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Heinrich MC, Jones RL, George S, Gelderblom H, Schöffski P, von Mehren M, Zalcberg JR, Kang YK, Razak AA, Trent J, Attia S, Le Cesne A, Siontis BL, Goldstein D, Boye K, Sanchez C, Steeghs N, Rutkowski P, Druta M, Serrano C, Somaiah N, Chi P, Reichmann W, Sprott K, Achour H, Sherman ML, Ruiz-Soto R, Blay JY, Bauer S. Ripretinib versus sunitinib in gastrointestinal stromal tumor: ctDNA biomarker analysis of the phase 3 INTRIGUE trial. Nat Med 2024; 30:498-506. [PMID: 38182785 PMCID: PMC10878977 DOI: 10.1038/s41591-023-02734-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/22/2023] [Indexed: 01/07/2024]
Abstract
INTRIGUE was an open-label, phase 3 study in adult patients with advanced gastrointestinal stromal tumor who had disease progression on or intolerance to imatinib and who were randomized to once-daily ripretinib 150 mg or sunitinib 50 mg. In the primary analysis, progression-free survival (PFS) with ripretinib was not superior to sunitinib. In clinical and nonclinical studies, ripretinib and sunitinib have demonstrated differential activity based on the exon location of KIT mutations. Therefore, we hypothesized that mutational analysis using circulating tumor DNA (ctDNA) might provide further insight. In this exploratory analysis (N = 362), baseline peripheral whole blood was analyzed by a 74-gene ctDNA next-generation sequencing-based assay. ctDNA was detected in 280/362 (77%) samples with KIT mutations in 213/362 patients (59%). Imatinib-resistant mutations were found in the KIT ATP-binding pocket (exons 13/14) and activation loop (exons 17/18). Mutational subgroup assessment showed 2 mutually exclusive populations with differential treatment effects. Patients with only KIT exon 11 + 13/14 mutations (ripretinib, n = 21; sunitinib, n = 20) had better PFS with sunitinib versus ripretinib (median, 15.0 versus 4.0 months). Patients with only KIT exon 11 + 17/18 mutations (ripretinib, n = 27; sunitinib, n = 25) had better PFS with ripretinib versus sunitinib (median, 14.2 versus 1.5 months). The results of this exploratory analysis suggest ctDNA sequencing may improve the prediction of the efficacy of single-drug therapies and support further evaluation of ripretinib in patients with KIT exon 11 + 17/18 mutations. ClinicalTrials.gov identifier: NCT03673501.
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Affiliation(s)
- Michael C Heinrich
- Division of Hematology/Oncology, Portland VA Health Care System, Portland, OR, USA
- Department of Medicine, OHSU Knight Cancer Institute, Portland, OR, USA
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Suzanne George
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Patrick Schöffski
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Margaret von Mehren
- Department of Hematology/Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - John R Zalcberg
- Department of Medical Oncology, Monash University School of Public Health and Preventive Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Yoon-Koo Kang
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Albiruni Abdul Razak
- Division of Medical Oncology, Toronto Sarcoma Program, Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Jonathan Trent
- Department of Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Steven Attia
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Axel Le Cesne
- Medical Oncology Department, Gustave Roussy, Villejuif, France
| | | | - David Goldstein
- Department of Medical Oncology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Kjetil Boye
- Department of Tumor Biology, Oslo University Hospital, Oslo, Norway
| | - Cesar Sanchez
- Department of Hematology-Oncology, Centro de Cáncer, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warszawa, Poland
| | - Mihaela Druta
- Sarcoma Program, Moffitt Cancer Center, Tampa, FL, USA
| | - César Serrano
- Sarcoma Translational Research Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Neeta Somaiah
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Kam Sprott
- Biometrics, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
- Translational Medicine, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Haroun Achour
- Biometrics, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
- Clinical Development, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Matthew L Sherman
- Clinical Development, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Rodrigo Ruiz-Soto
- Clinical Development, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Jean-Yves Blay
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Sebastian Bauer
- Department of Medical Oncology and Sarcoma Center, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany.
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2
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Gelderblom H, Jones RL, Blay JY, George S, von Mehren M, Zalcberg JR, Kang YK, Razak AA, Trent J, Attia S, Le Cesne A, Siontis BL, Goldstein D, Boye K, Sanchez C, Steeghs N, Rutkowski P, Druta M, Serrano C, Somaiah N, Chi P, Harrow B, Becker C, Reichmann W, Sherman ML, Ruiz-Soto R, Heinrich MC, Bauer S. Patient-reported outcomes and tolerability in patients receiving ripretinib versus sunitinib after treatment with imatinib in INTRIGUE, a phase 3, open-label study. Eur J Cancer 2023; 192:113245. [PMID: 37598656 DOI: 10.1016/j.ejca.2023.113245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE In the INTRIGUE trial, ripretinib showed no significant difference versus sunitinib in progression-free survival for patients with advanced gastrointestinal stromal tumour (GIST) previously treated with imatinib. We compared the impact of these treatments on health-related quality of life (HRQoL). PATIENTS AND METHODS Patients were randomised 1:1 to once-daily ripretinib 150 mg or once-daily sunitinib 50 mg (4 weeks on/2 weeks off). Patient-reported outcomes were assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Cancer-30 (EORTC QLQ-C30) questionnaire at day (D)1, and D29 of all cycles until treatment discontinuation. Change from baseline was calculated. Time without symptoms or toxicity (TWiST) was estimated as the mean number of days without progression, death, or grade ≥3 treatment-emergent adverse events per patient over 1 year of follow-up. RESULTS Questionnaire completion at baseline was 88.1% (199/226) for ripretinib and 87.7% (199/227) for sunitinib and remained high for enrolled patients throughout treatment. Patients receiving sunitinib demonstrated within-cycle variation in self-reported HRQoL, corresponding to the on/off dosing regimen. Patients receiving ripretinib reported better HRQoL at D29 assessments than patients receiving sunitinib on all scales except constipation. HRQoL was similar between treatments at D1 assessments, following 2 weeks without treatment for sunitinib patients. TWiST was greater for ripretinib patients (173 versus 126 days). CONCLUSION Patients receiving ripretinib experienced better HRQoL than patients receiving sunitinib during the dosing period and similar HRQoL to patients who had not received sunitinib for 2 weeks for all QLQ-C30 domains except constipation. Ripretinib may provide clinically meaningful benefit to patients with advanced GIST previously treated with imatinib.
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Affiliation(s)
| | - Robin L Jones
- Royal Marsden Hospital and Institute of Cancer Research, London, UK
| | - Jean-Yves Blay
- Centre Léon Bérard and University Claude Bernard Lyon 1, Lyon, France
| | | | | | - John R Zalcberg
- Department of Medical Oncology, Alfred Health and School of Public Health, Monash University, Melbourne, Australia
| | - Yoon-Koo Kang
- Asan Medical Center, University of Ulsan, Seoul, Korea
| | | | - Jonathan Trent
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | | | - David Goldstein
- Prince of Wales Hospital and Clinical School University of New South Wales, New South Wales, Australia
| | - Kjetil Boye
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Cesar Sanchez
- Department of Hematology and Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Piotr Rutkowski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warszawa, Poland
| | | | - César Serrano
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | | | - Ping Chi
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Claus Becker
- Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | | | | | | | - Michael C Heinrich
- Portland VA Healthcare System and Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Sebastian Bauer
- Department of Medical Oncology and Sarcoma Center at the West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
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3
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Salunkhe RR, O'Sullivan B, Huang SH, Su J, Xu W, Hosni A, Waldron J, Irish J, de Almeida J, Witterick I, Montero E, Gilbert RW, Razak AA, Zhang L, Brown D, Goldstein D, Gullane P, Tong L, Hahn E. Dawn of Staging for Head and Neck Soft Tissue Sarcoma: Validation of the Novel 8 th Edition AJCC T Classification and Proposed Stage Groupings. Int J Radiat Oncol Biol Phys 2023; 117:S149. [PMID: 37784378 DOI: 10.1016/j.ijrobp.2023.06.567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) After decades of stagnation, the 8th edition TNM (TNM8) introduced a new T classification for head and neck (HN) soft tissue sarcomas (STS). New size cutoffs of 2 and 4 cm define T1-3, and a novel T4 category is defined by local invasion of adjoining structures. These size cutoffs had been chosen arbitrarily to advance data collection in this unique disease site since literature showed approximately 70% of HN STS did not reach the previous size threshold (5 cm) for the existing T1 category. The definition of the TNM8 T categories also align with mucosal HN cancers. No stage grouping for HN STS was defined since this new classification required more data collection to derive stage groups. This study aims to validate the TNM8 T classification and to propose stage groupings. MATERIALS/METHODS Clinical data of all adult (>16 years) HN STS patients treated from 1988 - 2019 with curative intent in our tertiary cancer center were retrieved from a prospective database, and supplemented with chart review. As per TNM8, cutaneous angiosarcoma, embryonal and alveolar rhabdomyosarcoma, Kaposi sarcoma, and dermatofibrosarcoma protuberans were excluded due to their different behavior. Multivariate analysis (MVA) identified prognostic factors for overall survival (OS). Adjusted hazard ratios (AHR) and recursive partitioning analysis (RPA) were used to derive stage groupings. Stage grouping performance for OS was assessed and also compared against the existing TNM8 groups for non-HN STS. RESULTS A total of 221 patients (N1: 2; M1: 2) were included. Of the 219 M0 patients, 63% were males; median tumor size was 3.0 cm (range: 0.3-14.0); the proportion of TNM8 T1-T4 were 35%, 34%, 26%, and 5%, respectively. Median follow up was 5.9 years. Five-year OS was 79%. MVA confirmed the prognostic value of T category (T4 HR 7.73, 95% CI 3.62-16.5) and grade (G2/3 vs G1 HR 3.7, 95% CI 1.82-7.53), in addition to age (HR 1.03, 95% CI 1.01-1.04) (all p<0.001) for OS. AHR model derived T1-3_Grade 1 as stage 1; T1-3_Grade 2/3 as stage II; and T4_any Grade or any T_N1 as stage III (Table 1); the corresponding 5-year OS was 93%, 73%, and 38%, respectively. Both patients with M1 died within 1.5 years after diagnosis and M1 disease was designated stage IV. The AHR-grouping outperformed the RPA and non-HN TNM8 stage grouping for hazard consistency, hazard discrimination, percent variance explained, hazard difference, and sample size balance. CONCLUSION The novel T4 category introduced in TNM8 is associated with a >7 fold increased risk of death. Grade continues to be a critical prognostic factor in HN STS. The TNM8 HN STS T classifications have been validated, and the proposed new stage groupings with TNM8 incorporating grade have excellent performance for OS.
