Biotransformation and toxicokinetics of 2-phenoxyethanol after oral exposure in humans: a volunteer study

2-Phenoxyethanol (PhE) is an aromatic glycol ether and is used in a variety of functions and applications, e.g., as preservative in pharmaceuticals, cosmetic and personal care products, as biocide in disinfectants (e.g. human hygiene), or as a solvent in formulations (e.g. coatings, functional fluids). Despite its widespread use, little is yet known on its biotransformation and toxicokinetics in humans. Therefore, a pilot study was conducted with oral administration of PhE (5 mg/kg body weight) to five volunteers. Blood and urine samples were collected and analyzed for PhE and three of its presumed metabolites up to 48 h post-exposure. Additionally, one volunteer was dermally exposed to PhE and monitored until 72 h post-exposure. PhE was rapidly resorbed following both oral and dermal application with tmax-levels in blood of about 1 h and 3 h, respectively. Metabolism of PhE was observed to be rather extensive with phenoxyacetic acid (PhAA) and 4-hydroxyphenoxyacetic acid (4-OH-PhAA) as the main metabolites found in blood and urine following oral and dermal exposure. PhE was excreted rapidly and efficiently via urine mostly in metabolized form: following oral exposure, on average 77% and 12% of the applied dose was excreted within 48 h as PhAA and 4-OH-PhAA, respectively. A similar metabolism pattern was observed following the single dermal exposure experiment. The obtained data on biotransformation and toxicokinetics of PhE in humans provide valuable information on this important chemical and will be highly useful for pharmacokinetic modelling and evaluation of human PhE exposure.

A specific and sensitive GC-MS/MS method for the quantitative determination of 2-phenoxyethanol and selected metabolites in human blood and urine

2-Phenoxyethanol (PhE) is widely used as a preservative in consumer products such as cosmetics as well as at the workplace as a component of metal-working fluids and hydraulic fluids. Therefore, both industry workers and consumers may potentially be exposed to PhE. An analytical method for the quantification of PhE and three selected metabolites, namely phenoxyacetic acid (PhAA), 4-hydroxyphenoxyacetic acid (4-OH-PhAA), and 4-hydroxyphenoxyethanol (4-OH-PhE) in human urine and blood was developed and validated. The sample preparation includes enzymatic hydrolysis of urine samples or protein precipitation of blood samples, followed by liquid-liquid extraction and silylation of the target analytes. Analyses of the extracts were carried out by gas chromatography with tandem mass spectrometry (GC-MS/MS). 3,4-Hydroxyphenoxyethanol, a probably minor PhE metabolite could not reliable be analyzed due to its instability. The limits of quantification (LOQ) of the analytes ranged between 0.5 and 6.1 μg/L and 2.0 and 3.9 μg/L in urine and blood, respectively. The method was successfully applied to spot urine samples of 50 individuals without occupational exposure to PhE and additionally to blood samples from seven volunteers. In urine, PhAA and 4-OH-PhAA could be quantified in all analyzed samples, whereas 4-OH-PhE and unchanged PhE were found in 36 % and 32 % of the samples, respectively. In blood, PhAA was also found in every sample in levels above the LOQ, whereas PhE itself was detected in three of seven samples only. Neither 4-OH-PhAA nor 4-OH-PhE were found in any of the analyzed blood samples. The developed method promises to be a valuable tool for PhE monitoring of urine and blood samples and may also enable an advanced investigation of PhE biotransformation pathways in humans.

Human Metabolism and Urinary Elimination Kinetics of the Fragrance Geraniol after Oral Dosage

Geraniol is a fragrance with a characteristic rose-like smell, naturally occurring in terpene oil and also chemically synthesized on a large scale. Geraniol is widely used in consumer products such as cosmetics, personal care products, and household cleaners and as an additive in foods. An experimental study in human volunteers was carried out to investigate the metabolism and elimination kinetics of geraniol. Three subjects were orally exposed to geraniol in two different dosages (25 or 250 mg). In each case, one pre-exposure urine sample and all urine voids for 72 h after exposure were collected separately. The geraniol metabolites Hildebrandt acid, geranic acid, 3-hydroxycitronellic acid, and 8-carboxygeraniol were analyzed in every sample after enzymatic hydrolysis and liquid-liquid extraction using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Maximum urinary concentrations of the metabolites were measured between 1 and 5 h after oral dosing, and elimination half-lives were determined to be about 2-4 h. The predominant metabolite found in urine was Hildebrandt acid with 34.4 ± 5.6% of the ingested dose, followed by geranic acid (12.7 ± 5.6%), 3-hydroxycitronellic acid (2.2 ± 0.4%), and 8-carboxygeraniol (0.19 ± 0.09%). In total, the four metabolites determined represent 41.7-55.5% of the ingested dose. Only 8-carboxygeraniol is, however, a specific metabolite, while the other three target analytes are also formed from other terpenes like citral. Within this study, conversion factors were calculated, which allow for a rough estimate of the total geraniol uptake by back-calculation from metabolite concentrations of spot urine samples. Taking the conversion factor for all four metabolites into account, a mean daily uptake of geraniol of 1.43 mg was estimated from 41 urine samples of occupationally nonexposed adults. The metabolites Hildebrandt acid, geranic acid, 3-hydroxycitronellic acid, and 8-carboxygeraniol in urine are suitable biomarkers of exposure for geraniol and can be used for human biomonitoring studies.

