A phase I trial of the oral, multikinase inhibitor sorafenib in combination with carboplatin and paclitaxel

PURPOSE

This study evaluated the safety, maximum tolerated dose, pharmacokinetics, and antitumor activity of sorafenib, a multikinase inhibitor, combined with paclitaxel and carboplatin in patients with solid tumors.

PATIENTS AND METHODS

Thirty-nine patients with advanced cancer (24 with melanoma) received oral sorafenib 100, 200, or 400 mg twice daily on days 2 to 19 of a 21-day cycle. All patients received carboplatin corresponding to AUC6 and 225 mg/m(2) paclitaxel on day 1. Pharmacokinetic analyses were done for sorafenib on days 2 and 19 of cycle 1 and for paclitaxel on day 1 of cycles 1 and 2. Pretreatment tumor samples from 17 melanoma patients were analyzed for BRAF mutations.

RESULTS

Sorafenib was well tolerated at the doses evaluated. The most frequent severe adverse events were hematologic toxicities (grade 3 or 4 in 33 patients, 85%). Twenty-seven (69%) patients had sorafenib-related adverse events, the most frequent of which were dermatologic events (26 patients, 67%). Exposure to paclitaxel was not altered by intervening treatment with sorafenib. Treatment with sorafenib, paclitaxel, and carboplatin resulted in one complete response and nine partial responses, all among patients with melanoma. There was no correlation between BRAF mutational status and treatment responses in patients with melanoma.

CONCLUSIONS

The recommended phase II doses are oral 400 mg twice daily sorafenib, carboplatin at an AUC6 dose, and 225 mg/m(2) paclitaxel. The tumor responses observed with this combined regimen in patients with melanoma warrant further investigation.

Early discharge following liver resection for colorectal metastases

OBJECTIVE

Liver resection is currently the recognised treatment for localised colorectal liver metastases. Hospital stay in recently published series is between seven and 12 days for open surgery and five and eight days for laparoscopic resection. Recently there has been interest in the use of 'fast-track' recovery protocols following major abdominal surgery. Our aim was to measure the effect of such a protocol on hospital stay following liver resection.

METHODS

Data was collected prospectively from 12 consecutive patients undergoing open liver resection between August 2003 and September 2004. All patients had a large subcostal incision with full mobilisation of the liver. A 'fast-track' protocol was employed consisting of intra venous fluid restriction, patient controlled analgesia and early diet and mobilisation. Data on postoperative complications and hospital stay was recorded.

RESULTS

Twelve patients with a median age of 60 (range 43-74) years underwent liver resection. Resection consisted of one hepatic lobectomy, two trisegmentectomies, three bisegmentectomies and six segmentectomies. Median hospital stay was four (range two to seven) days. One epileptic patient developed carbamazepine toxicity delaying their discharge. A further patient developed a collection requiring no intervention.

CONCLUSION

Early discharge following major liver resection using a 'fast-track' recovery protocol is both safe and achievable.

Phase II trial of sorafenib in advanced thyroid cancer

PURPOSE

Given the molecular pathophysiology of thyroid cancer and the spectrum of kinases inhibited by sorafenib, including Raf kinase, vascular endothelial growth factor receptors, platelet-derived growth factor receptor, and RET tyrosine kinases, we conducted an open-label phase II trial to determine the efficacy of sorafenib in patients with advanced thyroid carcinoma.

PATIENTS AND METHODS

Eligible patients with metastatic, iodine-refractory thyroid carcinoma received sorafenib 400 mg orally twice daily. Responses were measured radiographically every 2 to 3 months. The study end points included response rate, progression-free survival (PFS), and best response by Response Evaluation Criteria in Solid Tumors.

RESULTS

Thirty patients were entered onto the study and treated for a minimum of 16 weeks. Seven patients (23%; 95% CI, 0.10 to 0.42) had a partial response lasting 18+ to 84 weeks. Sixteen patients (53%; 95% CI, 0.34 to 0.72) had stable disease lasting 14 to 89+ weeks. Seventeen (95%) of 19 patients for whom serial thyroglobulin levels were available showed a marked and rapid response in thyroglobulin levels with a mean decrease of 70%. The median PFS was 79 weeks. Toxicity was consistent with other sorafenib trials, although a single patient died of liver failure that was likely treatment related.

CONCLUSION

Sorafenib has clinically relevant antitumor activity in patients with metastatic, iodine-refractory thyroid carcinoma, with an overall clinical benefit rate (partial response + stable disease) of 77%, median PFS of 79 weeks, and an overall acceptable safety profile. These results represent a significant advance over chemotherapy in both response rate and PFS and support further investigation of this agent in these patients.

How should we design supportive cancer care? The patient's perspective

PURPOSE

Hospice services are designed to meet the needs of patients near the end of life. Although so-called open-access hospice programs and bridge programs are beginning to offer these services to patients who are still receiving treatment, it is not known whether they best meet patients' needs.

PATIENTS AND METHODS

Three hundred adult patients receiving treatment for cancer completed interviews in which each patient's value or ability for supportive care services were calculated from the choices that they made among combinations of those services. Preferences for five traditional hospice services and six alternative supportive care services were measured, and patients were followed up for 6 months or until death.

RESULTS

Patients' utilities for alternative services were higher than those for traditional hospice services (0.53 v 0.39; sign-rank test P < .001). Alternative services were also preferred among patients with poor functional status (Eastern Cooperative Oncology Group performance score > 2; n = 54; 0.65 v 0.48; P < .001) and among those who were in the last 6 months of life (0.68 v 0.56; sign-rank test P = .003). Even patients who were willing to forgo cancer treatment (n = 38; 13%) preferred alternative services (3.1 v 1.8; P < .001).

CONCLUSION

Patients who are receiving active treatment for cancer, and even those who are willing to stop treatment, express a clear preference for alternative supportive care services over traditional hospice services. Supportive care programs for patients with advanced cancer should reconsider the services that they offer and might seek to include novel services in addition to, or perhaps instead of, traditional hospice services.

Pilot study of DCE-MRI to predict progression-free survival with sorafenib therapy in renal cell carcinoma

BACKGROUND

The investigation of angiogenesis inhibitors is of particular interest in renal cell carcinoma (RCC), in which dysregulated blood vessel formation has been correlated with shortened survival. Sorafenib is a novel RAF and VEGF receptor tyrosine kinase inhibitor. We conducted this study to (a) determine if sorafenib is anti-angiogenic, and (b) to relate anti-angiogenic effect to outcome.

RESULTS

Four patients achieved partial response by WHO criteria (ORR 24%). Median time to progression (TTP) was 12.9 months. K(trans) decreased significantly during treatment with sorafenib (60.3% decline, 95% CI 46.1-74.6%). The percent decline in K(trans) and change in tumor size by CT scan were significantly associated with progression-free survival (p = 0.01 and 0.05, respectively). In addition, K(trans) at baseline was also significantly associated with progress-free survival (p = 0.02).

PATIENTS AND METHODS

Seventeen patients with metastatic RCC underwent dynamic-contrast enhanced magnetic resonance imaging (DCE-MRI). DCE-MRI was used to calculate the gadolinium exchange constant between blood and tumor interstitial tissue, K(trans).

CONCLUSIONS

In patients with RCC, inhibition of tumor vascular permeability by sorafenib was associated with improved outcome. Moreover, baseline tumor vascular permeability, expected to be a poor prognosis factor, was a predictive marker of favorable response to therapy.

The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater

BACKGROUND

Laparoscopic adrenalectomy (LA) has been shown to reduce hospital stay and morbidity when compared to open adrenalectomy (OA). It is uncertain if the laparoscopic resection of large (>/=6 cm) potentially malignant adrenal tumours is appropriate due to concern over incomplete resection and local recurrence. The aim of the present study was to compare the outcomes of LA for tumours >/=6 cm with those < 6 cm.

METHODS

Details of all patients referred with adrenal tumours between January 1999 and January 2006 had been recorded prospectively on a database. LA was performed using a lateral transabdominal approach. Contraindications to LA were local invasion requiring en bloc resection of adjacent organs or the requirement of additional open procedures.