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Affiliation(s)
- R R Salunkhe
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - B O'Sullivan
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - S H Huang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - J Su
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - W Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - A Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - J Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - J Irish
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - J de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - I Witterick
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - E Montero
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - R W Gilbert
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - A A Razak
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - L Zhang
- Mount Sinai Hospital, Toronto, ON, Canada
| | - D Brown
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - D Goldstein
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - P Gullane
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - L Tong
- Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - E Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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4
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Saha S, Huang SH, O'Sullivan B, Su J, Xu W, Hosni A, Waldron J, Irish J, de Almeida J, Witterick I, Monteiro E, Gilbert RW, Catton CN, Chung P, Brown D, Goldstein D, Razak AA, Gullane P, Hahn E. Outcomes of Head and Neck Cutaneous Angiosarcoma Treated in the IMRT Era. Int J Radiat Oncol Biol Phys 2023; 117:e620-e621. [PMID: 37785859 DOI: 10.1016/j.ijrobp.2023.06.2004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Clinical behavior, natural history, and varied presentations of cutaneous angiosarcomas of the head and neck region (HN), in conjunction with its rarity, have rendered standardization of treatment elusive. We aimed to assess outcomes and patterns of failure for patients treated with surgery and radiation (Sx+RT), and radiation alone (RT). MATERIALS/METHODS A retrospective review of all HN angiosarcoma patients amenable for upfront Sx or RT in our institution between 2004-2018 was completed. Generally, treatment included Sx when feasible, and RT for large or extensive/ill-defined tumors. Demographic, tumor characteristics, local (LC), regional (RC), distant control (DC), and overall survival (OS), as well as patterns (in-field, marginal, out-of-field) of local failure at 5-year were estimated. Univariate analysis (UVA) was conducted to assess association with outcomes. RESULTS A total of 33 patients were eligible (14 Sx+RT and 19 RT). Tumor locations were: scalp (16, 48%). face (n = 12, 36%), and overlapping (5, 15%). Lesion types were: nodular (n = 23, 70%), flat (n = 4, 12%) and mixed (n = 6, 18%). Tumor size was larger in the RT group (median: 10.00 vs 2.85 cm, p<0.01). RT and Sx+RT patients had otherwise similar baseline characteristics: median age 74.3; male 70%; and ECOG performance status ≤1 85%. RT dose fractionations ranged from 50-70 Gy in 25-35 fractions in the RT group and 50-66 Gy in 25-33 fractions in the Sx+RT group. Four (12%) patients received neoadjuvant chemotherapy. Median follow up was 5.5 years. Five-year LC, RC, DC, and OS for RT vs Sx+RT groups were 68% vs 85% (p = 0.28); 95% vs 86% (p = 0.89); 79% vs 86% (p = 0.39); and 45% vs 55% (p = 0.71), respectively. The in-field/marginal/out-of-field local failure rate at 5 years were 16% vs 7% (p = 0.46), 26% vs 15% (p = 0.41), and 13% vs 0% (p = 0.24) for the RT vs Sx+RT groups, respectively. UVA showed that scalp location and ulceration/bleeding were strong adverse features for OS. Bone invasion was significantly associated with lower DC (Table). Lesion type (nodular/flat/mixed), tumor size, and treatment type (Sx+RT vs RT), were not significantly associated with LC or pattern of local failure. CONCLUSION Scalp tumors, as compared to face, portended poorer prognosis, and ulceration/bleeding and bone invasion were associated with increased distant metastases. Sx+RT was the preferred treatment modality when possible and typically used for smaller and better defined tumors. RT was reserved for larger and extensive/ill-defined disease; despite this, in the IMRT era, RT achieves reasonable rates of control, markedly superior to historical series.
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Affiliation(s)
- S Saha
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - S H Huang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - B O'Sullivan
- CHUM (The University of Montreal Hospital Centre), Montreal, QC, Canada
| | - J Su
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - W Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - A Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - J Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - J Irish
- Department of Otolaryngology - Head & Neck Surgery, University Health Network-University of Toronto, Toronto, ON, Canada
| | - J de Almeida
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - I Witterick
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - E Monteiro
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - R W Gilbert
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - C N Catton
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - P Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - D Brown
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - D Goldstein
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - A A Razak
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - P Gullane
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - E Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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5
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Tzelnick S, Soroka HP, Tasnim N, Gilbert RW, Irish JC, Goldstein DP, Brown D, Gullane P, Chepeha DB, Yao CMKL, Sahovaler A, Witterick IJ, Monteiro E, Davies J, Huang SH, O'Sullivan B, Hahn E, Hosni A, Razak AA, Gupta AA, de Almeida JR. The impact of surgical resection margins on outcomes for adults with head and neck osteosarcomas: A Canadian sarcoma research and Clinical Collaboration (CanSaRCC) study. Oral Oncol 2023; 145:106495. [PMID: 37478572 DOI: 10.1016/j.oraloncology.2023.106495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE The aim of the study is to describe the factors that influence outcome in adults with head and neck osteosarcoma (HNO) with a specific focus on the margin status. METHODS Patients with a diagnosis of HNO between the years 1996-2021 were reviewed from the Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC) Database. Baseline characteristics, pathology, treatment, and outcomes were analyzed. Univariable (UVA) and multivariable (MVA) Cox regression models were performed. 5-year locoregional control rate and overall survival (OS) were estimated using Kaplan-Meier method and Log-Rank test. RESULTS Of 50 patients with a median age of 40 years (range 16-80), 27 (54%) were male. HNO commonly involved the mandible (n = 21, 42%) followed by maxilla (n = 15, 30%). Thirteen (33.3%) had low-intermediate grade and 26 (66.6%) had high grade tumors. Three patients (6%) had negative resection margins (>5 mm), 24 (48%) had close margins (1-5 mm), 15 (30%) had positive margins (<1mm) and 7 (16%) had unknown margin status. In total, 39 (78%) received chemotherapy - 22 (44%) received neoadjuvant chemotherapy while 17 (34%) received adjuvant chemotherapy. A total of 12 (24%) patients received radiotherapy, of whom 8 (16%) had adjuvant and 3 (6%) had neo-adjuvant. Median follow-up time was 6.3 years (range 0.26-24.9). Disease recurred in 21 patients (42%), of whom 15 (30%) had local recurrence only, 4 (8%) had distant metastasis, and 2 (4%) had both local and distant recurrence. 5-year locoregional control rate and OS was 62% and 79.2% respectively. Resection margins <3 mm was associated with lower 5 years OS and locoregional control rate (Log-Rank p = 0.02, p = 0.01 respectively). CONCLUSION Osteosarcomas of the head and neck are rare and local recurrence remains a concern. Surgical resection with negative resection margins may improve survival, and a 3 mm resection margin threshold may optimize survival. Radiotherapy and/or chemotherapy should be considered in a multidisciplinary setting based on risk-features.
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Affiliation(s)
- Sharon Tzelnick
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Hagit Peretz Soroka
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada; CanSaRCC, Princess Margaret Cancer Center, Ontario, Canada
| | - Najifah Tasnim
- CanSaRCC, Princess Margaret Cancer Center, Ontario, Canada
| | - Ralph W Gilbert
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Dale Brown
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Patrick Gullane
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Douglas B Chepeha
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Christopher M K L Yao
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Axel Sahovaler
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada
| | - Ian J Witterick
- Department of Otolaryngology-Head and Neck Surgery, Mt Sinai Hospital, Toronto, Ontario, Canada
| | - Eric Monteiro
- Department of Otolaryngology-Head and Neck Surgery, Mt Sinai Hospital, Toronto, Ontario, Canada
| | - Joel Davies
- Department of Otolaryngology-Head and Neck Surgery, Mt Sinai Hospital, Toronto, Ontario, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Albiruni Abdul Razak
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada; Department of Medical Oncology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - Abha A Gupta
- Division of Hematology/Oncology, Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada; CanSaRCC, Princess Margaret Cancer Center, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Hospital, University of Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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6
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Peretz Soroka H, Vora T, Noujaim J, Marcoux N, Cohen‐Gogo S, Alcindor T, Holloway C, Rodrigues C, Karachiwala H, Alvi S, Lee U, Cheng S, Banerji S, Oberoi S, Feng X, Smrke A, Simmons C, Razak AA, Gupta AA. Real-world experience of tyrosine kinase inhibitors in children, adolescents and adults with relapsed or refractory bone tumours: A Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC) study. Cancer Med 2023; 12:18872-18881. [PMID: 37724607 PMCID: PMC10557866 DOI: 10.1002/cam4.6515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/26/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES We conducted a retrospective multi-centre study to assess the real-world outcome of regorafenib (REGO) and cabozantinib (CABO) in recurrent/refractory bone tumours (BTs) including osteosarcoma (OST), Ewing sarcoma (EWS) and chondrosarcoma (CS)/extra-skeletal mesenchymal CS (ESMC). METHODS After regulatory approval, data from patients with recurrent BT (11 institutions) were extracted from CanSaRCC (Canadian Sarcoma Research and Clinical Collaboration) database. Patient characteristics, treatment and outcomes were collected. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS From July 2018 to May 2022, 66 patients received REGO or CABO; 39 OST, 18 EWS, 4 CS and 5 ESMC. Median age was 27.8 years (range 12-76); median starting dose was 60 mg for CABO (n = 37, range 40-60) and 120 mg for REGO (n = 29, range 40-160). Twenty-eight (42.4%) patients required dose reduction: hand-foot syndrome 7 (10.6%), nausea/vomiting 1 (1.5%), diarrhoea 1 (1.5%), 2 elevated LFTs (3%), elevated bilirubin 1 (1.5%) and mucositis 1 (1.5%). The median OS for patients with OST, EWS, CS and ESMC was 8.5 months (n = 39, 95% CI 7-13.1); 13.4 months (n = 18, 95% CI 3.4-27.2), 8.1 (n = 4, 95% CI 4.1-9.3) and 18.2 (n = 5, 95% CI (10.4-na), respectively. Median PFS for OST, EWS, CS and ECMS was 3.5 (n = 39, 95% CI 2.8-5), 3.9 (n = 18, 95% CI 2.1-5.9), 5.53 (n = 4. 95% CI 2.13-NA) and 11.4 (n = 5, 95% CI 1.83-14.7), respectively. Age, line of therapy, REGO versus CABO, or time from diagnosis to initiation of TKI were not associated with PFS on univariable analysis. CONCLUSION Our real-world data show that TKIs have meaningful activity in recurrent BT with acceptable toxicities when started at modified dosing. Inclusion of TKIs in earlier lines of treatment and/or maintenance therapy could be questions for future research.
