Abstract PD1-09: Phase 2 safety and efficacy results of TAK-228 in combination with exemestane or fulvestrant in postmenopausal women with ER-positive/HER2-negative metastatic breast cancer previously treated with everolimus

Background: TAK-228 is an investigational, oral and highly selective ATP-competitive inhibitor of TORC1/2. Targeting the PI3K/AKT/mTOR pathway with the dual TORC1/2 inhibitor TAK-228 may restore sensitivity to endocrine therapies in patients (pts) with breast cancer who have progressed on the combination of an endocrine agent plus a TORC1 inhibitor. Here we report data from the phase 2 portion of a phase 1b/2 study of TAK-228 plus exemestane (E) or fulvestrant (F).

Methods: Postmenopausal women with ER+ and HER2-, inoperable or metastatic breast cancer (MBC) following everolimus (EVE) plus E or F after progression, received oral TAK-228 (4 mg QD) plus E (25 mg QD) or F (500 mg monthly) for 28-day cycles until progressive disease (PD) or unacceptable toxicity (NCT02049957). Pts were enrolled into parallel cohorts based on prior response to EVE plus E or F and were given the same prior therapy (E or F) at their established dose: EVE-sensitive, defined as disease progression after complete response (CR), partial response (PR), or ≥6 mos stable disease (SD); or EVE-resistant, defined as disease progression without a CR or PR, or after <6 mos SD. Primary endpoint was clinical benefit rate at 16 wks (CR, PR, or SD at 16 wks; CBR-16). Secondary endpoints included CBR at 24 wks (CBR-24), overall response rate (ORR), progression-free survival (PFS), overall survival (OS) and safety.

Results: From Oct 2015 to Dec 2017, 94 pts were enrolled. Median age was 58 y (range 32–83). At baseline, most pts (67%) had stage IV disease and others were stage IA–IIIC (24%), other (3%) or unknown (5%); 94% of EVE-sensitive (93% E vs 100% F) and 88% of EVE-resistant pts (91% E vs 75% F) had received ≥4 prior lines of therapy. Pts received a median of 3 cycles (1–15) of TAK-228. At data cutoff (24 Apr 2018), 98% of pts had discontinued treatment, mainly due to PD (76%) or adverse events (AEs; 14%). CBR-16 was 41% (n=21) in EVE-sensitive and 26% (n=11) in EVE-resistant pts (table). CBR-24 was 24% in EVE-sensitive (19% E vs 50% F) and 23% in EVE-resistant (23% E vs 25% F) pts. Eleven of 21 pts who achieved CBR-16 also achieved CBR-24 (6 SD, 5 PR) in the EVE-sensitive cohort and 8 of 11 pts in the EVE-resistant cohort (6 SD, 2 PR). The ORR was 12% in EVE-sensitive pts and 9% in EVE-resistant pts (table). Median PFS (95% CI) was 4.1 mos (2.2–5.5) and 3.4 mos (1.9–5.4), and median OS (95% CI) was 15.9 mos (14.1–19.5) and 14.0 mos (13.0–16.0) in the EVE-sensitive and -resistant cohorts, respectively. Drug-related any grade and grade ≥3 AEs were seen in 90% and 29% of pts, respectively. Most common drug-related any grade AEs were nausea (50%), fatigue (38%), hyperglycemia and diarrhea (each 29%); 22% of pts reported a serious AE. No deaths were reported. Treatment is ongoing in two pts.

Conclusion: TAK-228 plus E or F showed modest clinical benefit in pts with previously treated, EVE-sensitive or -resistant MBC, with an acceptable safety profile.

 EVE-sensitive (N=51)EVE-resistant (N=43) TAK-228+TAK-228+Best response, n (%)E (n=43)F (n=8)E (n=35)F (n=8)ORR=CR+PR4 (9)2 (25)3 (9)1 (13)CR001 (3)0PR4 (9)2 (25)2 (6)1 (13)CBR-1617 (40)4 (50)9 (26)2 (25)

Citation Format: Diamond JR, Potter D, Salkeni M, Silverman P, Haddad T, Forget F, Awada A, Canon J-L, Danso M, Lortholary A, Bourgeois H, Tan-Chiu E, Patel C, Neuwirth R, Leonard EJ, Lim B. Phase 2 safety and efficacy results of TAK-228 in combination with exemestane or fulvestrant in postmenopausal women with ER-positive/HER2-negative metastatic breast cancer previously treated with everolimus [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-09.

