Osimertinib treatment based on plasma T790M monitoring in patients with EGFR-mutant non-small cell lung cancer (NSCLC): EORTC Lung Cancer Group 1613 APPLE phase II randomized clinical trial

BACKGROUND

The APPLE trial aimed to evaluate the feasibility of longitudinal plasma EGFR T790M monitoring for the best sequencing strategy of gefitinib and osimertinib.

METHODS

APPLE is a randomized, non-comparative, phase II study in patients with common EGFR-mutant, treatment-naïve NSCLC including 3-arms: Arm A (osimertinib upfront until RECIST progression, PD), Arm B (gefitinib until emergence of circulating tumor DNA EGFR T790M mutation by cobas EGFR Test v2 or RECIST PD) and Arm C (gefitinib until RECIST PD), and then switch to osimertinib in both arms. The primary endpoint is the progression-free survival rate "on osimertinib" at 18 months (PFSR-OSI-18) after randomization in Arm B (H₀: PFSR-OSI-18 of ≤40%). Secondary endpoints include response rate, overall survival (OS) and brain PFS (BPFS). We report the results of Arms B and C.

RESULTS

From November 2017 to February 2020, 52 and 51 patients were randomized into Arms B and C. Most patients were females (70%) and had EGFR Del19 (65%); one-third had baseline brain metastases. In Arm B, 17% of patients (8/47) switched to osimertinib based on the emergence of ct-DNA T790M mutation before RECIST PD, with a median time to molecular PD of 266 days. The study met its primary endpoint of PFSR-OSI-18 by 67.2% (84% CI: 56.4-75.9%) in Arm B vs. 53.5% (84% CI 42.3-63.5%) in Arm C, with a median PFS of 22.0 months vs. 20.2 months, respectively. The median OS was not reached in Arm B vs. 42.8 months in Arm C. Median BPFS in Arms B and C were 24.4 months and 21.4 months, respectively.

CONCLUSIONS

The serial monitoring of ct-DNA T790M-status in advanced EGFR-mutant NSCLC during treatment with first-generation EGFR inhibitors was feasible, and a molecular progression before RECIST PD led to an earlier switch to osimertinib in 17% of patients with satisfactory PFS and OS outcomes.

Analysis of mismatch repair (MMR) proteins expression in a series of malignant pleural mesothelioma (MPM) patients

BACKGROUND

Promising results have been reported with immune checkpoint inhibitors (ICI) in a small proportion of MPM patients. MMR deficiency (dMMR) has been well described in several malignancies and was approved as a biomarker for anti-PD-1 inhibitors. Next generation sequencing (NGS) data demonstrated that 2% of MPM harbor microsatellite instability. The aim of this study is to characterize MMR by immunohistochemistry (IHC) in a series of MPM including a subset of patients treated with immunotherapy.

METHODS

Tumors of 159 MPM p diagnosed between 2002 and 2017 were reviewed. Formalin-fixed, paraffin-embedded tissue was stained for MLH1, MSH2, MSH6 and PMS2 and tumors were classified as dMMR (MMR protein expression negative) and MMR intact (all MMR proteins positively expressed). We retrospectively collected clinical outcomes under standard chemotherapy and experimental immunotherapy in the entire cohort.

RESULTS

MMR protein expression was analyzed in 158 samples with enough tissue and was positive in all of the cases. Twenty two patients received ICI with anti-CTLA4 or anti-PD-1 blockade in clinical trials, 58% had a response or stable disease for more than 6 m, with median progression-free survival (PFS) of 5.7 m (2.1-26.1 m). The median overall survival (mOS) in all population was 15 months (m) (13.5-18.8 m). In a multivariable model factors associated to improved mOS were PS 0, neutrophil-lymphocyte ratio (NLR) < 5 and epithelioid histology (p < 0.001).

CONCLUSIONS

In our series we were unable to identify any MPM patient with dMMR by IHC. Further studies are needed to elucidate potential predictive biomarkers of ICI benefit in MPM.