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Affiliation(s)
- Hagit Peretz Soroka
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity of TorontoTorontoOntarioCanada
| | - Tushar Vora
- Division of Hematology/Oncology, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Jonathan Noujaim
- Division of Medical Oncology, Hôpital Maisonneuve RosemontUniversity of MontrealMontrealQuebecCanada
| | - Nicolas Marcoux
- Division of Hematology‐OncologyCentre Hospitalier Universitaire de QuébecQuebecCanada
| | - Sarah Cohen‐Gogo
- Division of Hematology/Oncology, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Thierry Alcindor
- Division of Medical OncologyMcGill University Health CentreMontrealQuebecCanada
| | - Caroline Holloway
- Division of Radiation Oncology, BC CancerUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Caroline Rodrigues
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity of TorontoTorontoOntarioCanada
| | - Hatim Karachiwala
- Division of Medical Oncology, Cross Cancer InstituteAlberta Health ServicesEdmontonAlbertaCanada
| | - Saima Alvi
- Division of Pediatric Hematology/OncologyJim Pattison Children's Hospital SaskatoonSaskatoonSaskatchewanCanada
| | - Ursula Lee
- Division of Medical Oncology, BC CancerUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Sylvia Cheng
- Division of Pediatric Hematology/Oncology/BMTB.C. Children's Hospital, BC CancerVancouverBritish ColumbiaCanada
| | - Shantanu Banerji
- Department of Pediatric Hematology‐Oncology, CancerCare Manitoba Research Institute, Rady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Sapna Oberoi
- Department of Pediatric Hematology‐Oncology, CancerCare Manitoba Research Institute, Rady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Xiaolan Feng
- Division of Medical Oncology, BC CancerUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Alannah Smrke
- Division of Medical Oncology, BC CancerUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Christine Simmons
- Division of Medical Oncology, BC CancerUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Albiruni Abdul Razak
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity of TorontoTorontoOntarioCanada
- Division of Medical Oncology, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | - Abha A. Gupta
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity of TorontoTorontoOntarioCanada
- Division of Hematology/Oncology, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
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Bauer S, Jones RL, Blay JY, Gelderblom H, George S, Schöffski P, von Mehren M, Zalcberg JR, Kang YK, Razak AA, Trent J, Attia S, Le Cesne A, Su Y, Meade J, Wang T, Sherman ML, Ruiz-Soto R, Heinrich MC. Ripretinib Versus Sunitinib in Patients With Advanced Gastrointestinal Stromal Tumor After Treatment With Imatinib (INTRIGUE): A Randomized, Open-Label, Phase III Trial. J Clin Oncol 2022; 40:3918-3928. [PMID: 35947817 PMCID: PMC9746771 DOI: 10.1200/jco.22.00294] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/11/2022] [Accepted: 06/20/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Sunitinib, a multitargeted tyrosine kinase inhibitor (TKI), is approved for advanced gastrointestinal stromal tumor (GIST) after imatinib failure. Ripretinib is a switch-control TKI approved for advanced GIST after prior treatment with three or more TKIs, including imatinib. We compared efficacy and safety of ripretinib versus sunitinib in patients with advanced GIST who were previously treated with imatinib (INTRIGUE, ClinicalTrials.gov identifier: NCT03673501). PATIENTS AND METHODS Random assignment was 1:1 to once-daily ripretinib 150 mg or once-daily sunitinib 50 mg (4 weeks on/2 weeks off) and stratified by KIT/platelet-derived growth factor α mutation and imatinib intolerance. The primary end point was progression-free survival (PFS) by independent radiologic review using modified Response Evaluation Criteria in Solid Tumors version 1.1. Secondary end points included objective response rate by independent radiologic review, safety, and patient-reported outcome measures. RESULTS Overall, 453 patients were randomly assigned to ripretinib (intention-to-treat [ITT], n = 226; KIT exon 11 ITT, n = 163) or sunitinib (ITT, n = 227; KIT exon 11 ITT, n = 164). Median PFS for ripretinib and sunitinib (KIT exon 11 ITT) was 8.3 and 7.0 months, respectively (hazard ratio, 0.88; 95% CI, 0.66 to 1.16; P = .36); median PFS (ITT) was 8.0 and 8.3 months, respectively (hazard ratio, 1.05; 95% CI, 0.82 to 1.33; nominal P = .72). Neither was statistically significant. Objective response rate was higher for ripretinib versus sunitinib in the KIT exon 11 ITT population (23.9% v 14.6%, nominal P = .03). Ripretinib was associated with a more favorable safety profile, fewer grade 3/4 treatment-emergent adverse events (41.3% v 65.6%, nominal P < .0001), and better scores on patient-reported outcome measures of tolerability. CONCLUSION Ripretinib was not superior to sunitinib in terms of PFS. However, meaningful clinical activity, fewer grade 3/4 treatment-emergent adverse events, and improved tolerability were observed with ripretinib.
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Affiliation(s)
- Sebastian Bauer
- Department of Medical Oncology and Sarcoma Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site Essen, Germany
| | - Robin L. Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | | | | | | | - Patrick Schöffski
- Department of General Medical Oncology, Leuven Cancer Institute, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | | | - John R. Zalcberg
- Monash University School of Public Health and Preventive Medicine and Department of Medical Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Yoon-Koo Kang
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Jonathan Trent
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL
| | | | | | - Ying Su
- Deciphera Pharmaceuticals, LLC, Waltham, MA
| | | | - Tao Wang
- Deciphera Pharmaceuticals, LLC, Waltham, MA
| | | | | | - Michael C. Heinrich
- Portland VA Health Care System, Portland, OR
- OHSU Knight Cancer Institute, Portland, OR
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Gounder MM, Razak AA, Somaiah N, Chawla S, Martin-Broto J, Grignani G, Schuetze SM, Vincenzi B, Wagner AJ, Chmielowski B, Jones RL, Riedel RF, Stacchiotti S, Loggers ET, Ganjoo KN, Le Cesne A, Italiano A, Garcia del Muro X, Burgess M, Piperno-Neumann S, Ryan C, Mulcahy MF, Forscher C, Penel N, Okuno S, Elias A, Hartner L, Philip T, Alcindor T, Kasper B, Reichardt P, Lapeire L, Blay JY, Chevreau C, Valverde Morales CM, Schwartz GK, Chen JL, Deshpande H, Davis EJ, Nicholas G, Gröschel S, Hatcher H, Duffaud F, Herráez AC, Beveridge RD, Badalamenti G, Eriksson M, Meyer C, von Mehren M, Van Tine BA, Götze K, Mazzeo F, Yakobson A, Zick A, Lee A, Gonzalez AE, Napolitano A, Dickson MA, Michel D, Meng C, Li L, Liu J, Ben-Shahar O, Van Domelen DR, Walker CJ, Chang H, Landesman Y, Shah JJ, Shacham S, Kauffman MG, Attia S. Selinexor in Advanced, Metastatic Dedifferentiated Liposarcoma: A Multinational, Randomized, Double-Blind, Placebo-Controlled Trial. J Clin Oncol 2022; 40:2479-2490. [PMID: 35394800 PMCID: PMC9467680 DOI: 10.1200/jco.21.01829] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/23/2021] [Accepted: 02/08/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Antitumor activity in preclinical models and a phase I study of patients with dedifferentiated liposarcoma (DD-LPS) was observed with selinexor. We evaluated the clinical benefit of selinexor in patients with previously treated DD-LPS whose sarcoma progressed on approved agents. METHODS SEAL was a phase II-III, multicenter, randomized, double-blind, placebo-controlled study. Patients age 12 years or older with advanced DD-LPS who had received two-five lines of therapy were randomly assigned (2:1) to selinexor (60 mg) or placebo twice weekly in 6-week cycles (crossover permitted). The primary end point was progression-free survival (PFS). Patients who received at least one dose of study treatment were included for safety analysis (ClinicalTrials.gov identifier: NCT02606461). RESULTS Two hundred eighty-five patients were enrolled (selinexor, n = 188; placebo, n = 97). PFS was significantly longer with selinexor versus placebo: hazard ratio (HR) 0.70 (95% CI, 0.52 to 0.95; one-sided P = .011; medians 2.8 v 2.1 months), as was time to next treatment: HR 0.50 (95% CI, 0.37 to 0.66; one-sided P < .0001; medians 5.8 v 3.2 months). With crossover, no difference was observed in overall survival. The most common treatment-emergent adverse events of any grade versus grade 3 or 4 with selinexor were nausea (151 [80.7%] v 11 [5.9]), decreased appetite (113 [60.4%] v 14 [7.5%]), and fatigue (96 [51.3%] v 12 [6.4%]). Four (2.1%) and three (3.1%) patients died in the selinexor and placebo arms, respectively. Exploratory RNA sequencing analysis identified that the absence of CALB1 expression was associated with longer PFS with selinexor compared with placebo (median 6.9 v 2.2 months; HR, 0.19; P = .001). CONCLUSION Patients with advanced, refractory DD-LPS showed improved PFS and time to next treatment with selinexor compared with placebo. Supportive care and dose reductions mitigated side effects of selinexor. Prospective validation of CALB1 expression as a predictive biomarker for selinexor in DD-LPS is warranted.
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Affiliation(s)
- Mrinal M. Gounder
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Neeta Somaiah
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Giovanni Grignani
- Division of Medical Oncology, Candiolo Cancer Institute, FPO—IRCCS, Candiolo, Torino, Italy
| | | | - Bruno Vincenzi
- Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | | | | | - Robin L. Jones
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Sutton, United Kingdom
| | | | | | | | | | | | | | | | - Melissa Burgess
- University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, PA
| | | | | | - Mary F. Mulcahy
- The Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | | | - Nicolas Penel
- Centre Oscar Lambret and Lille University, Lille, France
| | | | | | - Lee Hartner
- University of Pennsylvania, Philadelphia, PA
| | - Tony Philip
- Northwell Health Physician Partners, New Hyde Park, NY
| | | | - Bernd Kasper
- Mannheim University Medical Center, Mannheim, Germany
| | | | | | | | | | | | | | | | | | | | | | - Stefan Gröschel
- National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Heidelberg, Germany
| | - Helen Hatcher
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Florence Duffaud
- La Timone University Hospital Center and Aix-Marseille University, Marseille, France
| | | | | | - Giuseppe Badalamenti
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | | | | | | | | | - Katharina Götze
- Klinik und Poliklinik für Innere Medizin III, Hämatologie und Onkologie Klinikum rechts der Isar der TU Muenchen, Marburg, Germany
| | | | | | - Aviad Zick
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; The Oncology Department, Hadassah Medical Center, Jerusalem, Israel
| | - Alexander Lee
- The Christie NHS Foundation, Manchester, United Kingdom
| | - Anna Estival Gonzalez
- Catalan Institute of Oncology (ICO) Germans Trias I Pujol University Hospital, B-ARGO, Barcelona, Spain
| | | | - Mark A. Dickson
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | | | | | | | | | | | | | - Hua Chang
- Karyopharm Therapeutics Inc, Newton, MA
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9
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Hahn E, Barot S, O'Sullivan B, Huang SH, Gupta A, Hosni A, Razak AA, Waldron J, Irish J, Gullane P, Brown D, Gilbert R, de Almeida JR, Tsang D, Shultz D. Adult Head and Neck Rhabdomyosarcoma: Management, Outcomes, and the Impact of IMRT on Locoregional Control. Adv Radiat Oncol 2022; 7:101055. [DOI: 10.1016/j.adro.2022.101055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/11/2022] [Indexed: 10/31/2022] Open
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10
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Takebe N, Nguyen J, Kummar S, Razak AA, Chawla SP, George S, Patel SR, Keohan ML, Movva S, O’Sullivan G, Do K, Anderson L, Juwara L, Augustine B, Steinberg S, Kuhlmann L, Ivy SP, Doroshow JH, Chen AP. Abstract CT168: Randomized phase 2 trial of sunitinib or cediranib in alveolar soft part sarcoma. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-ct168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Alveolar soft part sarcoma (ASPS) is a rare, highly vascular tumor with few effective treatment options. Cediranib (C) and sunitinib (S) are potent oral inhibitors of all 3 VEGF receptors. Cediranib showed substantial single-agent activity (objective response rate [ORR] = 35%) in our previous trial in patients (pts) with metastatic ASPS (NCT00942877). Here we report a phase 2 randomized multicenter trial of single agent C or S in pts with ASPS (NCT01391962).