Abstract OT2-01-10: Pilot study of carboplatin, nab-paclitaxel and pembrolizumab for metastatic triple-negative breast cancer (ongoing clinical trial)

BACKGROUND. Triple-negative breast cancer (TNBC) is associated with an aggressive phenotype and decreased survival. TNBC is characterized by tumor-infiltrating lymphocytes (TIL) which predict for a better prognosis and likely reflect immune recognition of tumor-associated antigens by TIL. However, potent immune suppressive signals exist in the tumor microenvironment such as those mediated by PD-1 with its ligand, PD-L1. Therefore, to test the validity of decreasing PD-1/PD-L1-mediated immune suppression, a Phase Ib study of single-agent pembrolizumab in 32 patients with advanced TNBC showed a partial response of 16.1% and stable disease of 9.7%, thereby attesting to the effectiveness of single-agent pembrolizumab in these patients. Other studies have demonstrated that cytotoxic chemotherapy favorably modulates immunity against cancer and there is therefore a strong rationale to combine chemotherapy with an immune modulator such as pembrolizumab for the treatment of mTNBC.

TRIAL DESIGN. This is an investigator-initiated, industry-sponsored (Merck) pilot study of carboplatin (C), nab-paclitaxel (N) and pembrolizumab (P) in 30 patients with metastatic (m) TNBC. Eligible patients will receive 3 cycles of CNP, with each cycle consisting of C (AUC 6 on days 1 of a 21-day cycle), N (100 mg/m2 IV on days 1, 8 and 15 of a 21-day cycle), and P (200 mg IV on day 15 of each cycle). After completion of 3 cycles CNP, patients with responding or stable disease by RECIST 1.1 criteria will be eligible for additional cycle(s) of CNP.

ELIGIBILITY CRITERIA. Patients must have radiologically measurable mTNBC, an ECOG performance status of 0-1, must not have received more than 2 prior therapies for this disease, and must be willing to undergo a preliminary biopsy of a metastatic focus for research purposes. A second post-treatment biopsy will be encouraged but will not be mandated.

SPECIFIC AIMS. The primary objective is to determine overall response rate (ORR) in patients treated with CNP. The secondary objectives are to determine progression-free survival (PFS) and safety/tolerability of CNP. Correlative objectives include the identification of pathologic and genomic correlates of response to CNP.

STATISTICAL METHODS. Clinical response will be scored using RECIST 1.1 criteria. Under the proposed treatment, the expected clinical response is about 35%. With the precision of the 2-sided 95% confidence interval for the response rate set to 0.17 (the distance to the expected response rate of 35%), the sample size required for the study is 30 patients. The true response rate of therapy will be estimated based on the number of responses using a binomial distribution and its confidence intervals will be estimated using Wilson's method. The Kaplan-Meier method will be used to estimate PFS. Factors including pathologic and genomic correlates that predict survival outcomes will be identified by Cox model or extensions of the Cox model.

TARGET ACCRUAL. We plan to enroll 30 patients over 2 years, with the first patient expected to be enrolled in September 2016.

CONTACT INFORMATION. Joseph Baar, MD, PhD. Seidman Cancer Center of University Hospitals Case Medical Center. E-mail: joseph.baar@uhhospitals.org.

Citation Format: Baar J, Abraham J, Silverman P, Budd GT, Vinayak S, Varadan V, Moore H, Montero A, Fu P. Pilot study of carboplatin, nab-paclitaxel and pembrolizumab for metastatic triple-negative breast cancer (ongoing clinical trial) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-10.

Abstract P6-08-14: Meeting needs and expectations of breast cancer survivors: Learning from patients through a survey method

Introduction: Oncology patients have many needs throughout the care continuum. Identification of the most salient needs is critical in program planning in an environment where resources are limited. Choices for programming should be based on information regarding survivors’ perceived needs and their usage of services provided by the cancer center and in the community. We developed a survey to assess needs of patients seen at our Cancer Center. The purpose of the project was to establish the feasibility of the method in the population, identify needs, use these as a basis to develop programs to meet the needs, and establish a baseline for future needs assessments.

Methods: Previous U.S. cancer patient needs surveys were used as a background to create survey questions for cancer survivors using a quality of life framework. The scope of the survey was expanded based on feedback from Cancer Center leaders and Patent and Family Advisory Committee members. IRB approval was obtained and surveys were mailed to patients seen within 2 years at our sites. After eliciting demographic data, questions sought information about the performance of the cancer team and patient preferences for learning styles and what resources were used. Patients were asked by whom they preferred follow-up care to be given. Specific questions on the physical, emotional, social and spiritual effects of cancer were sought. Breast cancer respondents were compared to respondents with other types of cancer.

Results: 1005 of 2750 (37%) mailed surveys were returned; 518 (51.5%) were from breast cancer survivors. Of the breast cancer survivors, mean age was 64 (range 30-94); 82% were Caucasian, 15% African-American; 62% were married; 50% were retired; 24% remained on treatment, 14% <2 years, 29% 2-5 years, 33% >5 years after treatment. Slightly more than half used non-hospital (57%) or hospital (54%) resources. Most commonly used non-hospital resource was internet (34%); most commonly used hospital resource was information from the health care team (36%). One year after treatment 90% preferred follow-up care from primary oncology team (vs. primary care physician or other). While there was concordance that “attention to my physical needs” was excellent for 76% and this was “important” for 94%, only 46% rated “attention to my emotional needs” as excellent with this was “important” for 84%. Fear of cancer recurrence was the greatest concern for patients and had not significantly resolved for the respondents >5 years after treatment. Breast cancer patients differed significantly from patients with other types of cancer having less fatigue (p<0.001), more issues with sexual intimacy (p = 0.001), more interest in obtaining genetic counseling (p = 0.001) and more fear of developing a new cancer (p = 0.01).

