Detection of Enterobacteriaceae in cerebrospinal fluid fluid of neonates with meningitis from tertiary care hospitals

OBJECTIVE

This study aimed to determine the bacteriological profile of childhood acute bacterial meningitis in Pakistan.

PATIENTS AND METHODS

The study included a total of 100 children aged between 1 month and 5 years, who were admitted with a diagnosis of meningitis based on clinical findings and positive cerebrospinal fluid (CSF) tests. Out of the 100 CSF samples collected, 21 isolates were confirmed to contain Enterobacteriaceae. The most prevalent Enterobacteriaceae species were Pseudomonas (n=8, 38.09%), Klebsiella (n=4, 19.04%), E. coli (n=4, 19.04%), and Acinetobacter (n=4, 19.04%), while Citrobacter (n=1, 4.76%) was less common. Antibiotic susceptibility patterns were analyzed for these isolates.

RESULTS

Pseudomonas (n=8) exhibited 25% resistance to cefepime and 38% resistance to imipenem. Klebsiella (n=4) showed 75% resistance to imipenem. Acinetobacter (n=4) demonstrated 50% resistance to imipenem, along with varying resistance to cefepime, amikacin, ciprofloxacin, and gentamicin. E. coli (n=4) showed 0% resistance to imipenem and amikacin. However, Citrobacter (n=1) showed 0% resistance to ciprofloxacin, aztreonam, gentamicin, amikacin, levofloxacin, and cefepime. Acute bacterial meningitis primarily affects children under 1 year of age.

CONCLUSIONS

CSF culture revealed that Gram-negative bacteria, specifically Pseudomonas spp., were the predominant pathogens in this family based on Pakistani data.

Phase I trial of the MEK inhibitor selumetinib in combination with thoracic radiotherapy in non-small cell lung cancer

Background

The RAS/RAF/MEK/ERK signalling pathway has a pivotal role in cancer proliferation and modulating treatment response. Selumetinib inhibits MEK and enhances effects of radiotherapy in preclinical studies.

Patients and methods

Single-arm, single-centre, open-label phase I trial. Patients with stage III NSCLC unsuitable for concurrent chemo-radiotherapy, or stage IV with dominant thoracic symptoms, were recruited to a dose-finding stage (Fibonacci 3 + 3 design; maximum number = 18) then an expanded cohort (n = 15). Oral selumetinib was administered twice daily (starting dose 50 mg) commencing 7 days prior to thoracic radiotherapy, then with radiotherapy (6-6.5 weeks; 60-66 Gy/30-33 fractions). The primary objective was to determine the recommended phase II dose (RP2D) of selumetinib in combination with thoracic radiotherapy.

Results

21 patients were enrolled (06/2010-02/2015). Median age: 62y (range 50-73). M:F ratio 12(57%):9(43%). ECOG PS 0:1, 7(33%):14(67%). Stage III 16(76%); IV 5(24%). Median GTV 64 cm³ (range 1-224 cm³). 15 patients comprised the expanded cohort at starting dose. All 21 patients completed thoracic radiotherapy as planned and received induction chemotherapy. 13 (62%) patients received the full dose of selumetinib.In the starting cohort no enhanced radiotherapy-related toxicity was seen. Two patients had dose-limiting toxicity (1x grade 3 diarrhoea/fatigue and 1x pulmonary embolism). Commonest grade 3-4 adverse events: lymphopaenia (19/21 patients) and hypertension (7/21 patients). One patient developed grade 3 oesophagitis. No patients developed grade ≥3 radiation pneumonitis. Two patients were alive at the time of analysis (24 and 26 months follow-up, respectively). Main cause of first disease progression: distant metastases ± locoregional progression (12/21 [57.1%] patients). Six patients had confirmed/suspected pneumocystis jiroveci pneumonia.

Conclusion

We report poor outcome and severe lymphopenia in most patients treated with thoracic radiotherapy and selumetinib at RP2D in combination, contributing to confirmed/clinically suspected pneumocystis jiroveci pneumonia. These results suggest that this combination should not be pursued in a phase II trial.ClinicalTrials.gov reference: NCT01146756.