Reliable determination of the main metabolites of 2-phenoxyethanol in human blood and urine using LC-MS/MS analysis

2-Phenoxyethanol (PhE) is used as a broad-spectrum preservative in several consumer products like cosmetics and cleaning agents. To enable the analysis and assessment of human exposure to PhE, a fast and sensitive LC-MS/MS method for the quantification of two PhE metabolites, namely phenoxyacetic acid (PhAA) and 4-hydroxyphenoxyacetic acid (4-OH-PhAA) in human urine and blood was developed and validated. The method is based on liquid chromatography combined with tandem mass spectrometry (LC-MS/MS). Sample preparation was different for both matrices: either a simple "dilute&shoot"-approach for urine samples or a liquid-liquid-extraction (LLE) for blood samples was used. The limit of quantification (LOQ) is 10 μg L^-1 and 6 μg L^-1 for PhAA and 20 μg L^-1 and 10 μg L^-1 for 4-OH-PhAA in urine and blood, respectively. The method was applied to urine samples of 153 persons without occupational exposure to PhE and to blood samples of 7 additional volunteers. In blood, PhAA was detected in 57% of all samples (range: <LOQ - 0.017 mg L^-1), while 4-OH-PhAA was not detectable. In contrast to that, PhAA was found in 99% and 4-OH-PhAA in 95% of all urine samples. The median concentrations in urine were 0.99 mg L^-1 (range: <LOQ - 53.83 mg L^-1) for PhAA and 0.11 mg L^-1 (<LOQ - 4.98 mg L^-1) for 4-OH-PhAA, respectively. Analyses after acid hydrolysis showed that both urinary metabolites are excreted unconjugated.

The effect of ultrafiltration process on the fate of antibiotic-related microcontaminants, pathogenic microbes, and toxicity in urban wastewater

Ultrafiltration (UF) was assessed at chemical, microbiological, genetical and toxicological level and in terms of removing specific antibiotic-related microcontaminants from urban wastewater. The UF capacity to remove various antibiotics (clarithromycin, erythromycin, ampicillin, ofloxacin, sulfamethoxazole, trimethoprim, and tetracycline; [A₀] = 100 μg L^-1) was optimised with respect to the feed recirculation rate (25-50%) and feed/transmembrane pressure (1.5-3/1.5-2.4 bar, respectively). Here, we tested the UF capacity to reduce the cultivable bacteria (faecal coliforms, total heterotrophs, Enterococci, Pseudomonas aeruginosa), enteric opportunistic pathogens, including antibiotic-resistant bacteria (ARB) and antibiotic-resistance genes (ARGs) load. Moreover, the toxicity towards Daphnia magna and three plant species was investigated. Upon optimisation of UF, the removal of antibiotics ranged from 19% for trimethoprim to 95% for clarithromycin. The concentration of cultivable faecal coliforms in the permeate was significantly reduced compared to the feed (P < 0.001), whereas all the bacterial species decreased by more than 3 logs. A similar pattern of reduction was observed for the ARGs (P < 0.001) and enteric opportunistic pathogens (~3-4 logs reduction). A nearly complete removal of the antibiotics was obtained by UF followed by granular activated carbon adsorption (contact time: 90 min), demonstrating the positive contribution of such combination to the abatement of chemical microcontaminants.

Preparedness as a key factor for human biomonitoring programs after chemical incidents

BACKGROUND

Human biomonitoring (HBM) has been repeatedly recommended for and applied to post-incident chemical exposure assessment. The applicability of HBM and the validity of its results, however, closely depend on the existence and quality of preparatory measures such as information and instruction materials, sampling procedures, transport and storage facilities, and on the selection of appropriate biomarkers, sampling time, transport and storage conditions.

OBJECTIVE

To establish a standardized HBM program for emergency responders of a large chemical production site, considering the aforementioned aspects.

METHODS

An HBM program based on a comprehensive questionnaire, information and training of emergency responders, and availability of sampling material was established. The quantitative determination of metabolites of hazardous substances was carried out based on quality-controlled analytical methods.

RESULTS

The use of HBM after emergency operations was significantly increased immediately after the implementation of the program. Only in single cases, however, established HBM assessment values were exceeded. After one major incident, an increased exposure to benzene exceeding the internal action value was observed after firefighting and safeguarding.

SIGNIFICANCE

The experience with several minor and one major incident at a chemical production site suggests that the implementation of easily accessible and applicable routines is one paramount prerequisite for the success of HBM programs after chemical incidents.

