Immunogenicity and disease control induced by a multineoantigen vaccine (ADXS-503) in patients with metastatic non–small cell lung cancer who have progressed on pembrolizumab

9042

Background: The administration of a lung cancer-specific immunotherapy with 22 tumor-associated antigens (ADXS-503, A503), has been evaluated as an add-on therapy for patients (pts) with metastatic non-small-cell lung cancer (NSCLC) who have progressed on pembrolizumab (pembro) as last therapy [Haigentz M et al. ASCO 2021]. The present study explores the immunogenicity and potential reversal of immune resistance with A503 when added-on to pembro at the time of progressive disease (PD). Methods: A phase 2 study of A503 + pembro is being conducted in pts with metastatic squamous or non-squamous NSCLC. In Part B of the study, A503 was added-on to pembro within 12 weeks after the first scan showing disease progression following pembro therapy (per RECIST criteria v1.1). Both A503 (1x108 CFU) and pembro (200 mg) were infused by IV every 3 weeks until disease progression or dose-limiting toxicity. Immunogenicity assays included serum cytokine and chemokine levels; flow cytometry; and in-vitro stimulation FluoroSpot assay with 4 different antigen-pools represented in A503 [i.e., hot spot mutations, heteroclitic/wild-type tumor-associated antigens and other antigens not included in the A503 construct (antigen spreading)]. Results: A total of 14 pts have been treated in Part B, of which 13 are clinically evaluable and up to 11 have immune assessments. Combination therapy was well tolerated with transient increased secretion of cytokines for several hours after infusion of A503 consistent with the expected immune activation and transient ‘flu-like’ syndrome. The objective response rate (16%) and disease control rate (46%) were encouraging with 2 partial responses (PR), 4 stable diseases (SD) and 7 pts with PD. Pts with disease control, in particular, generated CD8+ T cells reactive to neoantigens in 1 or more of the 4 antigen pools tested in FluoroSpot. Also, activation of NK cells and of cytotoxic- and memory-CD8+ T cells was mainly observed in pts with PR or SD, but not in those with PD, as shown in the table. Conclusions: Adding A503 to pembro after PD appears to induce innate and adaptive immune responses that may restore or enhance sensitivity to checkpoint inhibitors in pts with clinical benefit. Clinical trial information: NCT03847519. [Table: see text]

A phase 2 study of an off-the-shelf, multi-neoantigen vector (ADXS-503) in patients with metastatic non–small cell lung cancer either progressing on prior pembrolizumab or in the first-line setting

9038

Background: ADXS-503 (A503) is an off-the-shelf, attenuated Listeria monocytogenes (Lm)-based immunotherapy bioengineered to elicit potent T-cell responses against 22 tumor antigens commonly found in non-small-cell lung cancer (NSCLC, i.e. 11 hotspot mutations and 11 tumor-associated antigens, TAAs). Pembrolizumab (pembro) is a programmed death receptor-1 (PD-1)-blocking antibody approved for the treatment of advanced lung cancer. A503 and pembro have complementary mechanisms of immune activation and reversal of immune tolerance. Methods: A phase 2 study of A503 ± pembro is being conducted in patients with metastatic squamous or non-squamous NSCLC. In Part B of the study, A503 was added-on to pembro within 12 weeks of the first scan showing disease progression following pembro (per RECIST criteria v1.1). In Part C of the study, A503 and pembro were administered to previously untreated patients. Both A503 (1x108 CFU) and pembro (200 mg) were infused by IV every 3 weeks until disease progression or limiting toxicity. Results: A total of 17 patients have been treated/evaluated from Part B (n = 14/13) and Part C (n = 3/3). Pembro + A503 was well tolerated in both parts of the study, with mostly grade 1–2, transient and reversible treatment-related adverse events, the most common being fever (47%), chills (35%), fatigue (29%) and nausea (21%). There have been no added immune-related toxicities associated with the combination. Of the 13 evaluable patients in Part B, 2 achieved partial response (PR) and 4 achieved stable disease (SD), yielding an objective response rate (ORR) of 15.4% and a disease control rate (DCR) of 46.2%. Two patients from Part C also achieved SD (DCR 67%). The 2 PRs in Part B have been durable (i.e. 710 and 189 days) as were 5 of the SDs: 3 in Part B (i.e. 448, 175, 117 days) and 2 in Part C (i.e. 322 and 175 days). Both patients with PR in Part B are still undergoing therapy in addition to the other patients who achieved SD. Patients who seem to achieve clinical benefit in both parts of the study include those with PD-L1 expression ≥ 50% and those who show proliferation and/or activation of NK and CD8+ T cells within the first weeks of therapy. In addition, patients with prior pembro exposure ≥ 6 months and DCR > 6 months seem to have clinical benefit when A503 is added to pembro (Part B). Conclusions: The addition of A503 to pembro after disease progression on pembro appears to be well tolerated and induced antigen-specific T-cell responses and durable disease control in 46% of patients in Part B and 67% of patients in Part C. Additional patients are currently being enrolled into both parts of the study to further explore the potential of A503 to restore or enhance sensitivity to checkpoint inhibitors. Clinical trial information: NCT03847519.

