Perspective on the Role of Gut Microbiome in the Treatment of Hepatocellular Carcinoma with Immune Checkpoint Inhibitors

Background and Objectives: Hepatocellular carcinoma (HCC) is the leading cause of liver cancer worldwide and has a high mortality rate. Its incidence has increased due to metabolic-associated liver disease (MAFLD) epidemics. Liver transplantation and surgery remain the most resolute measures. Despite the optimistic use of multi-kinase inhibitors, namely sorafenib, the co-existence of chronic liver disease made the response rate low in these patients. Immune checkpoint inhibitors (ICIs) have become a promising hope for certain advanced solid tumors and, also, for advanced HCC. Unfortunately, a large cohort of patients with HCC fail to respond to immunotherapy. Materials and Methods: We conducted a narrative search on the main medical databases for original articles, reviews, meta-analyses, randomized clinical trials, and case series using the following keywords and acronyms and their associations: hepatocellular carcinoma, immunotherapy, checkpoint inhibitors, gut microbiota, and fecal microbiota transplantation. Results: ICIs are a promising and sufficiently safe treatment option for HCC. In detail, they have significantly improved survival and prognosis in these patients vs. sorafenib. Although there are several highlighted mechanisms of resistance, the gut microbiota signature can be used both as a response biomarker and as an effect enhancer. Practically, probiotic dose-finding and fecal microbiota transplantation are the weapons that can be used to increase ICI's treatment-response-reducing resistance mechanisms. Conclusion: Immunotherapy has been a significant step-up in HCC treatment, and gut microbiota modulation is an effective liaison to increase its efficacy.

Time Domain NMR Approach in the Chemical and Physical Characterization of Hazelnuts (Corylus avellana L.)

'Tonda Gentile Romana' and 'Tonda di Giffoni' (Corylus avellana L.) are two Italian hazelnut cultivars, recognized under the quality labels "Protected Designation of Origin" (PDO) and "Protected Geographical Indication" (PGI), respectively. Hazelnut seeds are characterized by a complex microstructure and the presence of different physical compartments. This peculiarity has been studied and evidenced by Time Domain (TD) Nuclear Magnetic Resonance (NMR) experiments. This technique allowed the assessment of the presence of different diffusion compartments, or domains, by evaluating the distribution of the spin-spin relaxation time (T₂).The aim of this research was to develop a method based on ¹H NMR relaxometry to study the mobility in fresh hazelnut seeds ('Tonda di Giffoni' and 'Tonda Gentile Romana'), in order to determine differences in seed structure and matrix mobility between the two cultivars. TD-NMR measurements were performed from 8 to 55 °C in order to mimic post-harvest processing as well the microscopic textural properties of hazelnut. The Carr-Purcell-Meiboom-Gill (CPMG) experiments showed five components for 'Tonda Gentile Romana' and four components for 'Tonda di Giffoni' relaxation times. The two slowest components of relaxation (T_2,a about 30-40% of the NMR signal, and T_2,b about 50% of the NMR signal) were attributed to the protons of the lipid molecules organized in the organelles (oleosomes), both for the 'Tonda Gentile Romana' and for the 'Tonda di Giffoni' samples. The component of relaxation T_2,c was assigned to cytoplasmic water molecules, and showed a T₂ value dominated by diffusive exchange with a reduced value compared to that of pure water at the same temperature. This can be attributed to the water molecules affected by the relaxation effect of the cell walls. The experiments carried out as a function of temperature showed, for 'Tonda Gentile Romana', an unexpected trend between 30 and 45 °C, indicating a phase transition in its oil component. This study provides information that could be used to strengthen the specifications underlying the definitions of "Protected Designation of Origin" (PDO) and "Protected Geographical Indication" (PGI).

Spectropolarimetric fluctuations in a sunspot chromosphere

The instrumental advances made in this new era of 4 m class solar telescopes with unmatched spectropolarimetric accuracy and sensitivity will enable the study of chromospheric magnetic fields and their dynamics with unprecedented detail. In this regard, spectropolarimetric diagnostics can provide invaluable insight into magneto-hydrodynamic (MHD) wave processes. MHD waves and, in particular, Alfvénic fluctuations associated with particular wave modes were recently recognized as important mechanisms not only for the heating of the outer layers of the Sun's atmosphere and the acceleration of the solar wind, but also for the elemental abundance anomaly observed in the corona of the Sun and other Sun-like stars (also known as first ionization potential) effect. Here, we take advantage of state-of-the-art and unique spectropolarimetric Interferometric BIdimensional Spectrometer observations to investigate the relation between intensity and circular polarization (CP) fluctuations in a sunspot chromosphere. Our results show a clear link between the intensity and CP fluctuations in a patch which corresponds to a narrow range of magnetic field inclinations. This suggests the presence of Alfvénic perturbations in the sunspot. This article is part of the Theo Murphy meeting issue 'High-resolution wave dynamics in the lower solar atmosphere'.