RESULTS

103 patients were referred for adrenal resection. Three with metastatic adrenal carcinoma and two with severe cardiorespiratory disease were deemed unsuitable for operation. One hundred and eleven adrenalectomies were performed: 101 LAs and 10 OAs. Thirty-nine LA were for tumours >/=6 cm while nine OA were for tumours >/=6 cm. There were no significant differences between the median total anaesthetic time, postoperative complications or postoperative stay for patients undergoing LA for tumours >/=6 cm versus tumours <6 cm. Of the six conversions, five were performed for adrenal tumours >/=6 cm [local invasion (n = 3), adhesions (n = 1), primary renal carcinoma (n = 1)]. All tumours in the LA group were resected with clear margins and at a median follow up of 50 months (range 38-74 months). There has been no evidence of local recurrence.

CONCLUSIONS

In the absence of local invasion, the outcomes of laparoscopic adrenalectomy for patients with tumours >/=6 cm were comparable to those with tumours <6 cm. This has helped confirm a policy of initial laparoscopic resection for all noninvasive adrenal tumours can be applied safely.

A phase I and pharmacokinetic study of lapatinib in combination with infusional 5-fluorouracil, leucovorin and irinotecan

BACKGROUND

This study determined the optimally tolerated regimen (OTR) of oral lapatinib administered in combination with infusional 5-fluorouracil (5-FU), leucovorin and irinotecan (FOLFIRI) and assessed the safety, tolerability and pharmacokinetics of the combination.

PATIENTS AND METHODS

Twenty-five patients were enrolled; 12 patients were treated at three dose levels to determine OTR; then 13 patients were treated at OTR to evaluate the pharmacokinetics of the combination.

RESULTS

The 2-weekly OTR comprised lapatinib 1250 mg/day with irinotecan 108 mg/m(2) (day 1) and leucovorin 200 mg/m(2), 5-FU bolus 240 mg/m(2) and 5-FU infusion 360 mg/m(2) (days 1 and 2); doses of 5-FU and irinotecan represent a 40% reduction in dose compared to conventional FOLFIRI. Dose-limiting toxicities were grade 3 diarrhoea and grade 4 neutropenia. Co-administration of lapatinib increased the area under the plasma concentration-time curve of SN-38, the active metabolite of irinotecan, by an average of 41%; no other pharmacokinetic interactions were observed. Of 19 patients evaluable for disease response assessment, four patients had partial response and nine patients had stable disease.

CONCLUSION

The combination of lapatinib and FOLFIRI is safe and demonstrates clinical activity; the documented PK interaction can effectively be compensated by lowering the doses of 5-FU and irinotecan. This regime may be further tested in a phase II trial.

Effect of time interval between surgery and preoperative chemoradiotherapy with 5-fluorouracil or 5-fluorouracil and oxaliplatin on outcomes in rectal cancer

BACKGROUND AND OBJECTIVES

Preoperative chemoradiotherapy for locally advanced rectal cancer is now considered "standard of care." However, the optimal time interval for resection after neoadjuvant therapy is unknown.

METHODS

Between 11/90 and 11/04, 107 patients with rectal adenocarcinoma underwent preoperative chemo/RT at the University of Pennsylvania. Fifty-six percent had LAR and 40% had APR. Chemotherapy consisted of 5-FU/oxaliplatin in 28% and 5-FU in 72% of patients. All patients received preoperative RT.

RESULTS

A longer time interval between chemo/RT and surgery was associated with tumor downstaging (OR 1.24, P = 0.02). A longer time interval was not associated with: nodal downstaging (OR 1.00, P = 0.98); pathologic complete response (PCR) (OR 0.97, P = 0.80); likelihood of performing an LAR (OR 0.90, P = 0.47); improved disease free survival (DFS), local control, or distant control (HR 1.05, P = 0.49; HR 1.14, P = 0.22; HR 1.06, P = 0.52, respectively). The PCR rate was 34.5% in the 5-FU/oxaliplatin/radiation group, and 13.7% in the 5-FU/radiation group. If patients with microscopic CR were excluded, then the PCR rate for 5FU/OX was 21.4% and for 5-FU was 12.2%.

CONCLUSIONS

Time interval between surgery and chemo/RT appeared to have little effect on PCR or LAR rates. Patients receiving 5 FU/oxaliplatin/RT had a high PCR rate. A prospective randomized trial to test superiority of 5 FU/oxaliplatin is warranted.

Antitumor effect of the angiogenesis inhibitor bevacizumab is dependent on susceptibility of tumors to hypoxia-induced apoptosis

Angiogenesis inhibition has been shown to enhance the therapeutic efficacy of cytotoxic chemotherapy in colorectal cancer. The basis of the contribution of this modality has not been defined fully. To determine the potential role of hypoxia-induced apoptosis, we studied a series of colon cancer cell lines with varying susceptibility to hypoxia. We exposed HT29 and HCT116 colon adenocarcinoma cell lines to sublethal periods of hypoxia three times weekly for 40 exposures, and derived cell lines both more resistant (from HT29) and more sensitive (from HCT116) to hypoxia-induced apoptosis. Both hypoxia-derived cell lines demonstrated more rapid growth than the parental lines when implanted subcutaneously in immunodeficient mice. Treatment of tumor-bearing mice with bevacizumab resulted in depletion of tumor microvasculature, upregulation of Hypoxia-inducible factor-1 alpha (HIF-1alpha), and increased pimonidazole staining, consistent with an anti-angiogenic effect and induction of hypoxia in tumors derived from all cell lines. The proportion of apoptotic cells was increased in all the treated tumors, and was most pronounced in the bevacizumab-treated HCT116-derived cells. The bevacizumab-treated tumors showed growth delay in HT29 and its derivative, and the parental HCT116. In the hypoxia-sensitive HCT116-derived tumors, marked tumor shrinkage and prolonged growth control occurred. Therefore, bevacizumab treatment is an effective inducer of a hypoxic environment, but the resulting cell kill and tumor shrinkage is determined by the susceptibility of the tumor to apoptosis. The induction of apoptosis by hypoxia may contribute to the benefits of such treatment in the clinical setting.

Malignant disease in peptic ulcer surgery patients after long term follow-up: A cohort study of 1992 patients

AIMS

To assess the effect of previous peptic ulcer surgery on subsequent malignant events, in particular in relation to previous vagotomy, a historical cohort study was conducted.

METHODS

All patients undergoing surgery for peptic ulcer disease with accurate follow-up data at a large peptic ulcer clinic in the Western Infirmary, Glasgow, from 1965 to 1983 were assessed. All cancer events and specific cancer events (gastric, bronchial, laryngeal, colorectal, bladder, breast, prostate, pancreas, kidney, oesophageal cancers) were determined as outcome measures and expressed as standardised incidence ratio (SIR).

RESULTS

Vagotomy and drainage accounted for 67% of all procedures for peptic ulcer disease. Eighty-three percent were habitual smokers. For all peptic ulcer surgery patients, the SIR for all cancer events was 0.86. For specific cancers, the SIRs were bronchial cancer (SIR 1.13); laryngeal cancer (SIR 2.17), colorectal cancer (SIR 0.67). For vagotomised patients the risk of gastric cancer was significantly elevated (SIR 1.50).

CONCLUSIONS

An excess of cancers attributable to smoking have been found in peptic ulcer surgery patients. Vagotomised patients have a higher risk of gastric cancer after long term follow-up. This finding may have implications for screening and the safety of long term acid suppression with agents such as proton pump inhibitors.

Priorities in colorectal cancer research: recommendations from the Gastrointestinal Scientific Leadership Council of the Coalition of Cancer Cooperative Groups

Emerging technologies have greatly expanded our ability to detect, characterize, and treat colorectal cancer. The Coalition of Cancer Cooperative Groups convened a multidisciplinary panel, the Scientific Leadership Council in GI cancer, to discuss and advise on the priorities and opportunities to advance current and future approaches into the clinical arena to impact most rapidly the morbidity and mortality from this disease. The Council's recommendations for research priorities are the result of engagement of community and academic oncologists, patient advocacy groups, and other stakeholders including the pharmaceutical industry and governmental agencies. We detail some key prospects for investigation in the areas of colon cancer detection, prevention, and surgical and medical management. Many are in early or definitive clinical trials, and a focus on rapid accrual is urged. The implementation of biology-directed laboratory investigations, both in association with ongoing clinical trials and as a separate developmental strategy for targeted therapies, is supported as the route to individualized therapy.

