The state of research into children with cancer across Europe: new policies for a new decade

Overcoming childhood cancers is critically dependent on the state of research. Understanding how, with whom and what the research community is doing with childhood cancers is essential for ensuring the evidence-based policies at national and European level to support children, their families and researchers. As part of the European Union funded EUROCANCERCOMS project to study and integrate cancer communications across Europe, we have carried out new research into the state of research in childhood cancers. We are very grateful for all the support we have received from colleagues in the European paediatric oncology community, and in particular from Edel Fitzgerald and Samira Essiaf from the SIOP Europe office. This report and the evidence-based policies that arise from it come at a important junction for Europe and its Member States. They provide a timely reminder that research into childhood cancers is critical and needs sustainable long-term support.

Abstract P4-02-19: A Phase II Study of Adding the Multikinase Inhibitor Sorafenib to Existing Endocrine Therapy in Patients with Metastatic Estrogen Receptor Positive Breast Cancer

Background: Endocrine therapy for metastatic estrogen receptor (ER) positive breast cancer is effective and relatively nontoxic, but resistance eventually develops in all patients. Preclinical data suggest that growth factor signaling and angiogenesis may promote endocrine resistance and blocking such pathways may restore endocrine sensitivity and delay resistance.

Methods: We conducted a phase II trial of administering sorafenib, which inhibits VEGFR and Ras/Raf/MAPK, to patients with metastatic ER-positive breast cancer after at least 3 months of antiestrogen use. Patients were required to have either stable disease or progressive non-visceral metastasis. Measurable disease was required. Sorafenib 400 mg BID was administered along with the same antiestrogen patients were already taking. A core biopsy of accessible disease was offered at entry and after 28 days of sorafenib. Serum was collected on day 1 and day 28 for VEGF, VEGFR, and VEGFR2 analysis. Primary endpoint was response rate by RECIST criteria after 3 months of sorafenib. Secondary endpoints were safety, time to progression (TTP), and biomarker assessment. Planned sample size was 43 but the study closed after 11 patients because of slow accrual.

Results: Median age at entry was 45 years (Range 39-72). 7 patients were on tamoxifen, 3 on an aromatase inhibitor, and 1 on fulvestrant. Of the 11 patients enrolled, 8 had progressive disease (PD) on entry and 3 had confirmed stable disease (SD). One patient with SD at entry discontinued sorafenib after 2 weeks because of a grade 3 rash. Of the 10 patients evaluable for response, 7 had SD (70%) and 3 had PD. Two of the SD patients had minor responses, but no partial responses were seen. Median TTP after adding sorafenib was 182 days (6 months). Of the 8 patients who entered the study with progressive disease, 5 converted to stable disease (62%) with a median TTP of 136 days (4.5 months). There was a significant reduction in mean serum VEGFR2 on day 28 (P 0.0035) with borderline significant reduction of VEGFR (P 0.08). In the 7 patients with SD as best response, mean VEGFR and VEGFR2 levels were significantly reduced (P 0.016 and 0.038, respectively). There was no significant change in serum VEGF in any of the groups tested. Most common adverse events were rash in 9 patients, weight loss in 8, and hypertension in 6. Most common laboratory abnormalities were hypophosphatemia in 11 patients, hypokalemia in 9, and elevated ALT/AST in 4. The majority of toxicities were grade 1. There were 5 grade 3 toxicities; rash, anorexia, hypokalemia, and 2 hypophosphatemia. No grade 4 toxicities occurred. Overall, treatment was well tolerated and all toxicities were reversible upon sorafenib discontinuation. Tissue biomarkers including 4 paired biopsies will be examined.

Conclusions: Sorafenib may prolong antiestrogen benefit in patients with metastatic ERpositive breast cancer and in particular can restore endocrine sensitivity in patients with disease progression on such therapy. Clinical trials that target endocrine resistance remain critical for understanding mechanisms of resistance and can help preserve patient quality of life by avoiding the early use of more toxic treatments.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-02-19.