Sucralfate Prophylaxis of Fluorouracil-Induced Stomatitis

Aims and Background

Various attempts have been made to prevent 5-fluorouracil-induced stomatitis, with unsatisfactory results. Sucralfate is an aluminum hydroxide, complex of sulfated sucrose commonly used in the treatment of gastroduodenal ulcers. We used the compound in a phase II study to reduce and minimize the stomatotoxicity of 5-fluorouracil chemotherapy administered in a multiple-day schedule.

Methods

Fifty-two patients entered the study, and 129 cycles of chemotherapy were evaluated. Seven patients refused sucralfate rinses for taste intolerance.

Results

A low level of stomatotoxicity was recorded: grade 2 stomatitis was observed after 14 cycles (10.8%) and grade 3 after 3 cycles (2.3%).

Conclusions

Sucralfate administration could have a role in the prevention of 5-fluorouracil-induced stomatitis.

The cell biology of the thyroid-disrupting mechanism of dichlorodiphenyltrichloroethane (DDT)

OBJECTIVE

Dichlorodiphenyltrichloroethane (DDT) is an organochlorine known for its pesticide properties and for its negative effects on human health. It was banned in most countries for its toxicity to the endocrine system, but due to its persistence at clinically relevant concentrations in both soil and animal tissues, DDT is still linked to several health and social problems.

METHODS

We have previously shown that DDT exposure is causally related to the extracellular release of vesicular organelles such as microvesicles and/or exosomes by using immunocytochemistry with gold-tagged antibodies and various fluorescent membrane markers.

RESULTS

It is now well recognized that microvesicles and/or exosomes organelles are implicated in cell-to-cell communication, and that they are fundamental elements for transferring proteins, RNA, DNA, lipids and transcriptional factors among cells. In this short review, we discussed the role of extracellular vesicle formation in the thyroid-disrupting mechanism of DDT. In particular, we described how DDT, by dislodging the thyrotropin hormone (TSH) receptor from the raft containing compartments of the cells, prevents its activation and internalization.

CONCLUSION

Based on our earlier finding and on the large body of evidence here reviewed, we propose that DDT-induced formation of extracellular vesicles containing the TSH receptor could be directly involved in the development of autoimmune responses against the TSH receptor and that, therefore, their release could lead to the development of the Graves' disease.

Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defaecation syndrome and/or faecal incontinence. Very few reports exist on the use of biologic mesh for LVR. The aim of our study was to report the complication and recurrence rate of our first 100 cases of LVR for symptomatic internal rectal prolapse and/or rectocele using a porcine dermal collagen mesh.

METHODS

Prospectively collected data on LVR for internal rectal prolapse were analysed. Surgical complications and functional results in terms of faecal incontinence (measured with the Faecal Incontinence Severity Index = FISI) and constipation (measured with the Wexner Constipation Score = WCS) at 3, 6 and 12 months were analysed. It was considered an improvement if FISI or WCS scores were reduced by at least 25 % and a cure if the FISI score decreased to <10 and the WCS decreased to <5.

RESULTS

Between April 2009 and April 2013, 100 consecutive female patients (mean age 63 years, range 24-88 years) underwent LVR. All patients had internal rectal prolapse (grade III [n = 25] and grade IV [n = 75] according to the Oxford classification) and rectocele. Mean operative time was 85 ± 40 min. Conversion rate to open technique was 1 %. There was no post-operative mortality. Overall 16 patients (16 %) experienced 18 complications, including rectal perforation (n = 1), small bowel obstruction (n = 2), urinary tract infection (n = 8), subcutaneous emphysema (n = 3), wound haematoma (n = 2), long lasting sacral pain (n = 1) and incisional hernia (1). Median post-operative length of stay was 2 days. Ninety-eight out of 100 patients completed follow-up. At the end of follow-up, the mean FISI score improved from 8.4 (±4.0 standard deviation (SD) p = 0.003) to 3.3 ± 2.3 SD (p = 0.04). Incontinence improved in 37 out of 43 patients (86 %), and 31 patients (72 %) were cured. Similarly, the mean WCS score improved from 18.4 ± 11.6 SD to 5.4 ± 4.1 SD (p = 0.04). Constipation improved in 82 out of 89 patients (92 %), and 70 patients (79 %) were cured. No worsening of continence status, constipation or sexual function was observed. Fourteen patients (14 %) experienced persistence or recurrence of prolapse.

