A randomized study of temozolomide or temozolomide and capecitabine in patients with advanced pancreatic neuroendocrine tumors: Final analysis of efficacy and evaluation of MGMT (ECOG-ACRIN E2211)

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Background: Patients with advanced pancreatic neuroendocrine tumors (NETs) have few treatment options that yield objective tumor response. Retrospective and small, prospective studies suggest that the combination of capecitabine and temozolomide is associated with high response rates (RR) and relative long progression-free survival (PFS). This trial was conducted to establish a role for the combination of capecitabine and temozolomide. Methods: E2211 was a multicenter, randomized, phase II trial comparing temozolomide (200 mg/m2 PO QD days 1-5) vs. capecitabine/temozolomide (capecitabine 750 mg/m2 PO BID days 1-14; temozolomide 200 mg/m2 PO QD days 10-14) in patients with advanced pancreatic NETs. Eligibility criteria included: metastatic or unresectable, low or intermediate grade pancreatic NETs, progression within preceding 12 months, and no prior temozolomide, DTIC, capecitabine or 5-fluorouracil. The primary endpoint was PFS; secondary endpoints were Overall Survival (OS), RR, safety, and MGMT as evaluated by immunohistochemistry (IHC) and promoter methylation. Allowing for 5% ineligibility, 145 randomized patients were required to obtain 138 eligible patients to detect a difference in median PFS of 9 versus 14 months (hazard ratio of 0.64) using a two-sided log-rank test at the overall 0.20 significance level with 81% power. Results: 144 patients were enrolled between 4/2013 to 3/2016 to temozolomide (n = 72) or capecitabine/temozolomide (n = 72); the efficacy analysis population included 133 eligible patients. At the scheduled interim analysis in January 2018, median PFS was 14.4 months for temozolomide vs. 22.7 months for capecitabine/temozolomide (HR = 0.58), which was sufficient to reject the null hypothesis for this final primary endpoint (stratified log rank p = 0.022. In the final analysis (5/2021), median OS was 53.8 months for temozolomide and 58.7 months for capecitabine/temozolomide (HR = 0.82, p = 0.42) and RR was 34% for temozolomide and 40% for capecitabine/temozolomide (p = 0.59). Capecitabine/temozolomide was associated with higher rates of grade 3-4 AEs (45% vs. 22%, p = 0.005). MGMT deficiency, defined as either low IHC or positive promoter methylation, was associated with greater odds of response (OR [95% CI] = 6.38 [2.19, 18.60] and 9.79 [1.09, 87.71], respectively). Conclusions: E2211 is the first prospective randomized trial of capecitabine/temozolomide and shows the longest PFS and highest RR reported for patients with pancreatic NETs in a prospective randomized study. MGMT deficiency was associated with greater odds of objective response. Clinical trial information: NCT01824875.

A functional speech impression used to fabricate a maxillary speech prosthesis for a partial glossectomy patient

Surgery for cancer of the floor of the mouth often results in alteration of the muscles of the tongue and floor of the mouth. Both primary and secondary surgical procedures often result in scar formation with reduced mobility of the tongue during speech and deglutition. Speech is often used as a diagnostic tool in the placement of the anterior teeth during fabrication of a prosthesis. Speech can similarly be used to help determine the proper placement of a speech portion of the prosthesis. The prosthetic rehabilitation approach described lowers the palatal vault with a false palate to enable the tongue to function against it during speech (Fig. 15). Group studies have shown that the design and fabrication of speech prostheses for partial glossectomy patients have significantly improved speech and swallowing for these patients. A speech pathologist is helpful during diagnosis, and speech therapy is necessary for significant speech improvement. Prosthetic rehabilitation alone cannot be expected to improve speech.

Effect of gastroesophageal reflux on esophageal speech

Gastroesophageal reflux has been incriminated as a factor-inhibiting acquisition of esophageal speech after laryngectomy. Fourteen proficient esophageal speakers and 10 nonproficient speakers underwent esophageal manometry, esophageal pH probe testing, and Bernstein acid perfusion testing. Additionally, 175 laryngectomized members of Lost Chord Clubs answered mailed questionnaires about the frequency of reflux symptoms. Nonproficient and proficient esophageal speakers had a similar frequency of gastroesophageal reflux by pH probe testing, esophageal mucosal acid sensitivity by Bernstein testing, lower esophageal sphincter pressures, and gastroesophageal reflux symptoms. Gastroesophageal reflux does not appear to be a major factor in preventing esophageal speech.

Dominant inheritance of velopharyngeal incompetence

A family is described in which a girl, two boys and their father showed speech hypernasality. A half-sib, a grandfather, a great-aunt, and a cousin of these sibs also showed a similar speech defect. Analysis of recorded speech of the father and three sibs revealed articulation deficiencies in addition to hypernasality. Intra-oral examination and neurologic evaluation of the cranial nerves failed to reveal any abnormality in palate morphology or cranial nerve function. Psychometric and audiometric studies of the affected did not contribute to an explanation of the defect. Speech cinefluoroscopy and cephalometric radiographs confirmed that the speech defect involved velopharyngeal incompetence resulting from an anatomic disproportion of the velopharyngeal structures. The family pedigree supports the concept that this type of nasal speech, resulting from disproportion of velopharyngeal structures, is transmitted as an autosomal dominant trait.

Nasal obstruction as a complication of pharyngeal flap surgery

In a series of 85 patients who had pharyngeal flap surgery at Indiana University Medical Center, We found an unusually high incidence of hyponasality with total or near total nasal obstruction. The nasal obstruction was often occult, detected only after careful questioning and examination. Nasal obstruction was associated with peri-operative infection or micrognathia as in the Pierre Robin Anomalad. Flap division or port revision yielded a significant relief of the nasal obstruction and achievement of normal nasal balance.

Velopharyngeal relationships of /i/ and /s/ as seen cephalometrically for persons with suspected incompetence

Measurements of velopharyngeal gaps were obtained for 110 subjects with suspected velopharyngeal incompetence. Cephalometric x rays during a high vowel, /i/, and a sustained voiceless sibilant, /s/, were compared. Velopharyngeal gaps for the two phonemes differed in group means and for most individual subjects, with greater gaps being found for /i/ than for /s/. Persons with smaller gaps generally were found to have /i/ gaps in the absence of /s/ gaps, and greater /i-s/ discrepancy. Relationships between velum and pharyngeal wall perceived cephalometrically during /i/ and /s/ were not found to be equivalent. Generally, the /i/ radiograph agreed better with presumed velopharyngeal incompetence.

Effect of prolonged nasotracheal intubation on communication

Nasotracheal intubation from two weeks to 40 months of age and its effect on communication are described. The treatment program for this patient with the condition of asphyxiating thoracic dystrophy included four surgical procedures to expand her rib cage and positive pressure ventilation to subserve respiration. The positive pressure ventilator was connected to a nasotracheal tube. The results of laryngeal examinations are discussed, as is the patient’s development of language and speech. The prolonged use of nasotracheal intubation had minimal consequences on the vocal folds and the development of language and speech.