeated every 6 weeks), twenty-six patients treated with S-1 plus CDDP (S-1 40 mg/m2, twice daily, days 1-21, CDDP 60 mg/m2, day 8, repeated every 5 weeks), and twenty-one patients treated with paclitaxel (80 mg/m2, weekly). CTCs of whole blood at baseline, two weeks and four weeks after initiation of chemotherapy, were isolated and enumerated using immunomagnetics.

Results: Patients with ≥4 CTCs at two-week points and four-week points had a shorter median PFS (1.4, 1.4 months, respectively), than those with the median PFS of <4 CTCs (4.9, 5.0 months, respectively) (p<0.001, p<0.001, respectively). Patients with ≥4 CTCs at two-week points and four-week points had shorter median OS (3.5, 4.0 months, respectively) than those with the median PFS of <4 CTCs (11.7, 11.4 months, respectively) (p<0.001, p=0.001, respectively). In univariate analysis, PS, treatment regimen, Line of chemotherapy, and CTC levels at 2 weeks and 4 weeks predicted PFS and OS. In order to evaluate the independent predictive effect of chemotherapy, multivariate Cox regression analysis was carried out. CTC levels at 2 weeks and 4 weeks were the strongest predictors.

Conclusions: A threshold of lower than 4 CTC/7.5 ml at 2 weeks and 4 weeks was a significant predictor of the outcome for AGC patients treated with S-1 based regimen or paclitaxel regimen.

No significant financial relationships to disclose.

Retrospective analysis of first-line chemotherapy in 132 patients with advanced small-bowel adenocarcinoma

260

Background: No standard care has been established for advanced small-bowel adenocarcinoma (SBA). The aim of this study is to explore a most promising chemotherapy regimen for advanced SBA.

Methods: All data were collected from medical records of patients with advanced or recurrent SBA who received chemotherapy between April 1999 and March 2009 at 41 hospitals in Japan. Selection criteria were as follows: 1) histologically proven SBA, excluding ampullary carcinoma, 2) no previous chemotherapy or radiotherapy, 3) ECOG PS 0-2, 4) adequate bone marrow, hepatic and renal functions, 5) no concomitant malignancy. Patients were divided into the five groups by regimens: group A, fluoropyrimidine alone; group B, fluoropyrimidine + cisplatin; group C, fluoropyrimidine + oxaliplatin; group D, fluoropyrimidine + irinotecan; group E, others. Progression-free survival (PFS) and overall survival (OS) were calculated by Kaplan-Meier method.

Results: Demographics of selected 132 patients were: median age (range), 59 (23-78) years; male/female, 87/45; location of primary tumor, duodenum/jejunum/ileum/unknown, 80/32/17/3; advanced/recurrent disease, 91/41. The numbers of the patients in group A, B, C, D and E were 60, 17, 22, 11 and 22, and objective response rates (ORR) in the patients with target lesions were 20% (9/46), 38% (5/13), 42% (8/19), 25% (2/8), 21% (4/19), respectively. Median PFS and OS were 6.0 and 14.0 months for the whole population, and those in each group are shown in the Table.In comparison with fluoropyrimidine alone (A), oxaliplatin-combined regimens (C) associated with better PFS (HR=0.53 [0.31-0.93], p=0.03) and OS (HR=0.64 [0.33-1.25], p=0.19), while cisplatin-combined regimens (B) did not (HR=1.54 [0.88-2.68], p=0.13 for PFS and HR=1.67 [0.94-2.97], p=0.08 for OS) by univariate analysis.

Conclusions: It is suggested that oxaliplatin-combined regimens might be the most promising regimen for advanced SBA.

[Table: see text]

No significant financial relationships to disclose.

Effect of the addition of bevacizumab to first-line FOLFOX on efficacy, including response rate, progression-free survival, and overall survival, in patients with metastatic colorectal cancer

588

Background: Bevacizumab (BV) is a recombinant, humanized monoclonal antibody against vascular endothelial growth factor. Used in combination with chemotherapy, BV has been shown to improve survival in both first- and second-line treatment for metastatic colorectal cancer (mCRC). However, it was reported that addition of BV to FOLFOX conferred only little survival benefit (Saltz et al. JCO2008). The aim of this study was to assess the efficacy of addition of BV to FOLFOX in first-line treatment for patients with mCRC.

Methods: Bevacizumab was approved for mCRC in July 2007 in Japan. This study was conducted at a single institution and comprised 217 consecutive patients receiving first-line treatment for mCRC between 2005 and 2009. The primary objective was to compare survival benefit in patients treated with FOLFOX4 (FF) between 2005 and 2007 with that in patients receiving FOLFOX4+BV 5 mg/kg (FF+BV) between 2007 and 2009.