CONCLUSIONS

LVR using biologic mesh is a safe and effective procedure for improving symptoms of obstructed defaecation and faecal incontinence in patients with internal rectal prolapse associated with rectocele.

Abrogating G₂/M checkpoint through WEE1 inhibition in combination with chemotherapy as a promising therapeutic approach for mesothelioma

Malignant mesothelioma (MM) is a very aggressive asbestos-related neoplasm of the serous membranes, whose incidence is increasing worldwide. Although the introduction of new drug combinations, such as cisplatin plus pemetrexed/gemcitabine, has determined an improvement in the patient quality of life, MM remains a universally fatal disease. The observation that key G 1/S checkpoint regulators are often functionally inactivated in MM prompted us to test whether the use of G 2/M checkpoint inhibitors, able to sensitize G 1/S checkpoint-defective cancer cells to DNA-damaging agents, could be successful in MM. We treated six MM cell lines, representative of different histotypes (epithelioid, biphasic, and sarcomatoid), with cisplatin in combination with MK-1775, an inhibitor of the G 2/M checkpoint kinase WEE1. We observed that MK-1775 enhanced the cisplatin cytotoxic effect in all MM cell lines, except the sarcomatoid cell line, which is representative of the most aggressive histotype. As expected, the enhancement in cisplatin toxicity was accompanied by a decrease in the inactive phosphorylated form of cyclin-dependent kinase 1 (CDK1), a key substrate of WEE1, which is indicative of G 2/M checkpoint inactivation. Consistently, we also observed a decrease in G 2/M accumulation and an increase in mitotic entry of DNA-damaged cells and apoptosis, probably due to the loss of the cell ability to arrest cell cycle in response to DNA damage, irrespectively of p53 mutational status. Notably, this treatment did not increase cisplatin cytotoxicity on normal cells, thus suggesting a possible use of MK-1775 in combination with cisplatin for a safe and efficient treatment of epithelioid and biphasic MM.

Thermodynamic and kinetic investigation of monoketo-aldehyde-peroxyhemiacetal (MKA), a stereolabile degradation product of dihydroartemisinin

Theβ⇆αepimerization process ofMKAhas been studied under a thermodynamic and kinetic point of view in several solvents. LSER analyses and molecular modeling calculations allowed an effective rationalization of the findings.

Pharmacological targeting of p53 through RITA is an effective antitumoral strategy for malignant pleural mesothelioma

Malignant mesothelioma, a very aggressive tumor associated to asbestos exposure, is expected to increase in incidence, and unfortunately, no curative modality exists. Reactivation of p53 is a new attractive antitumoral strategy. p53 is rarely mutated in mesothelioma, but it is inactivated in most tumors by the lack of p14(ARF). Here, we evaluated the feasibility of this approach in pleural mesothelioma by testing RITA and nutlin-3, two molecules able to restore p53 function through a different mechanism, on a panel of mesothelioma cell lines representing the epithelioid (NCI-H28, NCI-H2452, IST-MES 2), biphasic (MSTO-211H), and sarcomatoid (NCI-H2052) histotypes compared with the normal mesothelial HMC-hTERT. RITA triggered robust caspase-dependent apoptosis specifically in epithelioid and biphasic mesothelioma cell lines, both through wild-type and mutant p53, concomitant to p21 downregulation. Conversely, nutlin-3 induced a p21-dependent growth arrest, rather than apoptosis, and was slightly toxic on HMC-hTERT.   Interestingly, we identified a previously undetected point mutation of p53 (p.Arg249Ser) in IST-MES 2, and showed that RITA is also able to reactivate this p53 mutant protein and its apoptotic function. RITA reduced tumor growth in a MSTO-211H-derived xenograft model of mesothelioma and synergized with cisplatin, which is the mainstay of treatment for this tumor. Our data indicate that reactivation of p53 and concomitant p21 downregulation effectively induce cell death in mesothelioma, a tumor characterized by a high intrinsic resistance to apoptosis. Altogether, our findings provide the preclinical framework supporting the use of p53-reactivating agents alone, or in combination regimens, to improve the outcome of patients with mesothelioma.

