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Petrelli F, Parisi A, Tomasello G, Mini E, Arru M, Russo A, Garrone O, Khakoo S, Ardito R, Ghidini M. Comparison of different second line treatments for metastatic pancreatic cancer: a systematic review and network meta-analysis. BMC Gastroenterol 2023; 23:212. [PMID: 37337148 DOI: 10.1186/s12876-023-02853-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 06/13/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND In metastatic pancreatic ductal adenocarcinoma (mPDAC), first line treatment options usually include combination regimens of folinic acid, 5-fluorouracil (5-FU), irinotecan, and oxaliplatin (FOLFIRINOX or mFOLFIRINOX) or gemcitabine based regimens such as in combination with albumin-bound paclitaxel (GEM + nab-PTX). After progression, multiple regimens including NALIRI + 5-FU and folinic acid, FOLFIRINOX, 5-FU-based oxaliplatin doublets (OFF, FOLFOX, or XELOX), or 5-FU-based monotherapy (FL, capecitabine, or S-1) are considered appropriate by major guidelines. This network meta-analysis (NMA) aimed to compare the efficacy of different treatment strategies tested as second-line regimens for patients with mPDAC after first-line gemcitabine-based systemic treatment. METHODS Randomized phase II and III clinical trials (RCTs) were included if they were published or presented in English. Trials of interest compared two active systemic treatments as second-line regimens until disease progression or unacceptable toxicity. We performed a Bayesian NMA with published hazard ratios (HRs) and 95%confidence intervals (CIs) to evaluate the comparative effectiveness of different second-line therapies for mPDAC. The main outcomes of interest were overall survival (OS) and progression free survival (PFS), secondary endpoints were grade 3-4 toxicities. We calculated the relative ranking of agents for each outcome as their surface under the cumulative ranking (SUCRA). A higher SUCRA score meant a higher ranking for efficacy outcomes. RESULTS A NMA of 9 treatments was performed for OS (n = 2521 patients enrolled). Compared with 5-FU + folinic acid both irinotecan or NALIRI + fluoropyrimidines had a trend to better OS (HR = 0.76, 95%CI 0.21-2.75 and HR = 0.74, 95%CI 0.31-1.85). Fluoropyrimidines + folinic acid + oxaliplatin were no better than the combination without oxaliplatin. The analysis of treatment ranking showed that the combination of NALIRI + 5-FU + folinic acid was most likely to yield the highest OS results (SUCRA = 0.7). Furthermore, the NMA results indicated that with the highest SUCRA score (SUCRA = 0.91), NALIRI + 5-FU + folinic acid may be the optimal choice for improved PFS amongst all regimens studied. CONCLUSIONS According to the NMA results, NALIRI + 5-FU, and folinic acid may represent the best second-line treatment for improved survival outcomes in mPDAC. Further evidence from prospective trials is needed to determine the best treatment option for this group of patients.
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Affiliation(s)
- Fausto Petrelli
- Oncology Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Alessandro Parisi
- Clinica Oncologica e Centro Regionale di Genetica Oncologica, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria delle Marche, Via Conca 71, Ancona, 60126, Italy.
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, 67100, Italy.
| | - Gianluca Tomasello
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
| | - Emanuele Mini
- General Surgery Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Marcella Arru
- General Surgery Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Alessandro Russo
- General Surgery Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Ornella Garrone
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
| | - Shelize Khakoo
- Department of Medicine, The Royal Marsden Hospital, London, SW3 6JJ, UK
| | - Raffaele Ardito
- Oncological Day Hospital, IRCCS Centro di Riferimento Oncologico Della Basilicata (CROB), Via Padre Pio 1, Rionero in Vulture PZ, 85028, Italy
| | - Michele Ghidini
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
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Slater S, Bryant A, Aresu M, Begum R, Chen HC, Peckitt C, Lazaro-Alcausi R, Carter P, Anandappa G, Khakoo S, Branagan G, George N, Abulafi M, Duff S, West N, Bucheit L, Rich TA, Chau I, Starling N, Cunningham D. Optimising longitudinal plasma-only circulating tumour DNA (ctDNA) for minimal residual disease (MRD) detection with combined genomic/methylation signals to predict recurrence in patients (pts) with resected stage I-III colorectal cancer (CRC) in the UK multicentre prospective study TRACC. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
169 Background: Absence of post-operative ctDNA identifies resected CRC pts with low recurrence risk for potential adjuvant chemotherapy (ACT) de-escalation. We present the largest resected CRC cohort with plasma-only MRD detection, facilitating fast turnaround times, rapid treatment decisions and circumventing the need for tissue analysis, a challenge in real world practice. Methods: TRACC included pts with stage I-III resectable CRC. Prospective longitudinal plasma collection for ctDNA occurred pre- and post-surgery, after completion of ACT, every 3m (yr 1), every 6m (yrs 2/3) with CT annually for 3yrs. Guardant’s Reveal assay evaluated genomic/methylation signals. The primary end point was 2 year recurrence free survival (RFS) by 3-12wk post-operative ctDNA detection. Secondary end points included landmark RFS (3-12wk post-definitive treatment; surgery/ACT), longitudinal (on/after landmark timepoint) sensitivity/specificity and lead time to recurrence. Survival outcomes were calculated using Cox regression. Results: Dec 16 - Aug 22, 1203 pts enrolled. Plasma samples (n = 997) from 214 pts were analysed. 143 pts were evaluable for the primary end point; 92 (64.3%) colon, 51 (35.7%) rectal cancer; 2 (1.4%) stage I, 64 (44.8%) stage II, 77 (53.8%) stage III. Median follow up was 30.4m (95% CI: 29.6-31.7). 