Conclusions: This method of assessment was feasible (with a project cost of $7000), was completed in two years and can be used as a baseline. As a result of this survey our Cancer Center created an educational print resource describing our supportive oncology programs, implemented an end of treatment distress screening tool piloted with breast cancer patients, and provided staff education regarding patient needs and intervention tools.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-14.

Phase II study of weekly administration of docetaxel (D) in combination with the epidermal growth factor receptor (EGFR) inhibitor erlotinib (E) in metastatic breast cancer (MBC)

Abstract #3124

Background: Single agent weekly docetaxel (D) is an active agent in the treatment of metastatic breast cancer (MBC) with response rates of 29% - 53%. Erlotinib (OSI-774, Tarceva®) is a tyrosine kinase inhibitor directed against EGFR, which is overexpressed in 30-40% of breast cancers, making EGFR an attractive treatment target. This study was designed to assess the combination of D and E in previously untreated recurrent and/or MBC.
 Methods: Adult patients with histologically confirmed MBC without prior chemotherapy for recurrence or metastases were eligible. Treatment plan was: D (initially 35 mg/m2 intravenous infusion weekly x 3 every 4 weeks) and E 150 mg orally daily uninterrupted. In patients with responding or stable disease, E was continued in 4 week cycles following a minimum of 6 cycles of D and E. Estimates of overall survival (OS) and progression free survival (PFS) were made by Kaplan-Meier method and the difference between groups by log-rank test. Tumor EGFR expression by immunohistochemisty and ER/PR was correlated with OS and PFS.
 Results: 39 female pts were enrolled between 12/02 and 8/06. The median age was 51 yrs (range 28-78). The median number of cycles of D and E received was 4 (range 1-26) and of E following D and E was 11 (range 2-18). EGFR, ER/PR and Her-2/neu status was determined on 35/39 patients. EGFR: 23 positive, 12 negative. ER/PR: 25 positive, 10 negative. Her-2/neu: 2 positive, 33 negative. Ten pts. were not evaluable for survival or response due to toxicity occurring within the first cycle. Best responses (n=29) ; PR 11(39%), SD 4 (14%), PD 13 (45%), and clinical benefit (PR+SD) 15 (54%). Median PFS was 8 mos (95% CI: 4.4-12.2). PFS for EGFR negative tumors appeared better than EGFR positive tumors (12 mos PFS 33% vs. 23%) but was not significant (p = 0.53). There was no difference in OS between these groups (p=0.38). PFS and OS for ER/PR positive pts was significantly higher than ER/PR negative pts 6 mos PFS 67% vs. 25% (p= 0.009) and 2 yr OS 53.9% vs. 12.5% (p=0.015). , All patients were included for toxicity assessment (n-39). The first 26 pts received planned D dose of 35mg/m2. Because of non-hematologic toxicity, trial was subsequently modified to start D at 25 mg/m2. Grade 3 or 4 Leukopenia was seen in 15% pts. Principal non-hematologic grade 3-4 toxicities included anorexia, diarrhea, and fatigue (18% pts).
 Conclusions: Combination therapy for advanced breast cancer with docetaxel and erlotinib shows promising activity with favorable response compared with other studies. There was no significant association with EGFR expression and PFS, however this combination is more favorable for ER positive patients. Randomized trials for ER positive disease is warranted to further investigate the efficacy of this combination compared to single agent docetaxel.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3124.

Thirty-year follow-up of chemo/hormonal therapy in node-positive breast cancer

Results of a thirty-year follow-up of a clinical trial of chemo-hormonal therapy are reported. Eligible patients had recently diagnosed operable breast cancer, positive lymph nodes, no previous history of cancer, age less than 76 years, and no evidence of metastatic disease. A total of 311 patients were stratified by estrogen receptor (ER) status and number of axillary nodes involved with tumor. After stratification, patients were randomly assigned to one of three treatment regimens: cyclophosphamide, methotrexate and 5-fluorouracil (CMF) for 1 year; CMF chemotherapy combined with anti-estrogen therapy (tamoxifen) for 1 year; or CMF plus tamoxifen with BCG during the second year. The endpoint of the trial was a first recurrence. Factors measured at diagnosis and used in the analyses were age, body mass index, ER status, menopausal status, number of positive nodes, tumor diameter, Charlson comorbidity index, socioeconomic status, and race. Causes of death and incidence of other cancer primaries were obtained from death certificates and medical records. Patients treated with tamoxifen had a marginally longer disease-free survival (hazard ratio (HR)=0.83, 95% CI identical with [0.66, 1.04]) and statistically significant longer overall survival (HR=0.77, 95% CI identical with [0.63, 0.96]) that decreased with time. Incidence of other primary cancers and causes of death were similar for the two treatment groups. The addition of 1 year of tamoxifen to CMF therapy provides an early disease-free and overall survival advantage; however long-term effects are negligible. Similarly, the survival advantage of patients diagnosed with ER+ tumors persists for the first two decades after diagnosis.