Quantitative determination of urinary metabolites of geraniol by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS)

Geraniol is a fragrance which occurs in natural terpene oil or is chemically synthesized on a large scale. It is used in a wide variety of consumer products such as perfumes, deodorants, household products and cosmetics. Hence, not only industry workers in the production of geraniol, but also consumers can come into contact with the substance. Human biomonitoring (HBM), i.e. the analytical determination of substances and their metabolites in human biological material, is a key element in the analysis and assessment of the distribution and intensity of occupational and environmental exposure of humans. Therefore, a procedure for the quantitative determination of the urinary metabolites Hildebrandt acid, geranic acid, 3-hydroxycitronellic acid and 8-carboxygeraniol as potential biomarkers of geraniol exposure was developed and validated. The method is based on ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) after enzymatic hydrolysis and liquid-liquid extraction (LLE) of the target analytes. The limit of quantification (LOQ) is 1.5 μg L^-1 for 8-carboxygeraniol, 2.7 μg L^-1 each for Hildebrandt acid and geranic acid, and 1.8 μg L^-1 for 3-hydroxycitronellic acid. The method was applied to urine samples of 41 persons without occupational exposure to geraniol. Hildebrandt acid and geranic acid were detected in all samples, 8-carboxygeraniol in 83% and 3-hydroxycitronellic acid in 81% of the samples. Hildebrandt acid (median: 313 μg L^-1, range: 37-1966 μg L^-1) was the most abundant metabolite, followed by geranic acid (93 μg L^-1; 9-477 μg L^-1), 3-hydroxycitronellic acid (18 μg L^-1; <LOQ to 70 μg L^-1) and 8-carboxygeraniol (9 μg L^-1; <LOQ to 46 μg L^-1). Hildebrandt acid, geranic acid and 3-hydroxycitronellic acid apparently represent larger relative fractions of the eliminated metabolites, but they are not strictly specific for geraniol since they are metabolites of other terpenes as well, such as citral. In contrast, geraniol seems to be the only parent compound for 8-carboxygeraniol, which makes this metabolite a promising candidate for specific human biomonitoring and risk assessment.

A chemical, microbiological and (eco)toxicological scheme to understand the efficiency of UV-C/H2O2 oxidation on antibiotic-related microcontaminants in treated urban wastewater

An assessment comprising chemical, microbiological and (eco)toxicological parameters of antibiotic-related microcontaminants, during the application of UV-C/H₂O₂ oxidation in secondary-treated urban wastewater, is presented. The process was investigated at bench scale under different oxidant doses (0-50 mg L^-1) with regard to its capacity to degrade a mixture of antibiotics (i.e. ampicillin, clarithromycin, erythromycin, ofloxacin, sulfamethoxazole, tetracycline and trimethoprim) with an initial individual concentration of 100 μg L^-1. The process was optimized with respect to the oxidant dose. Under the optimum conditions, the inactivation of selected bacteria and antibiotic resistant bacteria (ARB) (i.e. faecal coliforms, Enterococcus spp., Pseudomonasaeruginosa and total heterotrophs), and the reduction of the abundance of selected antibiotic resistance genes (ARGs) (e.g. bla_OXA, qnrS, sul1, tetM) were investigated. Also, phytotoxicity against three plant species, ecotoxicity against Daphnia magna, genotoxicity, oxidative stress and cytotoxicity were assessed. Apart from chemical actinometry, computational fluid dynamics (CFD) modelling was applied to estimate the fluence rate. For the given wastewater quality and photoreactor type used, 40 mg L^-1 H₂O₂ were required for the complete degradation of the studied antibiotics after 18.9 J cm^-2. Total bacteria and ARB inactivation was observed at UV doses <1.5 J cm^-2 with no bacterial regrowth being observed after 24 h. The abundance of most ARGs was reduced at 16 J cm^-2. The process produced a final effluent with lower phytotoxicity compared to the untreated wastewater. The toxicity against Daphnia magna was shown to increase during the chemical oxidation. Although genotoxicity and oxidative stress fluctuated during the treatment, the latter led to the removal of these effects. Overall, it was made apparent from the high UV fluence required, that the particular reactor although extensively used in similar studies, it does not utilize efficiently the incident radiation and thus, seems not to be suitable for this kind of studies.

A global multinational survey of cefotaxime-resistant coliforms in urban wastewater treatment plants

The World Health Organization Global Action Plan recommends integrated surveillance programs as crucial strategies for monitoring antibiotic resistance. Although several national surveillance programs are in place for clinical and veterinary settings, no such schemes exist for monitoring antibiotic-resistant bacteria in the environment. In this transnational study, we developed, validated, and tested a low-cost surveillance and easy to implement approach to evaluate antibiotic resistance in wastewater treatment plants (WWTPs) by targeting cefotaxime-resistant (CTX-R) coliforms as indicators. The rationale for this approach was: i) coliform quantification methods are internationally accepted as indicators of fecal contamination in recreational waters and are therefore routinely applied in analytical labs; ii) CTX-R coliforms are clinically relevant, associated with extended-spectrum β-lactamases (ESBLs), and are rare in pristine environments. We analyzed 57 WWTPs in 22 countries across Europe, Asia, Africa, Australia, and North America. CTX-R coliforms were ubiquitous in raw sewage and their relative abundance varied significantly (<0.1% to 38.3%), being positively correlated (p < 0.001) with regional atmospheric temperatures. Although most WWTPs removed large proportions of CTX-R coliforms, loads over 10³ colony-forming units per mL were occasionally observed in final effluents. We demonstrate that CTX-R coliform monitoring is a feasible and affordable approach to assess wastewater antibiotic resistance status.