2 year RFS is shown in the table. No association between CEA and ctDNA positivity was seen. 14 pts were landmark ctDNA positive, 8 of whom did not relapse. In-depth genomic review revealed true positives (positive in tissue), some with limited follow up and suspected false positives due to putative genomic (i.e., CHIP) or methylation calls. We observed dynamic genomic/methylation changes demonstrating cancer evolution over time. 9 landmark ctDNA negative pts relapsed/died; 5 had longitudinal samples available of whom 4 remained negative during follow up. Relapse sites included lung (n = 2), liver (n = 1) and nodal (n = 1). Longitudinal sensitivity and specificity were 50.0% (95% CI: 27.2-72.8) and 85.9% (95% CI: 78.9-91.3) respectively with a negative predictive value (NPV) of 92.1% (95% CI: 85.9-96.1) and median lead time from ctDNA detection to radiological recurrence of 5.2m (IQR: 3.2, 8.0) (n = 9). Conclusions: Plasma-only genomic/methylation MRD detection with longitudinal sampling can predict recurrence in pts with stage I-III CRC without need for tissue analysis. NPV is high supporting an ACT de-escalation strategy in post-operative ctDNA negative pts, now investigated in the ongoing UK TRACC C randomised study (NCT04050345). Clinical trial information: NCT04050345 . [Table: see text]
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Affiliation(s)
| | - Annette Bryant
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Maria Aresu
- Royal Marsden NHS Foundation Trust, Surrey, United Kingdom
| | - Ruwaida Begum
- The Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom
| | - Hsiang-Chi Chen
- The Royal Marsden Hospital, London, Greater London, United Kingdom
| | - Clare Peckitt
- The Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom
| | | | - Paul Carter
- Royal Marsden Hospital, Sutton, United Kingdom
| | | | - Shelize Khakoo
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Nicol George
- Broomfield Hospital Mid and South Essex NHS Foundation Trust, Chelmsford, United Kingdom
| | - Muti Abulafi
- Croydon University Hospital, Greater London, United Kingdom
| | - Sarah Duff
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Nicholas West
- Epsom and St Helier University Hospitals, Surrey, United Kingdom
| | | | | | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom
| | - Naureen Starling
- The Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom
| | - David Cunningham
- The Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom
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Khakoo S, Petrillo A, Salati M, Muhith A, Evangelista J, Seghezzi S, Petrelli F, Tomasello G, Ghidini M. Neoadjuvant Treatment for Pancreatic Adenocarcinoma: A False Promise or an Opportunity to Improve Outcome? Cancers (Basel) 2021; 13:cancers13174396. [PMID: 34503206 PMCID: PMC8431597 DOI: 10.3390/cancers13174396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Pancreatic cancer usually presents late when it has spread to distant sites. In a small proportion of patients, the cancer can be removed by surgery. Surgery is usually followed by chemotherapy, as studies have shown that this improves survival. However, due to complications after surgery and a decline in fitness, some patients do not start their chemotherapy and many do not complete the planned course. The cancer returns in the majority of patients. Chemotherapy or a combination of chemotherapy and radiotherapy before surgery are being investigated to improve survival. The best treatment regime and patient selection for different treatment strategies remains to be defined and is discussed here. Abstract Pancreatic ductal adenocarcinoma (PDAC) has an aggressive tumor biology and is associated with poor survival outcomes. Most patients present with metastatic or locally advanced disease. In the 10–20% of patients with upfront resectable disease, surgery offers the only chance of cure, with the addition of adjuvant chemotherapy representing an established standard of care for improving outcomes. Despite resection followed by adjuvant chemotherapy, at best, 3-year survival reaches 63.4%. Post-operative complications and poor performance mean that around 50% of the patients do not commence adjuvant chemotherapy, and a significant proportion do not complete the intended treatment course. These factors, along with the advantages of early treatment of micrometastatic disease, the ability to downstage tumors, and the increase in R0 resection rates, have increased interest in neo-adjuvant treatment strategies. Here we review biomarkers for early diagnosis of PDAC and patient selection for a neo-adjuvant approach. We also review the current evidence for different chemotherapy regimens in this setting, as well as the role of chemoradiotherapy and immunotherapy, and we discuss ongoing trials.
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Affiliation(s)
- Shelize Khakoo
- Department of Medicine, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK;
- Correspondence: (S.K.); (M.G.); Tel.: +39-02-5503-2660 (M.G.); Fax: +39-02-5503-2659 (M.G.)
| | - Angelica Petrillo
- Division of Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania Luigi Vanvitelli, 80131 Naples, Italy;
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy
| | - Massimiliano Salati
- Department of Oncology, University Hospital of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Abdul Muhith
- Department of Medicine, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK;
| | - Jessica Evangelista
- Department of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Silvia Seghezzi
- Nuclear Medicine Unit, ASST Bergamo Ovest, 24047 Treviglio, Italy;
| | - Fausto Petrelli
- Oncology Unit, Medical Sciences Department, ASST Bergamo Ovest, 24047 Treviglio, Italy;
| | - Gianluca Tomasello
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Correspondence: (S.K.); (M.G.); Tel.: +39-02-5503-2660 (M.G.); Fax: +39-02-5503-2659 (M.G.)