Toxicity and outcome data in a phase II study of weekly docetaxel in combination with erlotinib in recurrent and/or metastatic breast cancer (MBC)

10623

Background: Single agent weekly docetaxel (D) is an active agent in the treatment of MBC with response rates of 29% - 53%. Erlotinib (OSI-774, Tarceva) is a tyrosine kinase inhibitor directed against the epidermal growth factor receptor (EGFR), and is overexpressed in 30–40% of breast cancers. EGFR inhibition by erlotinib (E) and its possible modulation of growth factor synthesis by breast cancer (BC) cells is an attractive treatment target. This study was designed to assess the combination of D and E in previously untreated recurrent &/or MBC. Methods: Adult patients (pts) with histologically confirmed BC without prior chemotherapy for recurrence or metastases were eligible. Treatment plan was: D [35 mg/m2 iv infusion weekly x 3 q4wks] and E 150 mg/d uninterrupted (D+E). E was to be continued in 4 week cycles after maximum tumor response or disease stabilization [following a minimum of 6 cycles of D+E]. The overall survival (OS) was estimated by Kaplan-Meier method. Results: 31of 40 planned female pts were enrolled between 12/02 and 9/05. Median age 52 years, range: 29–79. The median number of cycles of D +E received was 4, (range 1–9) and of E following D+E was 4 (range 1–29). The first 26 pts received planned D dose of 35mg/m2. Because of non-hematologic toxicity, trial was subsequently modified to start D at 30mg/m2.11/31 (36%) were not evaluable due to toxicity. Hematologic grade 3 or 4 toxicity was seen in 45% cases. Principal non-hematologic grade 3–4 toxicities included nausea, diarrhea, and constitutional symptoms seen in 30% of the pts. 4/9 pts receiving E after D+E experienced hematologic, hepatic, constitiutional, and eye (1 each) grade 3 toxicity only. Best clinical response in the 20 evaluable pts included; PR 11(55%), SD 7 (35%), PD 2 (10%). OS (n = 31) was 71% at 12mos, 42% at 24 mos with median OS 23 mos. Conclusions: Combination therapy of advanced breast cancer with Docetaxel and Erlotinib showed promising activity with favorable response compared to other studies. The combination is associated with moderate to severe hematological and non-hematological toxicities. Randomized trials are warranted to further investivate the efficacy of this combination compared to single agent Docetaxel. (Support: Sanofi-Aventis & Genentech.)

[Table: see text]

Toxicity results and early outcome data on a randomized phase II study of docetaxel ± bevacizumab for locally advanced, unresectable breast cancer

3049

Background: Preclinical models of combination angiogenesis inhibitor bevacizumab (rhuMAbVEGF) and docetaxel demonstrate synergistic suppression of capillary vessel formation. Based upon these data, we developed a randomized phase II trial in order to evaluate the vascular effects on tumor regression with combination bevacizumab/docetaxel vs. docetaxel in the treatment of locally advanced breast cancer. Methods: 49 patients (pts) were randomized to receive neoadjuvant therapy with bevacizumab (10 mg/kg qowk) and docetaxel (two 8-week cycles of 35 mg/m2 weekly x 6 with a 2 wk break) (BD=24) or docetaxel (D=25) alone. Eligible pts had locally unresectable breast cancer with (n=6) or without distant metastasis (n=43); 16 patients presented with inflammatory breast cancer. Pts whose disease responded, sequentially underwent definitive surgery (4 weeks after BD or D), radiation, 4 cycles of conventional Adriamycin/cyclophosphamide, and tamoxifen or anastrazole (if ER/PR+). Results: Among the 49 pts: 7 clinical CRs, 32 PRs, 5 NR, and 5 PD. Of the 37 pts who underwent surgery: the median number of pathologically positive lymph nodes (LN) was 1 (BD=6, D=1; p=0.228); range 0–20; 43% were LN negative. Neoadjuvant treatment toxicity for both arms was acceptable with no significant differences between the two arms. Grade 4 toxicity included BD - new papillary thyroid cancer (1), neutropenia (1), hyperuricemia (1) and colon perforation (1); and D: - hyperglycemia (1) and hyperuricemia (1). 21 patients in each arm experienced a grade 3 toxicity. There were no episodes of uncontrolled hypertension, proteinuria, or thrombosis. Delayed wound healing (unable to start radiation w/in 6 weeks of surgery) occurred in 8 pts: BD=5; D=3 (p=0.691). Only 1 pt (D) experienced a change in LVEF by > 15% or below the institution’s lower limit of normal. Conclusions: Neoadjuvant therapy for locally advanced breast cancer using docetaxel with bevacizumab is well tolerated. Further studies are required to determine the added efficacy from bevacizumab. Correlative studies on impact of treatment on angiogenesis will be reported separately. (Sponsored by grants: K23CA 87725–01, M01 RR 00080, UO1 CA 62502, 5P30 CA43703-NCI/AVON, Aventis)

No significant financial relationships to disclose.

