Ottawa Cardiac Oncology Program wins 2013 Cancer Quality Council of Ontario Innovation Award

The Ottawa Cardiac Oncology Program (ocop) has won the 2013 Innovation award from the Cancer Quality Council of Ontario [...]

Managing latent tuberculosis in UK renal transplant units: how does practice compare with published guidance?

Renal transplantation significantly increases the risk of active tuberculosis (TB) in individuals with latent TB infection (LTBI). UK transplant recipients are often born in TB endemic areas. Using a self-completed questionnaire, we evaluated how the 23 UK renal transplant units' LTBI management compared with recently published national guidance. Three-quarters had a management protocol, but only one-third of these were in line with the guidance. Interferon-gamma release assays were rarely used to confirm LTBI. Almost half of the units prescribed LTBI treatment at the wrong dose or duration. We conclude that units should develop local protocols in line with evidence-based guidance. This must be in a format that enables national audit programmes and quality improvement to be routinely performed.

Impact of antioxidants on the ability of phenolic phytochemicals to kill HCT116 colon cancer cells

Certain phenolic phytochemicals can kill cancer cells. Possible interference from antioxidants is a concern, and this issue has not been studied appreciably. Therefore, the effect of ascorbate and N-acetylcysteine on the ability of epigallocatechin gallate (EGCG) and curcumin to kill HCT116 colon cancer cells was examined. EGCG and curcumin each caused DNA damage in the cells. The DNA-damaging ability of EGCG, but not curcumin, was hindered by either ascorbate or NAC, which was also shown in HT29 and SW480 colon cancer cells. Also, iron chelators (deferoxamine and 2,2'-dipyridyl) inhibited the ability of EGCG, but not curcumin, to cause damage to the DNA in HCT116 cells. Interestingly, curcumin, but not EGCG, increased the expression of growth arrest and DNA damage-inducible gene 153 and also heme oxygenase-1, and this stress gene upregulation by curcumin was antioxidant-insensitive. With prolonged incubation of HCT116 cells with either EGCG or curcumin, cell shrinkage, membrane blebbing, apoptotic bodies, and chromatin condensation/fragmentation were observed. These morphological changes were not apparent in EGCG-treated cells that had been pretreated with either ascorbate or NAC. However, the ascorbate and NAC pretreatments did not prevent the occurrence of the morphological changes in curcumin-treated cells. Thus, these findings suggest that ascorbate and NAC interfere with the ability of EGCG, but not curcumin, to kill HCT116 cells. This basic knowledge may help to better plan and optimize strategies for chemoprevention or chemotherapy.

A prospective study comparing contamination rates between a novel mid-stream urine collection device (Peezy) and a standard method in renal patients

INTRODUCTION

It is imperative that laboratories receive uncontaminated urine samples to avoid giving false-positive results and reduce antimicrobial use.

AIM

The aim of the study was to investigate a novel urine collection device (Peezy) in a renal outpatient clinic to determine whether it reduced contamination of urine samples.

METHODS

The novel device was used in 420 renal transplant recipients and the results were compared with 424 matched historical controls, who used the standard method of urine collection. High epithelial cell counts on microscopy and mixed urine cultures were used to identify contaminated samples.

RESULTS

Peezy increased the rates of both epithelial cells and mixed growths in the urine samples when compared with the historical controls.

CONCLUSIONS

Further randomised studies in other more generalisable populations need to be performed.

Targeted versus universal screening and decolonization to reduce healthcare-associated meticillin-resistant Staphylococcus aureus infection

BACKGROUND

The benefits of universal meticillin-resistant Staphylococcus aureus (MRSA) admission screening, compared with screening targeted patient groups and the additional impact of discharge screening, are uncertain.

AIMS

To quantify the impact of MRSA screening plus decolonization treatment on MRSA infection rates. To compare universal with targeted screening policies, and to evaluate the additional impact of screening and decolonization on discharge.

METHODS

A stochastic, individual-based model of MRSA transmission was developed that included patient movements between general medical and intensive care unit (ICU) wards, and between the hospital and community, informed by 18 months of individual patient data from a 900-bed tertiary care hospital. We simulated the impact of universal and targeted [for ICU, acute care of the elderly (ACE) or readmitted patients] MRSA screening and decolonization policies, both on admission and discharge.