Inhibition of G1/S transition potentiates oxaliplatin-induced cell death in colon cancer cell lines

In a series of colorectal cancer cell lines, both necrosis and apoptosis were induced upon exposure to oxaliplatin, and enhanced by co-administration of the Hsp90 inhibitor 17-AAG. We analyzed the effects of these interventions on the cell cycle, and found that oxaliplatin treatment caused G1 and G2 arrest in HCT116 cells, and S-phase accumulation in two p53-deficient cell lines (HT29 and DLD1). Addition of 17-AAG enhanced cell cycle effects of oxaliplatin in HCT116, and induced G1 arrest and decrease in S-phase population in the other cell lines. Analysis of cell cycle proteins revealed that the major difference between the cell lines was that in HCT116, 17-AAG resulted in profound inhibition of expression and phosphorylation of late G1 proteins cyclin E and cdk2, with no effect on p21/WAF1 induction. Consistent with these, an HCT116 p53(-/-) line, lacking p21, showed resistance to oxaliplatin, failure to enter apoptosis, and an accumulation of cells in S-phase. Introduction of p21 in these cells caused reversal of that phenotype, including restoration of the G1 block and re-sensitization to oxaliplatin. Inhibition of G1/S progression using cdk2 inhibitor also enhanced oxaliplatin cytotoxicity. We conclude that in colon cancer cells with impaired p53 function, interventions directed to cycle arrest in G1 may potentiate oxaliplatin activity.

Bevacizumab in combination with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) for previously treated metastatic colorectal cancer: results from the Eastern Cooperative Oncology Group Study E3200

PURPOSE

Colorectal cancer is the second leading cause of cancer mortality in the United States. Antiangiogenic therapy with bevacizumab combined with chemotherapy improves survival in previously untreated metastatic colorectal cancer. This study was conducted to determine the effect of bevacizumab (at 10 mg/kg) on survival duration for oxaliplatin-based chemotherapy in patients with previously treated metastatic colorectal cancer.

PATIENTS AND METHODS

Eight hundred twenty-nine metastatic colorectal cancer patients previously treated with a fluoropyrimidine and irinotecan were randomly assigned to one of three treatment groups: oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) with bevacizumab; FOLFOX4 without bevacizumab; or bevacizumab alone. The primary end point was overall survival, with additional determinations of progression-free survival, response, and toxicity.

RESULTS

The median duration of survival for the group treated with FOLFOX4 and bevacizumab was 12.9 months compared with 10.8 months for the group treated with FOLFOX4 alone (corresponding hazard ratio for death = 0.75; P = .0011), and 10.2 months for those treated with bevacizumab alone. The median progression-free survival for the group treated with FOLFOX4 in combination with bevacizumab was 7.3 months, compared with 4.7 months for the group treated with FOLFOX4 alone (corresponding hazard ratio for progression = 0.61; P < .0001), and 2.7 months for those treated with bevacizumab alone. The corresponding overall response rates were 22.7%, 8.6%, and 3.3%, respectively (P < .0001 for FOLFOX4 with bevacizumab v FOLFOX4 comparison). Bevacizumab was associated with hypertension, bleeding, and vomiting.

CONCLUSION

The addition of bevacizumab to oxaliplatin, fluorouracil, and leucovorin improves survival duration for patients with previously treated metastatic colorectal.

Prospective study on the role of C-reactive protein (CRP) in patients with an acute abdomen

INTRODUCTION

C-reactive protein (CRP) is used routinely in many hospitals to evaluate patients with an acute abdomen. We assessed CRP levels in non-specific abdominal pain (NSAP) and surgical conditions requiring operative or non-operative intervention. The aim of this study was to identify a level of CRP that can be useful in differentiating these three groups.

PATIENTS AND METHODS

All patients older than 25 years and admitted with acute abdominal pain other than those requiring emergency surgery were included. CRP within 24 h was assessed in all patients. Various cut-off values (< 6, > 6-50, > 50-100, > 100-150 and > 150 mg/l) were used to identify a useful diagnostic level of CRP in the 3 groups.

RESULTS

A total of 211 patients were prospectively evaluated - 129 women and 82 men with a mean age of 62.4 years (range, 27-92 years). CRP was performed in 196 within 24 h of admission. Sixty had NSAP while 136 had a surgical condition, of whom 69 had an operation/intervention while the rest were treated non-operatively. The median and interquartile (IQ) range for the three groups were: NSAP, 16 mg/l and 7.75-85.75 mg/l; surgical non-operative group, 75 mg/l and 30.5-150 mg/l; and surgical-operative, 111 mg/l and 42-212 mg/l, respectively. These results were statistically significant (P = 0.001). NSAP was diagnosed in 61% of patients at levels < 6 mg/l compared to 39% of patients in the surgical groups. At levels > 150 mg/l, NSAP was diagnosed in 15% of patients compared to only 54% and 31% for the operative and non-operative groups, respectively.

CONCLUSIONS

Despite statistically significant differences between the three groups, no useful level of CRP could be identified to differentiate between patients with NSAP and those requiring operative or non-operative management.

Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery

BACKGROUND

Laparoscopic colorectal surgery has been claimed to enhance recovery when compared with open surgery. The aim of our study was to investigate whether laparoscopic colorectal resection improved recovery with the use of a multimodal rehabilitation programme.

METHOD

We carried out a prospective audit of 80 patients undergoing elective colorectal resection between November 2003 and March 2005. All patients underwent a fast-track protocol with early feeding, mobilization and a fluid and sodium restriction regime. Recovery was measured in terms of return of gastrointestinal function, hospital stay, complications and quality of life measures.

RESULTS

Of the 80 patients in the study 22 underwent laparoscopic resection and 58 had open surgery. Patients were well matched for all baseline characteristics. The groups were not significantly different in terms of opioid or antiemetic use. They were also similar in median time to first flatus (69 h vs 69 h, P = 0.36) and median time to first bowel motion (127 h vs 101 h, P = 0.07). There was no difference in median hospital stay (5.8 days vs 5.9 days, P = 0.87) or complications (P = 0.46) between the laparoscopic and open group. There were no significant differences in Short Form 36 scores between the two groups for any of the components measured.

CONCLUSION

Laparoscopic colorectal resection does not appear to reduce the duration of ileus or hospital stay with the use of a multimodal rehabilitation regime. Further large randomized trials are required to confirm these findings.

Treatment of asymptomatic inguinal hernias

Inguinal hernia repair is one of the most common operations in general surgery with rates of repair ranging from 10 per 10,000 population in the United Kingdom to 28 per 10,000 in the United States. Most inguinal hernias cause mild to moderate discomfort, which increases with activity. Up to one-third of the patients with an inguinal hernia scheduled for surgery have an asymptomatic swelling. Inguinal hernias are a significant socioeconomic burden with direct costs to the health service and indirect costs to the economy due to time off work following operation. In addition, the morbidity associated with the operation is often underestimated. Therefore, it is important to critically review the risks and complications related to inguinal hernia repair in those with minimal symptoms to formulate the best management strategy for these patients.

Clinical activity and immune modulation in cancer patients treated with CP-870,893, a novel CD40 agonist monoclonal antibody

PURPOSE

The cell-surface molecule CD40 activates antigen-presenting cells and enhances immune responses. CD40 is also expressed by solid tumors, but its engagement results in apoptosis. CP-870,893, a fully human and selective CD40 agonist monoclonal antibody (mAb), was tested for safety in a phase I dose-escalation study.

PATIENTS AND METHODS

Patients with advanced solid tumors received single doses of CP-870,893 intravenously. The primary objective was to determine safety and the maximum-tolerated dose (MTD). Secondary objectives included assessment of immune modulation and tumor response.

RESULTS

Twenty-nine patients received CP-870,893 in doses from 0.01 to 0.3 mg/kg. Dose-limiting toxicity was observed in two of seven patients at the 0.3 mg/kg dose level (venous thromboembolism and grade 3 headache). MTD was estimated as 0.2 mg/kg. The most common adverse event was cytokine release syndrome (grade 1 to 2) which included chills, rigors, and fever. Transient laboratory abnormalities affecting lymphocytes, monocytes, platelets, D-dimer and liver function tests were observed 24 to 48 hours after infusion. Four patients with melanoma (14% of all patients and 27% of melanoma patients) had objective partial responses at restaging (day 43). CP-870,893 infusion resulted in transient depletion of CD19+ B cells in blood (93% depletion at the MTD for < 1 week). Among B cells remaining in blood, we found a dose-related upregulation of costimulatory molecules after treatment.

CONCLUSION

The CD40 agonist mAb CP-870,893 was well tolerated and biologically active, and was associated with antitumor activity. Further studies of repeated doses of CP-870,893 alone and in combination with other antineoplastic agents are warranted.