Scheduling nab-paclitaxel combined with gemcitabine as first-line treatment for metastatic pancreatic adenocarcinoma

BACKGROUND

Nab-paclitaxel plus gemcitabine (nabP+gemcitabine) offers modest survival gains for patients with metastatic pancreatic ductal adenocarcinoma (PDAC). Sequential scheduling of nabP+gemcitabine in a PDAC mouse model improved efficacy; this hypothesis was tested in a clinical trial.

METHODS

Patients with previously untreated metastatic PDAC were randomised to receive nabP+gemcitabine administered either concomitantly on the same day, or sequentially, with gemcitabine administered 24 h after nabP. The primary outcome measure was progression-free survival (PFS). Secondary outcome measures were objective response rate (ORR), overall survival (OS), safety, quality of life (QoL) and predictive biomarkers.

RESULTS

In total, 71 patients received sequential (SEQ) and 75 concomitant (CON) treatment. Six-month PFS was 46% with SEQ and 32% with CON scheduling. Median PFS (5.6 versus 4.0 months, hazard ratio [HR] 0.67, 95% confidence interval [95% CI] 0.47-0.95, p = 0.022) and ORR (52% versus 31%, p = 0.023) favoured the SEQ arm; median OS was 10.2 versus 8.2 months (HR 0.93, 95% CI 0.65-1.33, p = 0.70). CTCAE Grade ≥3 neutropaenia incidence doubled with SEQ therapy but was not detrimental to QoL. Strongly positive tumour epithelial cytidine deaminase (CDA) expression favoured benefit from SEQ therapy (PFS HR 0.31, 95% CI 0.13-0.70).

CONCLUSIONS

SEQ delivery of nabP+gemcitabine improved PFS and ORR, with manageable toxicity, but did not significantly improve OS.

CLINICAL TRIAL REGISTRATION

ISRCTN71070888; ClinialTrials.gov (NCT03529175).

Abstract OT1-06-02: Oncotype DX®-REMAR(Rhein-Main-Registry)-study: Use of the oncotype DX® assay in early breast cancer in certified breast cancer centers in Rhine-Main Region, Germany

A brief background discussion:

The OncotypeDX® multigene assay is recommended by several international guidelines as a predictive and prognostic factor for HR+/HER2- early breast cancer (EBC). Several trials have shown the necessity of OncotypeDX® Recurrence Score (RS) as a decision tool for HR+/HER2- EBC with 0-3 lymph nodes (LN) involved. At present, though, only limited data from the routine setting are available on the impact of treatment decision making process based on the usage of classical proliferation marker Ki67 with or without knowing the individual RS prior and after a treatment decision from a multidisciplinary tumor board (MTB) for the decision making of the adjuvant therapy of EBC. The Oncotype DX® assay is still not reimbursed by every insurance, therefore we expect that this registry will have an impact on reimbursement in Germany.

Trial design:

The OncotypeDX®-REMAR(Rhein-Main-Registry) study is a prospective, non-interventional, multicenter and non-randomized, study. 13 certified breast cancer (BC) centers in the Rhine-Main region in Germany participate. The sponsor of this trial is the AGAPLESION, Markus Hospital Frankfurt, Genomic Health provides the financial support.

After registration, the patient´s case will be discussed in the respective institution's MTB, before and after the RS result. The adjuvant treatment will be recommended based on available clinical and histopathological data according to the guidelines and the RS result. After each meeting, the physician and patient will fill in a questionnaire. In addition to the local determination of Ki67 and nuclear grading, a central pathology assessment of these two markers will be provided in a blinded fashion. Only the sponsor has access to these results. Consequently, this independent test has no influence both on the local histopathology result and on the recommended treatment.

Eligibility criteria:

Inclusion criteria:

Female patients, ≥18 years, with a hormone-receptor positive, HER2-negative EBC and 0-3 positive LN, T1-3, nuclear grading 1-3, Ki67:10-40%, cM0.

Specific aims:

Primary endpoint is the decision impact of the RS result in patients with mid-range Ki67 on adjuvant chemotherapy in EBC.