Surgical and radiological behavior of MRI-depictable mesh implants after TAPP repair: the IRONMAN study

PURPOSE

Knowledge of postoperative behavior of mesh implants used for hernia repair is generally limited to cases of recurrence, local complications or return to the previous operative field in other pathological conditions. Previous studies with MRI-visible mesh implants in different parts of the abdominal wall have led to variable findings with regard to mesh properties and mostly described a reduction in size over time with subsequently limited mesh overlap over hernia defects which could contribute to recurrence. We aimed to evaluate implant properties in a mechanically stable anatomical region after TAPP repair of primary unilateral inguinal hernias in men with clinical and MRI examinations 4 weeks and 1 year after surgery.

METHODS

From 11/2015 to 01/2019, 23 men with primary, unilateral, inguinal hernias underwent TAPP repair with iron particle-loaded, MRI-visible mesh implants in a prospective cohort study. In 16 patients the operative outcome could be evaluated 4 weeks and 12 months after surgery by clinical examination and MRI evaluation with regard to postoperative course, possible adverse outcomes and radiological findings related to implant behavior-namely MRI-identifiability, mesh dislocation or reduction in surface area.

RESULTS

All included patients had an uneventful postoperative clinical course. MRI after 4 weeks revealed one postoperative seroma, which resolved spontaneously. No recurrence was detected. Mesh implants could be accurately delineated in DIXON-IN studies and showed neither clinically nor statistically significant changes in size or position.

CONCLUSION

4 weeks and 1 year after a standardized TAPP procedure the mesh implant used in this study showed no tendency towards dislocation or reduction in size in this anatomical position. Its MRI visibility allows accurate delineation during the postoperative course by experienced radiologists in appropriate MRI protocols. Larger patient series are desirable to further support these findings. Shrinkage of implants in the groin as a reason for early recurrence may be overestimated.

Olaratumab plus anthracyline in advanced/metastatic soft tissue sarcoma: Data of real-world utilization in Austria

e22550

Background: Olaratumab is a humanized monoclonal anti platelet-derived growth factor receptor α antibody that has been approved in combination with doxorubicin for the treatment of patients with metastatic soft tissue sarcoma (STS). The purpose of this retrospective study was to assess the clinical efficacy in STS patients treated with olaratumab in a real-world setting in Austria. Methods: Retrospectively collected, longitudinal data from patients treated between November 2016 and September 2018 at 9 Austrian centers were obtained from respective medical charts. Eligible patients were all patients who received at least one dose of olaratumab. Parameters of most interest collected were response rates, progression-free survival (PFS) and overall survival (OS). Results: Altogether 55 patients were included into analysis. Median age was 58 years. In total, 65.5% (n = 36), 21.8% (n = 12) and 12.7% (n = 7) received olaratumab as first-, second- or ≥ third-line treatment, respectively. Olaratumab was administered either in combination with doxorubicin (81.8%, n = 45) or liposomal doxorubicin (16.4%, n = 9); 1 patient received olaratumab as upfront monotherapy. Median PFS and OS were 2.6 and 11.4 months. The objective response rate was 11.4 % and the disease control rate was 40.9 %. Conclusions: In this real-world analysis outcome was less pronounced compared to the results of the Phase Ib/II approval trial ( Tap WD et al. Lancet 2016). Thus, the results of the ongoing phase III trial (NCT02451943) are urgently needed to confirm the efficacy of the combination of olaratumab and doxorubicin in STS patients.

Reduction of Antibiotic Resistant Bacteria During Conventional and Advanced Wastewater Treatment, and the Disseminated Loads Released to the Environment

The occurrence of new chemical and microbiological contaminants in the aquatic environment has become an issue of increasing environmental concern. Thus, wastewater treatment plants (WWTPs) play an important part in the distribution of so-called new emerging pathogens and antibiotic resistances. Therefore, the daily loads released by the WWTP were calculated including a model system for the distribution of these loads within the receiving water body. UV-, as well as ozone-treatment in separate or in combination for wastewater treatment were under investigation aiming at the reduction of these loads. Here, the impact of these treatments on the DNA integrity via antibody staining and PCR efficiencies experiments were included. All three facultative pathogenic bacteria [enterococci (23S rRNA), Pseudomonas aeruginosa (ecfX), and Escherichia coli (yccT)] and seven clinically relevant antibiotic resistance genes (ARGs) (mecA (methicillin resistance gene), ctx-M32 (β- lactame resistance gene), ermB (erythromycine resistance gene), bla_TEM (β- lactame resistance gene), sul1 (sulfonamide resistance gene), vanA (vancomycin resistance gene), and intI1 (Integrase1 gene) associated with mobile genetic elements were detected in wastewaters. Different reduction efficiencies were analyzed during advanced wastewater treatments. ARGs were still found to be present in the effluents under the parameters of 1.0 g ozone per g dissolved organic carbon (DOC) and 400 J/m², like ctx-M32, ermB, bla_TEM, sul1, and intI1. Especially UV radiation induced thymidine dimerization which was analyzed via antibody mediated detection in the metagenome of the natural wastewater population. These specific DNA alterations were not observed during ozone treatment and combinations of UV/ozone treatment. The dimerization or potential other DNA alterations during UV treatment might be responsible for a decreased PCR efficiency of the 16S rRNA amplicons (176, 490, and 880 bp fragments) from natural metagenomes compared to the untreated sample. This impact on PCR efficiencies was also observed for the combination of ozone and UV treatment.