Differential gene expression patterns and interaction networks in BCR-ABL-positive and -negative adult acute lymphoblastic leukemias

PURPOSE

To identify gene expression patterns and interaction networks related to BCR-ABL status and clinical outcome in adults with acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

DNA microarrays were used to profile a set of 54 adult ALL specimens from the Medical Research Council UKALL XII/Eastern Cooperative Oncology Group E2993 trial (21 p185BCR-ABL-positive, 16 p210BCR-ABL-positive and 17 BCR-ABL-negative specimens).

RESULTS

Using supervised and unsupervised analysis tools, we detected significant transcriptomic changes in BCR-ABL-positive versus -negative specimens, and assessed their validity in an independent cohort of 128 adult ALL specimens. This set of 271 differentially expressed genes (including GAB1, CIITA, XBP1, CD83, SERPINB9, PTP4A3, NOV, LOX, CTNND1, BAALC, and RAB21) is enriched for genes involved in cell death, cellular growth and proliferation, and hematologic system development and function. Network analysis demonstrated complex interaction patterns of these genes, and identified FYN and IL15 as the hubs of the top-scoring network. Within the BCR-ABL-positive subgroups, we identified genes overexpressed (PILRB, STS-1, SPRY1) or underexpressed (TSPAN16, ADAMTSL4) in p185BCR-ABL-positive ALL relative to p210BCR-ABL-positive ALL. Finally, we constructed a gene expression- and interaction-based outcome predictor consisting of 27 genes (including GRB2, GAB1, GLI1, IRS1, RUNX2, and SPP1), which correlated with overall survival in BCR-ABL-positive adult ALL (P = .0001), independent of age (P = .25) and WBC count at presentation (P = .003).

CONCLUSION

We identified prominent molecular features of BCR-ABL-positive adult ALL, which may be useful for developing novel therapeutic targets and prognostic markers in this disease.

Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery

BACKGROUND

Use of intravenous fluids is an important part of perioperative management. The aim of this study was to compare outcome following administration of restricted or standard postoperative intravenous fluids and sodium in patients undergoing elective colorectal surgery.

METHODS

Eighty patients were randomized to restricted fluids (less than 2 litres water and 77 mmol sodium for 24 h after surgery) or a standard postoperative fluid regimen (3 litres water and 154 mmol sodium per day for as long as necessary). The primary endpoint was hospital stay.

RESULTS

The median (i.q.r.) total intravenous fluid intake in the restricted group was 4.50 (4.00-5.62) litres compared with 8.75 (8.00-9.80) litres in the standard group (P < 0.001). Intravenous sodium intake was also significantly less in the restricted group (229 (131-332) versus 560 (477-667) mmol; P < 0.001). There was no difference in median time to first flatus (2.9 versus 2.9 days; hazard ratio (HR) 0.85 (95 per cent confidence interval (c.i.) 0.54 to 1.32); P = 0.466) or first bowel motion (4.7 versus 4.9 days; HR 1.06 (95 per cent c.i. 0.68 to 1.65); P = 0.802) between the restricted and standard groups, or in median hospital stay (7.2 versus 7.2 days; HR 1.03 (95 per cent c.i. 0.66 to 1.61); P = 0.902).

CONCLUSION

Restriction of postoperative intravenous fluid and sodium does not reduce hospital stay following elective colorectal surgery.

The present and future of angiogenesis-directed treatments of colorectal cancer

The level of angiogenic activity in colorectal tumors has been shown to be a determinant of survival. Recent trials established that, in both the first- and second-line treatment of metastatic colorectal cancer, the addition of the vascular endothelial growth factor (VEGF)-directed antibody bevacizumab to chemotherapy significantly prolongs survival compared to chemotherapy alone. Those trials provided proof of principle that inhibition of angiogenesis has the potential to enhance the effectiveness of treatment of this disease. Oral agents directed toward VEGF receptor signaling are in advanced development, but none to date has proven beneficial in phase III trials in advanced colorectal cancer. Additional trials are needed to determine if improved pharmacological characteristics of the small molecules can be modified to replicate the activity of the antibody or if mechanistic differences require a more specific approach. Since bevacizumab has minimal activity as a single agent, a key question for future therapeutic development relates to the interaction between antiangiogenic strategies and cytotoxic therapies. We hypothesize that bevacizumab may potentiate the efficacy of cytotoxics not solely by alterations of tumor interstitial pressure but also by promoting sensitivity to proapoptotic signals consequent upon nutrient and oxygen withdrawal.

Gene expression profiling of human ovarian tumours

There is currently a lack of reliable diagnostic and prognostic markers for ovarian cancer. We established gene expression profiles for 120 human ovarian tumours to identify determinants of histologic subtype, grade and degree of malignancy. Unsupervised cluster analysis of the most variable set of expression data resulted in three major tumour groups. One consisted predominantly of benign tumours, one contained mostly malignant tumours, and one was comprised of a mixture of borderline and malignant tumours. Using two supervised approaches, we identified a set of genes that distinguished the benign, borderline and malignant phenotypes. These algorithms were unable to establish profiles for histologic subtype or grade. To validate these findings, the expression of 21 candidate genes selected from these analyses was measured by quantitative RT–PCR using an independent set of tumour samples. Hierarchical clustering of these data resulted in two major groups, one benign and one malignant, with the borderline tumours interspersed between the two groups. These results indicate that borderline ovarian tumours may be classified as either benign or malignant, and that this classifier could be useful for predicting the clinical course of borderline tumours. Immunohistochemical analysis also demonstrated increased expression of CD24 antigen in malignant versus benign tumour tissue. The data that we have generated will contribute to a growing body of expression data that more accurately define the biologic and clinical characteristics of ovarian cancers.

Sorafenib in advanced melanoma: a Phase II randomised discontinuation trial analysis

The effects of sorafenib – an oral multikinase inhibitor targeting the tumour and tumour vasculature – were evaluated in patients with advanced melanoma enrolled in a large multidisease Phase II randomised discontinuation trial (RDT). Enrolled patients received a 12-week run-in of sorafenib 400 mg twice daily (b.i.d.). Patients with changes in bi-dimensional tumour measurements <25% from baseline were then randomised to sorafenib or placebo for a further 12 weeks (ie to week 24). Patients with ⩾25% tumour shrinkage after the run-in continued on open-label sorafenib, whereas those with ⩾25% tumour growth discontinued treatment. This analysis focussed on secondary RDT end points: changes in bi-dimensional tumour measurements from baseline after 12 weeks and overall tumour responses (WHO criteria) at week 24, progression-free survival (PFS), safety and biomarkers (BRAF, KRAS and NRAS mutational status). Of 37 melanoma patients treated during the run-in phase, 34 were evaluable for response: one had ⩾25% tumour shrinkage and remained on open-label sorafenib; six (16%) had <25% tumour growth and were randomised (placebo, n=3; sorafenib, n=3); and 27 had ⩾25% tumour growth and discontinued. All three randomised sorafenib patients progressed by week 24; one remained on sorafenib for symptomatic relief. All three placebo patients progressed by week-24 and were re-started on sorafenib; one experienced disease re-stabilisation. Overall, the confirmed best responses for each of the 37 melanoma patients who received sorafenib were 19% stable disease (SD) (ie n=1 open-label; n=6 randomised), 62% (n=23) progressive disease (PD) and 19% (n=7) unevaluable. The overall median PFS was 11 weeks. The six randomised patients with SD had overall PFS values ranging from 16 to 34 weeks. The most common drug-related adverse events were dermatological (eg rash/desquamation, 51%; hand-foot skin reaction, 35%). There was no relationship between V600E BRAF status and disease stability. DNA was extracted from the biopsies of 17/22 patients. Six had V600E-positive tumours (n=4 had PD; n=1 had SD; n=1 unevaluable for response), and 11 had tumours containing wild-type BRAF (n=9 PD; n=1 SD; n=1 unevaluable for response). In conclusion, sorafenib is well tolerated but has little or no antitumour activity in advanced melanoma patients as a single agent at the dose evaluated (400 mg b.i.d.). Ongoing trials in advanced melanoma are evaluating sorafenib combination therapies.

Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) is a leading cause of admission to surgical emergency units. Strangulation is associated with a 10-fold increase in mortality. The aim of the present study was to identify the most frequent causes of strangulation in patients presenting with small bowel obstruction.

METHODS

A prospective study was conducted of all patients presenting with SBO in one teaching hospital between 2003 and 2004.