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Ghidini M, Fusco N, Salati M, Khakoo S, Tomasello G, Petrelli F, Trapani D, Petrillo A. The Emergence of Immune-checkpoint Inhibitors in Colorectal Cancer Therapy. Curr Drug Targets 2021; 22:1021-1033. [PMID: 33563194 DOI: 10.2174/1389450122666210204204415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/06/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022]
Abstract
Immunotherapy has revolutionized the treatment landscape in a number of solid tumors. In colorectal cancer, evidence suggests that microsatellite high (MSI-H) tumors are the most responsive to immune checkpoint blockade due to increased neo-antigen load and a favorable tumor microenvironment. Indeed, Pembrolizumab now represents a first-line option in such patients. However, MSI-H tumors represent the minority and a proportion of patients' progress despite initially responding. Trials are investigating different immunotherapy combinatorial strategies to enhance immune response in less immunogenic colorectal tumors. Such strategies include dual immune checkpoint blockade, combining immune checkpoint inhibitors with other treatment modalities such as radiotherapy, chemotherapy or other biological or targeted agents. Moreover, there is an increasing drive to identify biomarkers to better select patients most likely to respond to immunotherapy and understand intrinsic and acquired resistance mechanisms. Apart from MSI-H tumors, there is a strong rationale to suggest that tumors with alterations in DNA polymerase epsilon and DNA polymerase delta are also likely to respond to immunotherapy and trials in this subpopulation are underway. Other strategies such as priming O6-methylguanineDNA methyltransferase silenced tumors with alkylating agents to make them receptive to immune checkpoint blockade are also being investigated. Here we discuss different colorectal subpopulations together with their likelihood of response to immune checkpoint blockade and strategies to overcome barriers to a successful clinical outcome. We summarize evidence from published clinical trials and provide an overview of trials in progress whilst discussing newer immunotherapy strategies such as adoptive cell therapies and cancer vaccines.
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Affiliation(s)
- Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Fusco
- Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Massimiliano Salati
- PhD Program, Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Shelize Khakoo
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Gianluca Tomasello
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Fausto Petrelli
- Medical Oncology Unit, Azienda Socio-Sanitaria Territoriale Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
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Ghidini M, Petrillo A, Botticelli A, Trapani D, Parisi A, La Salvia A, Sajjadi E, Piciotti R, Fusco N, Khakoo S. How to Best Exploit Immunotherapeutics in Advanced Gastric Cancer: Between Biomarkers and Novel Cell-Based Approaches. J Clin Med 2021; 10:1412. [PMID: 33915839 PMCID: PMC8037391 DOI: 10.3390/jcm10071412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 02/07/2023] Open
Abstract
Despite extensive research efforts, advanced gastric cancer still has a dismal prognosis with conventional treatment options. Immune checkpoint inhibitors have revolutionized the treatment landscape for many solid tumors. Amongst gastric cancer subtypes, tumors with microsatellite instability and Epstein Barr Virus positive tumors provide the strongest rationale for responding to immunotherapy. Various predictive biomarkers such as mismatch repair status, programmed death ligand 1 expression, tumor mutational burden, assessment of tumor infiltrating lymphocytes and circulating biomarkers have been evaluated. However, results have been inconsistent due to different methodologies and thresholds used. Clinical implementation therefore remains a challenge. The role of immune checkpoint inhibitors in gastric cancer is emerging with data from monotherapy in the heavily pre-treated population already available and studies in earlier disease settings with different combinatorial approaches in progress. Immune checkpoint inhibitor combinations with chemotherapy (CT), anti-angiogenics, tyrosine kinase inhibitors, anti-Her2 directed therapy, poly (ADP-ribose) polymerase inhibitors or dual checkpoint inhibitor strategies are being explored. Moreover, novel strategies including vaccines and CAR T cell therapy are also being trialed. Here we provide an update on predictive biomarkers for response to immunotherapy with an overview of their strengths and limitations. We discuss clinical trials that have been reported and trials in progress whilst providing an account of future steps needed to improve outcome in this lethal disease.
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Affiliation(s)
- Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | - Andrea Botticelli
- Department of Clinical and Molecular Medicine, Sapienza University, 00189 Rome, Italy;
- Medical Oncology (B), Policlinico Umberto I, 00161 Rome, Italy
| | - Dario Trapani
- Division of Early Drug Development for innovative therapies, European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Alessandro Parisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
- Medical Oncology Unit, St. Salvatore Hospital, 67100 L’Aquila, Italy
| | - Anna La Salvia
- Department of Oncology, University Hospital 12 De Octubre, 28041 Madrid, Spain;
| | - Elham Sajjadi
- Division of Pathology, European Institute of Oncology, IRCCS, 20141 Milan, Italy; (E.S.); (R.P.); (N.F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Roberto Piciotti
- Division of Pathology, European Institute of Oncology, IRCCS, 20141 Milan, Italy; (E.S.); (R.P.); (N.F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Nicola Fusco
- Division of Pathology, European Institute of Oncology, IRCCS, 20141 Milan, Italy; (E.S.); (R.P.); (N.F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Shelize Khakoo
- Department of Medicine, Royal Marsden Hospital, London and Surrey, Sutton SM25PT, UK;