Methods: We conducted a multicenter phase 2 trial with an optimal 2-stage design targeting an ORR of 40%. Enrolled pts were >16 years with metastatic ASPS, previously not treated (N) and unresectable, or previously treated (T), who have progressed per RECIST 1 within the 6-month period preceding enrollment. Pts were randomized to receive C (30 mg) or S (37.5 mg) orally, once a day, in 28-day cycles and could crossover to the other treatment arm at disease progression. ORR (primary endpoint), median progression-free survival (mPFS), and PFS rate at 24 weeks for the 2 arms (C and S) were evaluated; T and N cohorts were assessed separately in each arm. Arm accrual closed if ≤ 1 of the first 10 enrolled pts responded to the first treatment.
Results: Thirty-four pts (47% white, 29.4% black, 17.6% Asian, 5.8% Pacific Islander) were enrolled; 29 pts were evaluable for response. One pt on each of the initial treatment arms had a confirmed partial response (PR), rates of 6.7% (1/154) and 7.1% (1/14) for C and S tx or tx-naive, respectively. Among pts who crossed over, there was 1 PR in a pt receiving C after initially responding (PR) on S (1/9; ORR 11.1%). Twenty-four pts had a best response of stable disease (86.7% and 78.6%) for C and S, respectively. The mPFS was 7.6 months (mo) (95% CI: 3.7-9.9 mo) and 5.5 mo (95% CI: 1.8-14.5 mo) for C and S, respectively administered as first therapy (p=0.92). PFS rate at 24 weeks was 62.5% (95% CI: 29.5-76.2%) and 50% (95% CI: 25.9-70.1%) for pts receiving C and S respectively, as initial therapy. There was no difference in mPFS between T or N pts in the C (6.7 mo [95% CI: 1.4-9.9 mo] vs 8.3 mo [95% CI: 2.7 - 16.6 mo]; P=0.35) arm, but some evidence of a potential difference in the S (4.8 mo [95% CI: 0.9-7.9 mo] vs 14.7 mo 95% CI: 1.8 - 21.6 mo]; P=0.058) arm. Overall, 43.7% (C) and 77.8% (S) of pts experienced grade ≥3 adverse events (AEs) at least possibly related to the study drug. Common grade ≥3 AEs included: diarrhea (C), neutropenia (S), hypertension (C and S). AEs were in line with the known safety profiles of each agent. As of August 2021, 1 pt (unevaluable for ORR) remains on study.
Conclusions: The study did not meet its endpoints for ORR. There were no differences in mPFS for the 2 treatment arms. The selection of pts with more aggressive disease, who had progressed in the 6 months prior to enrollment, may account for the low patient response rates compared to our previous study of cediranib in ASPS.
Funded by NCI Contract No. HHSN261200800001E. The study was a collaboration between NCI and Pfizer.
Citation Format: Naoko Takebe, James Nguyen, Shivaani Kummar, Albiruni Abdul Razak, Sant P. Chawla, Suzanne George, Shreyaskumar R. Patel, Mary Louise Keohan, Sujana Movva, Geraldine O’Sullivan, Khanh Do, Larry Anderson, Lamin Juwara, Brooke Augustine, Seth Steinberg, Laura Kuhlmann, S. Percy Ivy, James H. Doroshow, Alice P. Chen. Randomized phase 2 trial of sunitinib or cediranib in alveolar soft part sarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT168.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Khanh Do
- 5Dana Farber, Harvard Medical School, Boston, MA
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11
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Watson GA, Sanz-Garcia E, Zhang WJ, Liu ZA, Yang SC, Wang B, Liu S, Kubli S, Berman H, Pfister T, Genta S, Spreafico A, Hansen AR, Bedard PL, Lheureux S, Abdul Razak A, Cescon D, Butler MO, Xu W, Mak TW, Siu LL, Chen E. Increase in serum choline levels predicts for improved progression-free survival (PFS) in patients with advanced cancers receiving pembrolizumab. J Immunother Cancer 2022; 10:jitc-2021-004378. [PMID: 35705312 PMCID: PMC9204435 DOI: 10.1136/jitc-2021-004378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background Recent studies have demonstrated that T cells can induce vasodilation in a choline-acetyltransferase dependent manner, leading to an increase in T cell migration to infected tissues in response to viral infection, but its role in cancer is unclear. Choline acetyltransferase catalyzes the production of acetylcholine from choline and acetyl-CoA, however, acetylcholine is challenging to quantify due to its extremely short half-life while choline is stable. This study aims to correlate serum choline levels in patients with advanced solid tumors receiving pembrolizumab with treatment outcomes. Methods Blood samples were collected at baseline and at week 7 (pre-cycle 3) in patients treated with pembrolizumab in the INvestigator-initiated Phase 2 Study of Pembrolizumab Immunological Response Evaluation phase II trial (NCT02644369). Samples were analyzed for choline and circulating tumor DNA (ctDNA). Multivariable Cox models were used to assess the association between choline and overall survival (OS) and progression-free survival (PFS) when including ΔctDNAC3 (the change in ctDNA from baseline to cycle 3), cohort, PD-L1 expression and tumor mutation burden (TMB). An independent validation cohort from the LIBERATE study (NCT03702309) included patients on early phase trials treated with a PD-1 inhibitor. Results A total of 106 pts were included in the analysis. With a median follow-up of 12.6 months, median PFS and OS were 1.9 and 13.7 months, respectively. An increase in serum choline level at week 7 compared with baseline (ΔcholineC3) in 81 pts was significantly associated with a better PFS (aHR 0.48, 95% CI 0.28 to 0.83, p=0.009), and a trend toward a better OS (aHR 0.64, 95% CI 0.37 to 1.12, p=0.119). A combination of ΔctDNAC3 and ΔcholineC3 was prognostic for both OS and PFS. Multivariable analyses show ΔcholineC3 was a prognostic factor for PFS independent of ΔctDNAC3, cohort, PD-L1 and TMB. In the independent validation cohort (n=51), an increase in serum choline at cycle 2 was associated with a trend to improved PFS. Conclusions This is the first exploratory report of serum choline levels in pan-cancer patients receiving pembrolizumab. The association between improved PFS and ΔcholineC3 suggests a possible role for the cholinergic system in the regulation of antitumor immunity. Further pre-clinical and clinical studies are required to validate this finding. Trial registration number NCT03702309.
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Affiliation(s)
- Geoffrey Alan Watson
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Enrique Sanz-Garcia
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Wen-Jiang Zhang
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Zhihui Amy Liu
- Biostatistics, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada.,University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Sy Cindy Yang
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Ben Wang
- Laboratory Medicine and Pathobiology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Shaofeng Liu
- Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Kubli
- Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Hal Berman
- Laboratory Medicine and Pathobiology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Thomas Pfister
- Laboratory Medicine and Pathobiology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sofia Genta
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Albiruni Abdul Razak
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Dave Cescon
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Marcus O Butler
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Wei Xu
- Biostatistics, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Tak W Mak
- Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Eric Chen
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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12
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Taylor K, Loo Yau H, Chakravarthy A, Wang B, Shen SY, Ettayebi I, Ishak CA, Bedard PL, Abdul Razak A, R Hansen A, Spreafico A, Cescon D, Butler MO, Oza AM, Lheureux S, Stjepanovic N, Van As B, Boross-Harmer S, Wang L, Pugh TJ, Ohashi PS, Siu LL, De Carvalho DD. An open-label, phase II multicohort study of an oral hypomethylating agent CC-486 and durvalumab in advanced solid tumors. J Immunother Cancer 2021; 8:jitc-2020-000883. [PMID: 32753546 PMCID: PMC7406114 DOI: 10.1136/jitc-2020-000883] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose To evaluate whether administration of the oral DNA hypomethylating agent CC-486 enhances the poor response rate of immunologically ‘cold’ solid tumors to immune checkpoint inhibitor durvalumab. Experimental design PD-L1/PD-1 inhibitor naïve patients with advanced microsatellite stable colorectal cancer; platinum resistant ovarian cancer; and estrogen receptor positive, HER2 negative breast cancer were enrolled in this single-institution, investigator-initiated trial. Two 28 day regimens, regimen A (CC-486 300 mg QD Days 1–14 (cycles 1–3 only) in combination with durvalumab 1500 mg intravenous day 15) and regimen B (CC-486 100 mg QD days 1–21 (cycle 1 and beyond), vitamin C 500 mg once a day continuously and durvalumab 1500 mg intravenous day 15) were investigated. Patients underwent paired tumor biopsies and serial peripheral blood mononuclear cells (PBMCs) collection for immune-profiling, transcriptomic and epigenomic analyzes. Results A total of 28 patients were enrolled, 19 patients treated on regimen A and 9 on regimen B. The combination of CC-486 and durvalumab was tolerable. Regimen B, with a lower dose of CC-486 extended over a longer treatment course, showed less grade 3/4 adverse effects. Global LINE-1 methylation assessment of serial PBMCs and genome-wide DNA methylation profile in paired tumor biopsies demonstrated minimal changes in global methylation in both regimens. The lack of robust tumor DNA demethylation was accompanied by an absence of the expected ‘viral mimicry’ inflammatory response, and consequently, no clinical responses were observed. The disease control rate was 7.1%. The median progression-free survival was 1.9 months (95% CI 1.5 to 2.3) and median overall survival was 5 months (95% CI 4.5 to 10). Conclusions The evaluated treatment schedules of CC-486 in combination with durvalumab did not demonstrate robust pharmacodynamic or clinical activity in selected immunologically cold solid tumors. Lessons learned from this biomarker-rich study should inform continued drug development efforts using these agents. Trial registration number NCT02811497.