RESULTS

One hundred and sixty-one patients with symptoms and signs of small bowel obstruction were admitted. Eighty-three were confirmed with contrast studies. The male:female ratio was 1:1.6. The aetiology of obstruction was adhesions in 97 patients (60.2%), hernia in 29 (18%), malignancy in 17 (10.6%) and miscellaneous causes in 18 (11.2%). Operative procedures were performed on 74 patients (46%), 31 of them (42%) with adhesions, 25 (34%) with hernias and 18 (24%) due to other causes. Strangulated bowel occurred in 15 patients (9.3%); 12 had hernias whilst three had adhesions (P < 0.0001). Of the strangulated hernias, ten were femoral, one was inguinal and one was paraumbilical. There were seven deaths; three occurred in patients declared unfit for surgery, while four occurred post-operatively - two had strangulated bowel, the other two had advanced cancer.

CONCLUSION

Whilst adhesions are the most common cause of small bowel obstruction, hernias remain the most frequent cause of strangulation in patients presenting with this condition.

Phase II Placebo-Controlled Randomized Discontinuation Trial of Sorafenib in Patients With Metastatic Renal Cell Carcinoma

Purpose

This phase II randomized discontinuation trial evaluated the effects of sorafenib (BAY 43-9006), an oral multikinase inhibitor targeting the tumor and vasculature, on tumor growth in patients with metastatic renal cell carcinoma.

Patients and Methods

Patients initially received oral sorafenib 400 mg twice daily during the initial run-in period. After 12 weeks, patients with changes in bidimensional tumor measurements that were less than 25% from baseline were randomly assigned to sorafenib or placebo for an additional 12 weeks; patients with ≥ 25% tumor shrinkage continued open-label sorafenib; patients with ≥ 25% tumor growth discontinued treatment. The primary end point was the percentage of randomly assigned patients remaining progression free at 24 weeks after the initiation of sorafenib.

Results

Of 202 patients treated during the run-in period, 73 patients had tumor shrinkage of ≥ 25%. Sixty-five patients with stable disease at 12 weeks were randomly assigned to sorafenib (n = 32) or placebo (n = 33). At 24 weeks, 50% of the sorafenib-treated patients were progression free versus 18% of the placebo-treated patients (P = .0077). Median progression-free survival (PFS) from randomization was significantly longer with sorafenib (24 weeks) than placebo (6 weeks; P = .0087). Median overall PFS was 29 weeks for the entire renal cell carcinoma population (n = 202). Sorafenib was readministered in 28 patients whose disease progressed on placebo; these patients continued on sorafenib until further progression, for a median of 24 weeks. Common adverse events were skin rash/desquamation, hand-foot skin reaction, and fatigue; 9% of patients discontinued therapy, and no patients died from toxicity.

Conclusion

Sorafenib has significant disease-stabilizing activity in metastatic renal cell carcinoma and is tolerable with chronic daily therapy.

Value of biopsy in the assessment of a retroperitoneal mass

AIMS

A retroperitoneal mass arising outside a specific organ usually gives rise to diagnostic uncertainty. Because of this, many clinicians request a radiologically guided biopsy. The aim of this study was to compare clinical and radiologic assessment with and without biopsy in patients undergoing surgical resection of a large abdominal mass.

METHODS

All patients undergoing resection of a large retroperitoneal mass under the care of one surgeon between 1994 and 2004 were included in this study.

RESULTS

One hundred and twenty-one patients underwent resection of a large retriperitoneal mass, of whom 84 had primary disease (median size 20cm, range 7cm-40cm). Thirty-six had clinical and radiologic assessment with biopsy while 48 had no biopsy. In the biopsy group four patients had a false negative result while two had a false positive result for a malignant tumour. Three patients had incorrect malignant histology on biopsy which led to an error in management in two. In addition, two adverse events related to biopsy were observed. One patient in the no biopsy group had an error in management. Sensitivity for diagnosis of a soft tissue tumour was 80.8% (95% CI 69.5%-92.1%) for clinical and radiologic assessment alone versus 91.6% (95% CI 82.6%-100%) when biopsy was added.

CONCLUSIONS

Biopsy adds no value to clinical and radiologic assessment of the patient with a resectable large retroperitoneal mass.

Mechanisms of Hypertension Associated With BAY 43-9006

Purpose

BAY 43-9006 (sorafenib) is an inhibitor of Raf kinase, the vascular endothelial growth factor (VEGF) receptor-2, and angiogenesis in tumor xenografts. The current study investigated the incidence, severity, and mechanism of blood pressure (BP) elevation in patients treated with BAY 43-9006.

Patients and Methods

Twenty patients received BAY 43-9006 400 mg orally twice daily. BP and heart rate were measured at baseline and then every 3 weeks for 18 weeks. VEGF, catecholamines, endothelin I, urotensin II, renin, and aldosterone were measured at baseline and after 3 weeks of therapy. We assessed vascular stiffness at baseline, after 3 to 6 weeks of therapy, and again after 9 to 10 months of therapy.

Results

Fifteen (75%) of 20 patients experienced an increase of ≥ 10 mmHg in systolic BP (SBP), and 12 (60%) of 20 patients experienced an increase of ≥ 20 mmHg in SBP compared with their baseline value, with a mean change of 20.6 mmHg (P < .0001) after 3 weeks of therapy. There were no statistically significant changes in humoral factors, although there was a statistically significant inverse relationship between decreases in catecholamines and increases in SBP, suggesting a secondary response to BP elevation. Measures of vascular stiffness increased significantly during the period of observation.

Conclusion

Treatment with BAY 43-9006 is associated with a significant and sustained increase in BP. The lack of significant change in circulating factors suggests that these humoral factors had little role in the increase in BP.

Prospective study on the management of patients with complicated diverticular disease

INTRODUCTION

Diverticular disease is a common condition with high morbidity and mortality related to its complications. The aim of this study was to assess the predictive role of acute diverticulitis in the development of further complications from diverticular disease.

PATIENTS AND METHODS

Prospective assessment of all patients with complicated diverticular disease over a 1-year period in a large teaching hospital was undertaken. All patients had documented evidence of their diagnosis by radiological, endoscopic or histopathological techniques when feasible.

RESULTS

Seventy-seven patients with complicated diverticular disease were identified. There were 53 females and 24 males with a median age of 74 years (range 30-97 years). Complications included: acute diverticulitis (37), fistula (12), perforation (8), bleeding (7), abscess (7) and stricture (6). Only 8 had two or more previous documented episodes of diverticulitis. Twenty-five underwent surgery, 3 died (peritonitis 2, abscess1) and 5 had a complication (anastomotic dehiscence 1, adhesive obstruction 1, incisional hernia 2 and pneumonia 1). Three (5%) of 37 patients with acute diverticulitis had two or more admissions but none underwent surgery or developed further complications. CT was performed during acute admission in 14/37 patients with acute diverticulitis. The majority of patients with fistula (9/12), perforation 7/8, bleeding 6/7 and abscess 5/7 had no previous episode of diverticulitis while most patients with stricture (4/6) had previous documented episodes.

CONCLUSION

In our patient population acute diverticulitis is not a good predictor of the development of further complications from diverticular disease as only a minority of patients with perforation, fistula, abscess and bleeding had previous documented episodes of diverticulitis.

Macrophage migration inhibitory factor is a determinant of hypoxia-induced apoptosis in colon cancer cell lines

Hypoxia contributes to cytotoxic chemotherapy and radiation resistance and may play a role in the efficacy of antiangiogenesis cancer therapy. We have generated a series of cell lines derived from the colon adenocarcinoma models HT29 and HCT116 by exposing cells in vitro to repeated sublethal periods of profound hypoxia. These cell lines have altered sensitivity to hypoxia-induced apoptosis: those derived from HT29 are resistant, whereas those from HCT116 are more susceptible. We used cDNA selected subtractive hybridization to identify novel genes mediating sensitivity to hypoxia-induced apoptosis and isolated macrophage migration inhibitory factor (MIF) from the hypoxia-conditioned cell lines. MIF expression correlates with susceptibility of the cell lines to apoptosis. In hypoxia-resistant cells, the induction of apoptosis by hypoxia can be restored by the addition of exogenous recombinant MIF protein, suggesting that resistance may result in part from down-regulation of MIF production possibly through an autocrine loop. Inhibition of MIF using small interfering RNA in the susceptible lines conferred resistance to hypoxia-induced cell death. The relative expression of MIF in the hypoxia-conditioned cells implanted s.c. in severe combined immunodeficient mice in vivo was similar to that observed in vitro. In an analysis of 12 unrelated colon tumor cell lines, MIF expression and response to hypoxia varied widely. Cell lines in which MIF was inducible by hypoxia were more sensitive to oxaliplatin. In human colon tumor specimens analyzed by immunohistochemistry, MIF expression was similarly variable. There was no detectable expression of MIF in normal colon mucosa or adenoma but positive staining in all carcinomas tested. Taken together, these data indicate that MIF may be a determinant of hypoxia-induced apoptosis in vitro and that its variable expression in human colon cancers may indicate a functional role in vivo. We suggest that MIF expression in colorectal cancer may be a marker of susceptibility to therapies that may depend on induction of hypoxia, possibly including antiangiogenic therapy.