A phase 1 study of an off-the shelf, multi-neoantigen vector (ADXS-503) in subjects with metastatic non-small cell lung cancer (NSCLC) progressing on pembrolizumab as last therapy

2616

Background: ADXS-503 (A503) is an off-the-shelf, attenuated Listeria monocytogenes (Lm)-based immunotherapy bioengineered to elicit potent T cell responses against 22 tumor antigens commonly found in NSCLC (i.e., 11 hotspot mutations and 11 tumor-associated antigens, TAAs). Pembrolizumab (Pembro) is a programmed death receptor-1 (PD-1)- blocking antibody approved for the treatment of advanced lung cancer. A503 and Pembro have complementary mechanisms of immune activation and reversal of immune tolerance. Methods: A phase 1 study of A503 ± Pembro has been conducted in patients (pts) with metastatic squamous or non-squamous NSCLC. In dose-escalation part B, A503 was added-on to Pembro within 12 weeks of the first scan showing disease progression per RECIST criteria v1.1. Both, A503 (1 x108 CFU) and Pembro (200 mg) were infused by IV every 3 weeks until disease progression or limiting toxicity. The dose-escalation cohort has established safety, tolerability and immunogenicity of the combination therapy and it has been further expanded to evaluate efficacy (Goldman JW et.al., SITC 2020). Results: Nine pts have been treated and evaluated in Part B. Pembro + A503 combo has been well tolerated and without immune related AEs. Of the nine evaluable pts, one has achieved partial response (PR) and 3 stable disease (SD), yielding an overall response rate (ORR) of 11% and disease control rate (DCR) of 44%. Two patients have had clinical benefit for over 12 months (i.e., one PR and one SD) and both of them had been on Pembro therapy for 2 years before enrollment. The two other pts with SD have sustained it for almost 6 months thus far. Seven pts have been evaluated for immunogenicity. In all pts there was a transient release of pro-inflammatory cytokines and proliferation of cytotoxic- and memory-CD8+ T cells. Seven evaluable pts had antigen-specific T cells within 1-2 weeks after starting therapy and 4/7 showed antigen spreading. Conclusions: ADXS-503 as an add-on therapy to Pembro at disease progression has been well tolerated and it has induced antigen specific-T cell responses and durable disease control in 44% of pts. Part B cohort is currently enrolling additional pts to further explore the potential reversal of Pembro resistance with ADXS-503. Clinical trial information: NCT03847519.

A phase I study of ADXS-503 alone and in combination with pembrolizumab in subjects with metastatic squamous or non-squamous non-small cell lung cancer (NSCLC)

