High-dose silibinin rescue treatment for HCV-infected patients showing suboptimal virologic response to standard combination therapy

Incomplete suppression of hepatitis C virus (HCV) replication with persistence of minimal viremia (partial virologic response) leading to treatment failure can be observed in a significant proportion of HCV type 1-infected patients during antiviral therapy. Recently, high-dose intravenous silibinin has demonstrated strong antiviral activity against HCV. We were therefore interested in whether patients with partial virologic response can be rescued by the on-treatment addition of a short-term course of high-dose intravenous silibinin infusions. Twenty patients who failed to achieve a complete virologic response to different interferon-based regimens qualified for the rescue strategy and received 1400 mg/day silibinin infusions on two consecutive days. Complete viral suppression (below the limit of detection <6 IU/mL, TMA assay) could be induced in 13 of 20 patients within the first week after the short-term silibinin infusion, and all but one of them also remained HCV RNA negative during the subsequent follow-up period on continued peginterferon plus ribavirin treatment. In the remaining seven patients, no complete suppression could be achieved although four showed a significant HCV RNA reduction in response to silibinin. Silibinin infusions were generally well tolerated, and activation of abdominal peristalsis with nausea, diarrhoea and vomiting were the most prominent side effects. Of the twelve patients who exhibited a durable response to peginterferon and ribavirin treatment, three achieved an SVR, two achieved a week 12 SVR and four suffered a viral relapse. Three patients could not complete the assigned antiviral treatment with peginterferon alpha and ribavirin for nonvirological reasons. Short-term administration of high-dose intravenous silibinin might be an interesting approach to rescue patients with ongoing minimal residual viremia while on interferon-based therapy. These preliminary findings may stimulate further studies to evaluate more refined therapeutic strategies.

[Cyclic vomiting syndrome (CVS) in adults - frequently overlooked?]

CVS (cyclic vomiting syndrome) is a functional disorder that can occur in all age groups. Adults typically develop CVS in middle age (around the 35th year of life). CVS is characterised by recurrent stereotypic episodes of nausea and vomiting lasting hours or some days. Between these episodes there are intervals free of symptoms. The main symptoms include nausea, vomiting and often abdominal pain. CVS is a rare disorder in adult patients. Because of the lack of awarness, making the correct diagnosis is not easy und often delayed for some months or years. There is no specific test to secure the diagnosis. The accurate diagnosis is based on the typical anamnestic report and the exclusion of other disorders associated with a recurrent vomiting. No standard evidence-based treatment is currently available either to manage the acute vomiting episode or to manage the prophylactic therapy. For the acute treatment of the vomiting episodes antiemetic, antimigraine and sedative medications were used. The medications frequently used for the prophylactic therapy are amitriptyline and propranolol.

P1-01-16: Detecting a Breast Carcinoma-Deriving B-Cell Response: An Immunoproteomics Biomarker Approach

Background: Noninvasive biomarkers for the early detection of breast cancer are crucial due to the fact that the relapse risk of breast cancer is rising with the time point of its detection. Currently, none of the reported molecular biomarkers is established for the clinical use as a diagnostic tool. Previous proteomics-based studies showed the immunogenicity of breast carcinoma and the following B-cell mediated immune response. As a result, several autoantibodies against tumor proteins were detected in the sera of breast cancer patients. However, these putative biomarkers are still lacking of clinically reliable specificity and sensitivity, even of better discrimination of cancer patients when combining different biomarkers. The search for a new antibody biomarker signature remains very important as a potential cancer detection tool. For further investigations we analyzed the antibody pattern in serum samples of diseased patients and healthy controls after incubation with whole protein extract from a native carcinoma and identified the putative tumor-specific immunoreactive antigens.

Materials and methods: For our de novo profiling of tumor antigens we used a protein extract from a primary invasive ductal carcinoma. Sera from 20 women, of which 19 were diagnosed with breast carcinoma and one with DCIS (CA), and 20 sera from age-matched healthy donors (CTRL) were obtained and pooled separately. For an optimal separation of tumor antigens a two-dimensional sodium dodecylsulfate gel electrophoresis (2D SDS-PAGE) was applied. Following immunoblots with each serum pool were performed and the immunospecific reactions visualized with a horseradish peroxidase-conjugated anti-IgG antibody. The relevant tumor antigens were identified via Matrix-Assisted Laser Desorption Ionization Time of Flight Mass Spectrometry (MALDI TOF-TOF MS).