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Affiliation(s)
- Kirsty Taylor
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Helen Loo Yau
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Ankur Chakravarthy
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Genetics and Epigenetics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ben Wang
- Immunology, University of Toronto, Toronto, Ontario, Canada.,Immuno-Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Shu Yi Shen
- Genetics and Epigenetics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ilias Ettayebi
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Charles A Ishak
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Genetics and Epigenetics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Albiruni Abdul Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Dave Cescon
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcus O Butler
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Amit M Oza
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Neda Stjepanovic
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brendan Van As
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sarah Boross-Harmer
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lisa Wang
- Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Trevor J Pugh
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Genomics, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Pamela S Ohashi
- Immunology, University of Toronto, Toronto, Ontario, Canada.,Immuno-Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Daniel D De Carvalho
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada .,Genetics and Epigenetics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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13
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Al-Ezzi E, Gounder M, Watson G, Mazzocca A, D'Angelo SP, Bravetti J, Wang H, Abdul Razak A, Vincenzi B. Selinexor, a First in Class, Nuclear Export Inhibitor for the Treatment of Advanced Malignant Peripheral Nerve Sheath Tumor. Oncologist 2021; 26:e710-e714. [PMID: 33512749 DOI: 10.1002/onco.13692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/15/2021] [Indexed: 01/31/2023] Open
Abstract
Malignant peripheral nerve sheath tumor (MPNST) is a highly malignant neoplasm arising from peripheral nerve or its attendant sheath and is derived from Schwann or pluripotent cells of neural crest origin. Patients with recurrent, unresectable, or advanced stage disease have limited treatment options, and current therapies are associated with little benefit. In this article, we report nine cases of MPNST treated with selinexor, an orally bioavailable, selective inhibitor of nuclear export, accompanied by tumor stabilization or regression.
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Affiliation(s)
- Esmail Al-Ezzi
- Toronto Sarcoma Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Mrinal Gounder
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Geoffrey Watson
- Toronto Sarcoma Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Alessandro Mazzocca
- Department of Medical Oncology, University Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
| | - Sandra P D'Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Weill Cornell Medical Center, New York, New York, USA
| | | | - Hongwei Wang
- Karyopharm Therapeutics Inc, Newton, Massachusetts, USA
| | | | - Bruno Vincenzi
- Department of Medical Oncology, University Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
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14
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Lewin J, Malone E, Al-Ezzi E, Fasih S, Pedersen P, Accardi S, Gupta A, Abdul Razak A. A phase 1b trial of selinexor, a first-in-class selective inhibitor of nuclear export (SINE), in combination with doxorubicin in patients with advanced soft tissue sarcomas (STS). Eur J Cancer 2021; 144:360-367. [PMID: 33418486 DOI: 10.1016/j.ejca.2020.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/13/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Selinexor is a first-in-class selective inhibitor of nuclear export (SINE) compound with single-agent activity in soft tissue sarcoma (STS). The study's aim was to determine the safety and efficacy of selinexor in combination with doxorubicin in patients with locally advanced/metastatic STS. METHODS This phase 1b study used a mTPI design. Patients received selinexor at either 60 or 80 mg weekly PO plus doxorubicin (75 mg/m2 IV q21 days). Patients with clinical benefit (defined as ≥stable disease via RECIST 1.1) after six cycles of combination treatment received maintenance selinexor until disease progression or unacceptable toxicity. Disease assessments were conducted every two cycles. Pharmacokinetic data were collected on the first three patients per dose level. RESULTS Twenty-five patients were enrolled (20 female, ECOG 0/1: 13/12, median age 57 years [range 21-74]). Disease subtypes included leiomyosarcoma (n = 6), malignant peripheral nerve sheath tumour (n = 3) and other sarcomas (n = 16). Three (12%) and 22 (88%) patients were treated at 60 mg and 80 mg of selinexor, respectively. The most common ≥G3 drug-related adverse events (AEs) were haematological, including neutropenia (56%), febrile neutropenia (28%) and anaemia (24%). There were four dose-limiting toxicities (febrile neutropenia (x2), vomiting, fatigue) all at the 80 mg dose level. There was one death secondary to heart failure. Of the 24 evaluable patients, 5 (21%) had a partial response and 15 (63%) had SD as best response. The estimated median progression-free survival (PFS) and overall survival (OS) were 5.5 (95% CI:4.1-5.7) and 10.5 (95% CI:7.5-14) months. CONCLUSION In a heterogeneous group of patients with locally advanced/metastatic STS, the combination of selinexor and doxorubicin fulfilled the prespecified boundary for tolerability.
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Affiliation(s)
- Jeremy Lewin
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Eoghan Malone
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Esmail Al-Ezzi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Samir Fasih
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Pernille Pedersen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Sarah Accardi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Abha Gupta
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Albiruni Abdul Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Canada.
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15
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Barlesi F, Lolkema M, Rohrberg KS, Hierro C, Marabelle A, Razak AA, Teixeira L, Boni V, Miller WH, Aggarwal C, Stern M, Cirovic O, Cirovic O, Romagnoli B, Christen R, Dodia R, Smart K, Reis B, Staedler N, Watson C, Steeghs N. 291 Phase Ib study of selicrelumab (CD40 agonist) in combination with atezolizumab (anti-PD-L1) in patients with advanced solid tumors. J Immunother Cancer 2020. [DOI: 10.1136/jitc-2020-sitc2020.0291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BackgroundSelicrelumab is a human IgG2 agonistic anti-CD40 monoclonal antibody. Binding of the antibody to CD40 expressed on antigen-presenting cells results in T- cell priming and T-cell dependent anti-tumor activity. In response to T-cell activation, tumor cells express programmed-death ligand 1 (PD-L1) that can suppress effector T-cells. Atezolizumab interrupts this feedback loop by blocking PD-L1, thereby supporting the combination with selicrelumab.MethodsThis phase Ib open-label, multicenter, dose escalation (DE)/expansion clinical study (NCT02304393) investigated safety, pharmacokinetic (PK), pharmacodynamics (PD) and efficacy of selicrelumab in combination with atezolizumab in unselected patients with advanced/metastatic solid tumors, not amenable to standard therapy. In DE cohorts, a single dose of selicrelumab was given, either by intravenous (IV) infusion at a 16 mg fixed dose or subcutaneously (SC) at a range from 1 to 64 mg/dose. In dose-expansion cohorts (small bowel and colorectal cancer, head and neck squamous cell carcinoma [HNSCC] and non-small cell lung carcinoma), patients received multiple doses of selicrelumab SC at a dose of 16 mg. In all treatment cohorts, patients received atezolizumab at a fixed dose of 1200 mg IV Q3W.ResultsIn this study, 140 patients were treated. This included 95 patients in DE cohorts (6 patients in the IV cohort, 89 patients in the SC cohorts) and 45 patients in dose-expansion cohorts. In the IV cohort, infusion related reaction was the most frequent treatment-related adverse event (TRAE; 50%), while Grade ≥ 3 TRAE occurred in 1 patient (16.7%). In this cohort one dose-limiting toxicity (DLT) was reported (Grade 3 pancytopenia). In the SC cohorts, the most frequent TRAE was injection site reaction (ISR; 92%). Four DLTs were reported in four patients: three Grade 3 ISR and one Grade 3 transaminase increase. Grade ≥ 3 TRAE were reported in 22 patients (16.4%). Anti-tumor activity was observed across cohorts receiving SC selicrelumab (dose range 1 to 36 mg). Eight of 80 evaluable patients in DE cohorts experienced objective responses (9% ORR). In the dose-expansion HNSCC cohort, three of 16 evaluable patients responded (15.8% ORR). There were no objective responses in the IV cohort. Treatment with selicrelumab resulted in significant peripheral B-cell depletion and activation and CD8+ T cell proliferation.ConclusionsTreatment with selicrelumab in combination with atezolizumab was well tolerated in patients with advanced solid tumors. Signals of clinical and PD activity were observed. However, efficacy of the combination in this unselected population was limited, when compared to monotherapy efficacy of atezolizumab.Trial RegistrationNCT02304393Ethics ApprovalThis study was approved by the local IRB at each participating study site.
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16
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Music M, Iafolla M, Soosaipillai A, Batruch I, Prassas I, Pintilie M, Hansen AR, Bedard PL, Lheureux S, Spreafico A, Razak AA, Siu LL, Diamandis EP. Predicting response and toxicity to PD-1 inhibition using serum autoantibodies identified from immuno-mass spectrometry. F1000Res 2020; 9:337. [PMID: 33299547 PMCID: PMC7707117 DOI: 10.12688/f1000research.22715.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Validated biomarkers are needed to identify patients at increased risk of immune-related adverse events (irAEs) to immune checkpoint blockade (ICB). Antibodies directed against endogenous antigens can change after exposure to ICB. Methods: Patients with different solid tumors stratified into cohorts received pembrolizumab every 3 weeks in a Phase II trial (INSPIRE study). Blood samples were collected prior to first pembrolizumab exposure (baseline) and approximately 7 weeks (pre-cycle 3) into treatment. In a discovery analysis, autoantibody target immuno-mass spectrometry was performed in baseline and pre-cycle 3 pooled sera of 24 INSPIRE patients based on clinical benefit (CBR) and irAEs. Results: Thyroglobulin (Tg) and thyroid peroxidase (TPO) were identified as the candidate autoantibody targets. In the overall cohort of 78 patients, the frequency of CBR and irAEs from pembrolizumab was 31% and 24%, respectively. Patients with an anti-Tg titer increase ≥1.5x from baseline to pre-cycle 3 were more likely to have irAEs relative to patients without this increase in unadjusted, cohort adjusted, and multivariable models (OR=17.4, 95% CI 1.8-173.8, p=0.015). Similarly, patients with an anti-TPO titer ≥ 1.5x from baseline to pre-cycle 3 were more likely to have irAEs relative to patients without the increase in unadjusted and cohort adjusted (OR=6.1, 95% CI 1.1-32.7, p=0.035) models. Further, the cohort adjusted analysis showed patients with anti-Tg titer greater than median (10.0 IU/mL) at pre-cycle 3 were more likely to have irAEs (OR=4.7, 95% CI 1.2-17.8, p=0.024). Patients with pre-cycle 3 anti-TPO titers greater than median (10.0 IU/mL) had a significant difference in overall survival (23.8 vs 11.5 months; HR=1.8, 95% CI 1.0-3.2, p=0.05). Conclusions: Patient increase ≥1.5x of anti-Tg and anti-TPO titers from baseline to pre-cycle 3 were associated with irAEs from pembrolizumab, and patients with elevated pre-cycle 3 anti-TPO titers had an improvement in overall survival.
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Affiliation(s)
- Milena Music
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Marco Iafolla
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Antoninus Soosaipillai
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Toronto, ON, Canada
| | - Ihor Batruch
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Toronto, ON, Canada
| | - Ioannis Prassas
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Toronto, ON, Canada
| | - Melania Pintilie
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Canada, Toronto, ON, Canada
| | - Aaron R. Hansen
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Philippe L. Bedard
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Stephanie Lheureux
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Albiruni Abdul Razak
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Lillian L. Siu
- Division of Medical Oncology and Hematology, University Health Network, Canada, Toronto, ON, Canada
| | - Eleftherios P. Diamandis
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Toronto, ON, Canada
- Department of Clinical Biochemistry, University Health Network, Canada, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Toronto, ON, Canada
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17
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Janku F, Heinrich M, Chi P, Razak AA, Mehren MV, Gordon M, Ganjoo K, Trent J, Jones RL, Gelderblom H, Running K, Wang J, Ruiz-Soto R, George S. Abstract CT058: Ripretinib (DCC-2618) pharmacokinetics (PK) in a Phase I study in patients with gastrointestinal stromal tumors (GIST) and other advanced malignancies: A retrospective evaluation of the PK effects of proton pump inhibitors (PPIs). Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Objectives: Ripretinib is a novel, oral kinase switch control inhibitor of KIT and PDGFRα. Encouraging clinical benefit from the phase 1 dose escalation and expansion study as measured by ORR, DCR and PFS in 2nd, 3rd, and >4th line GIST patients with a favorable tolerability profile at doses >100 mg/day has been previously reported (ESMO 2018, abstract #1603O). It has been reported that more than 40% of GIST patients use acid-reducing agents. PPIs are the most potent acid-reducing agents that may impair the absorption of kinase inhibitors 1,2. This retrospective analysis aims to explore whether ripretinib can be used regardless of concomitant PPI use.
