A phase I/II study of belinostat (PXD101) in patients with unresectable hepatocellular carcinoma

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Background: Hepatocellular carcinoma (HCC) is a common cause of cancer morbidity and mortality. It is a highly aggressive tumor with 90% presenting with unresectable disease, resulting in a median survival of 3–6 months. Inhibitors of histone deacetylase (HDAC) have been demonstrated in HCC cell lines and xenografts to induce apoptosis and tumor regression, and have anti-proliferative, anti-metastatic and anti-invasive effects. Belinostat (N-hydroxy-3-[phenylsulphamoylphenyl] acryl amide) is a novel, low molecular weight, HDAC inhibitor. The Cancer Therapeutic Research Group (CTRG) is conducting a phase I/II study of belinostat as the first line therapy for pts with unresectable HCC. The phase I study aims to determine dose limiting toxicity (DLT) and maximum tolerated dose (MTD). Methods: Patient eligibilities include histologically or cytologically confirmed unresectable HCC, ECOG = 2, adequate hematologic, renal and hepatic functions. The dose of belinostat was started at 600 mg/m2/day i.v. on day 1–5 every 3 weeks; with increment of 300 mg/m2/day up to 1200 mg/m2/day. Dose limiting toxicities (DLT) are defined as grade 4 hematological toxicity or grade 3 or 4 nonhematological toxicity during cycle 1 (according to NCI CTC v3), or treatment delay >2 weeks. The MTD is defined as the dose below which ≥ 2 of 3 or ≥ 2 of 6 patients experiencing DLT. After determination of the MTD, 3 additional patients will be treated at this dose to further define toxicity. Results: From June-December 2006, 12 pts were entered; 3 were treated at level I (600 mg/m2/day), 3 at level 2 (900 mg/m2/day), and 6 at level 3 (1200 mg/m2/day). There were no DLTs on level 1, 2 or 3. Therefore, the MTD of belinostat was not reached. Overall toxicities were WBC gr. 0/1/2/3/4: 12/0/0/0/0, ANC gr. 0/1/2/3/4: 12/0/0/0/0; Hb gr. 0/1/2/3/4: 4/7/0/1/0; platelet gr. 0/1/2/3/4: 8/4/0/0/0; lethargy gr. 0/1/2/3: 12/0/0/0/0, phlebitis gr. 0/1/2/3: 10/0/2/0; Cough gr. 0/1/2/3: 9/0/3/0; Nausea gr. 0/1/2/3: 7/3/2/0 and vomiting gr. 0/1/2/3: 9/3/0/0. Conclusions: At the maximum dose of 1200 mg/m2/day (level 3), MTD has not been reached. Belinostat is very well tolerated. Phase II study will be started at dose level 1200 mg/m2/day. Sponsor: The Division of Cancer Treatment and Diagnosis, National Cancer Institute, USA.

No significant financial relationships to disclose.

Radial pressure waveform dP/dt max is a poor indicator of left ventricular systolic function

BACKGROUND

The first derivative of left ventricular (LV) pressure over time (dP/dt max) is a marker of LV systolic function that can be assessed during cardiac catheterization and echocardiography. Radial artery dP/dt max has been proposed as a possible marker of LV systolic function and we sought to test this hypothesis.

MATERIALS AND METHODS

We compared simultaneously recorded radial dP/dt max (by high-fidelity tonometry) with LV dP/dt max (by high-fidelity catheter and echocardiography parameters analogous to LV dP/dt max). In study 1, beat-to-beat radial dP/dt max and LV dP/dt max were recorded at rest and during supine exercise in 12 males (aged 61 +/- 12 years) undergoing cardiac catheterization. In study 2, 2D-echocardiography and radial dP/dt max were recorded in 54 patients (separate to study 1; 39 men; aged 64 +/- 10 years) at baseline and peak dobutamine-induced stress. Three basal septum measures were taken as being analogous to LV dP/dt max: 1. Peak systolic strain rate; 2. Strain rate (SR-dP/dt max) during isovolumic contraction (IVCT) and; 3. Tissue velocity during IVCT.