Secondary endpoints include the correlation of Ki67 with tumor grade and RS result. Moreover, an economic subanalysis will be done.

Statistical methods:

The change in physicians' treatment recommendations will be measured pre-assay vs. post-assay. The proportion of patients for whom the treatment recommendation changed and the 95% confidence interval will be reported overall and by select groups. McNemar's test will be used to compare the proportion of patients' recommended chemo-hormonal therapy pre-assay vs. post-assay.

Present accrual and target accrual:

Thirteen participating centers recruited 97 patients by the end of April 2017. 600 patients are planned in total.

Contact information for people with a specific interest in the trial:

In case of interest you can contact Ms. Louiza Anastasiadou, Tel: +4969-9533-66395, Fax: +4969-9533-2385, email: louiza.anastasiadou@fdk.info

Citation Format: Anastasiadou L, Aulmann S, Falk S, Baier P, Giesecke D, Buchen S, Hurst U, Krapfl E, Moebus V, Mosch D, Schulmeyer E, Solbach C, Ackermann S, Gabriel B, Jackisch C, Thill M. Oncotype DX®-REMAR(Rhein-Main-Registry)-study: Use of the oncotype DX® assay in early breast cancer in certified breast cancer centers in Rhine-Main Region, Germany [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-06-02.

Long-term results and recurrence patterns from SCALOP: a phase II randomised trial of gemcitabine- or capecitabine-based chemoradiation for locally advanced pancreatic cancer

BACKGROUND

SCALOP, a randomised, phase II trial, tested the activity and safety of gemcitabine (GEM)-based and capecitabine (CAP)-based chemoradiation (CRT) for locally advanced pancreatic cancer (LAPC). Here we present the long-term outcomes.

METHODS

Eligibility: histologically proven LAPC ⩽7 cm. Following 12 weeks of induction GEMCAP chemotherapy (three cycles: GEM 1000 mg m-2 days 1, 8, 15; CAP 830 mg m-2 days 1-21 q28 days) patients with stable/responding disease, tumour ⩽6 cm, and WHO Performance Status 0-1 were randomised to receive one cycle GEMCAP followed by CAP (830 mg m-2 b.d. on weekdays only) or GEM (300 mg m-2 weekly) with radiation (50.4 Gy per 28 fractions).

RESULTS

One-hundred fourteen patients (28 UK centres) were registered between 24 December 2009 and 25 October 2011, and 74 were randomised (CAP-RT=36; GEM-RT=38). At the time of this analysis, 105 of the 114 patients had died and the surviving 9 patients had been followed up for a median of 10.9 months (IQR: 2.9-18.7). Updated median OS was 17.6 months (95% CI: 14.6-22.7) in the CAP-CRT arm and 14.6 months (95% CI: 11.1-16.0) in the GEM-CRT arm (intention-to-treat adjusted hazard ratio (HR): 0.68 (95% CI: 0.38-1.21, P=0.185)); median progression-free survival (PFS) was 12.0 months (95% CI: 10.0-15.2) in the CAP-CRT arm and 10.4 months (95% CI: 8.8-12.7) in the GEM-CRT arm (intention-to-treat adjusted HR: 0.60 (95% CI: 0.32-1.14, P=0.120)). In baseline multivariable model, age ⩾65 years, better performance status, CA19.9<613 IU l-1, and shorter tumour diameter predicted improved OS. CAP-CRT, age ⩾65 years, better performance status, CA19.9 <46 IU ml-1 predicted improved OS and PFS in the pre-radiotherapy model. Nine-month PFS was highly predictive of OS.

CONCLUSIONS

CAP-CRT remains the superior regimen. SCALOP showed that patients with CA19.9 <46 IU ml-1 after induction chemotherapy are more likely to benefit from CRT.

Long-term results and recurrence patterns from SCOPE-1: a phase II/III randomised trial of definitive chemoradiotherapy +/- cetuximab in oesophageal cancer

BACKGROUND

The SCOPE-1 study tested the role of adding cetuximab to conventional definitive chemoradiotherapy (dCRT), and demonstrated greater toxicity and worse survival outcomes. We present the long-term outcomes and patterns of recurrence.