Methods: The analysis assessed the impact of PPIs on the plasma concentration of ripretinib using PK data from the expansion cohort at the recommended Phase 2 dose of 150 mg QD. Plasma concentrations of ripretinib and its active metabolite DP-5439 obtained from patients who used or did not use PPIs were compared on Cycle 1 Day 1 (C1D1, n=106) and Day 15 (C1D15, n=102). Patients using PPIs were defined as those who continuously took PPIs for at least 4 days prior to C1D1 or C1D15. Patients who did not use PPIs were defined as those who did not take PPIs or any other acid-reducing agents during the study.
Results: PK profiles were consistent between patients using and not using PPIs (Table 1), indicating a low likelihood of a clinically significant drug interaction between PPIs and ripretinib.
Conclusions: This retrospective PK analysis provides supporting evidence that restriction of co-administration of PPIs with ripretinib may not be necessary. A dedicated drug interaction study is planned to provide a definitive assessment. References: 1. Smelick et al, Mol. Pharmaceutics 2013, 10, 4055−4062 2. Budha et al, Clin Pharmacol Ther. 2012, 92(2):203-13
Table 1.PK Exposure of Ripretinib and DP-5439 in Patients Using or not Using PPIsPK ConcentrationsRipretinib in ng/mL [mean (CV%)]DP-5439 in ng/mL [mean (CV%)]Ripretinib + DP-5439 in ng/mL [mean (CV%)]Using PPIsNot using PPIsUsing PPIsNot using PPIsUsing PPIsNot using PPIsC1D1 6 hr566 (58%) n=24670 (53%) n=82302 (64%) n=23297 (59%) n=82862 (54%) n=24975 (48%) n=82C1D15 pre-dose364 (79%) n= 24344 (63%) n=78960 (80%) n=24889 (86%) n=781350 (72%) n=241260 (75%) n=78C1D15 6 hr834 (51%) n=24871 (47%) n=731170 (69%) n=241060 (67%) n=732040 (53%) n=241960 (49%) n=73Notes: Table 1 is based on data from patients without a history of gastrectomy. A separate analysis in patients with gastrectomy will be published after sufficient data is obtained.
Citation Format: Filip Janku, Michael Heinrich, Ping Chi, Albiruni Abdul Razak, Margaret von Mehren, Michael Gordon, Kristen Ganjoo, Jonathan Trent, Robin L. Jones, Hans Gelderblom, Kelli Running, Jing Wang, Rodrigo Ruiz-Soto, Suzanne George. Ripretinib (DCC-2618) pharmacokinetics (PK) in a Phase I study in patients with gastrointestinal stromal tumors (GIST) and other advanced malignancies: A retrospective evaluation of the PK effects of proton pump inhibitors (PPIs) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT058.
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Affiliation(s)
- Filip Janku
- 1The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Heinrich
- 2Portland VA Health Care System and Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Ping Chi
- 3Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY
| | | | | | - Michael Gordon
- 6Pinnacle Oncology Hematology, Arizona Center for Cancer Care, HonorHealth Research Institute Clinical Trials Program, Virginia G. Piper Cancer Center, Scottsdale, AZ
| | | | | | - Robin L. Jones
- 9Royal Marsden Hospital, The Institute of Cancer Research, London, United Kingdom
| | | | | | - Jing Wang
- 11Deciphera Pharmaceuticals, Waltham, MA
| | | | - Suzanne George
- 12Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA
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18
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Kanjanapan Y, Day D, Wang L, Al‐Sawaihey H, Abbas E, Namini A, Siu LL, Hansen A, Razak AA, Spreafico A, Leighl N, Joshua AM, Butler MO, Hogg D, Chappell MA, Soultani L, Chow K, Boujos S, Bedard PL. Hyperprogressive disease in early‐phase immunotherapy trials: Clinical predictors and association with immune‐related toxicities. Cancer 2019; 125:1341-1349. [DOI: 10.1002/cncr.31999] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/21/2018] [Accepted: 12/03/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Yada Kanjanapan
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Daphne Day
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Lisa Wang
- Biostatistics Department, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Hamad Al‐Sawaihey
- Joint Department of Medical Imaging, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Engy Abbas
- Joint Department of Medical Imaging, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Amirali Namini
- Joint Department of Medical Imaging, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Lillian L. Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Aaron Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Albiruni Abdul Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Natasha Leighl
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Anthony M. Joshua
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Marcus O. Butler
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - David Hogg
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Mary Anne Chappell
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Ludmilla Soultani
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Kayla Chow
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Samantha Boujos
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | - Philippe L. Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
- Drug Development Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
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19
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Hahn E, Huang SH, Hosni A, Razak AA, Jones RL, Dickson BC, Sturgis EM, Patel SG, O'Sullivan B. Ending 40 years of silence: Rationale for a new staging system for soft tissue sarcoma of the head and neck. Clin Transl Radiat Oncol 2018; 15:13-19. [PMID: 30582016 PMCID: PMC6293017 DOI: 10.1016/j.ctro.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 11/25/2022] Open
Abstract
For 40 years, all soft tissue sarcoma (STS) used the same TNM where T1 was <=5 cm. This staging is unsuited for STS of the head and neck (STSHN) since only a minority are >5 cm. Despite smaller size, local recurrence is higher in STSHN compared to other STS. A new T classification with 2 and 4 cm cut-offs for STSHN was introduced in TNM-8. Future requirements for STSHN Stage Group development are mentioned.
The tumor, node, metastases (TNM) anatomic staging system plays a pivotal role in cancer care, research, and cancer control activities. Since the first edition of the American Joint Committee on Cancer TNM staging classification published in 1977, soft tissue sarcomas have been staged in an anatomic site agnostic fashion whereby the primary tumor size (T) was categorized as T1 if <=5 cm and T2 if >5 cm; this remained unchanged through the 7th edition of the TNM. However, soft tissue sarcomas of the head and neck (STSHN) usually present smaller than sarcomas of other sites, but carry a disproportionate risk of local recurrence. Up to 70% of tumors are less than 5 cm at presentation, and therefore classified together as T1. Given the rarity of STSHN, there is a paucity of data to guide progress in their classification. Moreover, the majority of publications only report tumor size as less than or greater than 5 cm, presumably based on conventions of the TNM system that remained unchanged for 40 years, thereby affecting progress of STSHN classification. This formed the impetus for change in the 8th edition in 2 key ways: 1) several soft tissue sarcoma site based changes occurred including STSHN now having its own system, and 2) primary tumor size cut-offs of 2 cm and 4 cm used in STSHN now reflect sizes that head and neck specialists commonly encounter in their practice. This update was pragmatic in modifying the TNM from a system with a T category not serving STSHN and which was originally based on sarcoma data from non-head and neck anatomic sites. The background to this change is outlined which provides a framework in which data can be reported to generate evidence for future staging modifications.
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Affiliation(s)
- Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Canada
| | - Albiruni Abdul Razak
- Division of Medical Oncology, Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Canada
| | - Robin L Jones
- Royal Marsden Hospital/Institute of Cancer Research, United Kingdom
| | - Brendan C Dickson
- Department of Pathology & Laboratory Medicine, Sinai Health System, Toronto, Canada
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Snehal G Patel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Canada
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Razak AA, Bauer S, Blay JY, Quek R, Suárez C, Lin CC, Hütter-Krönke ML, Cubedo R, Ferretti S, Meille C, Halilovic E, Clementi G, Santos-Rosa M, Guerreiro N, Jullion A, Fabre C, Italiano A. Abstract CT009: Results of a dose- and regimen-finding Phase Ib study of HDM201 in combination with ribociclib in patients with locally advanced or metastatic liposarcoma. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-ct009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Well-differentiated/dedifferentiated liposarcoma (WDLPS/DDLPS) is characterized by a consistent coamplification of human double minute 2 homolog (HDM2) and cyclin-dependent kinase 4 (CDK4) which inactivates the tumor suppressor pathways p53 and Rb, respectively. HDM201 is a selective inhibitor of the p53-HDM2 interaction and ribociclib is a CDK4/6 inhibitor. Preclinical studies suggested a synergy in in vitro and in vivo models of WDLPS/DDLPS and both agents have demonstrated single-agent clinical activity in solid tumors. We aim to determine the optimal dose and regimen of HDM201 + ribociclib and to assess the preliminary antitumor activity of this combination in patients (pts) with liposarcoma.
Methods: In this multicenter, open-label, Phase Ib ongoing study, pts with locally advanced or metastatic liposarcoma that had unequivocally progressed on, or despite prior systemic therapy were treated orally with HDM201 + ribociclib. Three treatment regimens were explored: Regimen (Reg) 1 (HDM201 + ribociclib daily for the first 2 wks [QD 1st 2 wks] in a 4-wk cycle), Reg 4 (HDM201 every 3 wks + ribociclib QD 1st 2 wks in a 3-wk cycle), and Reg 5 (HDM201 every 4 wks + ribociclib QD 1st 2 wks in a 4-wk cycle).
Results: As of Nov 21, 2017, 74 pts received HDM201 + ribociclib (Reg 1 n=26; Reg 4 n=29; Reg 5 n=19); 12 pts (6 each in Reg 4 and 5) were still receiving treatment. Ten pts (Reg 1 n=3; Reg 4 n=6; Reg 5 n=1) discontinued treatment due to adverse events (AEs) and 2 pts (1 each in Reg 4 and 5) died. The most common AE of any grade, regardless of cause, reported across regimens (Reg 1; Reg 4; Reg 5) was nausea (81%; 76%; 63%) which was mainly Grade 1/2 and not dose limiting. Common Grade 3/4 AEs regardless of cause included neutropenia (39%; 52%; 42%), thrombocytopenia (35%; 45%; 42%), anemia (27%; 17%; 21%), leukopenia (27%; 28%; 37%), and lymphopenia (15%; 14%; 21%). Dose-limiting toxicities were reported in 16 pts (2; 9; 5) and all except 1 (prolonged QT) were hematologic (including neutropenia [n=5], thrombocytopenia [n=4], febrile neutropenia, and anemia [n=2 each]).
Partial responses were observed in 3 (4%) pts (2 in Reg 4; 1 in Reg 5). Stable disease was achieved by 36 (49%) pts (11 in Reg 1; 16 in Reg 4; 9 in Reg 5). The median progression-free survival (PFS) was 2.7 mo (95% confidence interval [CI]: 1.9-8.2 mo) in Reg 1, 4.8 mo (95% CI: 3.9 mo-not reached) in Reg 4, and 2.1 mo (95% CI: 1.4 mo-not reached) in Reg 5.