RESULTS

In study 1 there was a significant difference between resting LV dP/dt max (1461 +/- 383 mmHg s(-1)) and radial dP/dt max (1182 +/- 319 mmHg s(-1); P < 0.001), and a poor, but statistically significant, correlation between the variables (R(2) = 0.006; P < 0.05). Similar results were observed during exercise. In study 2 there were weak (R(2) = -0.12; P = 0.01) to non-significant associations between radial dP/dt max and all echocardiographic measures analogous to LV dP/dt max at rest or peak stress.

CONCLUSION

Radial pressure waveform dP/dt max is not a reliable marker of LV systolic function.

Pharmacogenetic influence of OATP1B1 variants *1b and *15 on irinotecan disposition in Asian and Caucasian cancer patients

13069

Background: The objective of this study was to evaluate the impact of OATP1B1 (SLCO1B1; OATP-C) functional variants on the disposition of irinotecan in Asian and Caucasian cancer patients. Methods: Irinotecan pharmacokinetic parameters and OATP1B1*1a, *1b, *5 and *15 genotyping data were obtained from Asian (N=71) and Caucasian (N=30) cancer patients receiving the drug as a 90-minute i.v. infusion. Genotypic-phenotypic correlations were assessed in cancer patients from each ethnic group. Results: The *1a/*1a genotype and the *15/*15 diplotype were absent in Caucasian cancer patients but present in Asians (*1a/*1a, N=6; *15/*15, N=1). Statistically insignificant differences were observed between patients carrying *1a/*1b and *1b/*1b genotypes and also between *1b/*15, *15/*15 and *15/*15 diplotypes. Compared to wild-type patients (N=6), total irinotecan clearance normalized by BSA was 2- and 3-fold lower in Asian patients carrying at least one *1b (*1a/*1b + *1b/*1b; N=54; P=0.055) and one *15 (*1b/*15 + *5/*15 + *15/*15; N=11; P=0.001) allele, respectively. Significant differences were also present between Asian patients carrying the *15 diplotype and wild-type patients with regard to exposure levels (Cmax/dose/BSA) to irinotecan (P=0.007), SN-38 (P=0.009) and SN-38G (P=0.004) as well as REC (P=0.005) and REG (0.001). The REG was 5-fold (P=0.022) and 27-fold (P=0.001) lower in Asian cancer patients carrying at least one *1b allele and at least one *15 haplotype, respectively, when compared with wild-type patients. No significant differences in pharmacokinetic parameters were found when comparing Caucasian cancer patients carrying at least one *1b allele and those carrying at least one *15 allele (P>0.05). Conclusions: The genotype and diplotype frequencies of the studied OATP1B1 variants were ethnically dependent, and OATP1B1 genotype status accounts, at least in part, for the observed differences in irinotecan disposition in Asian cancer patients. The lack of significant influence of OATP1B1 variants on irinotecan disposition in Caucasian cancer patients is not clear but may have resulted from the small patient population.

No significant financial relationships to disclose.

Cetuximab with irinotecan in first-line treatment of epidermal growth factor receptor (EGFR)-expressing metastatic colorectal cancer (mCRC): Preliminary safety results (CRYSTAL)

3555

Background: Cetuximab is an IgG1 monoclonal antibody targeting the EGFR with proven activity in previously treated mCRC patients (pts). The modified two-weekly de Gramont regimen of irinotecan with infusional 5-fluorouracil (5-FU)/folinic acid (FA) (FOLFIRI) is a standard for metastatic disease. This randomized trial investigates the effectiveness of cetuximab with this chemotherapy combination versus chemotherapy alone in (pts) with EGFR-expressing mCRC previously untreated for metastatic disease. Methods: This phase III trial compares cetuximab (400 mg/m2 week 1 then 250 mg/m2 weekly) added to FOLFIRI (irinotecan 180 mg/m2, FA 400 mg/m2, 5-FU bolus 400 mg/m2, 2400 mg/m2 infusional 5-FU) (group A) vs. FOLFIRI alone (group B) in pts with EGFR-detectable tumors. 1080 pts are planned to detect a difference of ≥ 2 months in PFS with 80% power. The Data Safety Monitoring Board (DSMB) has performed an independent preplanned safety evaluation of 401 treated pts. Results: Pts (M/F 252/149, median age 62 years [range, 19–84], ECOG performance status [PS]: PS0, 57.1%: PS1, 38.4%: PS2, 4.5%) received at least 3 treatment cycles to date. Of the 401 pts, 83 (20.7%) pts completed/discontinued the trial. There were 11 deaths (2.7%) within 30 days of the last study treatment: 5 related to disease, 3 to chemotherapy, and 3 other (2 unknown, 1 intercurrent illness). Most common adverse events of the pooled safety data were skin reactions, diarrhea and nausea. Conclusions: After review of all relevant safety information by the DSMB, the trial continues. Recruitment was completed with 1220 patients in December 2005.