Modified laparoscopic ventral mesh rectopexy

We present a modified laparoscopic ventral mesh rectopexy procedure using biological mesh and bilateral anterior mesh fixation. The rectopexy is anterior with a minimal posterior mobilization. The rectum is symmetrically suspended to the sacral promontory through a mesorectal window.

Collagen matrix injection combined with flap repair for complex anal fistula

Several biomaterials have been proposed to treat anal fistula alone or in combination with other surgical procedures aiming to reduce recurrence rates while minimizing continence impairment. More recently a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulae. We propose an approach consisting of non-cutting seton positioning followed several weeks later by flap repair associated with dermal matrix injection into the fistula tracts. We report our experience with this two-staged procedure on 24 consecutive patients with complex anal fistulae with a median follow up of > 12 months. In our experience this two-stage approach seems to be safe and effective.

Medical oncologist’s commitment in the end of life (EoL) care of cancer patients: The caregiver's perspective

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Background: Optimizing the impact of EoL care on cancer patients (pts) and their caregivers should be a primary goal of an oncology unit. In this study we evaluated satisfaction of family caregivers when the medical oncology team assisted pts until death. Methods: Two oncology units were reorganized to ensure continuity of care; oncologists trained in palliative care medicine assisted pts until EoL. The model assumes that the medical oncologist (MO) is the physician in charge throughout the entire disease trajectory. Relatives of pts assisted at home or at an inpatient hospice underwent a semistructured phone interview conducted by a psychologist or a social worker > 1 month after pts' death. Satisfaction was evaluated for symptoms control, communication, psychological support, overall quality of care and continuity of therapeutic relationship with the MO. A final open-ended question was included for any additional comment. Satisfaction was measured using a five-point Likert scale ranging from very dissatisfied to very satisfied and converted to a 0-to-100 scale. Results: Relatives of 65 pts were contacted, 55 accepted the interview (27 spouses, 22 sons, 5 in-laws, 1 parent); 50/55 were the leader caregiver. Patients were followed at home (41) or at an inpatient hospice (14), for 1-24 wks. Satisfaction mean scores were: symptoms control 76/100, communication 85, psychological support 82 and overall quality of care 87; a specific question on the relevance of the MO in EoL care produced a score of 87, with no negative or neutral responses recorded for this item. Of note, a common perception among caregivers was the appreciation of the MO's commitment during EoL in addition to the technical quality of the intervention. The overall satisfaction score was higher than in our previous study in which a continuity of care model was not formally adopted, with a score improvement from 55 to 87/100. Conclusions: A care pathway where the MO is involved in EoL management of cancer pts improved satisfaction of caregivers.When a longstanding and trusting relationship has been established, the pts-MO connection should not be lost to prevent feelings of abandonment.

Phosphorylated Akt and MAPK expression in primary tumors and in corresponding metastases and clinical outcome in colorectal cancer patients receiving irinotecan-cetuximab

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Background: Other than the well-known EGFR pathway activation via the Ras-Raf-MAP-kinase, a possible role of other potential biomarkers could be relevant in determining resistance to anti-EGFR treatment, such as the protein-serine/threonine kinase Akt. We tried to assess the role of Akt and MAPK expression in metastatic colorectal cancer patients and their relationship with outcome for patients receiving Irinotecan-Cetuximab. Methods: Eligible patients were metastatic colorectal cancer patients treated in 2nd or 3rd line setting with a irinotecan-cetuximab based regimen. Patients were tested for K-ras status and subsequently assessed by immunoistochemistry for pAkt and MAPK expression, both in primary tumours and metastases whenever sufficient tissue was available. The role of pAkt and MAPK expression was evaluated for K-ras wild type patients for different likelihood of response, overall survival and progression free survival. Response was evaluated by RECIST criteria. Survival analysis was performed via Kaplan-Meier method. Results: In metastases pAkt correlated with RR (9% vs. 58%, p=0.004), PFS (2.3 months vs.9.2 months p < 0.0001) and OS (6.1 months vs.26.7 months p < 0.0001) and pMAPK correlated with RR (10% vs, 47%, p = 0.002), PFS (2.3 months vs.8.6 months p < 0.0001) and OS (7.8 months vs.26 months p=0.0004). At multivariate analysis pAkt and pMAPK in metastases were able to independently predict PFS. pAkt in metastases independently correlated with RR as well. Conclusions: pAkt and pMAPK expression in metastases may modulate the activity of EGFR-targeted antibodies. We could speculate that in patients with pAkt and pMAPK metastases expression targeting these factors may be crucial.