A comparison of female and castrate pigs slaughtered at weights above and below 120 kg on carcass traits, intramuscular fat and fatty acid composition of carcasses intended for dry-cured ham and shoulder production

The objective of this trial was to study the impact of slaughter weight (SW) class: heavy (≥120 kg) or light (&lt;120 kg) on carcass fatness, development of main lean cuts and fat composition in barrows and gilts intended for dry-cured ham and shoulder elaboration. A total of 181 Duroc × (Landrace × Large White) pigs was used, being 94 barrows and 87 gilts. Carcasses from barrows had lower ham compactness but higher shoulder:ham weight ratio than those from gilts. The allometric growth coefficient of ham was higher in gilts whereas those for shoulder, loin and shoulder/ham were higher in barrows. An interaction sex × SW class was found for carcass fatness; the increase of fat thickness was higher in barrows than in gilts in light SW class but higher in gilts than in barrows in heavy SW class. In addition, the allometric growth coefficients for ham, loin and shoulder:ham ratio were higher in light than in heavy pigs. Percentage of rejected carcasses at slaughterhouse, due to lack of fat thickness, was higher for females than for barrows and for light than for heavy pigs. Sex and SW class had no effect on intramuscular fat content. However, more saturation was found in fat (intramuscular) from barrows and in that (subcutaneous) from light pigs. It can be concluded that carcasses from barrows are commercially more suitable than those from gilts and heavy SW might be more interesting when animals are intended for Teruel dry-cured ham and shoulder production.

Anisakis simplex allergy after eating chicken meat

BACKGROUND

Allergic reactions to food can be produced by contaminants that induce sensitization. Among these, Anisakis simplex can cause seafood infestation, and allergic symptoms (urticaria-angioedema, anaphylaxis, and asthma) can follow the eating or handling of affected fish. Although seafood is the principal source of human infections by this parasite, we have found allergic symptoms in 8 patients previously diagnosed as having A simplex sensitization after they ate chicken meat. Chicken feed usually has a high proportion of fishmeal, which might possibly be contaminated by this nematode.

OBJECTIVE

The aim of our study was to determine whether parasite proteins present in chicken meat could be responsible for the symptoms reported by these subjects.

METHODS

We carried out in vivo tests (prick, bronchial challenge, and double-blind placebo-controlled challenge with meat chicken) in these 8 patients. We performed immunoblotting using the sera from the 8 patients and controls in order to detect A simplex sensitization. We also investigated the presence of A simplex proteins in sera from chickens fed with fishmeal and in other sera from chickens fed only with cereals. We excluded sensitization to other chicken nematodes by serologic methods.

RESULTS

All 8 patients presented positive prick and challenges to A simplex. When we used serum from chickens fed with fishmeal as the antigen in blotting, patients 3, 4, 5, 6, 7, and 8 recognized a band of 16 kd, also obtained when using pools of fish-shellfish and A simplex larva. No detection was observed with sera from chickens fed with only cereals.

CONCLUSION

We provide evidence, based on in vivo and in vitro tests, that subjects highly sensitized to A simplex can detect the presence of Anisakis species allergens in chicken meat.

Living in towers as risk factor of pollen allergy

BACKGROUND

The effects of fluctuations in pollen counts have important implications for health services. Little research on the clinical implications of the vertical distribution of pollen in allergy symptoms has been carried out.

METHODS

We have investigated the allergic symptoms of a population of 17 171 patients coming from our health area (Valladolid, Spain) and living in the city and villages. We compared the prevalence of sensitization to different pollens: Graminae, trees and shrub in relation with the floor of the building where they were living.

RESULTS

Relative risk of pollen sensitization (confidence index, CI 95%) was higher in patients who were living at high floors than in those patients who were living in lower floors or at street level, independently of rural or urban conditions The chi-square showed a lineal trend in this relationship in the case of sensitization to grass pollen: chi(2): 1794, P > 0.00001

CONCLUSIONS

On the basis of our local investigations, natural pollen sensitization appears to increase with height where the patient lives. This paper reports clinical results on the influence of vertical pollen distribution in pollen allergy.

Cereal-induced anaphylaxis in an adult after eating a baby cereal formula

Ingestion of infant cereal formula as a cause of anaphylaxis has been exclusively described in children. We report the case of a man who experienced an anaphylactic reaction after eating his son's cereal formula. We believe that cereals constitute a rising problem and a hidden allergen that can cause severe reactions. Although these reactions are not fully understood, they may possibly be a life-long event.

Enhancement of tomato allergenicity after treatment with plant hormones

BACKGROUND

Practical applications to enhance the productivity of agriculture by using plants with improved resistance to pathogens are expected to increase in the near future. Although tomato has been widely investigated for breeding purposes, there have been no studies on tomato allergenicity after plant hormones treatments.

METHODS

Prick by prick tests were carried out with different tomato samples (fruits grown under biological conditions without addition of chemical products, and treated with ethylene and salicylic acid) in eight patients with ages between 12 and 27 years who suffered from anaphylaxis episodes after eating raw tomatoes. An immunoblot experiment with the different tomato extracts was performed using sera from these eight patients and controls.