Sicherheitspolitische Bedrohungen und Risiken und das „geltende“ Recht in der 2. Hälfte des 2. Jahrzehnts des 21. Jahrhunderts unter besonderer Berücksichtigung der Sicherstellungs- und Vorsorgegesetze. Sicherheitspolitik in Zeiten der Uneindeutigkeit

Das Grundgesetz (GG) kennt klare Regelungen zum Spannungs- und Verteidigungsfall, vgl. nur Art. 80a, 115a Abs. 1 GG. Diese Bestimmungen wurden unter den Bedrohungslagen des Kalten Krieges und seiner gefährlichsten Tage in der Kuba- Krise in einer Notstandsverfassung zusammengefasst, bei einer großen Wintex-Übung im Ausweichsitz der Verfassungsorgane in Mariental erprobt und von der ersten großen Koalition „verabschiedet“ (1966–1969, Kabinett Kiesinger/Brandt). Veränderungen folgten.

Live-dead discrimination analysis, qPCR assessment for opportunistic pathogens, and population analysis at ozone wastewater treatment plants

In respect to direct and indirect water reuse, the microbiological quality of treated wastewater is highly important. Conventional wastewater treatment plants are normally not equipped with advanced technologies for the elimination of bacteria. Molecular biology analyses were combined with live-dead discrimination analysis of wastewater population using Propidium monoazide (PMA) to study population shifts during ozonation (1 g ozone/g DOC) at a municipal wastewater treatment plant. Escherichia coli, enterococci, and Pseudomonas aeruginosa were quantified by polymerase chain reaction (qPCR) and the whole wastewater population was analyzed by metagenomic sequencing. The PMA-qPCR experiments showed that the abundances of P. aeruginosa didn't change by ozone treatment, whereas a reduction was observed for E. coli and enterococci. Results comparing conventional cultivation experiments with PMA-qPCR underlined the presence of viable but not culturable cells (VBNC) and their regrowth potential after ozone treatment. Illumina HiSeq sequencing results with and without PMA treatment demonstrated high population similarities in water samples originating from ozone inflow sampling sides. Upon using PMA treatment after ozonation, population shifts became visible and also underlined the importance of PMA treatment for the evaluation of elimination and selection processes during ozonation at WWTPs. Amongst a number of 14 most abundant genera identified in the inflow samples, 9 genera were found to be reduced, whereas 4 genera increased in relative abundance and 1 genus almost remained constant. The strongest increase in relative abundance after ozonation was detected for Oscillatoria spp., Microcoleus spp. and Nitrospira spp. Beside this, a continuous release of Pseudomonas spp. (including P. aeruginosa) to the downstream receiving body was confirmed. Regrowth experiments demonstrated a high prevalence of P. aeruginosa as part of the surviving bacterial population. Summing up, molecular biology analyses in combination with live-dead discrimination are comprehensive methods to evaluate the elimination processes targeting specific species and/or whole microbial populations.

Abstract P4-14-11: Efficacy and cardiac safety in neoadjuvant treatment of Her2 positive breast cancer with concomitant nonpegylated liposomal doxorubicin, docetaxel and dual blockade with trastuzumab and pertuzumab: A retrospective analysis

Background: Approval to pertuzumab as part of a complete treatment regimen for patients with early stage breast cancer (EBC) before surgery (neoadjuvant setting) was granted by the FDA in September 2013. Since then, the relevance of neoadjuvant treatment in Her2 overexpressing breast cancer has increased considerably. This for instance has been emphasized by the results of the Neosphere Study, in which dual blockade of Her2 was combined with docetaxel as chemotherapy backbone and resulted in favorable pCR rates.

But it is likely, that anthracyclines could play an important role in enhancing the effectiveness of the above mentioned treatment. However, there is only little data about the cardiac safety of this combination. The use of liposomal doxorubicin might be a valuable alternative with low cardiotoxicity, as it has been shown in comparable publications without the use of pertuzumab. Therefore we report pCR-rate and cardiac safety of a single arm, retrospective, multicenter analysis of neoadjuvant treatment for Her2 positive EBC with liposomal doxorubicin, docetaxel, trastuzumab and pertuzumab.