FINDINGS

Universal admission screening plus decolonization resulted in 77% (95% confidence interval: 76-78) reduction in MRSA infections over 10 years. Screening only ACE specialty or ICU patients yielded 62% (61-63) and 66% (65-67) reductions, respectively. Targeted policies reduced the number of screens by up to 95% and courses of decolonization by 96%. In addition to screening on admission, screening on discharge had little impact, with a maximum 7% additional reduction in infection.

CONCLUSIONS

Compared with universal screening, targeted screening substantially reduced the amount of screening and decolonization required to achieve only 12% lower reduction in infection. Targeted screening and decolonization could lower the risk of resistance emerging as well as offer a more efficient use of resources.

Hepatitis B status in migrants and refugees: increasing health burden in Western Australia

BACKGROUND

In light of increasing migration from endemic countries with chronic hepatitis B (CHB), this study describes the changing epidemiology of CHB patients born outside Australia referred to a tertiary hospital in Western Australia. It aims to stratify risk and progression to cirrhosis and hepatocellular carcinoma according to viral factors and to provide an indication of the growing burden of disease and current and future treatment costs.

METHODS

Demographic, serological and biochemical data were obtained from patients with CHB between July 2002 and December 2008. Hepatitis B virus DNA quantification was performed to assess baseline viral loads in the patients. Total cost estimates for surveillance and treatment are based on probabilities of the population anticipated to be at a given stage of the disease in a given year.

RESULTS

There is a progressive increase in referrals (n=478) with the majority coming from Asia (57%) and Africa (35%). The mean age of Africans is 11 years less than that of Asians, with a lower proportion of Africans having hepatitis B virus DNA>2000 IU/mL compared with Asians (36.7% vs 54.3%). Approximately 50% of CHB patients referred are at risk of cirrhosis and hepatocellular carcinoma unless treated. Without treatment, a substantial increase in cost over 10 years (from $401,460 to $2,027,078) is estimated at 400%.

CONCLUSION

This study highlights the increasing burden of CHB in Western Australia, from people born in endemic countries, in particular, the direct costs of treatment. It will help to develop strategies that can be tailored to Western Australia with appropriate allocation of resources.

Clinical outcomes of women with metastatic breast cancer treated with nab-paclitaxel: experience from a single academic cancer centre

BACKGROUND

Nab-paclitaxel is a solvent-free, taxane-based chemotherapy approved for the treatment of metastatic breast cancer (mbc). This study reports clinical benefit and toxicities experienced by women with mbc treated with nab-paclitaxel at the Ottawa Hospital Cancer Centre.

METHODS

Women with mbc treated with single-agent nab-paclitaxel between June 2006 and December 2010 were included in this analysis. Retrospective data obtained included demographics, disease characteristics, prior chemotherapy, nab-paclitaxel treatment, toxicity, and survival. Clinical benefit was defined as partial or complete response or stable disease (by clinical or radiologic evaluation, or both) at 6 months or more.

RESULTS

Of 43 women (mean age: 57.0 years; range: 34-74 years), most had disease positive for estrogen or progesterone receptor (72.1%, 58.1%), or both. Nab-paclitaxel was administered weekly (qw: 44.2%), every 3 weeks (q3w: 46.5%), q3w switched to qw (7.0%), or qw switched to q3w (2.3%). Median duration of therapy was 5.1 months (qw) and 3.0 months (q3w). Sensory neuropathy was the primary toxicity (45.4% qw, 38.1% q3w; p = 0.62). Clinical benefit was observed in most women (76.2% qw, 57.1% q3w; p = 0.20). Women receiving nab-paclitaxel had a median overall survival of 13.6 months qw (range: 8.1-28.3 months) and 10.8 months q3w (range: 5.9-17.9 months; p = 0.03). Regardless of dosing schedule, women experiencing clinical benefit lived significantly longer than those not experiencing a benefit (17.3 months vs. 7.7 months; hazard ratio: 0.14; 95% confidence interval: 0.06 to 0.33).

CONCLUSIONS

Our clinical experience demonstrates that most women treated with nab-paclitaxel experienced some clinical benefit. Patients achieving clinical benefit lived significantly longer than those who did not. Nab-paclitaxel was well tolerated, with the primary toxicity being mild sensory neuropathy. Nab-paclitaxel represents another treatment option, with a favourable toxicity profile, for women with mbc.