RESULTS

The wheals obtained in prick tests were significantly higher with the extracts of tomato treated with ethylene and SAA (chi(2) = 31.3, p < 0.0001) and the patients who presented higher wheal diameters in skin tests were those who had more severe episodes of anaphylaxis. Neither the protein stain nor the IgE immunodetection patterns clearly varied between the untreated and the hormone-treated samples.

CONCLUSIONS

In the case of anaphylaxis induced by tomato, the treatment with plant hormones induced a higher cutaneous response than with non-treated tomato, but the "in vitro" response was similar.

Allergy after ingestion or inhalation of cereals involves similar allergens in different ages

BACKGROUND

Cereals are among the major foods that account for food hypersensitivity reactions. Salt-soluble proteins appear to be the most important allergens contributing to the asthmatic response. In contrast, very limited information is available regarding cereal allergens responsible for allergic reactions after ingestion of cereal proteins.

OBJECTIVE

The aim of this study was to evaluate the allergenic reactivity of ingested and inhaled cereal allergens in different ages, in order to investigate if the response to different allergens would depend on the sensitization route.

METHODS

We included 66 patients in three groups. Group 1: 40 children aged 3 to 6 months who suffered from diarrhoea, vomiting, eczema or weight loss after the introduction of cereal formula in their diet and in which a possibility of coeliac disease was discarded. Group 2: 18 adults with food allergy due to cereals tested by prick tests, specific IgE and food challenge. Group 3: eight patients previously diagnosed as having baker's asthma. Sera pool samples were collected from each group of patients and IgE immunoblotting was performed.

RESULTS

We found an important sensitization to cereal in the 40 children. The most important allergens were wheat followed by barley and rye. Among the adults with cereal allergy, sensitization to other allergens was common, especially to Lolium perenne (rye grass) pollen. Immunoblotting showed similar allergenic detection in the three groups.

CONCLUSION

Clinically significant reactivity to cereal may be observed in early life. Inhalation and ingestion routes causing cereal allergy seem to involve similar allergens. The diet control was more effective in children. The possibility of cereal allergy after the introduction of cereal formula during the lactation period should not be underestimated.

Is Lolium pollen from an urban environment more allergenic than rural pollen?

BACKGROUND

Allergy to grass pollen is a highly prevalent allergic disease. Hay fever is more predominant in urban than in rural areas, despite the increasingly smaller areas of surrounding grassland. The effect of vehicle exhaust pollutants, mainly diesel particles, and other industrial sources of atmospheric pollution leading to plant damage has been implicated in this phenomenon.

OBJECTIVE

This study compared the in vivo and in vitro allergenicity of pooled samples of Lolium perenne grass pollen harvested from 10 different urban areas with that of samples of the same pollen from 10 neighboring rural areas.

METHODS

Lolium perenne pollen from different parts of a city and from a nearby rural area was harvested in 1999 and 2000 during the peak pollination period. Protein composition was compared by SDS-PAGE and in vivo and in vitro IgE-binding capacity was compared by skin-prick tests, RAST-inhibition and measurement of the major allergen, Lol p 5.

RESULTS

In the two years under study, urban samples contained approximately twice the protein content of the rural samples. Biological activity and Lol p 5 content was higher in urban pollen than in rural pollen and showed differences in the two years under study.

CONCLUSIONS

The protein content and allergenicity of Lolium perenne pollen was higher in urban areas than in rural areas. These differences might explain why allergy to grass pollen is more prevalent in urban areas. This finding should be taken into account in diagnosis, preventive measures and specific immunotherapy.

Early introduction of cereals into children's diets as a risk-factor for grass pollen asthma

BACKGROUND

The prevalence of asthma has increased from the 1950s to the 1990s. The relationship between diet and asthma is an area of controversy that has never been fully evaluated. Attempts at dietary prevention of asthma have produced conflicting results. We have recently identified allergens from cereals that show cross-reactivity with proteins in grass pollen. An early intake of cereals in the diet during early life might cause IgE sensitization to cereals. It is not known whether such sensitization predisposes the development of allergy to pollen.

METHODS

To test this hypothesis, a cross-sectional study and an observational case-control analysis of reviewed data were carried out on 16381 patients who had been admitted to our Allergy Unit between 1989 and 1999. All the patients underwent allergy tests to identify asthma risk-factors. All information in our data base was analysed using the SPSS computer system.