Conclusions: HDM201 + ribociclib demonstrated a manageable safety profile and preliminary efficacy in pts with locally advanced or metastatic WDLPS/DDLPS, with hematologic toxicities being dose limiting. The median PFS in Reg 4 compares favorably with single-agent CDK4 inhibitors and, alongside a tolerable safety profile, suggests further exploration of this regimen may be warranted in Phase II studies of HDM201 + ribociclib in this patient population.
Citation Format: Albiruni Abdul Razak, Sebastian Bauer, Jean-Yves Blay, Richard Quek, Cristina Suárez, Chia-Chi Lin, Marie L. Hütter-Krönke, Ricardo Cubedo, Stephane Ferretti, Christophe Meille, Ensar Halilovic, Giorgia Clementi, Maria Santos-Rosa, Nelson Guerreiro, Astrid Jullion, Claire Fabre, Antoine Italiano. Results of a dose- and regimen-finding Phase Ib study of HDM201 in combination with ribociclib in patients with locally advanced or metastatic liposarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT009.
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Affiliation(s)
- Albiruni Abdul Razak
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sebastian Bauer
- 2West German Cancer Center, University of Duisburg-Essen, Essen, Germany
| | | | - Richard Quek
- 4National Cancer Centre Singapore, Singapore, Singapore
| | | | - Chia-Chi Lin
- 6National Taiwan University Hospital, Taipei, Taiwan
| | | | | | | | | | - Ensar Halilovic
- 10Novartis Institutes for BioMedical Research, Cambridge, MA
| | | | | | - Nelson Guerreiro
- 9Novartis Institutes for BioMedical Research, Basel, Switzerland
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Salah S, Lewin J, Amir E, Abdul Razak A. Tumor necrosis and clinical outcomes following neoadjuvant therapy in soft tissue sarcoma: A systematic review and meta-analysis. Cancer Treat Rev 2018; 69:1-10. [PMID: 29843049 DOI: 10.1016/j.ctrv.2018.05.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/10/2018] [Accepted: 05/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic role of tumor necrosis following neoadjuvant therapy is established in bone sarcomas but remains unclear in soft tissue sarcomas (STS). METHODS We searched MEDLINE, MEDLINE in progress, EMBASE and Cochrane to identify studies that investigated neoadjuvant therapy in STS. Studies were required to report survival data based on extent of necrosis, or provided individual patient data allowing estimation thereof. Hazard ratios (HR) for relapse-free (RFS) and overall survival (OS) and odds ratios (OR) for recurrence at 3 years and for death at 5 years were pooled in a random effect meta-analysis. Associations between patient characteristics and attainment of ≥90% necrosis were explored. RESULTS 21 studies comprising 1663 patients were included. Extremity tumors were most common (n = 1554; 93%). Induction regimens included chemotherapy with radiotherapy (n = 924; 56%), chemotherapy alone (n = 412; 25%), radiotherapy alone (n = 78; 5%), isolated limb perfusion (ILP) (n = 231; 14%), and targeted therapy/radiotherapy (n = 18; 1%). Patients with <90% necrosis had higher hazard of recurrence (hazard ratio [HR] 1.47; 95% CI: 1.06-2.04; p = 0.02) and death (HR 1.86; 95% CI: 1.41-2.46; p < 0.001). Risk of recurrence at 3 years (OR = 3.35; 95% CI: 2.27-4.92; p < 0.001) and of death at 5 years (OR 2.60; 95% CI: 1.59-4.26; p < 0.001) were similarly increased. Compared to other modalities, ILP was associated with higher odds of achieving ≥90% necrosis (OR 12.1; 95% CI: 3.69-39.88; p < 0.001). CONCLUSION Tumour necrosis <90% following neoadjuvant therapy is associated with increased recurrence risk and inferior OS in patients with STS.
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Affiliation(s)
- Samer Salah
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Medical Oncology, King Hussein Cancer Centre, Queen Rania Al Abdullah St 202, Amman, Jordan.
| | - Jeremy Lewin
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Eitan Amir
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Albiruni Abdul Razak
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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Zer A, Prince RM, Amir E, Razak AA. Reply to L.A. Renfro et al. J Clin Oncol 2016; 34:3950. [DOI: 10.1200/jco.2016.69.1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alona Zer
- Alona Zer, Rabin Medical Centre, Petach Tikva, and Tel Aviv University, Tel Aviv, Israel; and Rebecca M. Prince, Eitan Amir, and Albiruni Abdul Razak, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Rebecca M. Prince
- Alona Zer, Rabin Medical Centre, Petach Tikva, and Tel Aviv University, Tel Aviv, Israel; and Rebecca M. Prince, Eitan Amir, and Albiruni Abdul Razak, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- Alona Zer, Rabin Medical Centre, Petach Tikva, and Tel Aviv University, Tel Aviv, Israel; and Rebecca M. Prince, Eitan Amir, and Albiruni Abdul Razak, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Albiruni Abdul Razak
- Alona Zer, Rabin Medical Centre, Petach Tikva, and Tel Aviv University, Tel Aviv, Israel; and Rebecca M. Prince, Eitan Amir, and Albiruni Abdul Razak, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
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Razak AA, Arzoglou V. A frontal external ventricular drain causing a third cranial nerve palsy. Br J Neurosurg 2016; 31:605-606. [PMID: 27241884 DOI: 10.3109/02688697.2016.1173195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This 47-year-old gentleman presented with acute hydrocephalus secondary to a colloid cyst. Bilateral external ventricular drains (EVDs) were inserted. The patient developed a third nerve palsy during post-operative period - cranial imaging demonstrated the tip of an EVD in this vicinity. The palsy recovered completely on slight withdrawal of the EVD.
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Affiliation(s)
- A A Razak
- a Department of Neurosurgery , Hull Royal Infirmary , Anlaby Road , Hull , HU3 2JZ , United Kingdom of Great Britain and Northern Ireland
| | - V Arzoglou
- a Department of Neurosurgery , Hull Royal Infirmary , Anlaby Road , Hull , HU3 2JZ , United Kingdom of Great Britain and Northern Ireland
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Zer A, Prince RM, Amir E, Abdul Razak A. Evolution of Randomized Trials in Advanced/Metastatic Soft Tissue Sarcoma: End Point Selection, Surrogacy, and Quality of Reporting. J Clin Oncol 2016; 34:1469-75. [PMID: 26951308 DOI: 10.1200/jco.2015.64.3437] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Randomized controlled trials (RCTs) in soft tissue sarcoma (STS) have used varying end points. The surrogacy of intermediate end points, such as progression-free survival (PFS), response rate (RR), and 3-month and 6-month PFS (3moPFS and 6moPFS) with overall survival (OS), remains unknown. The quality of efficacy and toxicity reporting in these studies is also uncertain. METHODS A systematic review of systemic therapy RCTs in STS was performed. Surrogacy between intermediate end points and OS was explored using weighted linear regression for the hazard ratio for OS with the hazard ratio for PFS or the odds ratio for RR, 3moPFS, and 6moPFS. The quality of reporting for efficacy and toxicity was also evaluated. RESULTS Fifty-two RCTs published between 1974 and 2014, comprising 9,762 patients, met the inclusion criteria. There were significant correlations between PFS and OS (R = 0.61) and between RR and OS (R = 0.51). Conversely, there were nonsignificant correlations between 3moPFS and 6moPFS with OS. A reduction in the use of RR as the primary end point was observed over time, favoring time-based events (P for trend = .02). In 14% of RCTs, the primary end point was not met, but the study was reported as being positive. Toxicity was comprehensively reported in 47% of RCTs, whereas 14% inadequately reported toxicity. CONCLUSION In advanced STS, PFS and RR seem to be appropriate surrogates for OS. There is poor correlation between OS and both 3moPFS and 6moPFS. As such, caution is urged with the use of these as primary end points in randomized STS trials. The quality of toxicity reporting and interpretation of results is suboptimal.
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Affiliation(s)
- Alona Zer
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada.
| | - Rebecca M Prince
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada
| | - Albiruni Abdul Razak
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada
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Memon MS, Yunus N, Razak AA. Some mechanical properties of a highly cross-linked, microwave-polymerized, injection-molded denture base polymer. INT J PROSTHODONT 2001; 14:214-8. [PMID: 11484567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
PURPOSE The impact strength and the flexural properties of denture base materials are of importance in predicting their clinical performance upon sudden loading. This study compares the impact and transverse strengths and the flexural modulus of three denture base polymers. MATERIALS AND METHODS The investigation included a relatively new microwave-polymerized polyurethane-based denture material processed by an injection-molding technique, a conventional microwave-polymerized denture material, and a heat-polymerized compression-molded poly(methyl methacrylate) (PMMA) denture material. Impact strength was determined using a Charpy-type impact tester. The transverse strength and the flexural modulus were assessed with a three-point bending test. The results were subjected to statistical analysis using a one-way analysis of variance and the Scheffé test for comparison. RESULTS The impact strength of the microwave-polymerized injection-molded polymer was 6.3 kl/m2, while its flexural strength was 66.2 MPa. These values were lower than those shown by the two compression-molded PMMA-based polymers. The differences were statistically significant. The flexural modulus of the new denture material was 2,832 MPa, which was higher than the conventional heat-polymerized polymer but was comparable to the other microwave-polymerized PMMA-based polymer. The difference in the flexural modulus was statistically significant. CONCLUSION In terms of the impact and flexural strengths, the new microwave-polymerized, injection-molded, polyurethane-based polymer offered no advantage over the existing heat- and microwave-polymerized PMMA-based denture base polymers. However, it has a rigidity comparable to that of the microwave-polymerized PMMA polymer.
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Affiliation(s)
- M S Memon
- Department of Prosthetic Dentistry, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Abstract
A strain of Fusarium oxysporum tolerated copper in the growth medium at concentrations up to 600 mg/L. The optimum growth was obtained at 200 mg Cu/L. The mycelium acquired a blue color in the presence of copper. The copper content of isolated cell walls obtained from mycelium grown in the presence of 600 mg Cu/L was 1.5 times higher than that of cell walls obtained from mycelium grown at 200 mg Cu/L and it contained 2.2 and 3.3% copper at 200 and 600 mg Cu/L, respectively. The amount of protein and total sugars increased in both the mycelium and its isolated cell walls in the presence of copper in the growth medium, chitin was also increased in the cell wall, reaching its maximum amount at 200 mg Cu/L--about 2.4 times higher than without copper. Most of amino acid concentrations in the cell wall were increased in the presence of 200 mg Cu/L and decreased above this concentration. Isoleucine, leucine, tyrosine, phenylalanine, and arginine showed the highest increase at this concentration. The altered cell walls obtained from mycelium grown at 200 and 400 mg Cu/L could rebind individual metals more than the control cell walls could. Rebinding of individual metals was in the order Zn > Fe > Ni > Cu > Co. Rebinding of copper by isolated cell walls depended on pH and temperature.