Results: Total number of patients in the FF and FF+BV groups was 132 and 85, respectively. Characteristics of patients were as follows (FF vs. FF+B): median age, 62 yrs (range 28-76 yrs) vs. 60 yrs (range16-74 yrs); ECOG PS0, 98.8% vs. 81.8%; and median follow-up time, 20.8 months vs. 24.4 months. Median progression-free survival (PFS) in the FF and FF+BV groups was 10 months (95% CI, 8.7-11.3) and 17 months (95% CI, 10.2-14.1), while median overall survival (OS) was 21 months (95% CI, 17.9-24.1) and not reached, respectively. Response rate was 46% (95% CI, 37- 54) in FF, and 62% (95% CI, 51-73) in FF+BV. Addition of BV to FOLFOX4 significantly improved PFS (p=0.002) and OS (p<0.001).

Conclusions: The additive effect of BV for first-line FOLFOX was reconfirmed. These data indicate potential survival benefits from the addition of BV to FOLFOX in first-line treatment of mCRC. In addition, PFS may be a sensitive indicator of outcome prior to post-treatment.

No significant financial relationships to disclose.

Use of circulating endothelial cells to predict response to FOLFOX4 plus bevacizumab in metastatic colorectal cancer

427

Background: The purpose of this study was to identify CEC threshold proposal for determining response to FOLFOX4 plus bevacizumab in metastatic colorectal cancer (mCRC).

Methods: All patients were enrolled using institutional review board-approved protocols at the Cancer Institute Hospital and provided informed consent. From July 2007 to June 2008, 33 patients treated with FOLFOX4 plus bevacizumab were enrolled in a prospective study. From January 2007 to June 2007, before bevacizumab was approved by the government in Japan, 31 patients treated with FOLFOX4 as a control were enrolled. The study population consisted of patients aged 18 years or older with histologically proven mCRC. Other inclusion criteria were Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, adequate organ function. CECs of whole blood at the baseline, day 4, 2 weeks after initiation of chemotherapy were isolated and counted using immunomagnetics.

Results: There was no correlation between CEC levels and the outcome in the FOLFOX4. In the FOLFOX4 plus bevacizumab, CEC levels at the baseline were significantly associated with the outcome. Patients with 65 or more CECs at the baseline had shorter median PFS (9.2 months), than the median PFS of fewer than 65 CECs at the baseline (18.9 months) in the FOLFOX4 plus bevacizumab (p = 0.003). Patients with 65 or more CECs at the baseline had shorter median OS (23.3 months), than the median OS of fewer than 65 CEC s at the baseline in the FOLFOX4 plus bevacizumab (p = 0.027). In the univariate analysis, lung metastasis, lymph node metastasis, and CEC levels at the baseline predicted PFS. In the univariate Cox regression analyses, peritoneal metastasis, CEC levels at the baseline were associated with OS. In order to evaluate the independent predictive effect of FOLFOX4 plus bevacizumab, multivariate Cox regression analysis was carried out. CEC levels at the baseline were the strongest predictor.

Conclusions: A threshold of lower than 65 CEC/4mL at the baseline was a significant predictor of the outcome for colorectal cancer patients treated with FOLFOX4 plus bevacizumab.

No significant financial relationships to disclose.

Coagulo-fibrinolytic activity as a predictor of efficacy in bevacizumab-combined chemotherapy in metastatic colorectal cancer patients

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Background: The combination of bevacizumab (BV) and chemotherapy in the first-line and second-line treatment of metastatic colorectal cancer (mCRC) has been shown to improve survival. Bevacizumab is a recombinant, humanized monoclonal antibody against vascular endothelial growth factor. However, the relationship between coagulo-fibrinolytic activity factors and treatment efficacy remains to be clarified. The aim of this study was to determine potential coagulo-fibrinolytic activity markers impacting survival.

Methods: Among 119 consecutive patients included in the study, 85 received first-line FOLFOX4 plus BV 5 mg/kg and 34 received second-line FOLFIRI plus BV 5 mg/kg until progression of disease or unmanageable toxicity occurred. Coagulo-fibrinolytic activity factors, including D-dimer, thrombin antithrombin complex (TAT) and carbohydrate antigen 125 (CA125) encoded by the MUC16 mucin gene were evaluated as candidate predictors of outcome.