e21682

Background: ADXS-503 (A503) is an off-the-shelf, attenuated Listeria monocytogenes (Lm)-based immunotherapy bioengineered to elicit potent T cell responses against 22 tumor antigens commonly found in NSCLC (i.e., 11 hotspot mutations and 11 tumor-associated antigens, TAAs). Pembrolizumab (Pembro) is a programed death receptor-1 (PD-1)- blocking antibody with proven efficacy in NSCLC. A503 and Pembro have complementary mechanisms of immune activation and reversal of immune tolerance. Methods: This is a phase I study of A503 ± Pembro in patients (pts) with metastatic squamous or non-squamous NSCLC. Dose escalation with A503 alone has been tested at two dose levels (i.e., 1 and 5 x108 CFU) in Part A in pts refractory or intolerant to prior systemic therapy. In dose escalation Part B, A503 is being evaluated at the same dose levels (DLs) in combination with Pembro in pts with disease progression on Pembro. Part C will be a dose expansion cohort with A503 + Pembro as first-line treatment in the metastatic setting. A503 ± Pembro (200 mg) will be infused intravenously every 3 weeks until disease progression or limiting toxicity. Main endpoints include safety, tolerability and immune-correlative data. Results: Nine patients have been treated: 7 with A503-alone in Part A and two pts with A503+ Pembro in Part B-DL1. No pts in Part A experienced dose-limiting toxicities at the 2 DLs tested. Two Grade 3 adverse events occurred in one pt related to the infusion: hypertension and flu-like syndrome. A transient and manageable SAE (Grade 2 acute kidney injury) was possibly related to A503 alone at 5 x108 CFU. A503+ Pembro have been well tolerated in 2 pts in Part B-DL1. Four pts achieved a best overall response of stable disease, three in Part A and one in Part B. A503 alone induced immune responses in pts so far evaluated in Part A. Conclusions: ADXS-503 alone has demonstrated a manageable safety profile and immune responses in Part A. The 1x108 CFU was identified as the recommended phase II dose. Dose escalation with A503+ Pembro is ongoing and dose expansion in first line treatment is due to start shortly. Clinical trial information: NCT03847519.

S1507: Phase II study of docetaxel and trametinib in patients with G12C or non-G12C KRAS mutation positive (+) recurrent non-small cell lung cancer (NSCLC)

9021

Background: KRAS+ NSCLC remains the most common genetically defined subset of NSCLC. Despite promising pre-clinical data, MEK inhibitors have failed to provide meaningful clinical benefit both as single agents and in combination with chemotherapy in KRAS+ NSCLC patients. Pre-clinical data suggest that efficacy of MEK inhibitors in KRAS+ NSCLC differs based on specific KRAS mutations such as G12C and by status of p53 or LKB1 mutations. We conducted a phase II study to assess the efficacy of docetaxel plus trametinib in KRAS+ NSCLC patients and in specific genetic subsets. Methods: KRAS+ NSCLC patients who had progressive cancer following 1 or 2 prior regimens were eligible. Docetaxel was given at 75 mg/m2 every 3 weeks and trametinib orally at 2 mg daily. The study was 2-stage design to rule out a response rate (RR) of 17% at the 3% level with 90% power if the true rate were 37%. The study required 45 pts with a futility analysis at 30 pts; 13/45 responses would indicate a success. RR was also assessed in G12C and non-G12C cohorts and will be assessed according to presence of co-mutations in p53 and LKB1. Progression free survival (PFS) and overall survival (OS) were secondary endpoints. Multivariate analysis including age, sex, number of prior treatments, prior immunotherapy (IO) and G12C status was conducted. Results: The study enrolled 54 evaluable pts (19 G12C, 9 G12D, 9 G12A); median age 65 years; female 57%; never smokers 7%; adenocarcinoma 89%; liver metastases 31%; 2 prior regimens 70%; prior IO 57%. Outcomes are summarized in Table. Median duration of therapy was 2.2 months and most common toxicities were fatigue (78%), diarrhea (68%), nausea (57%) and vomiting (28%). One patient died of treatment related respiratory failure. There was a trend for worse PFS (HR- 1.86, p = 0.06) and survival (HR- 1.80, p = 0.14) in G12C patients. Analysis of efficacy data according to co-mutations in p53 or LKB1 is ongoing. Conclusions: Docetaxel plus trametinib met the primary endpoint of the study, with a RR of 33% and median survival of 11.1 months in patients with KRAS+ NSCLC, 70% of whom had received 2 prior regimens. Although, there was no statistical difference between KRAS+ subtypes, these data suggest that outcomes may differ between G12C and non-G12C patients. Clinical trial information: NCT02642042. [Table: see text]