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Affiliation(s)
- M A Hefnawy
- Botany Department, Faculty of Science, Menoufia Unviersity, Shebin El-Kom, Egypt
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Abstract
The transverse bend test and surface microhardness test were used to determine the optimum curing cycle for a light- and heat-cured composite inlay material. Specimens were light-cured (control) and light- and heat-cured using the following temperatures: 50 degrees C for 5 min; 50 degrees C for 10 min; 100 degrees C for 1 min; 100 degrees C for 5 min; 100 degrees C for 10 min; and 100 degrees C for 15 min. Heat-curing in boiling water at 100 degrees C for at least 1 min significantly improved the transverse strength, modulus of elasticity and surface microhardness compared to light-curing only or at 50 degrees C. The curing cycle of 100 degrees C for 5 min is considered the most appropriate.
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Affiliation(s)
- A A Razak
- Department of Oral and Dental Science, University of Bristol Dental School, UK
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Abstract
STATEMENT OF PROBLEM Dimensional accuracy of a composite inlay restoration is important to ensure an accurate fit and to minimize cementation stresses. PURPOSE OF STUDY A method was developed to measure dimensional accuracy and stability of a composite inlay. MATERIAL AND METHODS A standard Class II (MOD) inlay cavity stainless steel mold was made with six circular indentations placed on the occlusal floor of the cavity and four indentations on each gingival floor to act as datum points in the measurement of linear polymerization shrinkage. The inlay restorations were prepared from an inlay-onlay composite material of different filler contents (50%, 65%, and 79% by weight). For each filler content group, three curing methods were used: light curing only, light curing and heat curing at 100 degrees C for 5 minutes, and light curing and heat curing at 100 degrees C for 5 minutes and then storage in distilled water for 7 days. The accuracy of the MOD inlays was determined by measuring the shrinkage of the restoration on the occlusal floor areas and the gingival seats. RESULTS The results demonstrated an inverse linear relationship between filler content and polymerization shrinkage. There was a tendency for the light-curing and heat-curing method to show an increase in polymerization shrinkage. An expansion was recorded between the mesial and distal boxes when the specimens were soaked in water for 7 days. CONCLUSIONS This study suggested that the inlay mold limits the physical shrinkage that can occur between the mesial and distal axial walls of the inlay restoration because the inlay cannot shrink to a smaller dimension than the mold. Water sorption then causes hygroscopic expansion, which enlarges the distance between the mesial and distal walls.
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Affiliation(s)
- A A Razak
- Department of Conservative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
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Abstract
Mycotoxin production from Penicillium expansum was effected by the 'biocontrol enhancer' 2-deoxy-D-glucose (DOG). Citrinin and gentisyl alcohol were produced in higher amounts, whereas patulin was inhibited, which represents a differential effect on the polyketide metabolic pathway. These effects have implications for the use of DOG in biocontrol.
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Affiliation(s)
- N F Abo-Dahab
- International Mycological Institute, Egham, Surrey, UK
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Abstract
Aspergillus terreus was cultivated on Harrold's medium supplemented with 0.1% (w/v) cadmium chloride as well as on sulfur free medium amended with 0.1% (w/v) sodium selenite and potassium tellurite separately. The cell free extract of the fungus for each treatment was fractionated on a column packed with Sephadex G 75. The results demonstrated the ability of the fungus to synthesize several cadmium, selenium, and tellurium-binding proteins as well as metallothionein. The results suggested the biosynthesis of heavy metals chelators as well. The amino acids composition of a cadmium-binding metallothionein revealed the presence of high levels of both aromatic and sulfur amino acids in the hydrolysate.
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Affiliation(s)
- I M Abbass
- Department of Chemistry, Faculty of Science, Cairo University, Giza, Egypt
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Abstract
Aspergillus funiculosus was isolated from rotted banana fruits, whereas Alternaria tenuis and Fusarium sp. were isolated from rotted tomato fruits. The isolated fungi tolerated relatively high levels of the fungicide, Dithane, up to 2560 ppm on solid medium, but grew well at 40 ppm when supplemented with liquid medium. They are able to tolerate selenite up to 2% (w/v) sodium selenite. A. funiculosus showed no growth in the presence of mixture of 2.5 ppm selenium and 20 ppm Dithane, whereas Fusarium sp. failed to grow at 2.5 ppm selenium and 10 ppm Dithane, or at 10 ppm of each. Nevertheless, Alternaria tenuis is more tolerant; it showed growth in the presence of relatively high levels of selenium and Dithane; up to 10 ppm selenium and 40 ppm Dithane, however, its growth was inhibited by the presence of a mixture of both. The results suggested new form of highly active fungicides. Selenium as an essential nutrient at such very low concentrations, as well as the application of very low concentrations of the fungicide, would certainly reduce the hazardous effect of such pollutant in the environment.
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Affiliation(s)
- A A Razak
- Department of Botany, Faculty of Science, Al-Azhar University, Cairo, Egypt
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Abstract
A selenium-dependent Bacillus sp. is able to grow well up to 3% sodium selenite-containing media. The bacterium completely failed to grow on media devoid of selenium. The presence of selenium in the growth media increased the bacterial contents of proteins, carbohydrates, and lipids. The highest quantities of amino acids were detected at 2% sodium selenite-containing media. The bacterium metabolized selenite into several protein selenoamino acids such as selenomethionine and selenocysteine/selenocystine, as well as nonprotein selenoamino acids, such as selenocystathionine. Several phosphoamino acids were detected in the presence of elevated levels of selenium. The synthesized protein seems not to be affected by the presence of selenium.
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Affiliation(s)
- A A Razak
- Department of Botany, Faculty of Science, Al-Azhar University, Cairo, Egypt
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Abstract
A selenium-dependent bacterium, Bacillus sp., failed to grow on selenium-free media. However, it is able to grow at high concentrations of sodium selenite containing media up to 3% (w/v). It accumulated extraordinary high quantities of selenium, 432 ppm/mL. The bacterium generated the transformation of inorganic selenium into volatile selenium form(s) into the atmosphere. The biological release of volatile selenium basically depended on several factors: incubation temperature, pH, incubation periods, and substrate concentration. Maximal quantity of the volatile selenium form was obtained at 30 degrees C, pH 7, and 1% (w/v) sodium selenite.
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Affiliation(s)
- A A Razak
- Department of Botany, Faculty of Science, Al-Azhar University, Medinet Nasr, Cairo, Egypt
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Abstract
Aspergillus carbonarius and a strain of Penicillium, a cadmium tolerant fungi, are able to metabolize cadmium chloride up to 2% (w/v). Their amino acids analysis on cadmium free and cadmium chloride containing media indicated certain disorders in their metabolic activities. Cystathionine was only detected in both fungi in the presence of cadmium chloride. However, cadmium was incorporated into several types of low and high molecular weight proteins. The amino acids hydrolyzates of a cadmium containing protein are characterized by the presence of high levels of sulfur amino acids; cysteine and methionine. Ethylasparagine was detected in the hydrolyzate of that cadmium containing protein as well.
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Affiliation(s)
- A A Razak
- Department of Botany, Faculty of Science, Al-Azhar University, Cairo, Egypt
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Abstract
Aspergillus fumigatus, Aspergillus terreus, and Penicillium chrysogenum, a tellurium tolerant fungi, are able to grow on sulfur free medium amended with 0.2% (w/v) tellurite. Tellurium was incorporated into several types of low and high molecular weight proteins. The newly detected telluro-proteins contained an extraordinary high level of tellurium, as well as telluro-cysteine, telluro-cystine, telluro-methionine, and serine.
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Affiliation(s)
- S E Ramadan
- Department of Botany, Faculty of Science, Al-Azhar University, Cairo, Egypt
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Razak IA, Razak AA. Patterns of tooth vulnerability to caries in 20-24-year-old subjects. Odontostomatol Trop 1988; 11:145-8. [PMID: 3272009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
Aspergillus carbonarius and a strain of Penicillium are able to grow on Harrold's agar media amended with different concentrations of cadmium chloride up to 2.5% (w/v). Considerable quantities of cadmium were absorbed by both fungi. A. carbonarius absorbed more cadmium than the Penicillium sp. did, under the same culturing conditions. In the presence of cadmium, the determined cellular contents of proteins, lipids, and carbohydrates were extraordinary high, whereas the activities of certain enzymes, lipases, amylases, and proteases were inhibited. The fungal rate of growth and sporulations were mostly suppressed. Conidiations were inhibited at lowest concentrations. At 1% Cd Cl2, A. carbonarius produced malformed conidiophores, whereas the Penicillium sp. was less affected. At higher concentrations conidiophores production were entirely suppressed and several hyphal swellings were produced.
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Affiliation(s)
- S E Ramadan
- Department of Botany, Faculty of Science, Al-Azhar University, Medinet Nasr, Cairo, Egypt
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Abstract
Fusarium sp. was isolated from Sinai soil at Egypt. It showed tendency to tolerate high concentrations of selenium in the form of sodium selenite up to 3.5% (w/v). The microscopic examination revealed some morphological distortions. However, the fungus was capable to circumvent the toxic effect of selenium. The fungus possess strong reducing ability as high quantities of elemental selenium were precipitated within the fungal cells as well as on the surface of the fungal hyphae and spores. The presence of selenium increased the cellular contents of carbohydrates, proteins, and lipids. Labeling studies indicate the incorporation of selenite into certain amino acids: selenocysteine and selenocysteic acid. Moreover, the presence of selenium induced the biosynthesis of several types of low molecular weight proteins. The results demonstrated different modes of detoxification of selenium toxicity.
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Affiliation(s)
- S E Ramadan
- Department of Botany, Faculty of Science, Al-Azhar University, Cairo, Egypt
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Abstract
Aspergillus terreus, a moderately selenium-tolerant fungus, metabolized Se-selenite into several protein seleno-amino acids: selenomethionine and selenocysteine, as well as, nonprotein seleno-amino acids, selenocystathionine, and y-glutamyl selenomethyl selenocysteine. The results indicate the failure of the fungus to discriminate between sulphur and selenium. Selenium was also incorporated into several proteins of different molecular weights, mostly of low molecular weight proteins. Labeled studies showed the presence of high levels of selenomethionine and selenocysteine in the protein hydrolysate. The actual incorporation of protein seleno-amino acids into the fungal protein was proven. The results demonstrated a finding that detracts from previous held views.
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Affiliation(s)
- S E Ramadan
- Faculty of Science for Girls, Al-Azhar University, Medinet Nasr, Cairo, Egypt
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Razak AA. The proximal finishing of posterior composite restorations. Singapore Dent J 1984; 9:11-4. [PMID: 6599642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Razak IA, Razak AA. Caries susceptibility of first permanent molars in 1808 schoolchildren aged 7-12 years. Singapore Dent J 1984; 9:23-5. [PMID: 6599645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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42
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Razak IA, Razak AA. Students' perception about the etiology and prevention of dental caries and gingivitis. Singapore Dent J 1983; 8:53-7. [PMID: 6596723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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