[Table: see text]

[Table: see text]

Final safety findings from a randomized phase III trial of capecitabine + oxaliplatin (XELOX) vs. bolus 5-FU/LV as adjuvant therapy for patients (pts) with stage III colon cancer

3569

Background: Adjuvant capecitabine results in at least equivalent disease-free survival (DFS) to i.v. bolus 5-FU/LV in stage III colon cancer [Twelves et al. 2005]. Early phase III data in 1st-line metastatic colorectal cancer suggest that XELOX is as safe as oxaliplatin + infusional 5-FU ± LV [Sastre et al. 2005; Ducreux et al. 2005]. The XELOXA study compared safety and efficacy of XELOX vs. bolus 5-FU/LV (the standard regimen at study start) as adjuvant therapy for stage III colon cancer. Methods: Pts with resected disease were randomized to receive either XELOX (capecitabine 1000 mg/m2 bid d1–14 + oxaliplatin 130 mg/m2 d1, q3w for 8 cycles) or i.v. bolus 5-FU/LV (Mayo Clinic, LV 20 mg/m2 + 5-FU 425 mg/m2 d1–5, q4w for 6 cycles; or Roswell Park [RP], LV 500 mg/m2 + 5-FU 500 mg/m2 d1, w1–6 in 8w cycles x4). Centers’ preferred 5-FU/LV regimen was selected at study start and used in all pts. Results: 1861/1886 pts randomized between Apr 03 and Oct 04 are evaluable for safety. The rate of related grade 3/4 adverse events (AEs) was 54% for XELOX and 45% for 5-FU/LV ( table ). 60-day all cause mortality was 1.0% in both arms. Treatment-related death rate within 28 days from last dose was 0.7% for XELOX and 0.5% for 5-FU/LV. Conclusions: XELOX causes less myelosuppression and stomatitis but more skin toxicity than 5-FU/LV. The inclusion of oxaliplatin adds neurosensory toxicity. Cross-study comparison of grade 3/4 AEs in the current and MOSAIC trials suggests that XELOX safety is similar to FOLFOX4, with the advantage of an oral fluoropyrimidine-based regimen. Final safety data will be presented at the meeting, and efficacy data will be available in 2007.

[Table: see text]

[Table: see text]

Phase II study of irofulven in recurrent or metastatic gastric cancer: A Cancer Therapeutic Research Group (CTRG) study

14105

Background: Cytotoxic chemotherapy has been widely used in patients (pts) with advanced or metastatic gastric cancer, but the reported high response rates in phase II settings have not been confirmed by randomized trials. Moreover, the therapeutic impact on survival has been modest. The purpose of this study was to evaluate Irofulven, a DNA interacting acylfulvene analog, as first line therapy for pts with recurrent or metastatic gastric cancer. Methods: The main eligibility criteria were: Histologically or cytologically confirmed disease; age > 18 yrs; ECOG ≤ 2; measurable disease; no prior chemotherapy for recurrent or metastatic disease; life expectancy > 3 months. Irofulven was given at 0.45 mg/kg i.v. over 30-min infusion (max. 50 mg), on Day 1 and 8, every 3 weeks. The primary endpoint was treatment response and toxicity; the secondary end-point was survival. A 2-stage phase II design was used. In the first stage, the target enrollment was 20, if ≤ 2 responses were observed, the study would be stopped and the treatment concluded to be ineffective; if ≥ 6 responses were observed, the study drug would be concluded to be active. Otherwise, another 15 pts would be entered into the second stage. Survival was constructed using the Kaplan-Meier method. All patients entering the trial were included in the survival analysis. Results: 23 pts were entered into the first stage. The median no. of cycles per pt was 2 (range: 1–6). 2 pts (9%) had ≥ 1 week delay in administration of subsequent cycle of chemotherapy. For the day 8 chemotherapy, 7 pts (30%) required dose reductions; 5 (22%) had dose omitted. 22% and 17% pts developed grade 3/4 anemia and neutropenia respectively. There was no grade 4 thrombocytopenia or neutropenic fever. Of the 20 evaluable pts, no responses was observed, 3 pts had stable disease after 2 cycles of treatment which was not confirmed by a further assessment. Median overall survival was 6.05 months (95% CI 4.55–9.39). Conclusions: Irofulven was tolerated at the described dose but showed no evidence of antitumor activity in patients with advanced gastric cancer. Acknowledgement: The study was sponsored by the Division of Cancer Treatment and Diagnosis, National Cancer Institute, U.S.A, and its collaborator MGI Pharma, Inc.