Results: In first-line treatment, overall response, median progression-free survival (PFS) and two-year survival rate were 61.9%, 518 days and 67.3%, respectively. In second-line treatment, overall response, median PFS and median overall survival (OS) were 23.5%, 248 days and 651 days, respectively. The outcomes of the univariate analysis were as follows: normal D-dimer and CA125 levels at baseline were associated with better PFS and OS in first-line treatment; normal TAT and CA125 levels at baseline were associated with better PFS and OS in second-line treatment. According to the results of the multivariate analysis, normal D-dimer level was associated with longer PFS in first-line treatment, and only CA125 level at baseline was an independent predictor of both PFS and OS in second-line treatment.

Conclusions: The results suggest that coagulo-fibrinolytic activity factors such as TAT, D-dimer or CA125 may be useful predictors of outcome in mCRC patients receiving BV in combination with chemotherapy.

No significant financial relationships to disclose.

Upper-extremity deep vein thrombosis related to central venous port systems implanted in cancer patients

The purpose of the current study was to evaluate the incidence and course of upper-extremity deep vein thrombosis (UEDVT) related to an implanted central venous port (CV-port) system in cancer patients. From July 2007 to July 2008, 92 consecutive patients who underwent implantation of a CV-port for chemotherapy for colorectal cancer were prospectively enrolled in the study. All patients were examined at prescribed intervals by ultrasonography (US) to estimate the incidence of catheter-related venous thrombosis. We categorised ultrasound diagnosis into three types: Type 0, no thrombus; Type I, thrombi around catheter without obstruction of venous flow; Type II: thrombi with obstruction of venous flow. Upon initial ultrasound examination, 25 cases (27%) were categorised as Type 0, 64 (70%) as Type I and III (3%) as Type II. Of the 64 Type-I cases, 4 cases worsened to Type II within a month, and 3 others (including 1 patient who developed pulmonary embolism) became Type II after 1 month. Of the other Type-I cases, 12 cases improved to Type 0 and 45 cases remained Type I. All 10 patients categorised as Type II underwent anticoagulant therapy and resumed their chemotherapy without exacerbations of thrombosis. In cancer patients undergoing long-term chemotherapy, there is an unexpectedly high prevalence of catheter-related UEDVT, which can be detected by ultrasound at an early stage after implantation of a CV-port. Given that cancer patients with UEDVT may have worse outcomes than those without, clinicians should consider careful monitoring for UEDVT and introducing anticoagulant therapy.

Tolerability and safety of oral neratinib (HKI-272) in Japanese patients with advanced solid tumors

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Background: Neratinib (HKI-272) is a potent irreversible pan-ErbB tyrosine kinase inhibitor. In non-Japanese pts, neratinib was found to have clinical activity against solid tumors and dose-limiting toxicity (DLT) of diarrhea. The maximum tolerated dose (MTD) was 320 mg daily and the recommended dose (RD) was 240 mg because of the diarrhea. In this phase 1 study, the MTD was determined and safety and preliminary efficacy were assessed in Japanese pts with advanced solid tumors. Methods: Pts (3- 6/cohort) received 80, 160, 240, or 320 mg oral neratinib. Each pt participated in only 1 dose group and received single doses of neratinib followed by 1 wk of observation; pts then received daily continuous administration at the same dose. DLTs were assessed from the first single dose to the end of 14 days of continuous treatment. Pharmacokinetics (PK) will be analysed via a noncompartmental method. Tumor measurements were made at screening and at the end of every 8 weeks (2 cycles) by RECIST. Results: Preliminary data for 21 pts as of 30 Oct 2008 are presented. Pts had a median age [range] of 61 yrs [39–78], were 62% male, and had all received ≥2 prior chemotherapy regimens. Tumor types at primary diagnosis were advanced colorectal (81%), breast (14%), and gastric (5%) cancer. Median duration of neratinib treatment [range] was 10 wks [3–29].Two patients at the 320-mg dose had DLTs of diarrhea plus anorexia. Therefore the MTD was determined to be 240 mg. Neratinib-related AEs, any grade in ≥25% of pts included diarrhea (95%), fatigue (67%), anorexia (43%), nausea (43%), abdominal pain (38%), decreased hemoglobin (38%), increased AST (33%), and rash (29%). Neratinib-related AEs, grade ≥3 in ≥1 pts were anorexia (3 pts) and diarrhea (2 pts). Two pts had partial response (PR), 8 pts had stable disease (SD) ≥8 wks, 2 had SD≥16 wks, 9 had progressive disease. The 2 pts with PR had ErbB-2+ advanced breast cancer. PK analysis is still ongoing. Conclusions: In Japanese pts, the MTD for neratinb was determined to be 240 mg and the RD will be confirmed as 240 mg. Neratinib is tolerable and demonstrates preliminary antitumor activity in pts with solid tumors.