Results: After the incubation of each serum pool with tumor antigens we obtained different extensive antibody profiles, whereas the visualized immunoreactive components varied in the signal intensity. We identified over 10 tumor antigens which reacted with the corresponding autoantibodies in CA or CTRL approach, showing again the complexity of immune response. Besides of already described breast carcinoma related antigens like alpha enolase, which showed immune reaction also with the healthy serum pool, we identified several potential antigens of interest like peroxiredoxin 6 which showed a strong immune response only after the incubation with cancer sera.

Discussion: In our study we visualized a complex immune response pattern showing the autoantibody profiles in cancer and healthy sera against tumor-deriving antigens. Also some of identified breast carcinoma antigens were already described; other novel breast carcinoma-related antigens were detected too. Our next step in the intriguing search for cancer antibody biomarkers is the individual screening of sera to confirm the specificity of the tumor-deriving B-cell responses and the validation of these results by using an independent study population.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-01-16.

[Severe airway distress following cervical spine operation: retrospective breakdown of the chain of errors]

A 71-year-old female patient received a prothesis due to a cervical disc prolapsed and bleeding into the collar soft tissues occurred postoperatively. Following a computed tomography examination severe peracute respiratory decompensation occurred while administering topical anesthesia to the pharynx in order to perform fiber optic intubation. Endotracheal intubation using conventional laryngoscopy was unsuccessful and the patient required immediate cricothyroidotomy. As an on-site cricothyrotomy set to establish a secure airway was not available the decision was taken to perform surgical cricothyroidotomy. As a conclusion to this life-threatening event in the case of symptoms, such as dyspnea, dysphonia and dysphagia after operations of the cervical spine the airway has to be secured early and according to the local algorithm.

[A systematic analysis of the compression pressure in the compression therapy for scars in childhood with the help of the Kikuhime® pressure device]

INTRODUCTION

Burns and scalds are among the most common trauma in childhood and more often than not lead to hypertrophic scarring. Compression therapy is one of the main concepts in the prophylaxis and therapy for hypertrophic scars. However, the mode of action and the optimal pressure are still unknown. In this study, we evaluated the possibility of measuring the pressure under compression garments with a simple pressure measuring device.

METHODS

The pressure under the compression garments was measured with the Kikuhime®-Subbandage & Body Pressure Measuring Device.

RESULTS

(1) Patient's age or sex did not make any significant difference. (2) Mean detected pressure was 25.7 mmHg. (3) The mean pressure was as follows: upper limb: 27 mmHg, lower limb: 30 mmHg, thorax: 19 mmHg, abdomen: 21 mmHg, neck: 19 mmHg and face: 16 mmHg. (4) Long-term results showed a clear decrease in pressure (12.15 %) during a period of 8 weeks. (5) A compression that was incorrectly fitted or incorrectly measured led to significantly worse results.

CONCLUSION

Compression garments used in the therapy for hypertrophic scars must be individually fitted in order to guarantee a sufficient pressure of on average 26 mmHg. Incorrectly measured compression garments lead to the development of highly hypertrophic scars. Our results also showed that compression garments must be changed regularly because of the natural loss of pressure. Only an individual compression therapy can guarantee perfect cosmetic as well as surgical results.

Phase I study of the combination of everolimus (RAD001) with 5FU/LV in patients with refractory solid malignancies

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Background: mTOR is a controller of cellular growth and other processes that is activated by several oncogenic pathways in cancer. Everolimus is an oral inhibitor of mTOR activation. The mTOR inhibitor, temsirolimus, when combined with high dose 5FU, was limited by significant mucosal toxicity. Purpose: Phase I study to determine the maximum tolerated doses (MTD) and the safety of everolimus combined with 5FU/LV in patients with refractory solid tumors.