Possible association of postmeiotic segregation increased 2 (PMS 2) gene deletion and myelodysplastic syndrome

e17021

Background: Postmeiotic segregation Increased 2 (PMS2) gene is one of the gene family members found in clusters on chromosome 7 involved in DNA mismatch repair. Mutations in this gene are associated with hereditary nonpolyposis colorectal cancer and Turcot syndrome. PMS-2 defects are not extensively studied and hence there is still considerable potential to detect new hemato-oncological associations with same. Chromosome 7 defects are the most commonly associated genetic abnormalities associated with myelodysplastic syndrome (MDS). Here, we describe a case of a patient with known PMS 2 gene deletion presenting with early onset MDS. Methods: A 52 year old caucasian female came in to our oncology clinic for evaluation after being diagnosed with DCIS of right breast. She underwent surgical resection followed by tamoxifen and surviellance mamograms. She developed gradual onset of fatigue, prompting follow-up laboratory tests which revealed WBC of 8,600, Hgb of 8.5, MCV of 101, and Plt 383,000. B12, folate, and iron studies were normal. Bone marrow biopsy revealed cellularity 80% and cytogenetics with trisomy 8.This lead to diagnosis of myelodysplastic syndrome, refractory cytopenia with multilineage dysplasia and ringed sideroblasts (RCMD-RS). Patient is currently treated with supportive transfusions after lack of benefit of darbopoietin (baseline epo level 67). Family history is pertinent for a son who died at age 21 from colon cancer and a daughter diagnosed at age 22 with colon cancer, who survives. Her daughter subsequently tested positive for G750 PMS-2 from her father and complete deletion of PMS2 from her mother (our patient). Results: PMS2 gene deletion might predispose patients to MDS. Conclusions: Given the common link with chromosome 7 abnormalities, it is therefore possible that there is an associated increased risk of MDS in PMS-2 patients. While our patient did not have any general abnormalities by karyotype, current assays and general karyotyping are of potentially limited value unless specific mutation points are identified. Therefore, additional evaluations may be necessary to better identify at-risk patients.

[Breast cancer: morbidity and mortality in Austria. Descriptive epidemiology 1983-1987]

The incidence and mortality rate from breast cancer in Austria from 1983 to 1987 were obtained from data of the Austrian Cancer Register. There were on average 3012 new cases per year (75.8 per 100,000 women). Age-standardized incidence (European standard population) as calculated by the WHO was 64.1 per 100,000. Distribution by stages ("US end-result group") showed stage I (localized) in 44.7%, stage II (spread to immediate neighbouring structures and regional lymph nodes) in 41.3% and stage III (generalized) in 14%. There was no significant difference between the various age groups regarding stage distribution. The number of deaths increased from 1,462 in 1983 to 1,675 in 1987, a raw mortality rate of 36.8 and 42.2, respectively. Age-standardized mortality increased from 29.0 to 31.2, respectively. These data point to a further increase in incidence and mortality rate from breast cancer in Austria.

Interstitial fluid concentrations of ceftriaxone (1 g.i.v.) in the subperitoneal space after hysterectomy

The ability of an antibiotic to penetrate into the extravascular site of infection is particularly important for a successful perioperative antibiotic prophylaxis and postoperative therapy of bacterial infection. We, therefore, measured interstitial fluid concentrations of ceftriaxone in the subperitoneal space following hysterectomy using Rubinstein's disc method after intravenous administration of 1 g of ceftriaxone preoperatively. After removal of the uterus, two disc units were implanted intraoperatively in the right and left subperitoneal space of 16 patients and were drawn out through the open vaginal cuff after given periods of time. Five disc and blood specimens were obtained after 90 min and 2, 6, 12, 24, and 48 h, respectively. Ceftriaxone concentrations were determined by bioassay. After administration of 1 g of ceftriaxone, interstitial fluid concentrations following hysterectomy were above the MIC90 of most pathogens encountered in gynecologic infections over a period of 24 h.

Comparison of ceftriaxone (1 x 1 g/day) versus cefotaxime (3 x 1 g/day) for gynecologic and obstetric infections. A randomized clinical trial