Binding, uptake, and degradation of internalized thyroglobulin in cultured thyroid and non-thyroid cells

Thyroid hormone release requires degradation of thyroglobulin (Tg) by thyroid epithelial cells, which occurs mainly in the lysosomal pathway following Tg endocytosis. Non-specific fluid-phase endocytosis is thought to be the main route of Tg uptake leading to degradation, whereas receptor- mediated endocytosis is believed to lead to post-endocytic pathways other than degradation. To gain more insights into these issues, we investigated handling of Tg by various cell types. Tg bound similarly to thyroid (FRTL-5, FRT) and non-thyroid (COS-7, IRPT) cells, indicating the presence of membrane-binding sites, presumably receptors, in both cell types. Tg was internalized and degraded by all cells and degradation paralleled uptake, with the exception of FRTL- 5 cells, in which a lower proportion of Tg was degraded, suggesting that in FRTL-5 cells mechanisms that target Tg to the various post-endocytic pathways (either receptors or postreceptorial factors) are differently represented. Immunoelectronmicroscopy showed a common path of endocytosis in FRTL-5, COS-7, and IRPT cells, namely the formation of pseudopods engulfing Tg, followed by internalization and accumulation of Tg in cytoplasmic vesicles and lysosomes. The fastest rate was observed in COS-7 cells, probably reflecting a lower impact of endocytic receptors. Our findings suggest that Tg uptake and degradation are not thyroid-specific, that Tg binding sites exist in different cell types, and that uptake and/or degradation are differently regulated in differentiated thyroid cells, presumably because of a different impact of endocytic receptors or post-endocytic mechanisms, which are probably responsible for the regulation of hormone release.

Abstract LB-227: New SRC inhibitors induce p27-mediated apoptosis in mesothelioma cell lines

Malignant mesothelioma (MM) is a highly aggressive tumor of the serous membranes for which there is currently no specific curative modality. Recent data suggest that hyperactivation of the tyrosine kinase SRC has a key role in MM development and therefore this kinase represents an important molecular target for MM therapy. We tested new pyrazolo-[3,4-d]-pyrimidine SRC inhibitors on a panel of MM cell lines expressing the active form of SRC. These SRC inhibitors exerted a significant proapoptotic effect on MM cells without affecting the normal mesothelial cell line MET-5A, supporting a possible use of these SRC inhibitors for a safe treatment of MM. We also showed that SRC inhibitor-induced apoptosis occurred concomitantly with an increase in the nuclear stability of the cyclin-dependent kinase inhibitor p27. This finding is remarkable considering that loss of nuclear p27 expression is a well-established adverse prognostic factor in MM and p27 nuclear localization is crucial for its tumor suppressive function. Consistently, SRC inhibition seems to promote the increase in p27 nuclear level also by inactivating the AKT kinase and downregulating cyclin D1, which would otherwise delay p27 nuclear import and provoke its cytoplasmic accumulation. To determine whether p27 stabilization has a direct role in apoptosis induced by SRC inhibition, we stably silenced the CDKN1B gene, encoding p27, in MSTO-211H and REN mesothelioma cells by transduction with lentiviral vectors expressing short hairpin RNAs against the CDKN1B transcript. Strikingly, p27 silencing was able to suppress the apoptosis induced by these SRC inhibitors in both MM cell lines, suggesting that p27 has a crucial proapoptotic role in MM cells treated with SRC inhibitors. Our findings reveal a new mechanism, dependent on p27 nuclear stabilization, by which SRC inhibition can induce apoptosis in MM cells and provide a new rationale for the use of SRC inhibitors in MM therapy.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-227. doi:10.1158/1538-7445.AM2011-LB-227

MEGAPOLI: concept of multi-scale modelling of megacity impact on air quality and climate