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Khakoo S, Carter PD, Brown G, Valeri N, Picchia S, Bali MA, Shaikh R, Jones T, Begum R, Rana I, Wotherspoon A, Terlizzo M, von Loga K, Kalaitzaki E, Saffery C, Watkins D, Tait D, Chau I, Starling N, Hubank M, Cunningham D. MRI Tumor Regression Grade and Circulating Tumor DNA as Complementary Tools to Assess Response and Guide Therapy Adaptation in Rectal Cancer. Clin Cancer Res 2020; 26:183-192. [PMID: 31852830 DOI: 10.1158/1078-0432.ccr-19-1996] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/30/2019] [Accepted: 10/21/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Response to preoperative chemo-radiotherapy (CRT) varies. We assessed whether circulating tumor DNA (ctDNA) might be an early indicator of tumor response or progression to guide therapy adaptation in rectal cancer. EXPERIMENTAL DESIGN A total of 243 serial plasma samples were analyzed from 47 patients with localized rectal cancer undergoing CRT. Up to three somatic variants were tracked in plasma using droplet digital PCR. RECIST and MRI tumor regression grade (mrTRG) evaluated response. Survival analyses applied Kaplan-Meier method and Cox regression. RESULTS ctDNA detection rates were: 74% (n = 35/47) pretreatment, 21% (n = 10/47) mid CRT, 21% (n = 10/47) after completing CRT, and 13% (n = 3/23) after surgery. ctDNA status after CRT was associated with primary tumor response by mrTRG (P = 0.03). With a median follow-up of 26.4 months, metastases-free survival was shorter in patients with detectable ctDNA after completing CRT [HR 7.1; 95% confidence interval (CI), 2.4-21.5; P < 0.001], persistently detectable ctDNA pre and mid CRT (HR 3.8; 95% CI, 1.2-11.7; P = 0.02), and pre, mid, and after CRT (HR 11.5; 95% CI, 3.3-40.4; P < 0.001) compared with patients with undetectable or nonpersistent ctDNA. In patients with detectable ctDNA, a fractional abundance threshold of ≥0.07% mid CRT or ≥0.13% after completing CRT predicted for metastases with 100% sensitivity and 83.3% specificity for mid CRT and 66.7% for CRT completion. All 3 patients with detectable ctDNA post-surgery relapsed compared with none of the 20 patients with undetectable ctDNA (P = 0.001). CONCLUSIONS ctDNA identified patients at risk of developing metastases during the neoadjuvant period and post-surgery, and could be used to tailor treatment.
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Affiliation(s)
- Shelize Khakoo
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Paul David Carter
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - Gina Brown
- Department of Radiology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Nicola Valeri
- Molecular Pathology, The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Simona Picchia
- Department of Radiology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Maria Antonietta Bali
- Department of Radiology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Ridwan Shaikh
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - Thomas Jones
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - Ruwaida Begum
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Isma Rana
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Andrew Wotherspoon
- Department of Histopathology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Monica Terlizzo
- Department of Histopathology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Katharina von Loga
- Department of Histopathology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Eleftheria Kalaitzaki
- Clinical Research and Development, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Claire Saffery
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - David Watkins
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Diana Tait
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Ian Chau
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Naureen Starling
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Michael Hubank
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - David Cunningham
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom.
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Petrelli F, Ghidini M, Ghidini A, Perego G, Cabiddu M, Khakoo S, Oggionni E, Abeni C, Hahne JC, Tomasello G, Zaniboni A. Use of Antibiotics and Risk of Cancer: A Systematic Review and Meta-Analysis of Observational Studies. Cancers (Basel) 2019; 11:cancers11081174. [PMID: 31416208 PMCID: PMC6721461 DOI: 10.3390/cancers11081174] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/10/2019] [Accepted: 08/11/2019] [Indexed: 12/19/2022] Open
Abstract
The association between antibiotic use and risk of cancer development is unclear, and clinical trials are lacking. We performed a systematic review and meta-analysis of observational studies to assess the association between antibiotic use and risk of cancer. PubMed, the Cochrane Library and EMBASE were searched from inception to 24 February 2019 for studies reporting antibiotic use and subsequent risk of cancer. We included observational studies of adult subjects with previous exposure to antibiotics and available information on incident cancer diagnoses. For each of the eligible studies, data were collected by three reviewers. Risk of cancer was pooled to provide an adjusted odds ratio (OR) with a 95% confidence interval (CI). The primary outcome was the risk of developing cancer in ever versus non-antibiotic users. Cancer risk’s association with antibiotic intake was evaluated among 7,947,270 participants (n = 25 studies). Overall, antibiotic use was an independent risk factor for cancer occurrence (OR 1.18, 95%CI 1.12–1.24, p < 0.001). The risk was especially increased for lung cancer (OR 1.29, 95%CI 1.03–1.61, p = 0.02), lymphomas (OR 1.31, 95%CI 1.13–1.51, p < 0.001), pancreatic cancer (OR 1.28, 95%CI 1.04–1.57, p = 0.019), renal cell carcinoma (OR 1.28, 95%CI 1.1–1.5, p = 0.001), and multiple myeloma (OR 1.36, 95%CI 1.18–1.56, p < 0.001). There is moderate evidence that excessive or prolonged use of antibiotics during a person’s life is associated with slight increased risk of various cancers. The message is potentially important for public health policies because minimizing improper antibiotic use within a program of antibiotic stewardship could also reduce cancer incidence.