Methods: In this study 42 women with Her2 positive EBC were investigated in 4 oncological departments in Austria. 41 patients were treated with liposomal doxorubicin (50 mg/m2), docetaxel (75 mg/m2) concurrent with trastuzumab and pertuzumab in standard dosage for 6 cycles as neoadjuvant therapy. One patient refused to receive a chemotherapy but agreed to be treated with combined antibody therapy alone. All patients were free of cardiovascular disease and had a left ventricular ejection fraction (LVEF) of ≥ 50%. Cardiac function was measured by LVEF and was examined at regular intervals (cycles 0-3, cycle 6, FU). Clinical response was evaluated by diagnostic breast imaging after cycles 3 and 6. All patients underwent surgery after neoadjuvant chemotherapy. The absence of any residual invasive cancer in the breast and axilla was defined as pathological complete response (pCR). Median follow up was 1.3 years.

Results: Median age of the patients was 49 years. After 6 cycles of treatment the pCR rate was 76.2%. In this cohort a negative estrogen-and/or progesteron receptor was predictive for pCR (p&lt;0.001). These patients achieved pCR in 95.2%. The antibody only treatment in one case also resulted in a pCR. No patient progressed during treatment. Only one of the patients (2,4%) suffered symptomatic heart failure after surgery. The patient initially presented with an LVEF of 16%.

Conclusions: In this multicenter analysis we observed a considerably high rate of pCR in HER2-positive EBC treated with liposomal doxorubicin, docetaxel, trastuzumab and pertuzumab. Especially the group of hormone receptor negative patients showed a remarkable response rate. The addition of liposomal doxorubicin entails a very favorable cardiotoxicity profile. This regimen is a safe treatment option in patients with HER-2 positive breast cancer.

Citation Format: Egle D, Hubalek M, Hager C, Poyßl C, Lang A, Jäger T, Volgger B, Abdel-Azim S, Tiechl J, Angerer J, Marth C. Efficacy and cardiac safety in neoadjuvant treatment of Her2 positive breast cancer with concomitant nonpegylated liposomal doxorubicin, docetaxel and dual blockade with trastuzumab and pertuzumab: A retrospective analysis. [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 P4-14-11.

Abstract P1-13-10: Capecitabine in combination with bendamustine in pretreated women with HER2-negative metastatic breast cancer: Stage 1 results of a phase II trial (AGMT MBC-6)

Background: Although there is no single accepted standard of care after failure of anthracycline and taxane therapy in HER2-negative metastatic breast cancer, capecitabine is a well-established treatment option. Bendamustine is a hybrid cytotoxic drug because of its structural similarity to alkylating agents and purine and it is generally well tolerated. Since bendamustine has already shown anticancer activity in breast cancer we evaluated the efficacy and tolerability of bendamustine in combination with capecitabine in 40 patients with advanced breast cancer after anthracycline and/or taxane pretreatment.

Patients and methods: MBC-6 is a non-randomized, multicenter, open-label, single-arm phase II study in patients with HER2-negative advanced breast cancer (ClinicalTrials.gov identifier: NCT01891227). All patients were pretreated with anthracyclines and/or taxans in the (neo-)adjuvant and/or metastatic setting and measurable disease according to RECIST 1.1. had to be present at baseline. Following a two-stage Green-Dahlberg design, 20 subjects were accrued and treated within stage 1 of the study. The trial was planned to enroll further 20 patients if there were at least four subjects (20%) with a complete (CR) or partial response (PR). Eligible patients received 1000 mg/m2 capecitabine twice daily on days 1 to 14 in combination with 80 mg/m2 bendamustine on day 1 and 8 of a 3-week cycle. After a maximum of eight cycles capecitabine was continued as single drug therapy until disease progression or unacceptable toxicity. The primary endpoint was overall response rate (ORR). Secondary endpoints were progression free survival (PFS), clinical benefit rate (CBR), safety profile and quality of life. Here we report the efficacy and safety analysis of stage 1 patients.

Results: From September 2013 to May 2015, 40 patients were recruited in eight Austrian centers. Median age of the stage 1 cohort was 59 years (range 29-77), 80% and 20% of patients had an ECOG performance score of 0 and 1, respectively. Thirty-three percent had triple-negative disease, 85% had had (neo-)adjuvant treatment and 65% patients were pretreated with at least one chemotherapy line for metastatic disease (15% one line, 50% two lines, 40% three lines). In stage 1, ORR was 50% with 9 confirmed PR and 1 confirmed CR, and ORR was comparable between hormone receptor-positive and triple-negative disease (54% vs. 43%). CBR was 55%. At data cut-off on 05/28/15 overall 15 of 20 patients had discontinued treatment: 10 patients (50%) due to progressive disease, 3 (15%) because of adverse events (AEs) and 2 patients on their own decision (10%). Five patients (25%) experienced at least one drug related non-hematological AE ≥ grade 3: 2 diarrhea, 2 fatigue, 3 respiratory or viral infections, 1 dyspnea, 1 thromboembolic event (each grade 3). One grade 4 hematological AE (neutropenia) was observed. One patient died as a result of restrictive cardiomyopathy, where a relationship to capecitabine cannot be excluded, but seems unlikely.