Abstract. The EU FP7 Project MEGAPOLI: "Megacities: Emissions, urban, regional and Global Atmospheric POLlution and climate effects, and Integrated tools for assessment and mitigation" (http://megapoli.info) brings together leading European research groups, state-of-the-art scientific tools and key players from non-European countries to investigate the interactions among megacities, air quality and climate. MEGAPOLI bridges the spatial and temporal scales that connect local emissions, air quality and weather with global atmospheric chemistry and climate. The suggested concept of multi-scale integrated modelling of megacity impact on air quality and climate and vice versa is discussed in the paper. It requires considering different spatial and temporal dimensions: time scales from seconds and hours (to understand the interaction mechanisms) up to years and decades (to consider the climate effects); spatial resolutions: with model down- and up-scaling from street- to global-scale; and two-way interactions between meteorological and chemical processes.

Downregulation and aberrant promoter methylation of p16INK4A: a possible novel heritable susceptibility marker to retinoblastoma

RB loss has long been recognized as the causative genetic alteration underlying retinoblastoma but it is increasingly evident that other alterations are required for the tumor to develop. Therefore, we set out to identify additional inheritable susceptibility markers and new potential preventive and therapeutic targets for retinoblastoma. We focused on the p16INK4A tumor suppressor gene because of its possible role in retinoblastoma pathogenesis and its involvement in predisposition to familial cancer. p16INK4A expression was analyzed in tumor samples from retinoblastoma patients by immunohistochemistry and in peripheral blood cells from both patients and their parents by real-time quantitative reverse transcription-PCR (qRT-PCR). Since promoter methylation is a common mechanism regulating p16INK4A expression, the methylation status of its promoter was also analyzed in blood samples from patients and their parents by methylation-specific PCR. A downregulation of p16INK4A was observed in 55% of retinoblastoma patients. Interestingly, in 56% of the cases showing p16INK4A downregulation at least one of the patients' parents bore the same alteration in blood cells. Analysis of p16INK4A promoter methylation showed hypermethylation in most patients with p16INK4A downregulation and in the parents with the same alteration in p16INK4A expression. The finding that p16INK4A was downregulated both in patients and their parents suggests that this alteration could be a novel inheritable susceptibility marker to retinoblastoma. The observation that p16INK4A downregulation seems to be due to its promoter hypermethylation opens the way for the development of new preventive and therapeutic strategies using demethylating agents.

Chemotherapy in very elderly cancer patients (85 years and over): A retrospective study

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Background: Elderly cancer patients (pts) population is expanding due to demographic changes. Currently 2.4 % of Italian population is older than 85, with this group accounting ∼8 % of all cancer pts in our geographic area. Since very elderly (85 years and over) cancer pts are generally excluded from clinical trials, few data are available about tolerability of chemotherapy in this population. Methods: We conducted a retrospective analysis of cancer pts aged 85 years and over receiving chemotherapy for advanced disease in the years 2005–2007 in three Oncology Unit of the Regione Marche, Italy. Results: We identified 50 patients (26 males, 24 females) with a mean age of 86.4 (range 85–95), ECOG PS 0 (4 pts) 1 (25 pts) 2 (13 pts) 3 (8 pts). Type of cancer (pts): NSCLC (13), colorectal (11), breast (5), prostate (4), gastric (3), NHL (3), bladder (2), head-neck (2), ovarian (2), vulvar (1), skin (1), pancreas (1), GIST (1), UPT (1). Main co-morbidities included hypertension (18 pts), COPD (8 pts) and heart disease (6 pts). The median number of cycles in first line chemotherapy were 6 (1–44); 20 pts received 2 or more lines of chemotherapy (range 2–5). Dose reductions were planned in all pts: in 26 dose reduction was 30 %, in 22 was 50%, in 2 > 50 %. Most used drugs were: vinorelbine os or iv (14 pts), capecitabine (9 pts), gemcitabine (7 pts). Target agents were used in 7 pts (5 erlotinib, 2 gefitinib, 2 rituximab, 1 sunitinib). Ten partial responses were observed; main toxicities were: grade 3–4 neutropenia (10 %), grade 3 diarrhea (5 %), and 1 pts had grade 3 hand-foot syndrome. No treatment related deaths were observed. Conclusions: Very elderly cancer pts (85 years and over) in good PS and few co-morbid conditions receiving dose reduced chemotherapy experienced acceptable toxic effects; a partial response was documented in 10 out of 50 pts. The expanding use of chemotherapy and target therapy in this clinical setting has profound influence on health care management and costs. Prospective studies specifically designed for this pts population could clarify the benefit, in terms of quality of life and survival, of an interventionist instead of a supportive care only approach.