Prospective validation of risk prediction indexes for acute and delayed chemotherapy-induced nausea and vomiting

BACKGROUND

Despite the use of standardized anti-emetic guidelines, up to 20% of cancer patients suffer from moderate-to-severe chemotherapy-induced nausea and vomiting (cinv)-that is, grade 2 or greater according to the U.S. National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. We previously developed cycle-based prediction models and associated scoring systems for acute and delayed cinv. As part of the validation process, we prospectively evaluated the ability of the scoring systems to accurately identify patients deemed to be high risk for grade 2 or greater cinv.

METHODS

Patients who were receiving any chemotherapy for solid tumours and who consented to participate were provided with symptom diaries. Compliance to the diaries was enhanced by 24-hour and 5-day telephone callbacks after chemotherapy in every cycle. All patients received anti-emetic prophylaxis as prescribed by the treating physician. Before each cycle of chemotherapy, the acute and delayed cinv scoring systems were used to stratify patients into low- and high-risk groups. Logistic regression modelling was then applied to compare the risk for grade 2 or greater cinv between patients considered to be at high and at low risk. The external validity of each system was also assessed using an area under the receiver operating characteristic curve (auroc) analysis.

RESULTS

We collected cinv outcomes data from 95 patients during 181 cycles of chemotherapy. The incidence of grade 2 or greater acute and delayed cinv was 17.7% and 18.2% respectively. As previously identified, major predictors for grade 2 or greater cinv included younger patient age, platinum- or anthracycline-based chemotherapy, low alcohol consumption, earlier cycles of chemotherapy, previous history of morning sickness, and prior emetic episodes after chemotherapy. The acute and delayed scoring systems both had good predictive accuracy when applied to the external validation sample (acute-auroc: 0.69; 95% confidence interval: 0.59 to 0.79; delayed-auroc: 0.70; 95% confidence interval: 0.60 to 0.80). Patients identified by the scoring systems to be at high risk were 2.8 (p = 0.025) and 3.1 (p = 0.001) times more likely to develop grade 2 or greater acute and delayed cinv.

CONCLUSIONS

The present study demonstrates that our scoring systems are able to accurately identify patients at high risk for acute and delayed cinv. Application and planned continued refinement of the scoring systems will be an important means of patient-specific risk assessment that will allow for optimization of anti-emetic therapy.

HCV NS5A and IRF9 compete for CypA binding

BACKGROUND & AIMS

Cyclophilin A (CypA) is vital for HCV replication. Cyp inhibitors successfully decrease viral loads in HCV-infected patients. However, their mechanisms of action remain unknown. Since interferon (IFN) can also suppress HCV replication, we asked whether a link between CypA and the IFN response exists.

METHODS

We used cellular and recombinant pulldown approaches to investigate the possibility of a specific association of CypA with host ligands.

RESULTS

We found for the first time that CypA binds to a major component of the IFN response - the IFN regulatory factor 9 (IRF9). IRF9 is the DNA-binding component of the transcriptional IFN-stimulated gene factor 3 (ISGF3). CypA binds directly to IRF9 via its peptidyl-prolyl isomerase (PPIase) pocket. Cyp inhibitors such as cyclosporine A (CsA) or non-immunosuppressive derivates such as alisporivir and SCY-635, prevent IRF9-CypA complex formation. CypA binds to the C-terminal IRF-association-domain (IAD), but not to the DNA-binding or linker domains of IRF9. Remarkably, CypA associates with the multimeric ISGF3 complex. We also obtained evidence that CypA neutralization enhances IFN-induced transcription. Interestingly, the hepatitis C virus (HCV) non-structural 5A (NS5A) protein, which is known to modulate the IFN response, competes with IRF9 for CypA binding and can prevent the formation of IRF9-CypA complexes.

CONCLUSIONS

This study demonstrates for the first time that CypA binds specifically to a component of the Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway, IRF9. This study also reveals a novel opportunity of HCV to modulate the IFN response via NS5A.

Abstract P3-13-05: Evaluating efficacy of de-escalated bisphosphonate therapy in metastatic breast cancer patients at low-risk of skeletal related events. TRIUMPH: A pragmatic multicentre trial

Background: Optimal bisphosphonate (BP) dosing intervals for breast cancer patients (pts) with bone metastases (BM) remain unknown. BP are usually prescribed q3-4 wk regardless of individual pt risk for skeletal related events (SREs). Recent evidence (Amadori J Clin Oncol, 2012 suppl; abstr 9005) shows that q12 wk BP is as effective as q4 wk in pts previously treated with >9 cycles of q4 wk therapy. Hence, further evaluation of modified BP dosing strategies is warranted. The objective of the current study was to show in women with biochemically defined low-risk bone disease that IV BP use every q12 wk for 1 year is sufficient to maintain stability of the bone turnover [measured by serum c-telopeptide (CTx) or bone specific alkaline phosphatase (BSAP)].