Modeling life satisfaction among the aged: a comparison of Chinese and Americans

This paper reports on a survey conducted among elderly Chinese in Taiwan and Americans in eastern Oregon. The focus is on health status and selected social network characteristics (such as range, density, and percentage of relatives) as they relate to life satisfaction. In addition to examining differences among these and other variables in the two national samples, two hypotheses are tested using hierarchical regression analysis. The first hypothesis relates higher values of range and density to greater life satisfaction. The second is a test of the stress-buffering hypothesis. We then examine the data controlling for gender and conclude with a discussion and interpretation of both the national and gender differences yielded by this analysis.

NHPCO Task Force Statement on the Ethics of Hospice Participation in Research

There is an urgent need for robust empirical data to guide the assessment and treatment of patients near the end of life. Because they are important providers of end-of-life care in this country, hospices have an important role to play in facilitating this research. However, hospices may also face considerable ethical challenges in doing so. This task force statement begins by discussing the importance of hospices' potential contributions to research. Next, we describe ways in which characteristics of hospice patients, and hospices' structure, create ethical challenges that may limit these contributions. We conclude by proposing ways in which hospices and national professional organizations can begin to overcome some of these challenges.

An academic radiology information system (RIS): a review of the commercial RIS systems, and how an individualized academic RIS can be created and utilized

Current commercial radiology information systems (RIS) are designed for scheduling, billing, charge collection, and report dissemination. Academic institutions have additional requirements for their missions for teaching, research and clinical care. The newest versions of commercial RIS offer greater flexibility than prior systems. We sent questionnaires to Cerner Corporation, ADAC Health Care Information Systems, IDX Systems, Per-Se' Technologies, and Siemens Health Services regarding features of their products. All of the products we surveyed offer user customizable fields. However, most products did not allow the user to expand their product's data table. The search capabilities of the products varied. All of the products supported the Health Level 7 (HL-7) interface and the use of structured query language (SQL). All of the products were offered with an SQL editor for creating customized queries and custom reports. All products included capabilities for collecting data for quality assurance and included capabilities for tracking "interesting cases," though they varied in the functionality offered. No product offered dedicated functions for research. Alternatively, radiology departments can create their own client-server Windows-based database systems to supplement the capabilities of commercial systems. Such systems can be developed with "web-enabled" database products like Microsoft Access or Apple Filemaker Pro.

Risperidone for the treatment of cocaine dependence: randomized, double-blind trial

A partial blockade of the multiple actions of cocaine is one strategy by which cocaine dependence may be treated. Risperidone, a 5-hydroxytryptamine and dopamine D2 antagonist, is an atypical antipsychotic and was a candidate medication for the treatment of cocaine dependence. One hundred ninety-three cocaine-dependent subjects were enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. Subjects initially received either placebo or 4 or 8 mg of risperidone, with a subsequent change to active doses of 2 mg and 4 mg. Subjects attended the clinic twice each week, provided urine samples, obtained medication, and underwent one behavioral therapy session per week. The study was terminated at the interim analysis. Retention was worse for the 4- and 8-mg active medication groups. Side effects were primarily associated with the 8-mg dose, although neither 2 mg nor 4 mg was well accepted by subjects. There was no reduction in cocaine use associated with risperidone. The results suggest that although antagonists might be a useful treatment approach, such as in the treatment of opiate dependence, risperidone is unlikely to find broad acceptance with the treatment-seeking population.

Jasmonate-Inducible Genes Are Activated in Rice by Pathogen Attack without a Concomitant Increase in Endogenous Jasmonic Acid Levels

The possible role of the octadecanoid signaling pathway with jasmonic acid (JA) as the central component in defense-gene regulation of pathogen-attacked rice was studied. Rice (Oryza sativa L.) seedlings were treated with JA or inoculated with the rice blast fungus Magnaporthe grisea (Hebert) Barr., and gene-expression patterns were compared between the two treatments. JA application induced the accumulation of a number of pathogenesis-related (PR) gene products at the mRNA and protein levels, but pathogen attack did not enhance the levels of (-)-JA during the time required for PR gene expression. Pathogen-induced accumulation of PR1-like proteins was reduced in plants treated with tetcyclacis, a novel inhibitor of jasmonate biosynthesis. There was an additive and negative interaction between JA and an elicitor from M. grisea with respect to induction of PR1-like proteins and of an abundant JA-and wound-induced protein of 26 kD, respectively. Finally, activation of the octadecanoid signaling pathway and induction of a number of PR genes by exogenous application of JA did not confer local acquired resistance to rice. The data suggest that accumulation of nonconjugated (-)-JA is not necessary for induction of PR genes and that JA does not orchestrate localized defense responses in pathogen-attacked rice. Instead, JA appears to be embedded in a signaling network with another pathogen-induced pathway(s) and may be required at a certain minimal level for induction of some PR genes.