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Affiliation(s)
- Fausto Petrelli
- Oncology Unit, Oncology Department, ASST Bergamo Ovest, 24047 Treviglio (BG), Italy.
| | - Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Antonio Ghidini
- Medical Oncology Unit, Casa di Cura Igea, 20129 Milan, Italy
| | - Gianluca Perego
- Pharmacy Unit, School of Hospital Pharmacy-University of Milan, ASST Bergamo Ovest, 24047 Treviglio (BG), Italy
| | - Mary Cabiddu
- Oncology Unit, Oncology Department, ASST Bergamo Ovest, 24047 Treviglio (BG), Italy
| | - Shelize Khakoo
- Department of Medicine, Royal Marsden Hospital, London and Surrey, Sutton SM2 5PT, UK
| | | | - Chiara Abeni
- Oncology Unit, Fondazione Poliambulanza, 25124 Brescia, Italy
| | - Jens Claus Hahne
- Division of Molecular Pathology, The Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Gianluca Tomasello
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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Khakoo S, Chau I, Pedley I, Ellis R, Steward W, Harrison M, Baijal S, Tahir S, Ross P, Raouf S, Ograbek A, Cunningham D. ACORN: Observational Study of Bevacizumab in Combination With First-Line Chemotherapy for Treatment of Metastatic Colorectal Cancer in the UK. Clin Colorectal Cancer 2019; 18:280-291.e5. [PMID: 31451367 DOI: 10.1016/j.clcc.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 04/26/2019] [Accepted: 07/07/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Survival in metastatic colorectal cancer is worse than expected in the United Kingdom. Real-world data are needed to better understand UK-specific treatment practices that may explain this. PATIENTS AND METHODS The Avastin ColORectal Non-interventional (ACORN) study is a multicenter, prospective, UK-based, observational, phase 4 study (ClinicalTrials.gov, NCT01506167) that recruited patients with metastatic colorectal cancer scheduled to receive bevacizumab in combination with first-line chemotherapy as part of routine clinical practice. Primary end points included progression-free survival, overall survival (OS), serious adverse events (AEs), and grade 3 to 5 bevacizumab-related AEs. RESULTS A total of 714 patients were recruited between August 30, 2012, and February 4, 2014. Median follow-up was 16.4 months. Median first-line chemotherapy duration was 5.6 months, with capecitabine/oxaliplatin (265 [37.1%]) being the most common regimen. Median total chemotherapy duration was 8.1 months and did not vary by geographic location in the UK. Median progression-free survival (95% confidence interval) was 8.7 (8.2-9.1) months, and median OS was 17.8 (16.1-19.3) months. There was no significant difference in efficacy by chemotherapy regimen administered. Ninety-nine patients (13.9%) received bevacizumab after disease progression. The safety profile of bevacizumab was consistent with previous studies. CONCLUSION ACORN provided evidence that there were no clear differences observed in outcomes between bevacizumab with capecitabine-based chemotherapy and fluorouracil-based regimens, and confirmed the safety profile of bevacizumab in a real-world UK-based population. The lower-than-expected OS is likely due to the short total chemotherapy duration, less frequent use of bevacizumab after disease progression, and higher rates of in-situ primary tumors.
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Affiliation(s)
- Shelize Khakoo
- Department of Medicine, The Royal Marsden Hospital, London & Surrey, UK
| | - Ian Chau
- Department of Medicine, The Royal Marsden Hospital, London & Surrey, UK
| | - Ian Pedley
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Richard Ellis
- Department of Clinical Oncology, Royal Cornwall Hospital, Truro, UK
| | - Will Steward
- Leicester Cancer Research Centre, Leicester Royal Infirmary, Leicester, UK
| | - Mark Harrison
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
| | - Shobhit Baijal
- Department of Oncology, Heartlands Hospital, Birmingham, UK
| | | | - Paul Ross
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | | | - Agnes Ograbek
- Medical Affairs, Roche Products Limited, Welwyn Garden City, UK
| | - David Cunningham
- Department of Medicine, The Royal Marsden Hospital, London & Surrey, UK.
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Khakoo S, Carter P, Valeri N, Shaikh R, Jones T, Begum R, Rana I, Picchia S, Bali M, Brown G, Wotherspoon A, Terlizzo M, von Loga K, Ahmed I, Watkins D, Chau I, Starling N, Tait D, Hubank M, Cunningham D. Circulating tumour DNA (ctDNA) as a tool to assess response and guide therapy adaptation in rectal cancer. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy303.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Khakoo S, Georgiou A, Gerlinger M, Cunningham D, Starling N. Circulating tumour DNA, a promising biomarker for the management of colorectal cancer. Crit Rev Oncol Hematol 2018; 122:72-82. [PMID: 29458792 DOI: 10.1016/j.critrevonc.2017.12.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/18/2017] [Accepted: 12/06/2017] [Indexed: 02/08/2023] Open
Abstract
Circulating cell free tumour DNA (ctDNA) maintains the same genomic alterations that are present in the corresponding tumour, thereby allowing for quantitative and qualitative real-time evaluation in body fluids as an alternative to onerous repeat biopsies. Improvements in the sensitivity of techniques used to identify ctDNA has led to a surge of research investigating its role in the detection of: early disease, relapse, response to therapy and emerging drug resistance mechanisms. Following curative surgery, ctDNA detection is a promising marker of minimal residual disease and could better select patients for adjuvant chemotherapy. Longitudinal monitoring could help identify early relapse. In metastatic disease, ctDNA can predict response to chemotherapy prior to evidence of disease progression on imaging and investigate novel primary and acquired resistance mechanisms to targeted therapies. More experience in detecting, analysing and interpreting ctDNA within prospective trials, will better define its role for implementation into routine clinical practice.
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Affiliation(s)
- Shelize Khakoo
- Department of Medicine, Royal Marsden Hospital, London and Surrey, United Kingdom
| | - Alexandros Georgiou
- Department of Medicine, Royal Marsden Hospital, London and Surrey, United Kingdom; Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Marco Gerlinger
- Department of Medicine, Royal Marsden Hospital, London and Surrey, United Kingdom; Centre of Evolution and Cancer, The Institute of Cancer Research, London, United Kingdom
| | - David Cunningham
- Department of Medicine, Royal Marsden Hospital, London and Surrey, United Kingdom
| | - Naureen Starling
- Department of Medicine, Royal Marsden Hospital, London and Surrey, United Kingdom.