Methods: Eligible pts with BM, who had received >3 months of q3-4 wk IV BP and no systemic treatment change within 4 wks of study entry were enrolled. Low risk was defined as serum CTx <600 ng/L. Biochemical failure was defined as CTx levels >600 ng/L at baseline, weeks 6, 12, 24, 36 or 48. Evaluation of palliative benefit of 12-wk IV BP therapy was measured by SREs, analgesic use, and self-reported pain (BPI and FACT-BP).

Results: Between Oct. 2010-Sept. 2011, 85 pts consented to screening, with 13 found ineligible. In the 71 accrued pts baseline characteristics were: mean age 60 (SD 13), median time from breast cancer diagnosis to development of bone metastases 4 months (IQR 82), median duration of prior BP therapy 14 months (IQR 19), and mean number of SREs/yr prior to entering study 0.35 (SD 0.76). Baseline median CTx was 120 ng/L (IQR 240) and BSAP 9.2 IU/L (IQR 3). To date: 26/71 pts (36%) remain on study. Reasons for coming off study include; study completion (18), elevation of CTx >600ng/L (10), or on study SRE (3). An elevation of CTx between baseline and wk 6 was significantly associated with coming off study early (p = 0.008). For pts who had had an SRE before study entry the odds ratios for coming off study early due to an on study SRE or elevated CTx was 1.005 (CI 1.002–1.009; p = 0.007) and for coming off early for an SRE was 0.0245 (CI 0.061–0.094; p = 0.046) respectively. Of the 8/13 pts who were ineligible due to baseline CTx >600ng/L, 6 had an SRE within 1 year of screening.

Conclusion: De-escalating BP therapy to 12 weekly in low risk pts has advantages for both the pt and the health care system. Individual risk of SREs is highly variable, however baseline serum CTx levels <600 ng/L is associated with a low risk of subsequent SREs. While larger trials are required to assess whether increasing CTx with de-escalated therapy will lead to higher rates of SREs or not (Coleman et al. J Clin Oncol 2012 suppl; abstr 511). However, the results of this study and Amadori et al. would suggest that de-escalated BP treatment will likely become a new standard of care after a limited period of q 4wk treatment.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-13-05.

Sequencing and phylogenetic characterisation of a fatal Crimean - Congo haemorrhagic fever case imported into the United Kingdom, October 2012

A patient with fever, and haemorrhagic symptoms was admitted to a hospital in Glasgow on 2 October 2012. Since he had returned from Afghanistan, serum samples were sent for diagnosis at the Rare and Imported Pathogens Laboratory, where a real-time reverse transcriptase-PCR diagnosis of Crimean – Congo haemorrhagic fever was made within 3 hrs after receipt of the sample. Hereafter the patient was transferred to a high-security infectious diseases unit in London but died on 6 October.

Sequencing and phylogenetic characterisation of a fatal Crimean – Congo haemorrhagic fever case imported into the United Kingdom, October 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Development of a flow cytometry live cell assay for the screening of inhibitors of hepatitis C virus (HCV) replication

In this study, we established a flow cytometry live cell-based assay that permits the screening of hepatitis C virus (HCV) inhibitors. Specifically, we created a stable cell line, which harbors a subgenomic replicon encoding an NS5A-YFP fusion protein. This system allows direct measurement of YFP fluorescence in live hepatoma cells in which the HCV replicon replicates. We demonstrated that this stable fluorescent system permits the rapid and sensitive quantification of HCV replication inhibition by direct-acting antiviral agents (DAA) including protease and NS5A inhibitors and host-targeting antiviral agents (HTA) including cyclophilin inhibitors. This flow cytometry-based live cell assay is well suited for multiple applications such as the evaluation of HCV replication as well as antiviral drug screening.