Phase I trial of high-dose mitoxantrone plus cyclophosphamide and filgrastim in patients with advanced breast carcinoma

PURPOSE

To determine the maximum-tolerated dose (MTD) of mitoxantrone that could be safely used in combination with cyclophosphamide and filgrastim in patients with advanced breast carcinoma.

PATIENTS AND METHODS

Twenty-seven patients with metastatic (n = 24) or locally advanced (n = 3) breast carcinoma received escalating doses of mitoxantrone (16, 20, 24, 28, or 32 mg/m2) plus cyclophosphamide at one of three dose levels: group 1, 1,200 mg/m2; group 2, 2,400 mg/m2; and group 3,600 mg/m2. All patients also received filgrastim 5 micrograms/kg administered subcutaneously beginning on day 2 and continuing until the post-nadir absolute neutrophil count (ANC) was > or = 10,000/microL. Treatment was repeated every 3 weeks if the ANC was > or = 2,000/microL and platelet count > or = 90,000/microL for a maximum of six cycles. Dose escalation occurred within each group if zero of three or one of four patients had dose-limiting toxicity during the first cycle.

RESULTS

The MTD of mitoxantrone was 24 mg/m2 in group 1, less than 16 mg/m2 in group 2, and 28 mg/m2 in group 3. Neutropenia was dose-limiting, and cumulative neutropenia and thrombocytopenia occurred with continued therapy. Nonhematologic toxicity consisted predominantly of nausea, vomiting, alopecia, and fatigue. Three patients (11%) had a > or = 10% decrease in the left ventricular ejection fraction (LVEF), one patient (4%) had a decrease in the LVEF below normal, and none developed clinical congestive heart failure. Of patients with stage IV breast carcinoma who had not received prior chemotherapy for advanced disease, objective responses occurred in nine of 20 (45%), and the median response duration was 5 months.

CONCLUSION

In combination with 600 mg/m2 of cyclophosphamide and filgrastim, the MTD of mitoxantrone is 28 mg/m2, a dose that is approximately twofold to 2.8-fold higher than the conventional dose used without a hematopoietic growth factor.

Race-Specific Elicitors of Cladosporium fulvum Induce Changes in Cell Morphology and the Synthesis of Ethylene and Salicylic Acid in Tomato Plants Carrying the Corresponding Cf Disease Resistance Gene

Defense responses mediated by the genetically unlinked Cf-9 and Cf-2 genes were compared with those involving no Cf gene (Cf0). Compatible tomato (Lycopersicon esculentum)-Cladosporium fulvum intercellular washing fluids were injected into tomato cotyledons, and the kinetics of responses was monitored under conditions of 70 and 98% relative humidity. The latter conditions suppressed the normal macroscopic responses. For the Cf-9-Avr9 interaction, stomatal opening was induced within 3 to 4 h and after 9 h mesophyll cell death commenced. A burst of ethylene production occurred between 9 and 12.5 h and remained elevated. Free salicylic acid levels increased after 12 h, peaked at 24 h, and thereafter declined. For the Cf-2-Avr2 interaction, stomata became plugged after 8 h, and salicylic acid and ethylene levels increased by 12 and 18 h, respectively, and thereafter declined. Host cell death commenced around vascular tissue by 24 h. Cell death in both incompatible interactions was frequently preceded by cell enlargement. For Cf0-injected plants, no significant responses were detected. High humidity delayed and reduced the Cf-Avr-gene-dependent cell death and ethylene synthesis, whereas induced salicylic acid levels were unaffected for Cf-2-Avr2 and reduced in magnitude only for Cf-9-Avr9.

Social work in the academic medical center: advanced training--a necessity

Although the total number of social workers within the academic medical center will probably decrease because of decreasing hospital bed usage, the role for those who remain will be that of a clinical specialist, a sophisticated and adaptable practitioner who can work flexibly under minimal supervision. The valued social work practitioner will be an independent player on the health care team who assumes a significant role which no other member of that team is equipped to take. Advanced training is more important today than ever before in the evolution of social work practice in academic health care. However, this training is not now available within the parameters of the two year master's program.