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Circulating tumor cells (CTCs) as a surrogate marker for determining response to chemotherapy in advanced gastric cancer (AGC)

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Background: The purpose of this study was to quantitate circulating tumor cells (CTCs) in advanced gastric cancer (AGC) patients and to demonstrate the role of CTCs in cancer therapy. This study investigates the hypothesis that CTC levels can predict clinical outcomes in patients with AGC. Methods: Eligibility criteria: PS (ECOG) of 0 to 2; histopathology of adenocarcinoma; adequate major organ functions. Chemotherapy regimen was S-1 based regimen (S-1 with or without cisplatin) or paclitaxel. Treatment was continued unless disease progression was observed. CTCs of whole blood in baseline, 2 week and 4 week after initiation of chemotherapy were isolated and enumerated using immunomagnetics. Results: From November 2007 to September 2008, thirty patients with unresectable or recurrent gastric cancer were enrolled onto a prospective study. Pts characteristics were as follows: median age: 60 years (range 24–78), PS 0/1/2: 21/8/1, primary tumor ±: 21/9 and regimen S-1/S-1with cisplatin/paclitaxel: 3/15/12. Among 30 pts, best response rates were 36.7% (CR/PR/SD/PD: 0/11/8/11). Patients with ≥4 CTCs at 2 week points and 4 week points had the shorter median progression-free survival (PFS) (1.4, 1.4 months, respectively), than the median PFS of <4 CTCs (6.3, 6.3 months, respectively) (logrank test; p=0.0008, p=8.78E-07, respectively). A finding of <4, CTCs of 2 week and 4 week after initiation of chemotherapy was associated with significantly longer overall survival (OS) as compared with these patients with ≥4 CTCs (p=0.016702, p=0.027788 respectively). Conclusions: These data demonstrate that CTC measurement may be useful as a surrogate marker for determining response to S1 based regimen or paclitaxel regimen in AGC.

No significant financial relationships to disclose.

Cognitive impairment in spinocerebellar degeneration

It has been reported that patients with spinocerebellar degenerations (SCDs) have cognitive dysfunction as well as limb and truncal ataxia, dysarthria and dysphagia. We review cognitive dysfunction in common types of SCD, including spinocerebellar ataxia types 1, 2, 3, 6, and 17, dentatorubral-pallidoluysian atrophy, Friedreich's ataxia, and multiple system atrophy. There are few studies that address cognitive function in SCD. Although there are few comparison studies among the various SCDs, cognitive dysfunction may be more common and severe in spinocerebellar ataxia type 17 and dentatorubral-pallidoluysian atrophy. While cognitive dysfunction in SCD appears to represent frontal dysfunction, the mechanisms of cognitive dysfunction have not been directly clarified. Nevertheless, various lesions, including those in the cerebrocerebellar circuitry, cortico-striatal-thalamocortical circuitry, and the frontal lobe, may influence cognitive function to various degrees for each disease.

Cognitive impairments in multiple system atrophy: MSA-C vs MSA-P

OBJECTIVE

We evaluated comprehensive neuropsychological tests and regional brain blood flow to compare cognitive dysfunction between two types of multiple system atrophy: predominant cerebellar ataxia (MSA-C) and predominant parkinsonism (MSA-P).

METHODS

Twenty-one patients with MSA-C, 14 patients with MSA-P, and 21 age- and education-matched control subjects were subjected to neuropsychological tests and SPECT. The neuropsychological tests examined general cognition, verbal and visual memory, working memory, visuospatial and constructional ability, language, executive function, depression, and anxiety, while SPECT analysis examined brain perfusion.

RESULTS

Patients with MSA-P showed severe involvement of visuospatial and constructional function, verbal fluency, and executive function compared with control subjects. Patients with MSA-C showed involvement only in visuospatial and constructional function compared with control subjects and a milder degree of involvement compared with patients with MSA-P. Patients with MSA-P tended toward a wide and severe impairment in cognitive function compared with patients with MSA-C. In addition, neuropsychological impairment in patients with MSA-P was significantly correlated with a decrease in prefrontal perfusion. This significant relation was not correlated to other factors such as age, education, and severity of cerebellar ataxia and parkinsonism, which are relevant factors associated with cognitive performance.

CONCLUSIONS

Patients with multiple system atrophy-parkinsonism show more severe and more widespread cognitive dysfunctions than patients with multiple system atrophy-cerebellar ataxia. Our results also indicate that cognitive dysfunction in patients with multiple system atrophy-parkinsonism may be associated with prefrontal involvement.