The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use

A standardised methodology for a combined point prevalence survey (PPS) on healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals developed by the European Centre for Disease Prevention and Control was piloted across Europe. Variables were collected at national, hospital and patient level in 66 hospitals from 23 countries. A patient-based and a unit-based protocol were available. Feasibility was assessed via national and hospital questionnaires. Of 19,888 surveyed patients, 7.1% had an HAI and 34.6% were receiving at least one antimicrobial agent. Prevalence results were highest in intensive care units, with 28.1% patients with HAI, and 61.4% patients with antimicrobial use. Pneumonia and other lower respiratory tract infections (2.0% of patients; 95% confidence interval (CI): 1.8–2.2%) represented the most common type (25.7%) of HAI. Surgical prophylaxis was the indication for 17.3% of used antimicrobials and exceeded one day in 60.7% of cases. Risk factors in the patient-based protocol were provided for 98% or more of the included patients and all were independently associated with both presence of HAI and receiving an antimicrobial agent. The patient-based protocol required more work than the unit-based protocol, but allowed collecting detailed data and analysis of risk factors for HAI and antimicrobial use.

Ribotyping in the detection of Clostridium difficile outbreaks in a single university hospital

Clostridium difficile infection (CDI) is the most important bacterial cause of hospital-acquired diarrhoea. Although reports of deaths associated with CDI have been decreasing since a peak in 2007 in England and Northern Ireland, it remains a major cause of morbidity and mortality. The Health Protection Agency's Clostridium difficile Ribotyping Network (CDRN) aims to provide information to help optimize the management of cases of CDI. This study assesses the value of ribotyping to detect outbreaks of potential strains causing severe disease.

Cyclophilin inhibitors: an emerging class of therapeutics for the treatment of chronic hepatitis C infection

The advent of the replicon system together with advances in cell culture have contributed significantly to our understanding of the function of virally-encoded structural and nonstructural proteins in the replication cycle of the hepatitis C virus. In addition, in vitro systems have been used to identify several host proteins whose expression is critical for supporting such diverse activities as viral entry, RNA replication, particle assembly, and the release of infectious virions. Among all known host proteins that participate in the HCV replication cycle, cyclophilins are unique because they constitute the only host target that has formed the basis of pharmaceutical drug discovery and drug development programs. The introduction of the nonimmunosuppressive cyclophilin inhibitors into clinical testing has confirmed the clinical utility of CsA-based inhibitors for the treatment of individuals with chronic hepatitis C infection and has yielded new insights into their mechanism(s) of action. This review describes the biochemical evidence for the potential roles played by cyclophilins in supporting HCV RNA replication and summarizes clinical trial results obtained with the first generation of nonimmunosuppressive cyclophilin inhibitors.

The cyclophilin inhibitor SCY-635 suppresses viral replication and induces endogenous interferons in patients with chronic HCV genotype 1 infection

BACKGROUND & AIMS

SCY-635 is a non-immunosuppressive analog of cyclosporin A that inhibits cyclophilins A and B and hepatitis C virus (HCV) replication in vitro. In a phase 1b multi-dose escalation study, we evaluated the safety, plasma pharmacokinetics, and antiviral activity of 15 days of monotherapy with SCY-635 in adults with chronic genotype 1 HCV infection.

METHODS

Twenty adults with chronic HCV genotype 1 were randomized to SCY-635 oral doses of 100, 200, or 300 mg three times daily for 15 days.

RESULTS

No dose-limiting clinical or laboratory toxicities were identified. On day 15, the mean decline in plasma viremia was 2.24±1.74 log(10) IU/ml with SCY-635 900 mg/d. Individual antiviral responses correlated with host IL28B genotype. Post hoc analyses indicated treatment with SCY-635 increased plasma protein concentrations of interferon α (IFNα), IFNs λ(1) and λ(3), and 2'5' oligoadenylate synthetase 1 (2'5'OAS-1), with the greatest increases in IL28B CC and CT subjects. Changes in plasma concentrations for all markers were coincident with changes in the plasma concentration of SCY-635. Peaks of IFNs α, λ(1), and λ(3) and 2'5'OAS-1 were observed within 2 h after drug administration. In replicon cells, SCY-635 enhanced secretion of type I and type III IFNs and increased the expression of IFN-stimulated genes (ISG).

CONCLUSIONS

These studies establish clinical proof of concept for SCY-635 as a novel antiviral agent and suggest that restoration of the host innate immune response to chronic hepatitis C infection may represent a major mechanism through which cyclophilin inhibitors exert clinical antiviral activity.