No significant financial relationships to disclose.

Irofulven as first line therapy in recurrent or metastatic gastric cancer: a phase II multicenter study by the Cancer Therapeutics Research Group (CTRG)

BACKGROUND

The purpose of this study was to evaluate the tolerability and efficacy of irofulven, a DNA interacting acylfulvene analog, as first line therapy for patients with recurrent or metastatic gastric cancer.

PATIENTS AND METHODS

Twenty-three patients with recurrent or metastatic gastric cancer received irofulven at a dose of 0.45 mg/kg administered intravenously over 30-min infusion (up to a maximum of 50 mg), on days 1 and 8, every 3 weeks.

RESULTS

The median number of cycles delivered per patient was 2 (range 1-6). Two patients (9%) had >or= 1-week delay in administration of subsequent cycle of chemotherapy. For the day 8 chemotherapy, dose reductions were required in seven patients (30%); dose omitting occurred in five patients (22%). Grade 3/4 anemia and neutropenia occurred in 22 and 17% of patients, respectively. There was no grade 4 thrombocytopenia and no neutropenic fever was observed. Of the 20 evaluable patients, there were no responses observed, 3 patients had stable disease after 2 cycles of treatment which was not confirmed by a further assessment. Median overall survival was 6.05 months (95% CI 4.55-9.39).

CONCLUSIONS

Irofulven was tolerated at the dose of 0.45 mg/kg on days 1 and 8, every 3 weeks but showed no evidence of antitumor activity in patients with advanced gastric cancer.

HPB Online: an electronic health education portal in Singapore

In 2001, the Health Promotion Board (HPB) developed HPB Online, an internet-based health education portal to disseminate health messages. The objective of this article is to describe the structure of HPB Online, review its reach as a tool to deliver health information in Singapore, and discuss the advantages of using the internet to complement traditional media such as the television, newspapers and radio. Since its inception in 2001, the numbers of page-views, monthly visits and repeat visitors have increased markedly. The most popular webpages have consistently been Food Info Search. The average length of visit also showed a gradual increase during the study period, from about 11.0 minutes in January 2002 to 18.5 minutes in December 2004. The key advantage of using the HPB Online is that it allows quick delivery of information to the public and this is ideal for time-sensitive issues. It helps Singaporeans to make better informed decisions to maintain and to improve their health. With its high utilisation, the HPB will continue to use the internet as part of its multichannel marketing strategy to disseminate health information.

Clinical and molecular characteristics of hereditary non-polyposis colorectal cancer families in Southeast Asia