Salicylic Acid in Rice (Biosynthesis, Conjugation, and Possible Role)

Salicylic acid (SA) is a natural inducer of disease resistance in some dicotyledonous plants. Rice seedlings (Oryza sativa L.) had the highest levels of SA among all plants tested for SA content (between 0.01 and 37.19 [mu]g/g fresh weight). The second leaf of rice seedlings had slightly lower SA levels than any younger leaves. To investigate the role of SA in rice disease resistance, we examined the levels of SA in rice (cv M-201) after inoculation with bacterial and fungal pathogens. SA levels did not increase after inoculation with either the avirulent pathogen Pseudomonas syringae D20 or with the rice pathogens Magnaporthe grisea, the causal agent of rice blast, and Rhizoctonia solani, the causal agent of sheath blight. However, leaf SA levels in 28 rice varieties showed a correlation with generalized blast resistance, indicating that SA may play a role as a constitutive defense compound. Biosynthesis and metabolism of SA in rice was studied and compared to that of tobacco. Rice shoots converted [14C]cinnamic acid to SA and the lignin precursors p-coumaric and ferulic acids, whereas [14C]benzoic acid was readily converted to SA. The data suggest that in rice, as in tobacco, SA is synthesized from cinnamic acid via benzoic acid. In rice shoots, SA is largely present as a free acid; however, exogenously supplied SA was converted to [beta]-O-D-glucosylSA by an SA-inducible glucosyltransferase (SA-GTase). A 7-fold induction of SA-GTase activity was observed after 6 h of feeding 1 mM SA. Both rice roots and shoots showed similar patterns of SA-GTase induction by SA, with maximal induction after feeding with 1 mM SA.

The fracture, dislodgement and retrieval of a probe III balloon-on-a-wire catheter

The fracture and dislodgement of an angioplasty device within the coronary arteries is a rare but increasingly noted complication. If the fragment of angioplasty balloon or guidewire is dislodged in a proximal and patent coronary artery, the likelihood of acute embolization which could lead to an acute coronary thrombus and/or myocardial infarction exists. Therefore, the immediate removal of the broken piece of the angioplasty catheter is imperative. A case of unusual fracture and dislodgement of a Probe III Balloon-on-A-Wire catheter and retrieval of the broken piece is reported.

A pilot study of chemotherapy alternating with twice-a-day accelerated radiation therapy as an alternative to cystectomy in muscle infiltrating (stages T2 and T3) cancer of the bladder: preliminary results

Laboratory studies have suggested that rapidly alternating chemotherapy and accelerated radiation therapy might act synergistically. We evaluated the toxicity and effectiveness of this approach in muscle infiltrating transitional cell carcinoma of the bladder in patients who were poor risks for or who refused cystectomy. We treated 18 men and 3 women with stage T2 or T3 transitional cell carcinoma of the bladder by transurethral resection, followed by 3 cycles of chemotherapy (during weeks 1, 4 and 7) rapidly alternating with 3 cycles of twice-a-day radiation therapy (during weeks 2, 5 and 8). Chemotherapy consisted of methotrexate, vinblastine, doxorubicin and cisplatin. The total dose of radiation therapy was 5,400 to 6,000 cGy, during 6 1/2 weeks and the total duration of chemotherapy and radiation therapy was 7 1/2 weeks. One patient died of hematological toxicity during treatment. With a median followup of 2 years (range 0.5 to 5.5 years) the observed survival rate was 72% at 2 years and 60% at 3 years. To date, only 1 patient (5%) had recurrence of invasive cancer in the pelvis. Only 3 others (15%) had carcinoma in situ but to date none has required cystectomy. Bladder function was normal in 15 of 18 evaluable patients (83.5%). This pilot study suggests that chemotherapy alternating with radiation therapy produced an encouraging survival rate without cystectomy and deserves further study. These patients require continued surveillance for carcinoma in situ.

Intracoronary ultrasound assessment of morphological and functional abnormalities associated with cardiac allograft vasculopathy

BACKGROUND

The diffuse nature of cardiac allograft vasculopathy makes early detection of the disease by traditional noninvasive methods or coronary angiography difficult. The aim of this study was to determine if there is a relation between abnormalities in vessel wall morphology, as assessed by intracoronary ultrasound, and a decreased vasodilatory response to the endothelium-dependent vasodilator papaverine hydrochloride and if cardiac allograft vasculopathy detected by coronary angiography is associated with specific intracoronary ultrasound findings.