In vitro hypoxia-conditioned colon cancer cell lines derived from HCT116 and HT29 exhibit altered apoptosis susceptibility and a more angiogenic profile in vivo

Hypoxia is an important selective force in the clonal evolution of tumours. Through HIF-1 and other transcription factors combined with tumour-specific genetic alterations, hypoxia is a dominant factor in the angiogenic phenotype. Cellular adaptation to hypoxia is an important requirement of tumour progression independent of angiogenesis. The adaptive changes, insofar as they alter hypoxia-induced apoptosis, are likely to determine responsiveness to antiangiogenic strategies. To investigate this adaptation of tumour cells to hypoxia, we recreated in vitro the in vivo situation of chronic intermittent exposure to low-oxygen levels. The colon carcinoma cell lines HT29 and HCT116 were subjected to 40 episodes of sublethal hypoxia (4 h) three times a week. The resulting two hypoxia-conditioned cell lines have been maintained in culture for more than 2 years. In both cell lines changes in doubling times occurred: in HT29 an increase, and in HCT116 a decrease. Cell survival in response to hypoxia and to DNA damage differed strikingly in the two cell lines. The HT29 hypoxia-conditioned cells were more resistant than the parental line to a 24 h hypoxic challenge, while those from HCT116 surprisingly were more sensitive. Sensitivity to cisplatin in vitro was also significantly different for the hypoxia-conditioned compared with the parental lines, suggesting a change in pathways leading to apoptosis following DNA damage signaling. The growth of both conditioned cell lines in vivo as xenografts in immunodeficient (SCID) mice was more rapid than their parental lines, and was accompanied in each by evidence of enhanced vascular proliferation as a consequence of the hypoxia-conditioning. Thus the changes in apoptotic susceptibility were independent of altered angiogenesis. The derivation of these lines provides a model for events within hypoxic regions of colon cancers, and for the acquisition of resistance and sensitivity characteristics that may have therapeutic implications for the use of antiangiogenesis drugs.

Is pre-operative radiotherapy necessary in T-T rectal cancer with TME?

OBJECTIVE

The indications for pre-operative radiotherapy in rectal cancer are still unclear with the exception of T4 tumours. The aim of this study was to assess local and overall recurrence in patients with T1-T3 rectal cancers undergoing total mesorectal excision (TME).

METHODS

Prospective data was collected from 150 patients with rectal cancer treated in one surgical centre between July 1997 and July 2002. One hundred and twenty-nine primary resections were carried of which 102 were with curative intent. Seventy-nine patients with T1-T3 tumours were included in the analysis. Nine had local resections and 70 underwent TME; 19 of the 70 patients were node positive and 51 were node negative.

RESULTS

At a median follow-up of 37 months (range 19-79 months) there were 3 (4.3%) isolated local recurrences. One node positive patient developed isolated local recurrence compared with 2 node negative patients. The node positive patient died from a myocardial infarction while the two node negative patients died as a consequence of local recurrence. Three (4.3%) of 70 patients developed systemic relapse all of whom were node positive. The cancer specific mortality rate over the same follow-up period was 3/19 for node positive patients and 2/51 for node negative patients. Of 9 patients who had local resections, none developed local recurrence or systemic relapse.

CONCLUSIONS

With TME the rate of local recurrence in T1-T3 tumours is low. Our results do not support the use of pre-operative radiotherapy for these patients.

Laparoscopic or open preperitoneal repair in the management of recurrent groin hernias

Laparoscopic repair is considered by many to be the operation of choice for a recurrent hernia. The aim of this study was to compare long-term outcome of laparoscopic and open preperitoneal repair of recurrent groin hernias. All patients operated on by one surgeon for recurrent groin hernia between January 1994 and December 2001 were reviewed. Forty-five percent had their data collected prospectively, while in 55% the data was collected retrospectively. Over the study period 128 patients underwent repair of a recurrent groin hernia of whom 99 had either a laparoscopic or open preperitoneal repair. The mean age was 60 years (range 15-88), 93 were men while 6 were women. Forty-five had their hernia repaired laparoscopically while 54 had an open preperitoneal repair. Patients have been followed for a median of 5 years (range 2-9 years). There has been no recurrence in either group of patients. Two patients in the laparoscopic group and four in the open group suffered from chronic groin pain. One patient in either group developed a Hydrocele that was dealt with surgically. Laparoscopic and open preperitoneal repair of a recurrent groin hernia are associated with similar long-term outcomes.

Prospective study on the presentation and outcome of patients with an acute hernia

Recent advances in hernia surgery should help to make operation more acceptable to patients and their doctors. The aim of this study was to prospectively assess the presentation and management of patients with an acute hernia in light of these changes. Data on all patients admitted with an acute hernia between March 2001 and February 2004 was entered on a prospective database. During the 3 year study period, of the 91 patients admitted with an acute hernia, 41 were ventral, 24 femoral, 24 inguinal and 2 parastomal. Forty-six had a previous medical assessment, 18 of these had been declared unfit for operation at that assessment; ten were ASA4 (ASA, American Society of Anaesthesiology), five ASA3 and three ASA2. Eleven patients were on the waiting list for operation, three of whom had a previous acute hospital admission. For 30 patients this hospital admission was the first indication that they had a hernia while the remaining were aware that they had a hernia but did not seek medical advice. Of the five patients who died, two while being assessed for operation and three postoperatively, three were ASA4 and had a ventral hernia while two were ASA3 with a femoral hernia. Despite advances in hernia surgery there is still room for improvement in preoperative assessment of patients presenting with an acute hernia.

Surgeon perspectives on options for ventral abdominal wall hernia repair: results of a postal questionnaire

BACKGROUND

Ventral abdominal wall hernias are a common cause of morbidity and mortality. Opinion varies as to appropriate management. A recent consensus meeting on incisional hernia identified the need to standardise repair. On this background, a survey of current practice was performed.

METHOD

A questionnaire was sent to 101 practicing general surgeons within the West of Scotland. Incisional, epigastric and para-umbilical defects were subdivided into defect size <2, 2-5 and >5 cm. The surgeons were asked to indicate the most appropriate repair (suture, mayo or mesh) for each. The influence of reducibility on the decision to repair was also assessed.

RESULTS

Sixty-one of 101 questionnaires were returned valid giving a response rate of 60%. Suture repair was significantly more likely to be used in all defects <2 cm (P<0.001). Mesh repair was significantly more likely to be recommended in all defects >5 cm (P<0.001). Of defects >5-cm, mesh was recommended for 90% of incisional hernia compared with 81% of epigastric and 76% of para-umbilical hernia (P<0.001). There was no significant difference in choice of repair for defect size 2-5 cm with opinion divided between suture and mesh. Irreducibility increased the likelihood of recommendation for repair.

CONCLUSION

This survey shows a lack of consensus on the appropriate repair of ventral abdominal wall hernia among practicing consultant general surgeons. This reflects the contrasting views within the current literature.