Lee S-C, Guo J-Y, Lim R, Soo R, Koay E, Salto-Tellez M, Leong A, Goh B-C. Clinical and molecular characteristics of hereditary non-polyposis colorectal cancer families in Southeast Asia. Hereditary non-polyposis colorectal cancer (HNPCC), predominantly due to germline MLH1/MSH2 mutations, is the commonest form of hereditary colorectal cancer (CRC), but data in Asians are sparse. We sequenced the MLH1/MSH2 coding and promoter core regions in CRC patients diagnosed below age 40, and/or with multiple primary cancers or familial cancer clustering suggestive of HNPCC, and correlated deleterious mutations with clinical and tumour features. Forty-six Chinese, Malay and Indian kindreds participated. Of the 153 cancers reported in the 46 kindreds, stomach (14%) and urogenital cancers (13%) were the most common extracolonic cancers, whereas endometrial cancer comprised only 7%. Eleven different MLH1 and 12 MSH2 mutations were identified, including nine novel and four recurring mutations in the Chinese. One Indian was a compound heterozygote for an MLH1 and MSH2 mutation. The MLH1/MSH2 mutation data in the Malays and the Indians represents the first in these ethnic groups. Factors strongly associated with deleterious mutations were the Amsterdam criteria, family history of stomach or multiple primary cancers, and MSI-high tumours, whereas family history of endometrial cancer and young cancer age alone correlated poorly. Distinct clinical and molecular characteristics were identified among Asian HNPCC kindreds and may have important clinical implications.

Liver Resection after Irinotecan, 5-Fluorouracil, and Folinic Acid for Patients with Unresectable Colorectal Liver Metastases: A Multicenter Phase II Study by the Cancer Therapeutic Research Group

The main objectives of this study were to assess the use of irinotecan, 5-fluorouracil (5-FU), and leucovorin (FA) as neoadjuvant chemotherapy for patients with unresectable colorectal liver metastases and to determine the response rate and proportion of patients that could be down-staged to resectable tumors. Forty patients were treated with irinotecan (180 mg/m2 over 30 min) on d 1, FA (200 mg/m2 over 30 min) followed by 5-FU (400 mg/m2 bolus and continuous infusion of 600 mg/m2 over 22 h) on d 1 and 2 every 2 wk. The overall response rate was 55% (95% CI: 39.5-70.4%). The progression-free survival was 12.1 mo (95% CI: 11.4-14.8 mo). The median overall survival was 20 mo (95% CI: 17.7-26.6 mo). Four patients (10%) have undergone liver resection after a median of eight cycles. Those patients remained alive with a median follow up period of 33 mo. The principal grade 3-4 toxicity was neutropenia in 20 patients (50%). We conclude that the regimen of irinotecan/5-FU/FA was highly active in patients with colorectal cancer and liver metastases with limited toxicity. In a subgroup of patients with initial inoperable liver metastases, this regimen was able to down-stage the disease to an operable stage.

Evaluation of the integrals of target/seabed scattering using the method of complex images

In this paper the integrals which arise in target/seabed scattering problems are examined. These are the integrals which express the propagation of a spherical harmonic term in a fluid above or below a half-space and the integrals which compute the conversion coefficients of outgoing spherical harmonics into incident spherical harmonics after a seabed reflection. A very efficient and accurate method of computing these integrals, using the method of complex images, is derived. Numerical comparisons with the exact integral expressions show the accuracy of this approach.

Retention of corneal epithelial cells following Goldmann tonometry: implications for CJD risk

AIMS

To assess the adequacy of current decontamination methods for the Goldmann tonometer in the context of variant Creutzfeldt-Jakob disease (vCJD).

METHODS

Reusable Goldmann tonometer prisms were used to perform applanation tonometry on different groups of patients. Following tonometry, retained materials were collected from the tonometer prism head and examined using cytological methods. The used tonometers were subjected to a series of conditions to evaluate their effect on the residual cell numbers found on the tonometer heads. These included wiping alone and wiping or washing followed by disinfection of the tonometer prism. The effect on cell counts of drying the prism overnight was studied, as well as drying overnight and then wiping and disinfecting. All disinfections were performed with sodium hypochlorite (0.05% w/v).

RESULTS

The cytology specimens of 69 patients were studied. Patients using eye drops regularly desquamated significantly more corneal epithelial cells with Goldmann tonometry than patients not using regular eye drops. The mean number of cells was 156 (range 0-470) for patients using eye drops and 14 (4-57) for patients not using eye drops (p = 0.004). Wiping or washing the tonometer head reduced the cell number significantly but neither method completely eliminated cells. The two methods were not significantly different (p=0.3). Drying left a large number of cells (23-320 cells).

CONCLUSIONS

Retained corneal epithelial cells, following the standard decontamination routine of tonometer prisms, may represent potential prion infectivity. Manual cleaning was the most important step in reducing epithelial cell retention.