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Khakoo S, Georgiou A, Hughes D, Lanese A, Baratelli C, Coakley M, Shepherd S, Calamai V, Kouvelakis K, Kalaitzaki R, Ring A, Chau I, Watkins D, Rao S, Cunningham D, Starling N. Real world use of palliative systemic therapy (tx) in elderly patients (pts) with metastatic colorectal cancer (mCRC) within a UK specialist cancer centre. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx659.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Georgiou A, Khakoo S, Minchom A, Kouvelakis K, Kalaitzaki R, Nobar N, Calamai V, Ifijen M, Lethby M, Arouri F, Chau I, Watkins D, Rao S, Cunningham D, Starling N. Real world use of palliative systemic therapy (tx) in patients (pts) with metastatic early onset colorectal cancer (mEOCRC) within a UK specialist cancer centre. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx393.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Battersby NJ, Dattani M, Rao S, Cunningham D, Tait D, Adams R, Moran BJ, Khakoo S, Tekkis P, Rasheed S, Mirnezami A, Quirke P, West NP, Nagtegaal I, Chong I, Sadanandam A, Valeri N, Thomas K, Frost M, Brown G. A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial. Trials 2017; 18:394. [PMID: 28851403 PMCID: PMC5576102 DOI: 10.1186/s13063-017-2085-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 07/03/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pre-operative chemoradiotherapy (CRT) for MRI-defined, locally advanced rectal cancer is primarily intended to reduce local recurrence rates by downstaging tumours, enabling an improved likelihood of curative resection. However, in a subset of patients complete tumour regression occurs implying that no viable tumour is present within the surgical specimen. This raises the possibility that surgery may have been avoided. It is also recognised that response to CRT is a key determinant of prognosis. Recent radiological advances enable this response to be assessed pre-operatively using the MRI tumour regression grade (mrTRG). Potentially, this allows modification of the baseline MRI-derived treatment strategy. Hence, in a 'good' mrTRG responder, with little or no evidence of tumour, surgery may be deferred. Conversely, a 'poor response' identifies an adverse prognostic group which may benefit from additional pre-operative therapy. METHODS/DESIGN TRIGGER is a multicentre, open, interventional, randomised control feasibility study with an embedded phase III design. Patients with MRI-defined, locally advanced rectal adenocarcinoma deemed to require CRT will be eligible for recruitment. During CRT, patients will be randomised (1:2) between conventional management, according to baseline MRI, versus mrTRG-directed management. The primary endpoint of the feasibility phase is to assess the rate of patient recruitment and randomisation. Secondary endpoints include the rate of unit recruitment, acute drug toxicity, reproducibility of mrTRG reporting, surgical morbidity, pathological circumferential resection margin involvement, pathology regression grade, residual tumour cell density and surgical/specimen quality rates. The phase III trial will focus on long-term safety, regrowth rates, oncological survival analysis, quality of life and health economics analysis. DISCUSSION The TRIGGER trial aims to determine whether patients with locally advanced rectal cancer can be recruited and subsequently randomised into a control trial that offers MRI-directed patient management according to radiological response to CRT (mrTRG). The feasibility study will inform a phase III trial design investigating stratified treatment of good and poor responders according to 3-year disease-free survival, colostomy-free survival as well as an increase in cases managed without a major resection. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02704520 . Registered on 5 February 2016.
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Affiliation(s)
- Nick J. Battersby
- Pelican Cancer Foundation, The Ark, Basingstoke, RG24 9NN UK
- North Hampshire Hospital Foundation Trust, Basingstoke, RG24 9NA UK
| | - Mit Dattani
- Pelican Cancer Foundation, The Ark, Basingstoke, RG24 9NN UK
| | - Sheela Rao
- Department of Medicine Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - David Cunningham
- Department of Medicine Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Diana Tait
- Department of Medicine Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Richard Adams
- Velindre Cancer Centre Velindre Hospital Cardiff, Cardiff, CF4 7XL UK
| | - Brendan J. Moran
- Pelican Cancer Foundation, The Ark, Basingstoke, RG24 9NN UK
- North Hampshire Hospital Foundation Trust, Basingstoke, RG24 9NA UK
| | - Shelize Khakoo
- Gastrointestinal Unit Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Paris Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital London, London, SW3 6JJ UK
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital London, London, SW3 6JJ UK
| | - Alex Mirnezami
- Department of Surgery and Department for Tissue Microarray analysis, University of Southampton, Southampton, SO16 6YD UK
| | - Philip Quirke
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, Wellcome Trust Brenner Building, St. James’s University Hospital, Leeds, LS9 7TF UK
| | - Nicholas P. West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, Wellcome Trust Brenner Building, St. James’s University Hospital, Leeds, LS9 7TF UK