A prospective, randomized clinical trial was conducted to compare the efficacy and tolerance of a single dose of 1 g ceftriaxone i.v. daily with 3 doses of 1 g cefotaxime i.v. daily for obstetric and gynecologic infections. Both agents are characterized by a wide spectrum and potent activity. Furthermore, ceftriaxone has an outstanding serum half-life of 8 h. 41 patients with pelvic inflammatory disease, pelvic or wound infections after vaginal or abdominal hysterectomy, endomyometritis and urinary-tract infection were included. Patients were monitored clinically by routine laboratory methods (erythrocyte sedimentation rate, white blood cell count and cross-reacting protein) and bacteriologically. Clinical parameters of infection were fever, local pain and/or tenderness, a sactosalpinx or pyosalpinx at palpation and cervical secretion. Clinical cure was achieved in 77.3% in the ceftriaxone and in 78.9% in the cefotaxime group, improvement in 3 (13.6%) and 4 patients (21.0%), respectively. 2 clinical failures were seen in the ceftriaxone group. One was a severe pelvic infection following vaginal hysterectomy, which responded to the addition of metronidazole, the other was due to a chlamydial salpingitis, which was cured with a 10-day course of doxycycline. Both antibiotics were well tolerated. Our results suggest that for obstetric and gynecologic infections a single 1-gram dose of ceftriaxone is equally effective as three 1-gram doses of cefotaxime.

Influence of brachytherapy (192Ir afterloading) on cell-mediated immune reactions in patients with stage I endometrial cancer

The influence of radiation therapy on cell-mediated immune reactions in cancer patients seems to depend on source, dose, and area of irradiation, as well as on the variables reflected by the patient population investigated. In the present study we demonstrated that brachytherapy (192Ir afterloading), applied to patients with inoperable stage I endometrial cancer, has no immediate or sustained effect on lymphocyte function. Both lymphocyte mitogen response and natural killer cell (NK) activity are not significantly changed in terms of baseline values compared with test results during and after therapy. Brachytherapy, as used in this study, has no influence on cell-mediated immunity in patients with endometrial cancer stage I.

Amoxicillin in the treatment of asymptomatic bacteriuria in pregnancy: a single dose of 3 g amoxicillin versus a 4-day course of 3 doses 750 mg amoxicillin

A prospective, randomized, controlled comparative clinical trial was carried out with the aim of investigating the efficacy and tolerance of two different dosage regimens of amoxicillin in the treatment of asymptomatic bacteriuria during pregnancy. Patients in group A received a single dose of 3 g amoxicillin, which was compared to a 4-day course of 3 X 750 mg amoxicillin tablets taken every 8 h (group B). Significant bacteriuria (CFU greater than or equal to 10(5)/ml clean catch midstream urine and CFU greater than or equal to 10(4)/ml urine obtained by bladder catheterization) was diagnosed using the dip-slide method (Uricult). 91 pregnant women with a mean gestational age of 25 weeks (14-38) were randomly allocated to the two treatment groups. 53 patients were assigned to group A and 38 patients to group B. The treatment groups were comparable in terms of age and duration of pregnancy. Urine culture tests were performed 1 and 4 weeks after completion of therapy. The predominant species was Escherichia coli, which was isolated in 60-65% of the cases. Bacteriological cure rates at 1 and 4 weeks, respectively, were 77 and 74% in group A, and 62 and 62% in group B. These differences were statistically not significant. The incidence of side effects was 4% in group A and 13% in group B. The results obtained in the present study suggest that in the treatment of asymptomatic bacteriuria in pregnancy, a single dose of 3 g amoxicillin is as effective and acceptable as a 4-day course. In addition, the single-dose regimen offers the advantage of a reduction in total dose, lower costs and better patient compliance.

Single and multiple dose pharmacokinetics of ciprofloxacin in gynecological tissues

In a prospective pharmacokinetic study the serum and tissue concentrations of ciprofloxacin (Bay O9867), a new carboxyquinolone antimicrobial agent were studied. 22 patients were given 300 mg ciprofloxacin i. v. before the operation (group A), and 19 patients were premedicated with 500 mg ciprofloxacin orally twice daily for three days followed by 300 mg i. v. preoperatively. Tissue samples weighing approximately 2 g were taken from the fallopian tubes, the ovaries, the fundus myometrium and the cervix. Ciprofloxacin concentrations were measured biologically by the cup plate agar diffusion method. Ciprofloxacin concentrations in serum and gynecological tissues were within the same range in both groups. Maximal serum concentrations of 6 and 4 mg/l, respectively, were recorded immediately after infusion. After 2 h serum concentrations ranged from 0.6 to 1.3 mg/l in both groups. At the same time, the tissue concentrations ranged from 0.62 to 3.3 mg/kg, indicating that tissue levels exceed corresponding serum concentrations. On average ciprofloxacin is concentrated in the extravascular space two-fold, as compared to the corresponding serum concentrations. There is no drug accumulation. The tissue concentrations obtained provide a full antibacterial coverage for gynecological infections, since the MIC for the most pathogenic bacteria is less than 1 mg/l.