METHODS

SCOPE-1 was a phase II/III trial in which patients were randomised to cisplatin 60 mg m-2 (day 1) and capecitabine 625 mg m-2 bd (days 1-21) for four cycles +/- cetuximab 400 mg m-2 day 1 then by 250 mg m-2 weekly. Radiotherapy consisted of 50 Gy/25# given concurrently with cycles 3 and 4. Recruitment was between February 2008 and February 2012, when the IDMC recommended closure on the basis of futility.

RESULTS

About 258 patients (dCRT=129; dCRT+cetuximab (dCRT+C)=129) were recruited from 36 centres. About 72.9% (n=188) had squamous cell histology. The median follow-up (IQR) was 46.2 (35.9-48.3) months for surviving patients. The median overall survival (OS; months; 95% CI) was 34.5 (24.7-42.3) in dCRT and 24.7 (18.6-31.3) in dCRT+C (hazard ratio (HR)=1.25, 95% CIs: 0.93-1.69, P=0.137). Median progression-free survival (PFS; months; 95% CI) was 24.1 (15.3-29.9) and 15.9 (10.7-20.8) months, respectively (HR=1.28, 95% CIs: 0.94-1.75; P=0.114). On multivariable analysis only earlier stage, full-dose RT, and higher cisplatin dose intensity were associated with improved OS.

CONCLUSIONS

The mature analysis demonstrates that the dCRT regimen used in the study provided useful survival outcomes despite its use in patients who were largely unfit for surgery or who had inoperable disease. Given the competing risk of systemic and local failure, future studies should continue to focus on enhancing local control as well as optimising systemic therapy.

Surgical timing after chemoradiotherapy for rectal cancer, analysis of technique (STARRCAT): results of a feasibility multi-centre randomized controlled trial

BACKGROUND

The optimal time of rectal resection after long-course chemoradiotherapy (CRT) remains unclear. A feasibility study was undertaken for a multi-centre randomized controlled trial evaluating the impact of the interval after chemoradiotherapy on the technical complexity of surgery.

METHODS

Patients with rectal cancer were randomized to either a 6- or 12-week interval between CRT and surgery between June 2012 and May 2014 (ISRCTN registration number: 88843062). For blinded technical complexity assessment, the Observational Clinical Human Reliability Analysis technique was used to quantify technical errors enacted within video recordings of operations. Other measured outcomes included resection completeness, specimen quality, radiological down-staging, tumour cell density down-staging and surgeon-reported technical complexity.

RESULTS

Thirty-one patients were enrolled: 15 were randomized to 6 and 16-12 weeks across 7 centres. Fewer eligible patients were identified than had been predicted. Of 23 patients who underwent resection, mean 12.3 errors were observed per case at 6 weeks vs. 10.7 at 12 weeks (p = 0.401). Other measured outcomes were similar between groups.

CONCLUSIONS

The feasibility of measurement of operative performance of rectal cancer surgery as an endpoint was confirmed in this exploratory study. Recruitment of sufficient numbers of patients represented a challenge, and a proportion of patients did not proceed to resection surgery. These results suggest that interval after CRT may not substantially impact upon surgical technical performance.

Abstract P2-08-15: Impact of OncotypeDX on treatment decision for early stage, hormone-receptor-positive breast cancer

BACKGROUND and OBJECTIVE

The OncotypeDX multigene assay analyzes the individual biology of an invasive breast cancer by examining the activity of 16 breast cancer related genes and 5 reference genes in the tumour tissue. It is used in patients with early hormone-receptor-positive breast cancer with up to 3 positive lymphnodes. The results of the analysis are fed into a formula that calculates a Recurrence Score® (RS) result. The RS result is a number between 0 and 100, and can provide information about how likely your breast cancer is to recur within 10 years of diagnosis. Since becoming available, the test is successfully validated in 18 studies for both N0 and N1.