| | - Iris Nagtegaal
- Department of Pathology Radboud University, Nijmegen, 6500HB Netherlands
| | - Irene Chong
- Division of Molecular Pathology Institute of Cancer Research, London, SW3 6JB UK
| | - Anguraj Sadanandam
- Division of Molecular Pathology Institute of Cancer Research, London, SW3 6JB UK
| | - Nicola Valeri
- Division of Molecular Pathology Institute of Cancer Research, London, SW3 6JB UK
| | - Karen Thomas
- Statistics Unit, R&D Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Michelle Frost
- Department of Radiology, Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Gina Brown
- Department of Radiology, Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
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Dolly SO, Migali C, Tunariu N, Della-Pepa C, Khakoo S, Hazell S, de Bono JS, Kaye SB, Banerjee S. Indolent peritoneal mesothelioma: PI3K-mTOR inhibitors as a novel therapeutic strategy. ESMO Open 2017; 2:e000101. [PMID: 28761723 PMCID: PMC5519796 DOI: 10.1136/esmoopen-2016-000101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 09/05/2016] [Indexed: 12/29/2022] Open
Abstract
Peritoneal mesothelioma (MPeM) is a scarce abdominal-pelvic malignancy that presents with non-specific features and exhibits a wide clinical spectrum from indolent to aggressive disease. Due to it being a rare entity, there is a lack of understanding of its molecular drivers. Most treatment data are from limited small studies or extrapolated from pleural mesothelioma. Standard treatment includes curative surgery or pemetrexed-platinum palliative chemotherapy. To date, the use of novel targeted agents has been disappointing. Described is the management of two young women with papillary peritoneal mesothelioma with widespread recurrence having received platinum-pemetrexed chemotherapy. Both patients obtained symptomatic and disease benefit with apitolisib, a dual phosphoinositide 3-kinase-mammalian target of rapamycin (PI3K-mTOR) inhibitor for subsequent relapses, with one patient having a partial response for almost 3 years. Both are alive and well 10-13 years from diagnosis. CONCLUSION These case presentations highlight a subgroup of rare MPeM that behave indolently that is compatible with long-term survival. This series identifies the use of targeted therapies with PI3K-mTOR-based inhibitors as a novel approach, warranting further clinical assessment. Development of prognostic biomarkers is essential to aid identify tumour aggressiveness, help stratify patients and facilitate treatment decisions.
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Affiliation(s)
- Saoirse O Dolly
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Cristina Migali
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Nina Tunariu
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | | | - Shelize Khakoo
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Steve Hazell
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Johann S de Bono
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Stanley B Kaye
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
- Drug Development Unit, Institute of Cancer Research, Surrey, UK
| | - Susana Banerjee
- Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, UK
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Cross TJS, Villanueva A, Shetty S, Wilkes E, Collins P, Adair A, Jones RL, Foxton MR, Meyer T, Stern N, Warshow U, Khan N, Prince M, Khakoo S, Alexander GJ, Khan S, Reeves H, Marshall A, Williams R. A national survey of the provision of ultrasound surveillance for the detection of hepatocellular carcinoma. Frontline Gastroenterol 2016; 7:82-89. [PMID: 28840911 PMCID: PMC5369506 DOI: 10.1136/flgastro-2015-100617] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/19/2015] [Accepted: 09/11/2015] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Hepatocellular carcinoma (HCC), the sixth most common cancer worldwide and third most common cause of cancer related death, is closely associated with the presence of cirrhosis. Survival is determined by the stage of the cancer, with asymptomatic small tumours being more amenable to treatment. Early diagnosis is dependent on regular surveillance and the primary objective of this survey was to gain a better understanding of the baseline attitudes towards and provision of ultrasound surveillance (USS) HCC surveillance in the UK. In addition, information was obtained on the stages of cancer of the patients being referred to and discussed at regional multidisciplinary team meetings. DESIGN UK hepatologists, gastroenterologists and nurse specialists were sent a questionnaire survey regarding the provision of USS for detection of HCC in their respective hospitals. RESULTS Provision of surveillance was poor overall, with many hospitals lacking the necessary mechanisms to make abnormal results, if detected, known to referring clinicians. There was also a lack of standard data collection and in many hospitals basic information on the number of patients with cirrhosis and how many were developing HCC was not known. For the majority of new HCC cases was currently being made only at an incurable late stage (60%). CONCLUSIONS In the UK, the current provision of USS based HCC surveillance is poor and needs to be upgraded urgently.