Influenza and meningococcal vaccinations are effective in healthy subjects treated with the interleukin-1 beta-blocking antibody canakinumab: results of an open-label, parallel group, randomized, single-center study

The objective of this study was to evaluate the efficacy of influenza and meningococcal vaccines in healthy subjects exposed to the anti-interleukin-1β (anti-IL-1β) monoclonal antibody canakinumab. This was an open-label, parallel group, randomized, single-center study of healthy subjects (aged 18 to 45 years). At baseline, antibody (Ab) titers were measured and subjects were randomized (1:1) to a single 300-mg canakinumab dose administered subcutaneously (s.c.) or received no treatment (control group). After 2 weeks, subjects were treated with inactivated, unadjuvanted influenza and conjugated group C meningococcal (MenC) vaccines, administered intramuscularly (i.m.). The primary efficacy variable was the response (≥ 2-fold increase in Ab titer in ≥ 2 of 3 influenza virus strains) after 4 weeks in subjects treated with canakinumab compared to the control group. Secondary efficacy variables were the antibody response to vaccines at different thresholds and time points. Fifty-one of 112 subjects screened were randomized to canakinumab (n = 25) or the control group (n = 26). Antibody responses to vaccinations measured against different influenza virus strains and one MenC strain at 4 weeks were comparable in the canakinumab and control groups. The primary efficacy variable, the response to influenza vaccination (≥ 2-fold increase in Ab titer in ≥ 2 of 3 serotypes) at 4 weeks, was shown in 24/25 subjects in the canakinumab group compared to 25/25 subjects in the control group. Antibody responses remained comparable in the two groups at the different time points assessed. Headache was the most frequently reported adverse event. No deaths or serious adverse events were reported during the study. We concluded that a single dose of 300 mg canakinumab s.c. does not affect the induction or persistence of antibody responses after vaccination with unadjuvanted influenza or alum-adjuvanted MenC vaccines in healthy subjects.

Relationship between coronary microvascular dysfunction and cardiac energetics impairment in type 1 diabetes mellitus

BACKGROUND

Asymptomatic subjects with diabetes mellitus have an impaired cardiac energetics status that may play a significant role in the development of heart failure. In the present study, we assessed the role of microvascular dysfunction in the development of impaired cardiac energetics in subjects with type 1 diabetes mellitus.

METHODS AND RESULTS

Twenty-five asymptomatic subjects with type 1 diabetes mellitus (mean age +/-1 SD 33+/-8 years) and 26 age-, sex-, and body mass index-matched healthy control subjects (32+/-8 years old) were recruited into the study. The type 1 diabetes mellitus subjects were divided into 2 age-matched groups (newly diagnosed [<5 years] and longer-duration [>10 years] diabetes) to assess the impact of microvascular disease. All subjects had an echocardiogram and an exercise ECG performed, followed by magnetic resonance spectroscopy and stress magnetic resonance imaging. Compared with healthy control subjects, the phosphocreatine/gamma-ATP ratio was reduced significantly both in subjects with longer-term (2.1+/-0.5 versus 1.5+/-0.4, P<0.000) and newly diagnosed (2.1+/-0.5 versus 1.6+/-0.2, P<0.000) diabetes. The phosphocreatine/gamma-ATP ratio was similar in newly diagnosed diabetes subjects and those with longer-term disease (1.6+/-0.2 versus 1.5+/-0.4, P=0.32). The mean myocardial perfusion reserve index in the longer-term type 1 diabetes mellitus subjects was significantly lower than in healthy control subjects (1.7+/-0.6 versus 2.3+/-0.4, P=0.005). On univariate analysis, there was no significant correlation of phosphocreatine/gamma-ATP ratio with myocardial perfusion reserve index (r=0.21, P=0.26).

CONCLUSIONS

We demonstrate that young subjects with uncomplicated type 1 diabetes mellitus have impaired myocardial energetics irrespective of the duration of diabetes and that the impaired cardiac energetics status is independent of coronary microvascular function. We postulate that impairment of cardiac energetics in these subjects primarily results from metabolic dysfunction rather than microvascular impairment.

Towards the selection of chickens resistant to Salmonella and Campylobacter infections