17-Allylamino-17-demethoxygeldanamycin overcomes TRAIL resistance in colon cancer cell lines

Tumor necrosis factor related apoptosis-inducing ligand (TRAIL) is a promising candidate for treatment of cancer, but displays variable cytotoxicity in cell lines. The mechanisms of sensitivity and resistance have not been fully elucidated; both AKT and NF-kappaB pathways may modulate cytotoxic responses. We have shown that the Hsp90 inhibitor 17-AAG enhances the cytotoxicity of oxaliplatin in colon cancer cell lines through inhibition of NF-kappaB. We analyzed the effects of TRAIL and 17-AAG in combination in a series of nine colon cancer cell lines and characterized activation of the pathways to apoptosis. IC(50) values for a 72 h exposure to TRAIL ranged from 30 to 4000 ng/ml. Cytotoxicity assays demonstrated additivity or synergism of the TRAIL/17-AAG combination in all cell lines, with combination indices at IC(50) ranging from 0.53 to 1. The sensitizing effect of 17-AAG was greater in the TRAIL-resistant cell lines. In TRAIL-resistant cell lines, the combination of 17-AAG and TRAIL resulted in activation of both extrinsic and intrinsic apoptotic pathways, though with quantitative differences between HT29 and RKO cells: differential effects of 17-AAG on AKT and NF-kappaB characterized these cell lines. In both cell lines, the combination also led to down-regulation of X-linked inhibitor of apoptosis protein (XIAP) and enhanced activation of caspase-3. We conclude that either AKT or NF-kappaB may promote resistance to TRAIL in colon cancer cells, and that the ability of 17-AAG to target multiple putative determinants of TRAIL sensitivity warrants their further investigation in combination.

A technically difficult endorectal ultrasound is more likely to be inaccurate

OBJECTIVE

Endorectal ultrasound (ERUS) is well established as an accurate modality for local staging of rectal tumours. The aim of this study was to identify reasons for inaccurate staging of tumours, and to assess whether difficulties encountered during scanning are likely to influence accuracy.

PATIENTS AND METHODS

ERUS was performed by a single operator using a 10 MHz rigid instrument. One hundred and seventeen patients that had both ERUS and surgery are included in this study (patients that had pre-operative radiotherapy were excluded). During ERUS, procedural conditions and limiting factors were recorded. Data was collected prospectively.

RESULTS

In 78 (66.7%) patients no technical difficulty was encountered during ERUS. In this group accuracy was 80% for T-stage and 77% for N-stage. Specific reasons for inaccuracy identified in this group were: inflammatory lymph nodes (from a tumour associated abscess and a colovesical fistula) and deep biopsy causing a submucosal defect with intramural haemorrhage in benign lesions (2 cases). In the remaining 39 (33.3%), the following problems were encountered: stenotic lesions (23), patient discomfort (8), poor bowel preparation (6), and scarring from previous surgery (2). In 11 patients from this group, the scan was considered inconclusive and no stage could be determined. For the other 28, the accuracy for T-stage was 68% and for N-stage 67%.

CONCLUSION

A technically difficult ERUS is likely to give an inconclusive or inaccurate result for both T-stage (P = 0.001) and N-stage (P = 0.003). In this situation a repeat scan may be considered (where appropriate). Alternatively, further assessment by MRI or flexible endoscopic ultrasound may be considered.

Prospective study on the role of the CT scan in patients with an acute abdomen

OBJECTIVES

Recent reports indicate that early CT scan (within 24 h) increases diagnostic accuracy, reduces hospital stay and mortality in patients with an acute abdomen. The aim of this study was to assess the surgeons' use of CT in patients with an acute abdomen and the impact of this on diagnostic accuracy and mortality.

PATIENTS AND METHODS

Patients older than 25 years admitted as an emergency with acute abdominal pain were prospectively evaluated.

RESULTS

Two hundred and eleven patients fulfilled the inclusion criteria including 129 women and 82 men with a mean age of 62.4 years (range 27-92 years). The correct diagnosis on admission was made in 99 (47%) patients. CT was performed in 81 (38%), including 24 who had the scan performed within 24 h of admission. The sensitivity, specificity and accuracy of CT were 86%, 79% and 84%. CT was considered to have changed clinical management in 40 patients. Fifteen patients died, and one death may have been prevented by an early CT. Five had a delay in diagnosis of a serious condition; all could have been prevented by early CT.

CONCLUSION

Selective use of CT increases diagnostic accuracy and improves the management of patients with an acute abdomen. Clinical trials are necessary to assess outcome following selective vs routine use of CT in this group of patients.

A phase II trial of gefitinib with 5-fluorouracil, leucovorin, and irinotecan in patients with colorectal cancer

Inhibition of epidermal growth factor receptor (EGFR) signalling contributes to the therapy of colorectal cancer. Gefitinib, an oral EGFR tyrosine kinase inhibitor, shows supra-additive growth inhibition with irinotecan and fluoropyrimidines in xenograft models. We designed a study to determine the tolerability and efficacy of gefitinib in combination with irinotecan, infusional 5-fluorouracil (5-FU) and leucovorin (LV), on a 2-week schedule. Among 13 patients with advanced colorectal cancer, 10 required dose reductions of irinotecan and 5-FU because of dehydration, diarrhoea, and neutropenia, seven of whom required hospitalisation, three with neutropenic fever. One patient achieved partial response and seven had disease stabilisation. The combination of this standard chemotherapy regimen with gefitinib is associated with excessive toxicity, suggesting an interaction at a pharmacokinetic or pharmacodynamic level.

Identification of genes associated with platinum drug sensitivity and resistance in human ovarian cancer cells

Platinum-based chemotherapeutic regimens are ultimately unsuccessful due to intrinsic or acquired drug resistance. Understanding the molecular basis for platinum drug sensitivity/resistance is necessary for the development of new drugs and therapeutic regimens. In an effort to identify such determinants, we evaluated the expression of approximately 4000 genes using cDNA microarray screening in a panel of 14 unrelated human ovarian cancer cell lines derived from patients who were either untreated or treated with platinum-based chemotherapy. These data were analysed relative to the sensitivities of the cells to four platinum drugs (cis-diamminedichloroplatinum (cisplatin), carboplatin, DACH-(oxalato)platinum (II) (oxaliplatin) and cis-diamminedichloro (2-methylpyridine) platinum (II) (AMD473)) as well as the proliferation rate of the cells. Correlation analysis of the microarray data with respect to drug sensitivity and resistance revealed a significant association of Stat1 expression with decreased sensitivity to cisplatin (r=0.65) and AMD473 (r=0.76). These results were confirmed by quantitative RT–PCR and Western blot analyses. To study the functional significance of these findings, the full-length Stat1 cDNA was transfected into drug-sensitive A2780 human ovarian cancer cells. The resulting clones that exhibited increased Stat1 expression were three- to five-fold resistant to cisplatin and AMD473 as compared to the parental cells. The effect of inhibiting Jak/Stat signalling on platinum drug sensitivity was investigated using the Janus kinase inhibitor, AG490. Pretreatment of platinum-resistant cells with AG490 resulted in significant increased sensitivity to AMD473, but not to cisplatin or oxaliplatin. Overall, the results indicate that cDNA microarray analysis may be used successfully to identify determinants of drug sensitivity/resistance and future functional studies of other candidate genes from this database may lead to an increased understanding of the drug resistance phenotype.

Phase I Trial of Combretastatin A-4 Phosphate with Carboplatin

PURPOSE

Preclinical evidence of synergy led to a phase I trial employing combretastatin A-4 phosphate (CA4P), a novel tubulin-binding antivascular drug, in combination with carboplatin.

EXPERIMENTAL DESIGN

Based on preclinical scheduling studies, patients were treated on day 1 of a 21-day cycle. Carboplatin was given as a 30-minute i.v. infusion and CA4P was given 60 minutes later as a 10-minute infusion.

RESULTS

Sixteen patients with solid tumors received 40 cycles of therapy at CA4P doses of 27 and 36 mg/m(2) together with carboplatin at area under the concentration-time curve (AUC) values of 4 and 5 mg min/mL. The dose-limiting toxicity of thrombocytopenia halted the dose escalation phase of the study. Four patients were treated at an amended dose level of CA4P of 36 mg/m(2) and carboplatin AUC of 4 mg min/mL although grade 3 neutropenia and thrombocytopenia were still observed. Three lines of evidence are adduced to suggest that a pharmacokinetic interaction between the drugs results in greater thrombocytopenia than anticipated: the carboplatin exposure (as AUC) was greater than predicted; the platelet nadirs were lower than predicted; and the deviation of the carboplatin exposure from predicted was proportional to the AUC of CA4, the active metabolite of CA4P. Patient benefit included six patients with stable disease lasting at least four cycles.

CONCLUSION

This study of CA4P and carboplatin given in combination showed dose-limiting thrombocytopenia. Pharmacokinetic/pharmacodynamic modeling permitted the inference that altered carboplatin pharmacokinetics caused the increment in platelet toxicity.