Fatal ALK-negative systemic anaplastic large cell lymphoma presenting with disseminated cutaneous dome-shaped papules and nodules

Anaplastic large cell lymphoma (ALCL) is classified as a CD30 positive non-Hodgkin lymphoma. Systemic ALCL (S-ALCL) is further subdivided into two subgroups based on anaplastic lymphoma kinase (ALK) expression. In systemic ALCL, positive ALK expression correlates with a favorable prognosis, whereas negative ALK expression correlates with poorer overall survival. By definition, primary cutaneous ALCL (cut-ALCL) is limited to the skin and is uniformly ALK-negative. Cut-ALCL closely resembles LyP with regards to its benign clinical course and CD30 positivity. We describe a unique case of ALK-negative (ALK-) S-ALCL presenting with cutaneous disseminated dome-shaped papules.

P4-15-01: High Prevalence of Prospective Memory (PM) Impairment in Early Breast Cancer (EBC) Survivors within 1 Year of Adjuvant Chemotherapy Completion: Novel Findings Concerning Post Chemotherapy Cognitive Effects

Background Numerous studies have demonstrated that EBC survivors report more memory problems than healthy controls. However, evidence of impairment on objective tests of memory remains inconclusive. Past research has focussed exclusively on retrospective memory (remembering information from the past when asked to do so), but the complaints of EBC patients appear better described as “prospective memory” failures defined as forgetting to carry out in the future previously formed intentions. The effective performance of many day-to-day activities relies on PM and its impairment has negative consequences in everyday life. Despite its high ecological relevance, no study has evaluated PM functioning in EBC survivors. Consequently, we assessed the prevalence of PM impairment among EBC survivors in the year following completion of chemotherapy. Methods We undertook a cross sectional quantitative case-control study aiming to recruit 80 patients from the Ottawa Hospital Regional Cancer Centre and 80 matched healthy controls from the community. Patients were within 1 year of having completed a first course of chemotherapy. A standardized test of prospective memory (Memory for Intention Screening Test) was administered to both groups. Following the International Cognition and Cancer Task Force recommendation (2008), impairment was defined as a score that fell one standard deviation below the mean performance of the control group. Standardized measures of depression (CESD), anxiety (STAI) and fatigue (Fact-F) were also completed. Results Data are available on 36 patients and 18 controls. Age was well balanced between the groups (case-control mean age 54y vs. 51y, respectively, p=.204). Overall PM impairment was observed in 41% of the participants. More importantly, the rate of PM impairment was significantly higher in the EBC group than controls (53% vs 17%; p < 0.005; odds ratio = 5.588; 95% CI=1.376 to 22.7). Multivariate logistic regression showed that PM performance was unaffected by age (p=0.459), depression (p=0.358), anxiety (p=0.512) or fatigue (p=0.595). Conclusions These preliminary findings provide further support for the hypothesis that breast cancer treatment can impair cognitive processes and yield new and important insights into the type of memory problems experienced by EBC survivors. They suggest that a significant proportion of patients exhibit deficits in PM, an aspect of memory involved in effective daily functioning. Our results also suggest that emotional distress and fatigue do not contribute to PM functioning. Further studies in this area should be directed at understanding the severity and duration of PM impairment. Acknowledging and studying this vexing problem in EBC survivors will aid in developing appropriate rehabilitation strategies.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-01.

OT1-01-02: A Multicentre Study Assessing 12-Weekly Intravenous Bisphosphonate Therapy in Women with Low Risk Bone Metastases from Breast Cancer – The TRIUMPH Trial

Background: Metastatic bone disease is a major cause of morbidity and mortality for breast cancer patients. Bisphosphonates (BP) have been shown to significantly delay the onset and frequency of skeletal related events (SREs), improve pain control and overall quality of life. Most patients receive intravenous BP every 3–4 weeks regardless of their individual risk for a SRE. This “one size fits all” strategy could expose those patients at a relatively low risk of SREs to an increased chance of adverse drug effects, as well as to the financial and quality of life burden of multiple visits to the cancer centre for treatments. This study aimed to assess whether IV BP can be safely given at reduced frequency.