Resistance to infection with enteric pathogens such as Salmonella and Campylobacter can be at many levels and include both non-immune and immune mechanisms. Immune resistance mechanisms can be specific, at the level of the adaptive immune response, or non-specific, at the level of the innate immune response. Whilst we can extrapolate to some degree in birds from what is known about immune responses to these pathogens in mammals, chickens are not "feathered mice", but have a different repertoire of genes, molecules, cells and organs involved in their immune response compared to mammals. Fundamental work on the chicken's immune response to enteric pathogens is therefore still required. Our studies focus particularly on the innate immune response, as responses of heterophils (the avian neutrophil equivalent) from commercial birds, and macrophages from inbred lines of chickens, correlate with resistance or susceptibility to Salmonella infection with a variety of Salmonella serovars and infection models. We work on two basic resistance mechanisms - resistance to colonization with Salmonella or Campylobacter, and resistance to systemic salmonellosis (or fowl typhoid). To map genes involved in resistance to colonization with Salmonella and Campylobacter, we are using a combination of expression quantitative trait loci (eQTLs) from microarray studies, allied with whole genome SNP arrays (WGA), a candidate gene approach and analysis of copy number variation across the genome. For resistance to systemic salmonellosis, we have refined the location ofa novel resistance locus on Chromosome 5, designated SAL1, using high density SNP panels, combined with advanced back-crossing of resistant and susceptible lines. Using a 6th generation backcross mapping population we have confirmed and refined the SAL1 locus to 8-00 kb of Chromosome 5. This region spans 14 genes, including two very striking functional candidates; CD27-binding protein (Siva) and the RAC-alpha serine/threonine protein kinase homologue, AKT1.

A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 microg clonidine and 9 ml 0.9% saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P < 0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.

Morphological localisation of sulfonylurea receptor 1 in endocrine cells of human, mouse and rat pancreas

AIMS/HYPOTHESIS

Sulfonylurea receptor 1 (SUR1) is the regulatory subunit of ATP-sensitive K channels in beta cells. Morphological methods (immunohistochemistry and sulfonylurea binding) were used to establish the cellular and subcellular location of SUR1 in human and rodent islets.

RESULTS

In the human, mouse and rat pancreas, all endocrine cells of the islets were immunolabelled with an anti-SUR1 antibody, whereas tissues containing SUR2 were consistently negative, as were those from Sur1 (also known as Abcc8)(-/-) mice. In beta cells of the three species, the plasma membrane was distinctly stained, but SUR1 was mainly present over the cytoplasm, with an intensity that varied between cells. Electron microscopy showed that SUR1 was immunolocalised in insulin, glucagon and somatostatin granules. In rat beta cells degranulated by in vivo treatment with glibenclamide (known as glyburide in the USA and Canada), the insulin and SUR1 staining intensity was similarly decreased by approximately 45%, whereas SUR1 staining was not changed in non-beta cells. In all islet cells, binding of glibenclamide labelled with fluorescent dipyrromethane boron difluoride (BODIPY-FL) was punctate over the cytoplasm, compatible with the labelling of endocrine granules. A faint labelling persisted in Sur1 (-/-) mice, but it was not different from that obtained with BODIPY-FL alone used as negative control.

CONCLUSIONS/INTERPRETATION

Our study immunolocalised SUR1 in alpha, beta and delta cells of human, mouse and rat islets, and for the first time visualised it in the plasma membrane. We also show that SUR1 is abundant in endocrine granules, where its function remains to be established. No specific sulfonylurea-binding sites other than SUR1 are identified in islet cells by the glibenclamide-BODIPY-FL technique.

Outcome of children with posterior fossa medulloblastoma: a single institution experience over the decade 1994-2003

AIM

While the impact of radiotherapy in the management of medulloblastoma was recognised, the introduction of chemotherapy was investigated in clinical trials and shown to confer an additional advantage. We reviewed the outcome of a series of consecutive patients to assess the impact in a population-based clinical establishment.

MATERIALS AND METHODS

A series of 38 children treated for medulloblastoma at Birmingham Children's Hospital between 1994 and 2003 was analysed. The effect of surgery, radiotherapy, chemotherapy and metastasis on survival was analysed.

RESULTS

The overall 5-year survival rate was 61.4% for the 36 patients who had resective surgery, while 2 patients had biopsy only and died within a few months. There was no operative mortality. The incidence of hydrocephalus needing permanent shunting was higher in the first 3 years of life (p = 0.007, chi-square). The 5-year survival rate of patients with total and sub-total excision of medulloblastoma was 61.1% and 61.8%, respectively. The 5-year survival rate of patients older than 3 years was 73.4% and for patients under 3 years was 36.3% (p = 0.007, log rank). Metastases at presentation did not influence survival. All deaths occurred in the first 32 months.

CONCLUSION

The contribution of chemotherapy in the improvement of the overall survival appears more evident in children younger than 3 years or presenting with metastases. The absence of significant difference in survival between patients with total or sub-total excision of medulloblastoma supports the view that total excision of medulloblastoma can be avoided when the risk for potential intra-operative damage and consequent neurological deficits is high.