The primary study objective was to evaluate the impact of the RS on physicians' adjuvant therapy decision-making in a cohort of consecutive patients with early ER+, HER2-negative, N0/N1 (until two positive lymph-nodes) breast cancer in our multidisciplinary team (MDT). Secondary study objectives were to assess the impact of the RS on patients' decisional conflict.

PATIENTS and METHODS

This prospective clinical study was carried out in the Breast Cancer Center at the AGAPLESION Markus Hospital. 140/890 (15,7%) patients were enrolled between 02/2013 and 04/2015 with early ER+, HER2-negative (IHC or FISH), N0/N1, T1-3, histological grade 1-3. We kept records from the treatment decision before and after having the result of OncotypeDX. Further inclusion criteria were age &gt;18 years and no contraindication for receiving systemic chemoendocrine therapy. Also, the treating physician and the enrolled patient had to confirm that she was principally willing to consider her initial recommendation and decision.

Each patient's case was discussed twice within the respective institution's MDT. In the first meeting, adjuvant treatment was recommended based on available clinical and histopathological data according to the guidelines. In a second meeting, the case was rediscussed and treatment was recommended with the RS result as an additional piece of information.

RESULTS

100/140 (71,4%) patients were node negative (N0), whereas 40/140 (28,6%) were node positive (N+). Treatment recommendation changed in overall 34,3% of the cases (N0 33%, N+ 35%). In 48% of all patients (N0 43.5%, N+ 52%) with an initial recommendation for chemoendocrine therapy, the post-RS recommendation changed into endocrine therapy, in 25% (N0 30%, N+ 6.7%) of the cases with an initial recommendation for endocrine therapy only to combined chemoendocrine therapy, respectively. Only 48% of the patients with an inital endocrine therapy recommendation followed post-RS recommendation change to chemoendocrine therapy. On the other hand, 100% of the patients with an initial chemoendocrine therapy recommendation followed the post-RS recommendation change to endocrine therapy.

CONCLUSION

Our results show that OncotypeDX has an impact on the initial treatment decision on node positive as well as node negative patients. A substantial therapy change was evident in 34,3% of the cases. The data confirm, that OncotypeDX can help the doctor to formulate an individually treatment plan for patients with conflicting combination of clinical and pathological parameters.

Citation Format: Anastasiadou L, Schneider M, Barinoff J, Khandan F, Falk S, Thill M. Impact of OncotypeDX on treatment decision for early stage, hormone-receptor-positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-15.

Randall Selitto pressure algometry for assessment of bone-related pain in rats

BACKGROUND

Deep pain is neglected compared with cutaneous sources. Pressure algometry has been validated in the clinic for assessment of bone-related pain in humans. In animal models of bone-related pain, we have validated the Randall Selitto behavioural test for assessment of acute and pathological bone pain and compared the outcome with more traditional pain-related behaviour measures.

METHODS

Randall Selitto pressure algometry was performed over the anteromedial part of the tibia in naïve rats, sham-operated rats, and rats inoculated with MRMT-1 carcinoma cells in the left tibia, and the effect of morphine was investigated. Randall Selitto measures of cancer-induced bone pain were supplemented by von Frey testing, weight-bearing and limb use test. Contribution of cutaneous nociception to Randall Selitto measures were examined by local anaesthesia.

RESULTS

Randall Selitto pressure algometry over the tibia resulted in reproducible withdrawal thresholds, which were dose-dependently increased by morphine. Cutaneous nociception did not contribute to Randall Selitto measures. In cancer-bearing animals, compared with sham, significant differences in pain-related behaviours were demonstrated by the Randall Selitto test on day 17 and 21 post-surgery. A difference was also demonstrated by von Frey testing, weight-bearing and limb use tests.

CONCLUSION

Our results indicate that pressure applied by the Randall Selitto algometer on a region, where the bone is close to the skin, may offer a way to measure bone-related pain in animal models and could provide a supplement to the traditional behavioural tests and a means to study deep pain.