METHODS AND RESULTS

Twenty-three heart transplant recipients underwent 25 intracoronary ultrasound studies and 24 studies of coronary vasomotor tone 10 days to 8.3 years after surgery using a 20-mHz intracoronary ultrasound catheter. The studies were divided in two groups according to the presence (n = 7, group 1) or absence (n = 18, group 2) of angiographically evident cardiac allograft vasculopathy. Qualitative assessment of vessel wall morphology and quantitative analysis of the vasodilator response to the injection of papaverine hydrochloride into the coronary artery distal to the imaging site were performed off-line, and results for the two study groups were compared. A significantly higher percentage of patients with than without angiographic evidence of cardiac allograft vasculopathy had a three-interface vessel wall morphology by intracoronary ultrasound (100% versus 11%, P < .001). In two recipients who underwent two serial studies, the appearance of three interfaces in the vessel wall or a progressive thickening of the inner interface of the vessel wall occurred in conjunction with the appearance of angiographic cardiac allograft vasculopathy. The vasodilator response to papaverine was less in patients with than in those without angiographically evident cardiac allograft vasculopathy both in terms of absolute and relative increases in lumen diameter (+0.1 +/- 0.12 mm versus +0.3 +/- 0.17 mm, P < .05, and +5.1 +/- 5.3% versus +8.2 +/- 5.3%, P = NS) and lumen cross-sectional area (+0.5 +/- 0.6 mm2 versus +1.7 +/- 1.1 mm2, P < .02, and +7.1 +/- 8.8% versus 16.6 +/- 11.0%, P = .055), respectively.

CONCLUSIONS

Intracoronary ultrasound assessment of vessel wall morphology and evaluation of vascular response to endothelium-dependent vasodilators are useful techniques for detecting cardiac allograft vasculopathy.

Localization, conjugation, and function of salicylic acid in tobacco during the hypersensitive reaction to tobacco mosaic virus

Salicylic acid (SA) is hypothesized to be a natural signal that triggers the systemic induction of pathogenesis-related proteins and disease resistance in tobacco. When Xanthi-nc (NN genotype) tobacco was inoculated with tobacco mosaic virus (TMV) there was an increase in endogenous SA in both inoculated and virus-free leaves. The highest levels of SA were detected in and around necrotic lesions that formed in response to TMV. Chemical and enzymatic hydrolysis of extracts from TMV-inoculated leaves demonstrated the presence of a SA conjugate tentatively identified as O-beta-D-glucosyl-SA. The SA conjugate was detected only in leaves that contained necrotic lesions and was not detected in phloem exudates or uninoculated leaves of TMV-inoculated Xanthi-nc tobacco. When exogenous SA was fed to excised tobacco leaves, it was metabolized within 10 hr. However, this reduction in free SA did not prevent the subsequent accumulation of the PR-1 family of pathogenesis-related proteins. The absence of SA accumulation in TMV-inoculated tobacco plants incubated at 32 degrees C was not a result of the glucosylation of SA. The addition of SA to the medium elevated levels of SA in the leaves of virus-free tobacco grown hydroponically. Increasing the endogenous level of SA in leaves to those naturally observed during systemic acquired resistance resulted in increased resistance to TMV, expressed as a reduction in lesion area. These data further support the hypothesis that SA is a likely natural inducer of pathogenesis-related proteins and systemic acquired resistance in TMV-inoculated Xanthi-nc tobacco.

Cushing's syndrome with cranial and pulmonary lesions: necessity for tissue diagnosis

This report describes two cases of Cushing's syndrome associated with radiologic abnormalities in the lung and brain. In both cases, the pathologic diagnosis of the intracranial lesion was unsuspected and prompted changes in management. These cases illustrate that the etiology of pulmonary and central nervous system mass lesions in patients with Cushing's syndrome may not be predicted on clinical grounds or by conventional radiologic methods. A tissue diagnosis is essential as a guide to appropriate management, and biopsies of such lesions are indicated.

Salicylic acid is a systemic signal and an inducer of pathogenesis-related proteins in virus-infected tobacco

Systemic induction of pathogenesis-related (PR) proteins in tobacco, which occurs during the hypersensitive response to tobacco mosaic virus (TMV), may be caused by a minimum 10-fold systemic increase in endogenous levels of salicylic acid (SA). This rise in SA parallels PR-1 protein induction and occurs in TMV-resistant Xanthi-nc tobacco carrying the N gene, but not in TMV-susceptible (nn) tobacco. By feeding SA to excised leaves of Xanthi-nc (NN) tobacco, we have shown that the observed increase in endogenous SA levels is sufficient for the systemic induction of PR-1 proteins. TMV infection became systemic and Xanthi-nc plants failed to accumulate PR-1 proteins at 32 degrees C. This loss of hypersensitive response at high temperature was associated with an inability to accumulate SA. However, spraying leaves with SA induced PR-1 proteins at both 24 and 32 degrees C. SA is most likely exported from the primary site of infection to the uninfected tissues. A computer model predicts that SA should move rapidly in phloem. When leaves of Xanthi-nc tobacco were excised 24 hr after TMV inoculation and exudates from the cut petioles were collected, the increase in endogenous SA in TMV-inoculated leaves paralleled SA levels in exudates. Exudation and leaf accumulation of SA were proportional to TMV concentration and were higher in light than in darkness. Different components of TMV were compared for their ability to induce SA accumulation and exudation: three different aggregation states of coat protein failed to induce SA, but unencapsidated viral RNA elicited SA accumulation in leaves and phloem. These results further support the hypothesis that SA acts as an endogenous signal that triggers local and systemic induction of PR-1 proteins and, possibly, some components of systemic acquired resistance in NN tobacco.