Methods: Using a standard 3+3 design, starting doses were everolimus 15mg weekly, and q2 weekly 5FU 400mg/m2 bolus and 1800mg/m2 infusion (over 46 hours) and LV 400mg/m2. Daily dosing of everolimus was instituted during level 3 as data emerged about improved target inhibition and adverse event profile with daily dosing. Dose escalation to the maximum planned levels was achieved: everolimus 10mg daily, 5FU 400mg/m2 bolus and 2400mg/m2 infusion, and LV 400mg/m2. Dose limiting toxicities (DLT) were assessed in cycle 1 (4 weeks), defined as any grade 3/4 non-hematologic toxicity (except grade 3 skin rash, nausea and diarrhea), or complicated grade 3-4 heme toxicity. Tumors were measured every 8 weeks.

Results: From 03/2008 and 11/2009, 21 patients were treated. Median age 58 (range 35-77), male/female 13/8, PS 0/1 10/11. One DLT was seen at dose level 1 (grade 3 hypersensitivity/angioedema); two at dose level 6 (grade 3 diarrhea, grade 3 hypophosphatemia). As such, dose level 5 is the MTD. Dose reductions were required in 4 patients for mouth sores (2), nasal sores (1), and grade 3 transaminitis (1). Responses are as follows: 11 stable disease and 8 progressive disease; 2 patients were not evaluable.

Conclusions: MTD is everolimus 5mg daily, with q2 weekly 5FU 400mg/m2 bolus and 2400mg/m2 infusion and LV 400mg/m2. We are currently expanding the study to evaluate the addition of oxaliplatin and panitumumab to the 5-FU/LV and everolimus base.

[Table: see text]

[Table: see text]

The role of elicited responding in behavioral contrast

An attempt was made to separate operant and elicited pecks occurring in multiple schedules of food reinforcement by moving the component stimuli to a second key, upon which pecks had no effect. The operant key stimulus was constant, regardless of the reinforcement schedule in effect. Experiments included two- and three-component multiple schedules and a comparison of the single-key and the two-key procedures. In general, conditions that typically produce positive contrast in single-key procedures reduced responding to the constant-stimulus key (induction) and increased responding to the component-stimulus key (contrast) in the two-key procedure. The results were interpreted as supporting the contention that two response classes, operant and elicited, are present in standard multiple schedules. In addition, elicited responses were strongly implicated in contrast phenomena.

The stages of acquisition in stimulus fading

Pigeons were exposed to a stimulus fading procedure in which control of responding was transferred from red and black stimuli to lines of different angular orientation. After superimposing one line on the red stimulus and the other line on the black stimulus, the intensity of the lines was gradually increased and that of the red stimulus was gradually reduced. Probes consisting of red and line stimuli presented separately were used during the course of fading to assess control exerted by each element of the compound. As the lines were faded in, they did not acquire control of responding. As red was faded out, control of responding was acquired first by the lower intensity red stimuli in combination with the line stimulus, and finally by the angular orientation of the lines. Probes also determined the point at which the line stimuli, presented alone, would maintain a high degree of stimulus control. The results demonstrated that new stimuli in fading acquire dimensional control of responding in two sequential stages. Acquisition of stimulus control in fading was explained in terms of attenuation of stimulus blocking.

Der Einfluss des Kuhgewichts auf die Betriebsrentabilität und auf die ökonomischen Gewichte der Fleischrindmerkmale

Abstract. Title of paper: Impact of mature cow weight on farm profitability and economic weights of beef cattle traits The impact of mature cow weight on the profitability of beef cattle farming and on the economic importance of 10 performance and functional traits was analyzed. The examined traits were: calving performance, stillbirth and calf losses till weaning, weight of calves at birth, at 120 and at 205 days of age, mature weight of cows, conception rates of heifers and cows and productive lifetime of cows. The cow weight was varied from 500 to 700 kg in 50 kg intervals. The economic efficiency of all farming systems was expressed as profit per cow and year. The economic importance of a trait (marginal economic value) was defined as partial derivative of the profit function with respect to trait mean. The program package ECOWEIGHT was used for all calculations. The results showed that beef cattle farming with all cow weight classes could be profitable when including subsidies in the incomes of a farm. Without subsidies, a positive profitability can be reached only when keeping small-framed cows (500 to 550 kg). In all modelled production systems, the most important trait was conception rate of cows followed by weaning weight of calves (at 205 days of age) for light cows or productive lifetime of cows in systems with heavy cows.