Measurements and modeling of acoustic scattering from partially and completely buried spherical shells

The use of low-frequency sonars (2-15 kHz) is explored to better exploit scattering features of buried targets that can contribute to their detection and classification. Compared to conventional mine countermeasure sonars, sound penetrates better into the sediment at these frequencies, and the excitation of structural waves in the targets is enhanced. The main contributions to target echo are the specular reflection, geometric diffraction effects, and the structural response, with the latter being particularly important for man-made elastic objects possessing particular symmetries such as bodies of revolution. The resonance response derives from elastic periodic phenomena such as surface circumferential waves revolving around the target. The GOATS'98 experiment, conducted jointly by SACLANTCEN and MIT off the island of Elba, involved controlled monostatic measurements of scattering by spherical shells which were partially and completely buried in sand, and suspended in the water column. The analysis mainly addresses a study of the effect of burial on the dynamics of backscattered elastic waves, which can be clearly identified in the target responses, and is based on the comparison of measurements with appropriate scattering models. Data interpretation results are in good agreement with theory. This positive result demonstrates the applicability of low-frequency methodologies based on resonance analysis to the classification of buried objects.

Prophylactic lamivudine prevents hepatitis B reactivation in chemotherapy patients

BACKGROUND

Chronic hepatitis B virus carriers receiving chemotherapy develop a high hepatitis B virus reactivation rate (38-53%) with a high mortality (37-60%). Few studies have characterized the efficacy of lamivudine in the treatment of chemotherapy-induced hepatitis B virus reactivation.

AIM

To determine whether lamivudine prophylaxis reduces chemotherapy-induced hepatitis B virus reactivation and mortality.

METHODS

The medical records of all hepatitis B surface antigen-positive patients with malignancy treated with chemotherapy since 1995 at the National University Hospital of Singapore were identified, and divided into those who received lamivudine prophylaxis before chemotherapy (P) and those who did not (NP). The parameters examined included gender, age, malignancy type, steroid usage, number of chemotherapy courses and regimens, follow-up duration and hepatitis B virus status. The outcome measures were hepatitis B virus reactivation (abrupt rise of serum alanine aminotransferase to > 200 IU/L) and reactivation death. Patients with primary hepatoma or liver metastasis were excluded.

RESULTS

Thirty-five patients were identified: 16 in the P group and 19 in the NP group. The baseline characteristics of the two groups were similar. Seven of the 19 patients in the NP group and none of the 16 patients in the P group developed reactivation (36.8% vs. 0%, P=0.009). Six of the seven patients in the NP group who developed reactivation received lamivudine at that time, but five died (mortality, 71.4%), whilst no patient in the P group died from reactivation (P=0.064).

CONCLUSIONS

Prophylactic lamivudine appears to prevent hepatitis B virus reactivation and its associated mortality in patients treated with chemotherapy. This should be confirmed with prospective studies.

Effects of glia maturation factor overexpression in primary astrocytes on MAP kinase activation, transcription factor activation, and neurotrophin secretion

Using the replication-defective adenovirus vector, we overexpressed rat glia maturation factor (GMF) in primary astrocyte cultures derived from embryonic rat brains. Among the three isoforms of MAP kinase, there was a big increase in the phosphorylation of p38, as detected with Western blotting using the phosphospecific antibody. Likewise, there was a substantial increase in the phosphorylation of the transcription factor CREB. Using the electrophoretic mobility shift assay (EMSA), we found a stimulation in the transcription factor NF-kappaB. The activations of CREB and NF-kappaB were blocked by inhibitors of either p38 (SB-203580) or MEK (PD-098059), suggesting that they were events downstream of MAK kinase. There was an increased secretion of BDNF and NGF into the conditioned medium, along with an increase in their messenger RNA. The inductions of BDNF and NGF were also blocked by inhibitors of p38 and MEK, as well as by the inhibition of NF-kappaB with a decoy DNA sequence. Taken together, the results suggest that GMF functions intracellularly in astrocytes as a modulator of MAP kinase signal transduction, leading to a series of downstream events including CREB and NF-kappaB activation, resulting in the induction and secretion of the neurotrophins.