[Burkitt's lymphoma of the ovary. Case report]

Bilateral adnexal masses in an 18-year old turkish girl were diagnosed as Burkitt's lymphoma. Aetiology, diagnosis and therapy (surgery and chemotherapy) of this by gynecologists rarely seen disease are presented.

[Amoxicillin in the treatment of asymptomatic bacteriuria in pregnancy--3g single dose versus 3 times 750mg 4-day therapy]

A prospective, randomized, controlled comparative clinical trial was conducted to assess the efficacy and tolerability of 2 regimens of amoxicillin. In group A a single dose of 3 g amoxicillin and in group B a 4-day course of 3 doses of 750 mg amoxicillin tablets were administered 8-hourly. Significant bacteriuria (greater than or equal to 10(5) cfu/ml midstream urine) and of urine samples obtained by bladder catheterization (greater than or equal to 10(4) cfu/ml) was diagnosed with the dip-slide method (Uricult). 91 pregnant women with a mean gestational age of 25 weeks (14-38) were randomly allocated to both treatment groups. Group A consisted of 53 patients, group B of 38. The treatment groups were comparable in terms of age, duration of pregnancy and additional therapy. Control examinations of urine cultures were taken after 1 and 4 weeks following therapy. The predominant bacterial species was E. coli isolated in 60 to 65 percent. Bacteriological cure rates at 1 and 4 weeks were in group A 77% and 74% and in group B 62% each respectively. The differences in cure rates were not significant. Side effects occurred in group A in 4% and in group B in 13%. Our results suggest that for the treatment of asymptomatic bacteriuria in pregnancy a single dose of 3 g of amoxicillin is equally effective and acceptable as a 4-day course with the advantage of a lower total-dose, lower costs and a better compliance.

[Value of breast palpation in gynecologic practice]

A representative inquiry was carried out among 100 Austrian gynecologists and obstetricians. Aim of the study was to determine the percentage of gynecologists, who carry out routinely the palpation of the breast in their office: 73% of all gynecologists are performing breast-palpation routinely in every patient, 27% only in case of complaints. The highest percentage of routine-breast-palpation performing gynecologists was found among doctors, who are in private-practice only (97%). Particularly low percentages, however, were found e. g. among doctors, who have contracts with all social insurances (58%), who have a high frequency of social-insured patients (55%) or have many patients per day (61%). Since the routine-breast-palpation is of particular importance for the reduction of breast cancer mortality, this examination should be also performed routinely by all general practitioners, internists and surgeons. Therefore, from the point of view of preventive medicine and public health the routine examination of the female breast should be refunded by social insurance in Austria.

[Facts on the topic "gentle birth": a representative survey of Austrian gynecologists]

With regard to discussions in the public being held in this country throughout the past months, a representative inquiry was carried out among Austrian gynaecologists and obstetricians. Aim of the study was to determine the percentage of obstetricians performing the so-called "birth without violence" according to Leboyer as well as their opinion to this alternative obstetrical thinking: Approximately one half of Austrian gynaecologists is carrying out so-called "births without violence." However, the vast majority of them (78%) prefers for their own wives and their own children "electronic fetal monitoring" during labour and delivery. Analysis of our data according to the age of the doctor, the geographic region of his office, and the number of treated patients shows a considerable discrepancy between performance and personal preference of "alternative" obstetrical methods. These results should be taken into account for further discussions in the public about "births without violence", as obstetricians are among all professions those experts who can estimate the risks of pregnancy and delivery best.

Radiation therapy for primary carcinoma of the female urethra: a survey over 25 years

Sixty-two patients with primary carcinoma of the female urethra were treated with a combined radiation therapy (high-dose intracavitary vaginal radium and external beam). Treatment was strictly individualized, but an administered tumor dose of 5500-7000 rad (55-70 Gy) was always attempted. Forty-two patients (67.7%) had tumors of the anterior urethra, and in 20 women (32.3%) the posterior urethra was involved. In 19 patients (30.6%) the clinical diagnosis of lymph node involvement was made. The overall 5-year-survival rate was 64.5%. Patients with anterior urethral carcinoma had a higher 5-year-survival rate (71.4%) than patients with posterior carcinoma (50.0%). The favorable results underline the substantial role of radiation therapy for this malignancy.