Use of surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI-TOF-MS) to detect breast cancer markers in serum

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Background: Breast cancer is one of the most frequent and deadly cancers worldwide. Although the survival of patients has increased over the last decades, many patients die from metastatic relapse. Progresses in screening or early diagnosis will improve survival of breast cancer. Breast cancer has never had any good serum tumor markers. Therefore, we developed and evaluated a proteomics approach to search for new biomarkers in serum of breast cancer patients. Methods: Blood samples of 50 women with breast cancer (CA) and 50 healthy women (CTRL), matched to the age, were drawn prior to surgery. We used SELDI-TOF-MS for protein profiling with three different active surfaces of the protein chips: cationic exchanger (CM-10), hydrophobic surface (H50) and a strong anion exchange surface (Q10) with different binding properties. Data were analyzed by multivariate statistical techniques and artificial neural networks. Results: SELDI-TOF- MS could discriminate between serum of breast cancer patients and healthy women. We could generate a statistic significant (p<0.001) panel with 15 biomarkers resulting of multiple peaks with different molecular weights. The diagnostic pattern could differentiate CA from CRTL with specificity of 77% and sensitivity of 85% in serum. Conclusions: In this study we could exemplify SELDI-TOF-MS as a potential screening method to detect breast cancer patients by serum analysis. The protein chip technology could greatly facilitate the discovery of new and better biomarkers in breast cancer patients. This promising approach provides a high sensitivity and specificity by a less invasive method similar to mammography that is used in screening programs.

No significant financial relationships to disclose.

Preliminary results of a phase I trial of sorafenib combined with cisplatin/etoposide (CE) or carboplatin/pemetrexed (CbP) in solid tumor patients (pts)

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Background: Sorafenib had demonstrated single agent activity in non-small cell and small cell lung cancer. Methods: A non-comparative, two arm phase I trial escalating sorafenib in combination with fixed doses of CE or CbP was performed. A 3-patient cohort design was utilized to determine the maximum tolerated dose (MTD) and dose limiting toxicities (DLT). Dose level 0 for all pts was a sorafenib dose of 200 mg po BID continuously. Pts on arm A received C (60 mg/m2) on day 1 and E 120 mg/m2 on days 1,2,3 every 3 weeks with escalating doses of sorafenib. On arm B, pts received treatment with Cb (AUC=6) and P 500 mg/m2 every 3 weeks with escalating doses of sorafenib. However, excessive toxicity was observed on arm B, therefore the trial was amended such that Cb dose was lowered to AUC=5 (arm C). DLT were assessed in the 1st cycle and defined as grade (gr.) 4 anemia or thrombocytopenia, gr. 4 neutropenia lasting > 7 days, gr. ≥ 3 non-hematologic toxicity (except nausea, vomiting, and alopecia) and > 2 week dose delay. Response was assessed every 2 cycles according to RECIST, and best response was recorded. Results: Between 9/2007 and 9/2008, 20 pts were treated on the trial; median age 62 (range 47–73), male/female: 12/8, PS of 0/1: 6/14, and median number of prior therapies 2 (range 1–4). The most common tumor types were NSCLC (n=8), SCLC (n=4) and head/neck (n=2). At dose level 0 arm A (200 mg BID), 2 of 4 patients experienced DLT (gr.4 thrombocytopenia, gr.3 fatigue, febrile neutropenia and gr.4 neutropenia for > 7 days, gr.3 febrile neutropenia, diarrhea, hypokalemia, hyponatremia); 2 pts have been enrolled at dose level -1 (200 mg po QD) without DLT. Two of 3 patients enrolled on arm B at dose level 0 had gr.4 thrombocytopenia. On arm C at dose level 0 (200 mg po BID), 1/6 pts experienced DLT (gr.3 hyponatremia, dehydration, hypoglycemia). Enrollment continued at dose level 1 (400 mg po BID), but 2/5 pts experienced a DLT (both gr. 3 fatigue/anorexia). Responses observed were: PR (n=3) (all arm C), and SD (n=6). Conclusions: The MTD of sorafenib in combination with carboplatin (AUC=5) and pemetrexed 500 mg every 3 weeks is 200 mg po BID. The MTD of sorafenib in combination with cisplatin/etoposide has yet to be determined and is currently accruing at dose level -1.

[Table: see text]