Conclusion: The combination of capecitabine and bendamustine has a moderate toxicity profile and the response data of the stage 1 are promising. Final study results are awaited in the first half of 2016.

Citation Format: Rinnerthaler G, Gampenrieder SP, Fridrik M, Petzer A, Hubalek M, Petru E, Jäger T, Andel J, Balic M, Ulmer H, Mlineritsch B, Greil R. Capecitabine in combination with bendamustine in pretreated women with HER2-negative metastatic breast cancer: Stage 1 results of a phase II trial (AGMT MBC-6). [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 P1-13-10.

[Investigation of the use of triclosan in patients with indwelling catheters: a randomized, double blind, multicenter, placebo-controlled clinical study]

BACKGROUND

This article presents the first randomized, double blind, multicenter, placebo-controlled, non-interventional trial with a medical product after approval by the ethical committee of the medical council of North-Rhine. The study investigated the use of the antimicrobial agent triclosan (Farco-fill® Protect) as a liquid for inflation of catheter balloons in patients with chronic indwelling catheters.

PATIENTS AND OBJECTIVES

In this study 84 patients were investigated (43 in the treatment group and 41 in the placebo group) all with a suprapubic catheter and a positive history of catheter incrustation. The catheters were changed after 6 weeks and endpoints were the quantitative analysis of the incrustation, weight of the catheter, pain during catheter change and the number of urinary tract infections. The maintenance of the catheter was a secondary endpoint.

RESULTS

The primary endpoint could not be reached because the study, which was initially planned with 70 patients in each arm, had to be terminated due to logistical and technical problems with the catheter weighing. The maintenance of the catheter as the most important clinical parameter showed statistically significant differences with a longer indwelling time in the triclosan group. Adverse events with respect to the product were not recorded.

CONCLUSIONS

Using the antimicrobial solution triclosan as a fluid for inflation of catheter balloons led to a statistically significant extension in the catheter indwelling time. The reduction of pain during changing the catheter and the reduction of incrustation, although not statistically significant, led to an improvement in the quality of life of these patients.

Rail or roll: a new, convenient and safe way to position self-gripping meshes in open inguinal hernia repair

PURPOSE

In open inguinal hernia repair self-gripping meshes are currently commonly employed. Assumed benefits are saving of time, ease of handling and omission of fixation. Self-gripping meshes are, however, not as easy to handle and position as commonly stated. We describe a newly developed way of intra-operative mesh preparation and implantation and compare it to the conventional technique of insertion of self-gripping meshes.

METHODS

A two-armed, randomized trial with 64 patients was performed. For implantation of the self-gripping, light weight and partially absorbable mesh we used either a newly described rolling technique (group 1: n = 32) or the conventional way of insertion (group 2: n = 32). Primary endpoints of the study were feasibility with regard to actual implantation time and surgeons' satisfaction with the methods. Secondary endpoints were total operating time, length of hospital stay, postoperative pain, duration of pain medication intake and postoperative morbidity. In addition all patients were prospectively followed up according to the Hernia Med® registry's standards.

RESULTS

Implantation time (seconds) 140 ± 74 vs. 187 ± 84, p = 0.008, duration of pain medication intake (days) 3.6 ± 2.8 vs. 4.8 ± 2.6; p = 0.046 and postoperative morbidity 2 (6%) vs. 8 (25%) was significantly beneficial in group 1 (rolling technique) compared to group 2 (conventional method). Blinded questionnaire revealed that rolling the mesh is generally easier with less repositioning maneuvers than conventional placement. Neither overall procedure time, length of stay nor postoperative pain scores differed significantly between groups.

CONCLUSION

The newly introduced rolling technique for the actual placement of self-gripping meshes in open inguinal hernia repair is technically less demanding and therefore significantly faster when compared to the conventional way of insertion of the same product. In addition the rolling technique has shown to be safe for the patients and to also provide higher surgeons' satisfaction.

Analysis of Experts' and Trainers' Views on Cyberbullying

Partners from nine European countries developed a cyberbullying training manual for the benefit of trainers working with parents, school staff and young people.1The development of the training manual built on a two-level qualitative research process that combined elements of the Delphi method and online focus groups. The two studies outlined in this article aimed to assess trainers' and experts' views on the problem of cyberbullying while also gathering insight in relation to their preferences in terms of a training manual. This article outlines the main outcomes of a content analysis of experts' and trainers' views. According to experts and trainers, the sources of cyberbullying were specifically related to new technical developments and new patterns of usage, a lack of media literacy and media education, and the lack of appropriate laws, control and reporting mechanisms. Approaches for tackling cyberbullying suggested by experts and trainers included the provision of enhanced information on ICT and e-safety, adequate rules, monitoring mechanisms and sanctions. Furthermore a range of approaches targeting children and young people, parents and other adults, schools as well as approaches run by authorities and IT providers were suggested. In terms of the elements and style of a training manual, experts and trainers emphasised that it should be practically oriented, and that elements like narratives, case examples or video clips would be vital for the implementation of training.