No significant financial relationships to disclose.

Identification of an isomer impurity in piperaquine drug substance

A significant contaminant of the antimalarial drug piperaquine (1,3-bis-[4-(7-chloroquinolyl-4)-piperazinyl-1]propane) has been identified using liquid chromatography-mass spectrometry (LC-MS) and 2D NMR spectroscopy (1H-1H COSY, 1H-13C HSQC, 1H-13C HMBC). The impurity was identified as the positional isomer 1-[(5-chloroquinolin-4)-piperazinyl]-3-[(7-chloroquinolin-4)-piperazinyl]propane. The impurity is formed because of contamination of batches of 4,7-dichloroquinoline (a precursor in the synthesis of piperaquine) with 4,5-dichloroquinoline. The amount of impurity (peak area impurity/peak area piperaquine using LC-UV at 347 nm) in old batches of piperaquine and in Artekin (the combination of dihydroartemisinin-piperaquine) ranged from 1.5 to 5%.

Paclitaxel and epirubicin followed by cyclophosphamide, methotrexate and 5-fluorouracil for patients with stage IIIC breast cancer with ten or more involved axillary lymph nodes

OBJECTIVE

The aim of this study was to evaluate the feasibility of a combination of epirubicin and paclitaxel followed by intravenous (iv) cyclophosphamide, methotrexate, and 5-fluorouracile (CMF) as adjuvant treatment of breast cancer patients with 10 or more metastatic axillary lymph nodes.

METHODS

Forty-four patients entered this multicenter study and received 4 cycles of epirubicin (E 120 mg/m2 day 1, q3 weeks) and paclitaxel (T 135 mg/m2 day 1, q3 weeks), followed by 4 cycles of iv CMF (days 1 and 8, q4 weeks). Patients with positive hormonal receptors received sequentially tamoxifen associated with LH-RH analogue if premenopausal. The endpoints were the evaluation of the feasibility of this schedule and disease free survival (DFS).

RESULTS

Median age of patients was 55; median number of positive axillary nodes was 14 (range, 10-47). Hormonal receptor status was positive in 57% of patients. The combination of epirubicin and paclitaxel was well tolerated; NCI grade 3/4 events were: leucopenia in 27% of patients, neutropenic fever in 5 patients, anemia in 7%, thrombocytopenia in 7%, nausea in 18%, vomiting in 14%, and neurotoxicity in 4%. CMF regimen caused a few cases of grade 3/4 hematologic toxicity. No cardiac toxicity was recorded. With a median follow-up of 59 months, 18 (41%) patients relapsed. Sites of relapse were mainly bone, skin/soft tissues, liver, and lung. Median DFS was 78 months, with a 5-year rate of 60%.

CONCLUSIONS

The combination of paclitaxel at low dose and epirubicin followed by CMF is a feasible regimen, which seems to be effective in high-risk node positive breast cancer patients and requires further investigations.

Extreme heat reduces and shifts United States premium wine production in the 21st century

Premium wine production is limited to regions climatically conducive to growing grapes with balanced composition and varietal typicity. Three central climatic conditions are required: (i) adequate heat accumulation; (ii) low risk of severe frost damage; and (iii) the absence of extreme heat. Although wine production is possible in an extensive climatic range, the highest-quality wines require a delicate balance among these three conditions. Although historical and projected average temperature changes are known to influence global wine quality, the potential future response of wine-producing regions to spatially heterogeneous changes in extreme events is largely unknown. Here, by using a high-resolution regional climate model forced by the Intergovernmental Panel on Climate Change Special Report on Emission Scenarios A2 greenhouse gas emission scenario, we estimate that potential premium winegrape production area in the conterminous United States could decline by up to 81% by the late 21st century. While increases in heat accumulation will shift wine production to warmer climate varieties and/or lower-quality wines, and frost constraints will be reduced, increases in the frequency of extreme hot days (>35 degrees C) in the growing season are projected to eliminate winegrape production in many areas of the United States. Furthermore, grape and wine production will likely be restricted to a narrow West Coast region and the Northwest and Northeast, areas currently facing challenges related to excess moisture. Our results not only imply large changes for the premium wine industry, but also highlight the importance of incorporating fine-scale processes and extreme events in climate-change impact studies.