Phase I study of the novel taxane CT-2103 in patients with advanced solid tumors

BACKGROUND

CT-2103 (Cell Therapeutics, Seattle, Wash.) is a water-soluble macromolecular conjugate of paclitaxel to a polyglutamate backbone, designed to enhance tumor permeability and to improve intratumoral delivery of paclitaxel. Preclinical studies indicate that CT-2103 has substantial antitumor efficacy in xenograft tumor models.

METHODS

We performed a phase I trial in patients with advanced solid tumors to determine the maximum tolerated doses (MTD) of CT-2103 when administered as short intravenous infusion every 3 weeks.

RESULTS

Seven patients received a total of 16 cycles (range 1-3) of CT-2103 at doses of 235 and 270 mg/m(2). Two of five patients treated at 235 mg/m(2) and one of two patients treated at 270 mg/m(2) experienced grade 3/4 neutropenia. Four patients experienced a marked increase in PTT within 30 min of the start of infusion. Neuropathy was more severe than expected. Two patients developed grade 3 neuropathy that prompted a 50% dose reduction of CT-2103 and persisted for 8 months in one, and over a year in the other. Three patients experienced grade 1 or 2 neuropathy. Neurotoxicity was cumulative and prevented patients from receiving prolonged administration of CT-2103.

CONCLUSIONS

The unexpectedly high rate of cumulative toxicity observed in our study needs to be taken into consideration in future trials of CT-2103. Prior taxane use may not be a predictor of severe neurotoxicity.

Genetic linkage of prostate cancer risk to the chromosome 3 region bearing FHIT

We conducted linkage analysis of 80 candidate genes in 201 brother pairs affected with prostatic adenocarcinoma. Markers representing two adjacent candidate genes on chromosome 3p, CDC25A and FHIT, showed suggestive evidence for linkage with single-point identity-by-descent allele-sharing statistics. Fine-structure multipoint linkage analysis yielded a maximum LOD score of 3.17 (P = 0.00007) at D3S1234 within FHIT intron 5. For a subgroup of 38 families in which three or more affected brothers were reported, the LOD score was 3.83 (P = 0.00001). Further analysis reported herein suggested a recessive mode of inheritance. Association testing of 16 single nucleotide polymorphisms (SNP) spanning a 381-kb interval surrounding D3S1234 in 202 cases of European descent with 143 matched, unrelated controls revealed significant evidence for association between case status and the A allele of single nucleotide polymorphism rs760317, located within intron 5 of FHIT (Pearson's chi(2) = 8.54, df = 1, P = 0.0035). Our results strongly suggest involvement of germline variations of FHIT in prostate cancer risk.

Genetic Linkage of Prostate Cancer Risk to the Chromosome 3 Region Bearing FHIT

We conducted linkage analysis of 80 candidate genes in 201 brother pairs affected with prostatic adenocarcinoma. Markers representing two adjacent candidate genes on chromosome 3p, CDC25A and FHIT, showed suggestive evidence for linkage with single-point identity-by-descent allele-sharing statistics. Fine-structure multipoint linkage analysis yielded a maximum LOD score of 3.17 (P = 0.00007) at D3S1234 within FHIT intron 5. For a subgroup of 38 families in which three or more affected brothers were reported, the LOD score was 3.83 (P = 0.00001). Further analysis reported herein suggested a recessive mode of inheritance. Association testing of 16 single nucleotide polymorphisms (SNP) spanning a 381-kb interval surrounding D3S1234 in 202 cases of European descent with 143 matched, unrelated controls revealed significant evidence for association between case status and the A allele of single nucleotide polymorphism rs760317, located within intron 5 of FHIT (Pearson's χ2 = 8.54, df = 1, P = 0.0035). Our results strongly suggest involvement of germline variations of FHIT in prostate cancer risk.

Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia

BACKGROUND

Claims that laparoscopic groin hernia repair is followed by less persisting pain and numbness than open mesh repair were tested by follow-up within a multicentre randomized clinical trial.

METHODS

Participants in the UK Medical Research Council Laparoscopic Groin Hernia Trial were followed up by means of self-completed postal questionnaires from 2 to 5 years after trial entry. The principal measures were pain (groin and testicular) and numbness (groin and thigh).

RESULTS

Seven hundred and fifty (80.8 per cent) of the original 928 participants returned at least one questionnaire between 2 and 5 years; respondents were similar to the baseline randomized groups. Fewer respondents in the laparoscopic group had groin pain (absolute differences varied between 7.9 and 2.0 per cent, but were of marginal statistical significance); rates of testicular pain were similar in the two groups. Groin numbness was reported about half as commonly at all time points in the laparoscopic group (P < 0.001); there were no significant differences in thigh numbness.

CONCLUSION

Laparoscopic surgery was associated with less long-term numbness and probably less pain in the groin.

Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair

Background

Severe chronic pain is a long-term problem that may occur after inguinal hernia repair. The aim of this randomized study was to compare pain of any severity at 12 months after inguinal hernia repair with a partially absorbable lightweight mesh (LW group) or with a non-absorbable heavyweight mesh (HW group).

Methods

Patients were assessed for pain at 1, 3 and 12 months by questionnaire, and were examined clinically at 12 months.

Results

Some 321 patients were included in an intention-to-treat analysis, 162 in the LW group and 159 in the HW group. At 12 months, significantly fewer patients in the LW group than in the HW group had pain of any severity: 39·5 versus 51·6 per cent (difference—12·1 (95 per cent confidence interval—23·1 to—1·0) per cent; P = 0·033). The recurrence rate was higher in the LW group (5·6 versus 0·4 per cent; P = 0·037). Five of eight recurrences in LW group were associated with a single participating centre.

Conclusion

Use of lightweight mesh was associated with less chronic pain but an increase in hernia recurrence after inguinal hernia repair. The latter may be related to technical factors associated with fixation of such meshes rather than any inherent defect in the mesh.

Phase I and pharmacokinetic study of the cytotoxic ether lipid ilmofosine administered by weekly two-hour infusion in patients with advanced solid tumors

PURPOSE

A Phase I trial was performed to determine the dose-limiting toxicity and maximum tolerated dose, and to describe the pharmacokinetics of the alkyl-lysophospholipid, ilmofosine, when administered as a weekly 2-h infusion in patients with solid tumors.

EXPERIMENTAL DESIGN

Thirty-nine patients were entered into a trial of ilmofosine administered weekly for 4 weeks followed by a 2-week rest period. Dose escalation occurred in 10 levels from 12 to 650 mg/m(2).

RESULTS

Thirty-six patients were evaluable for toxicity. The median number of cycles per patient was 1 (range, 1-4). Dose-limiting gastrointestinal toxicity occurred at 650 mg/m(2) with grade 3 nausea in two patients and grade 3 vomiting and diarrhea in one patient. Grade 2 diarrhea was observed in four of six patients treated at 550 mg/m(2). In addition, two patients treated at 550 mg/m(2) and two patients treated at 650 mg/m(2) experienced a decline in performance status of two or more levels that was determined to be due to treatment. There were no tumor responses. Stabilization of disease for at least 8 weeks occurred in six patients. Plasma concentrations of ilmofosine and its sulfoxide metabolite were evaluated by high-pressure liquid chromatography. The elimination of both compounds was biexponential with terminal half-lives of approximately 40 h for ilmofosine and 48 h for the sulfoxide. The area under the concentration-time curve was dose-proportional for each compound, and there was no evidence of saturable kinetics.

CONCLUSIONS

The dose-limiting toxicity of ilmofosine is gastrointestinal and the recommended dose for Phase II trials is 450 mg/m(2) as a 2-h weekly infusion. The relatively long half-life of ilmofosine and its active metabolite support the use of this intermittent schedule.

Monoclonal antibodies in the treatment of colorectal cancer

Monoclonal antibodies have been developed to target specific proteins involved in the development and progression of cancer. These reagents have the advantage of exquiste specificity, and as currently engineered, low toxicity. The impact monoclonal antibody therapy has recently been demonstrated in colorectal cancer, in which two pathways critical to carcinogenesis have been targeted. The targets are the epidermal growth factor receptor signaling pathway and angiogenesis. Antibodies directed to proteins in both pathways have shown significant activity especially in combination with chemotherapy, and studies in the adjuvant setting are in progress. We review the use of monoclonal antibodies in the treatment of colorectal cancer with particular attention to edrecolomab (Mab 17-1A), bevacizumab (Avastin), cetuximab (IMC-C225), ABX-EGF and EMD 72000. Additional compounds are in earlier stages of development, and the future of this approach in solid tumours is promising.