RESULTS

There has been an increase of 7.8% in incidences of allergic asthma and a 7.3% increase in asthma due to grass pollen in the last decade. Grass-pollen asthma was associated with sensitization to cereals. The early introduction of cereals in the diet of children was found to be a risk factor for grass-pollen asthma (OR = 5.95; 95% CI 3.89-9.10).

CONCLUSIONS

These findings document the progression of allergic asthma during a decade in a large sample of people who were influenced by similar environmental conditions and studied with the same diagnostic methods. This study represents the largest database of patients in which a common food is shown to be a risk factor for asthma.

Anaphylaxis associated with antiphospholipid syndrome

BACKGROUND

To our knowledge, no previously published reports have described food-induced anaphylaxis associated with the antiphospholipid syndrome.

OBJECTIVE

We undertook a study of four patients with thrombosis associated with the antiphospholipid syndrome after each patient experienced anaphylaxis attributable to ingestion of vegetal foods.

METHODS

IgE antibody levels to various foods were determined in serum specimens from the study patients, and skin prick tests with the same allergens were conducted to determine their in vivo responses. Hematologic, cardiopulmonary, vascular, and rheumatologic studies were also performed. IgG anticardiolipin antibody levels were determined by ELISA.

RESULTS

All four patients fulfilled the criteria for antiphospholipid syndrome and had high levels of specific IgE antibodies for certain food allergens. By immunoblot analysis, the presence of serum IgE specific for a 45-kD protein band in an almond extract was detected in these four patients who experienced food-related anaphylaxis. No specific IgE was detected in sera from normal subjects. No IgE antibodies specific for the food panallergen lipid transfer proteins were detected.

CONCLUSIONS

This is the first report of severe food-precipitated anaphylaxis associated with the antiphospholipid syndrome and the first description of a patient with allergy to blackberry. The possible involvement of food panallergens distinct from lipid transfer proteins is also discussed.

Anaphylaxis after ingestion of sharon fruit

BACKGROUND

The sharon fruit is the edible fruit of the persimmon tree (Diospyros kaki) which belongs to the Ebenaceae family. There are few references of allergic reaction to this fruit. We introduce a case of a 33-years old man with a anaphylactic reaction immediately after ingestion of sharon fruit.

METHODS

Skin prick test (SPT) were performed by prick by prick with sharon fruit, legumes, vegetables, and fresh fruit. The test was considered positive when the average diameter of the wheal was > 3 mm. Serum-specific IgE was identified with use of the EIA, and SDS-PAGE Immunoblotting.

RESULTS

The skin by prick test with sharon fruit was positive in our case, and negative in five controls patients. Specific IgE in patient serum, assayed by EIA was positive for sharon fruit, but the results of immunoblotting were non-specific.

CONCLUSION

We have introduced a cause of anaphylaxis by sharon fruit that suggest an IgE mediated hypersensitivity reaction.

Occupational asthma by Anisakis simplex

BACKGROUND

No cases of occupational asthma caused by the inhalation of antigens from Anisakis simplex have been published.

OBJECTIVE

The purpose of this study was to evaluate the possibility that A simplex can play a role in the asthma experienced by 2 workers when handling fish and fish flour.

METHODS

Skin prick and bronchial challenge tests with A simplex were performed. We also carried out measurements of specific IgE to A simplex and immunoblotting.

RESULTS

Both patients had strong positive skin test responses, challenge test responses, and specific IgE to A simplex. Immunoblotting showed that both patients also had IgE against several bands in the fish flour extract, suggesting contamination by Anisakis allergens.

CONCLUSION

These 2 patients provide evidence for occupational asthma caused by A simplex, based on in vivo and in vitro tests for Anisakis-specific IgE.

Celiac plexus block as treatment for refractory pain related to sclerosing cholangitis in AIDS patients

Sclerosing cholangitis may be a cause of refractory pain in patients infected with the human immunodeficiency virus. We performed celiac plexus block in three such patients with sever pain from sclerosing cholangitis and a poor response to conventional analgesia. The pain had been centered in the epigastrium and/or upper-right quadrant of the abdomen for 2, 10, and 15 weeks, respectively. Computed tomography-guided celiac plexus block with absolute alcohol and bupivacaine was performed. All three patients reported complete disappearance of the pain immediately after the procedure in two cases and 3 days later in the remaining patient. All patients were discharged free of pain and without analgesics and were followed up for 2, 8, and 11 months, respectively, without recurrence of pain. Celiac plexus block deserves further trial for the treatment of severe pain associated with sclerosing cholangitis in patients with acquired immunodeficiency syndrome. The quality of life of our three patients was considerably improved with this relatively simple procedure.