Changes in functional vasomotor reactivity in migraine with aura

Migraine with aura (MA) is associated with cerebral hyper- and hypoperfusion during and after the attacks. Several attempts to estimate individual perfusion changes and asymmetries in patients with MA using transcranial Doppler (TCD) have not been consistent. In 70 patients with MA and 40 controls with migraine without aura (MoA) or without any history of migraine, interictally recorded TCD sequences were prospectively analysed. Formal curve analysis of the visually evoked flow response (VEFR) was performed semiautomatically. As a main parameter for functional vasomotor reactivity (fVMR), the visually evoked flow rate (VEFR%) was calculated. The VEFR% showed a significantly higher mean difference of 14.7 +/- 12% in MA patients vs. 5.8 +/- 4.4% (P < 0.001) in controls. The significant asymmetry of fVMR in MA patients is suggested to reflect interattack persisting vasomotor changes which are of pathophysiological interest and may be used as a monitoring tool under prophylactic medication.

[Expression levels of the IAP antagonists XAF1, Smac/DIABLO and HtrA2 in testicular germ cell tumours]

PURPOSE

Down-regulation of the IAP antagonistis XAF1, Smac/DIABLO and HtrA2, has been related to the onset and progression of various malignancies. We examined the mRNA-expression of these pro-apoptotic parameters in testicular germ cell tumors (TGCT) and normal testicular tissue and correlated their expression levels to clinicopathological tumour features.

MATERIAL AND METHODS

Real-time RT-PCR was used to quantify the mRNA-expression of XAF1, Smac/DIABLO and HtrA2 in normal testicular tissue (n = 18), carcinoma in situ (n = 4), seminomas (n = 64), and non-seminomatous germ cell tumors (n = 35).

RESULTS

Compared to normal testicular tissue, the expression levels of XAF1 were increased in TGCT (p < 0.001), whereas those of Smac/DIABLO and HtrA2 were decreased (p < 0.001 and p < 0.001). Smac/DIABLO expression levels showed a significant trend towards a gradual decrease from normal testicular tissue to CIS and seminomas and finally to NSGCT (p < 0.001). Moreover, XAF1 and HtrA2 expression levels gradually increased with progression of clinical tumour stage in seminoma patients (p = 0.001 and p = 0.018), their expression levels being strongly intercorrelated (Spearman rho correlation coefficient: 0.674; p < 0.001).

CONCLUSION

These data suggest that a down-regulation of Smac/DIABLO and HtrA2 is implicated in the development and progression of TGCT, whereas overexpression of XAF1 in TGCT might contribute to their extraordinary sensitivity to chemotherapy. Regarding the additional correlation of XAF1 and HtrA2 expression with clinical tumour stage in seminoma patients, it appears reasonable to further evaluate these three IAP antagonists as molecular parameters for the prediction of treatment response and prognosis of TGCT patients.

[From marker expression to individual therapy of patients with bladder cancer]

Urothelial carcinoma of the bladder is a tumor entity with a heterogenous clinical course. At one end of the spectrum, patients are treated for low-grade carcinomas, which are likely to reccur but show low rates of tumor progression. At the other end, patients suffer from noninvasive or early invasive high-grade carcinomas. In these cases, risk-adapted treatment decisions are more complicated. The following article gives an overview of research activities on bladder cancer with the aim to individualize treatment of patients with bladder cancer.

[Differential therapy of prostate cancer]

Prostate cancer has become the most common malignancy in males worldwide. Standard therapy in local confined prostate cancer with curative intent is a radical ablation of the gland. Brachytherapy seems to be an alternative treatment but long-term results are not yet available. In cases of advanced disease androgen deprivation is applied to eliminate testosterone which is the natural stimulator of tumor growth. The application of chemotherapy is limited to androgen-independent disease without curative intention. Standard chemotherapy is Docetaxel. Both early detection and aftercare are based on measurement of prostate-specific antigen.

Urogenitale Symptome und urologische Interventionsmöglichkeiten in der palliativen Situation

During the course of malignancies of nearly all tumor entities the urogenital organs are frequently influenced. The resulting disorders are subsumed under the term"urogenital symptoms". Especially with the goal of improving quality of life these symptoms have to be treated with respect. In addition further therapeutic measures, e.g. the application of a palliative chemotherapy, makes an unobstructed urinary excretion necessary. This article gives an overview of the indications for treating urogenital symptoms and contrasts different therapy concepts.

[Is there an indication for adjuvant or neoadjuvant systemic therapy in prostate cancer?]

In the meantime prostate cancer has become the most common malignancy in the male population. Due to the shift in age at the time of first diagnosis in favour of younger men with a high life expectancy and a maximum of physical and sexual activity it would be desirable to have neoadjuvant or adjuvant therapy concepts at hand which lead to an improvement of therapeutic success. So far the results of studies for adjuvant and neoadjuvant hormonal ablation therapy concepts have not led to a clear therapeutic reference. Only before radiation therapy is neoadjuvant hormonal ablation a standard part of therapy at most centres. Existing data for chemotherapeutic concepts are limited to androgen-independent advanced prostate cancer. An international study using docetaxel as an adjuvant drug is currently being performed, but the results are not yet available.