[Infections in patients with gynecologic malignancies]

Infections in patients with gynecologic malignancies occur frequently and are the cause of death in 50 to 60% of the cases. The patient with cancer is a compromised host with an increased susceptibility to infection due to the malignancy itself on the one hand and due to therapeutic-modalities, like extensive surgical procedures, radiation- and cytotoxic chemotherapy on the other hand. Aetiologically these infections are mostly due to a disruption of anatomic structures which normally prevent the invasion of exogenous or endogenous microorganisms, or to obstructive processes or to tumour necrosis. Septicaemia can result from propagation of such a localized infection beyond the site of the tumour. The causative pathogens infecting the compromised host are mostly members of the indigenous microbial flora of the genital tract, which is influenced by surgery, irradiation and chemotherapy. Postoperatively in the vaginal vault the number of most potentially pathogenic aerobic and anaerobic bacterial species is higher, polymicrobial mixed infections are frequent. Neither the intracavitary radiation-therapy with Radium or Iridium-192 (afterloading) nor the external high-voltage therapy decrease the number of pathogenic bacterial species in the uterus and in the vagina of patients with cervical or endometrial cancer. The symptoms of infection in cancer patients can be "masked". Fever in patients with genital malignancies is mostly due to local infections and influences the prognosis negatively. The 5-year survival rate of irradiated patients with fever is significantly lower. Infections following radical hysterectomy, irradiation and/or cytotoxic chemotherapy like pelvic abscesses, peritonitis, pneumonia and septicaemia can be fatal. Urinary-tract-, wound- and vaginal vault-infections occur frequently, but are rarely severe. Therapeutically in severe infections a combination antibiotic therapy, which is effective against most pathogenic members of the genital flora, is required. Short courses of perioperative prophylactic antibiotics are useful both in radical hysterectomy and with intracavitary irradiation.

Endometrial bacteriology in patients with endometrial cancer before and after primary intracavitary irradiation using IR-192 and an afterloading technique

In a prospective clinical and bacteriological study the endocervical and endometrial flora of 38 patients with biopsy proven cancer of the endometrium was studied before and after intrauterine irradiation with 10 Gy (Ir-192, afterloading device, Buchler, Braunschweig). Bacteriological swabs were taken transcervically. Anaerobic transport media were used and cultures were done aerobically and anaerobically. The mean number of aerobic organisms per patient increased from 2.13 to 2.49 (not significant (n.s.)), and of anerobic organisms from 1.42 to 2.00 (n.s). Neither the recovery rate of aerobic and anaerobic bacteria nor the composition of endometrial flora was altered significantly by intracavitary irradiation. Only aerobic sporeformers increased from 5.3% to 21% (2 p less than 0.05). The most prevalent aerobic species were S. epidermidis, streptococci and E. coli, the predominant anaerobic species Pepto- and Peptostreptococcus and Bacteroides. Our results clearly show that the intrauterine administration of 10 Gy by a Ir-192-afterloading device does not sterilize the endocervix or endometrium and infections may occur after intracavitary radiotherapy.

Vaginal organisms in prepubertal children with and without vulvovaginitis. A vaginoscopic study

In a prospective clinical and microbiological study covering 67 prepubertal children the vaginal flora of 31 asymptomatic children was compared to 36 children suffering from abnormal vaginal discharge and/or vulvovaginitis. Vaginoscopy was employed to obtain bacteriological specimens without contamination. Swabs were inoculated into prereduced transportmedia (PORT A CUL, BBL) and cultured aerobically and anaerobically. The most prevalent aerobic organisms were Staphylococcus epidermidis. Enterococci and Escherichia coli; the predominant anaerobic bacteria were Peptococcus and Peptostreptococcus, Veillonella parvula, Eubacteria, Propionibacterium and Bacteroides species. A similar microbiological pattern was found in both groups, although anaerobes, like Peptococci and Peptostreptococci and Bacteroides species, as well as yeasts, like Candida albicans were significantly more frequent in the group with signs and symptoms. Lactobacilli were less common in this group.