Methods: The primary objective of this study is to demonstrate in women with biochemically defined low-risk bone metastases that the administration of IV BP every 12 weeks is sufficient to maintain biochemical stability for one year. Eligibility criteria include; bone metastases from breast cancer, have received at least three months of regular 3–4 weekly IV BP, satisfactory renal function, adequate dental health, no systemic treatment change or recent SRE within 4 weeks of study entry. Low risk disease will be defined as serum CTx levels <600 ng/L Biochemical failure is defined as CTx levels >600 ng/L measured at predefined time points (6, 12, 24, 36 and 48th). Secondary objectives are to evaluate the palliative benefit of 12-weekly IV BP therapy as reflected by occurrence of SREs, analgesic use, self-reported pain using the validated BP and FACT-BP questionnaires. Sample size was calculated at 68 patients. Given the small sample size, nonparametric Bootstrapping will be employed to calculate point estimates, standard deviations and 95% confidence intervals (CIs). An exploratory multivariable analysis will also be undertaken to determine baseline factors that were associated with patient's maintaining their telopeptide levels in the low risk range. Conclusion: TRIUMPH opened in October 2010 and as of June 2011, has quickly accrued 54/68 patients (79%). This trial has the potential to allow lower risk women to receive less frequent dosing of bisphosphonates, thus improving their quality of life with less cancer center visits and reducing their chance of drug induced adverse events.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-01-02.

Panton-Valentine leukocidin associated staphylococcal disease: a cross-sectional study at a London hospital, England

Recently, there has been international concern at the rapid emergence of highly pathogenic strains of Staphylococcus aureus associated with a toxin called Panton-Valentine leukocidin (PVL). In the UK, these strains are considered to be rare and mainly severe. We estimate the proportion of staphylococcal infections that are caused by strains containing the PVL genes, and describe risk factors for these infections. Three hundred and ninety consecutive S. aureus clinical isolates, submitted for routine diagnostic purposes were screened for PVL genes. Risk factors for infection were identified from the patient medical record. 9.7% (95% CI 7.0-13.1%) of clinical isolates and 20.8% of skin and soft tissue specimens contained the genes for PVL. Methicillin-resistant S. aureus with PVL was rare (0.8% of all isolates) but PVL with methicillin-sensitive S. aureus was common (9.0% of all specimens). PVL infection was more frequent in males (OR 3.0, 95% CI 1.3-7.0), and in young adults aged 20-39 years (OR 3.7, 95% CI 1.3-10.4). Over half of PVL positive S. aureus infections originated in patients based in the community. Community-onset PVL-associated disease is common in the UK and mainly causes skin and soft tissue infections that do not require admission to hospital. Consideration should be given to current infection control strategy, which advocates household contact screening and decolonization on the assumption that PVL-associated disease is rare.

Campylobacter jejuni cellulitis in a patient with pan-hypogammaglobulinaemia

The case of a 17-year-old male with recurrent episodes of cellulitis affecting his left shin is presented. The cellulitis had been present on an intermittent basis over an 18-month period despite several courses of both intravenous and oral antibiotics. Each course of antibiotics resulted in a temporary remission, but on four occasions the cellulitis then relapsed. The patient was known to have pan-hypogammaglobulinaemia and was receiving intravenous IgG replacement therapy every 3 weeks. Other than cellulitis, he remained generally well. The organism responsible for the cellulitis was unknown until Campylobacter jejuni was grown in blood cultures during one of the relapse episodes. Based on microbial sensitivity, the patient was treated with ciprofloxacin. This resulted in full resolution of the cellulitis and he remains well. This case illustrates the value of blood cultures in helping microbial identification, particularly in immunocompromised patients with atypical infections.

Cyclophilin inhibitors for the treatment of HCV infection

Cyclophilins (Cyps) constitute one of the three families of peptidyl prolyl isomerase enzymes. CypA is the prototypical member of the Cyp family and is the predominant Cyp expressed in human cells. Recent studies indicate that CypA has an essential role in supporting HCV-specific RNA replication and protein expression. CypA interacts with several virally expressed proteins, including the non-structural (NS) proteins NS2, NS5A and NS5B, and may regulate diverse activities ranging from polypeptide processing to viral assembly. The introduction of non-immunosuppressive Cyp inhibitors into clinical trials confirms that Cyp inhibition is a valid strategy for developing novel therapeutics for the treatment of chronic HCV infection. This review describes the cyclophilin protein family and the potential roles played by cyclophilins in supporting HCV RNA replication and protein expression, as well as the initial clinical results obtained with a novel series of non-immunosuppressive cyclophilin inhibitors that established the clinical proof of concept for this emerging class of therapeutic agents.