A rate-based transcutaneous CO2 sensor for noninvasive respiration monitoring

The pain and risk of infection associated with invasive blood sampling for blood gas measurements necessitate the search for reliable noninvasive techniques. In this work we developed a novel rate-based noninvasive method for a safe and fast assessment of respiratory status. A small sampler was built to collect the gases diffusing out of the skin. It was connected to a CO2 sensor through gas-impermeable tubing. During a measurement, the CO2 initially present in the sampler was first removed by purging it with nitrogen. The gases in the system were then recirculated between the sampler and the CO2 sensor, and the CO2 diffusion rate into the sampler was measured. Because the measurement is based on the initial transcutaneous diffusion rate, reaching mass transfer equilibrium and heating the skin is no longer required, thus, making it much faster and safer than traditional method. A series of designed experiments were performed to analyze the effect of the measurement parameters such as sampler size, measurement location, subject positions, and movement. After the factor analysis tests, the prototype was sent to a level IV NICU for clinical trial. The results show that the measured initial rate of increase in CO2 partial pressure is linearly correlated with the corresponding arterial blood gas measurements. The new approach can be used as a trending tool, making frequent blood sampling unnecessary for respiratory status monitoring.

Role of chemoradiotherapy in the adjuvant and neoadjuvant settings for resectable pancreatic cancer

Pancreatic cancer is the 10th most commonly diagnosed malignancy in the USA and the fourth most common cause of cancer-related death. Worldwide, the mortality incidence ratio approaches 98%. Although only 15-20% of patients present with resectable disease, there is international consensus that complete surgical resection (R0, i.e. grossly and microscopically negative margins) is a vital part of any curative treatment paradigm. Despite advances in surgical technique, peri-operative care, chemotherapy and radiation delivery techniques over the past two decades, 5 year overall survival rates for resected pancreatic cancer with modern therapies remain around 20-25%. There is level I evidence for adjuvant chemotherapy in fully resected pancreatic cancer, but randomised trials examining the role of adjuvant chemoradiotherapy to date do not provide clear support for radiation therapy in this setting. In addition, efforts to increase the proportion of long-term survivors have recently centred on increasing the resectability of locoregional disease by incorporating neoadjuvant treatment before definitive surgery. Post-hoc analysis of randomised data as well as retrospective reviews have shown that there are several independent prognostic factors that may have considerable impact on survival outcomes, complicating interpretation and comparison of historical data. There is considerable interest in adjuvant and neoadjuvant therapy, but there is significant controversy as to whether radiation is of value, especially in the adjuvant context. Herein, we explore the sources of those controversies.

Oesophageal Chemoradiotherapy in the UK--current practice and future directions

The SCOPE 1 trial closed to recruitment in early 2012 and has demonstrably improved the quality of UK radiotherapy. It has also shown that there is an enthusiastic upper gastrointestinal clinical oncology community that can successfully complete trials and deliver high-quality radiotherapy. Following on from SCOPE 1, this paper, authored by a consensus of leading UK upper gastrointestinal radiotherapy specialists, attempts to define current best practice and the questions to be answered by future clinical studies. The two main roles for chemoradiotherapy (CRT) in the management of potentially curable oesophageal cancer are definitive (dCRT) and neoadjuvant (naCRT). The rates of local failure after dCRT are consistently high, showing the need to evaluate more effective treatments, both in terms of optimal local and systemic therapeutic components. This will be the primary objective of the next planned UK dCRT trial and here we discuss the role of dose escalation and systemic therapeutic options that will form the basis of that trial. The publication of the Dutch 'CROSS' trial of naCRT has shown that this pre-operative approach can both be given safely and offer a significant survival benefit over surgery alone. This has led to the development of the UK NeoSCOPE trial, due to open in 2013. There will be a translational substudy to this trial and currently available data on the role of biomarkers in predicting response to therapy are discussed. Postoperative reporting of the pathology specimen is discussed, with recommendations for the NeoSCOPE trial. Both of these CRT approaches may benefit from recent developments, such as positron emission tomography/computed tomography and four-dimensional computed tomography for target volume delineation, planning techniques such as intensity-modulated radiotherapy and 'type b' algorithms and new treatment verification methods, such as cone-beam computed tomography. These are discussed here and recommendations made for their use.