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Affiliation(s)
- T J S Cross
- Department of Hepatology, The Royal Liverpool Hospital, Liverpool, UK
| | - A Villanueva
- Institute of Liver Studies, Kings College Hospital, London, UK
| | - S Shetty
- The Liver Unit, Queen Elizabeth Hospital II Hospital, Birmingham, UK
| | - E Wilkes
- Digestive Diseases Unit, Queens Medical Centre, Nottingham, UK
| | - P Collins
- Department of Hepatology, Bristol Royal Infirmary, Bristol, UK
| | - A Adair
- Scottish Liver Transplant Unit, Edinburgh, UK
| | - R L Jones
- Department of Hepatology and Liver Transplantation, St James University Hospital, Leeds, UK
| | - M R Foxton
- Department of Gastroenterology, Chelsea and Westminster Hospital, Liverpool, UK
| | - T Meyer
- Department of Oncology, The Royal Free Hospital, London, UK
| | - N Stern
- Department of Hepato-Biliary Medicine, Aintree University Hospital, Liverpool, UK
| | - U Warshow
- The Southwest Liver Unit, Derriford Hospital, Plymouth, UK
| | - N Khan
- The Royal Marsden Hospital, London, UK
| | - M Prince
- Department of Gastroenterology and Hepatology, Manchester, UK
| | - S Khakoo
- Department of Academic and Translational Medicine, University of Southampton, Southampton, UK
| | - G J Alexander
- Department of Hepatology and Liver Transplant Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - S Khan
- The Liver Unit, St Mary Hospital, London, UK
| | - H Reeves
- Department of Hepatology and Liver Transplantation, Freeman Hospital, Newcastle-on-Tyne, UK
| | - Aileen Marshall
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - R Williams
- Institute of Hepatology, Foundation for Liver Research, London, UK
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Fliser D, Shilo V, Covic A, Besarab A, Provenzano R, Duliege AM, Chen M, Tong S, Francisco C, Gao HY, Polu K, De Francisco AL, Macdougall I, Macdougall I, Schiller B, Locatelli F, Wiecek A, Francisco C, Tang H, Tong S, Chen M, Duliege AM, Polu K, Mayo M, Covic A, Macdougall I, Macdougall I, Casadevall N, Stead R, Taal M, Faller B, Karras A, Chen M, Tong S, Duliege AM, Rowell R, Polu K, Eckardt KU, Locatelli F, Dusilova Sulkova S, Arnaud S, Bruno P, Arnaud G, Dorina V, Eric A, Gerard M, Cases A, Portoles JM, Calls J, Martinez Castelao A, Sanchez-Guisande D, Segarra A, Tsubakihara Y, Tsubakihara Y, Saito A, Saito A, Saito A, Tsubakihara Y, Martinez-Castelao A, Martinez-Castelao A, Cases A, Fort J, Bonal J, Fulladosa X, Galceran JM, Torregrosa V, Coll E, Minutolo R, Cozzolino M, DI Iorio B, Polito P, Santoro D, Manenti F, Nappi F, Feriozzi S, Conte G, De Nicola L, Mikhail A, Provenzano R, Schiller B, Besarab A, Francisco C, Gao HY, Daley R, Tong S, Mayo M, Yang A, Polu K, Macdougall I, Wiecek A, Schiller B, Canaud B, Locatelli F, Yang A, Chen M, Polu K, Francisco C, Gao HY, Tong S, Duliege AM, Provenzano R, Locatelli F, Locatelli F, Provenzano R, Besarab A, Rath T, Yang A, Mayo M, Francisco C, Macdougall I, Bartnicki P, Baj Z, Majewska E, Rysz J, Fievet P, Assem M, Brazier F, Xu X, Soltani ON, Demontis R, Barsan L, Stancu S, Stancu S, Stanciu A, Capusa C, Petrescu L, Zugravu A, Mircescu G, Malyszko JM, Levin-Iaina N, Malyszko J, Glowinska I, Koc-Zorawska E, Slotki I, Mysliwiec M, Mircescu G, Mircescu G, Capusa C, Stancu S, Barsan L, Grabowski D, Blaga V, Dumitru D, Pchelin I, Shishkin A, Kus T, Usalan C, Tiryaki O, Chin HJ, Chae DW, Kim S, Bertram H, Keller F, Rumjon A, Wood C, Wilson P, Khakoo S, Chai MO, Macdougall IC, Nuria GF, Maria Asuncion F, Jose Maria MG, Carmen C, Paloma Leticia MM, Francisco Javier L, Moniek DG, De Goeij M, Yvette M, Diana G, Friedo D, Nynke H, Lezaic V, Miljkovic B, Petkovic N, Maric I, Vucicevic K, Simic Ogrizovic S, Djukanovic L, Cases A, Martinez-Castelao A, Fort A, Bonal J, Fulladosa X, Galceran JM, Torregrosa V, Coll E, DI Giulio S, DI Giulio S, Galle J, Kiss I, Herlitz H, Wirnsberger G, Claes K, Suranyi M, Guerin A, Winearls C, Addison J, D'souza M, Froissart M, Garrido P, Garrido P, Teixeira M, Costa E, Rodrigues-Santos P, Parada B, Belo L, Alves R, Teixeira F, Santos-Silva A, Reis F, Winearls C, Winearls C, DI Giulio S, Galle J, Kiss I, Herlitz H, Wirnsberger G, Claes K, Suranyi M, Guerin A, Addison J, D'souza M, Fouqueray B, Floris M, Conti M, Cao R, Pili G, Melis P, Matta V, Murgia E, Atzeni A, Binda V, Angioi A, Peri M, Pani A, Besarab A, Belo D, Diamond S, Martin E, Sun C, Lee T, Saikali K, Franco M, Leong R, Neff T, Yu KHP, Tiranathanagul K, Praditpornsilpa K, Katavetin P, Kanjanabuch T, Avihingsanon Y, Tungsanga K, Eiam-Ong S, Macdougall IC, Casadevall N, Percheson P, Potamianou A, Foucher A, Fife D, Vercammen E. Renal anaemia - CKD 1-5. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Khakoo S, Glue P, Grellier L, Wells B, Bell A, Dash C, Murray-Lyon I, Lypnyj D, Flannery B, Walters K, Dusheiko GM. Ribavirin and interferon alfa-2b in chronic hepatitis C: assessment of possible pharmacokinetic and pharmacodynamic interactions. Br J Clin Pharmacol 1998; 46:563-70. [PMID: 9862245 PMCID: PMC1873804 DOI: 10.1046/j.1365-2125.1998.00836.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS The primary objective of this study was to determine whether pharmacokinetic interactions occurred between interferon alpha-2b (IFN) and ribavirin in patients with chronic hepatitis C infections. Additionally this study assessed the single and multiple-dose pharmacokinetics of ribavirin and IFN, and compared the safety, tolerability and antiviral pharmacodynamics of IFN plus ribavirin compared with either drug alone. METHODS In this open label parallel group study, patients with chronic hepatitis C were randomized to receive IFN 3 million IU thrice weekly s.c. alone, ribavirin 600 mg twice daily p.o. alone or both drugs in combination over 6 weeks. Single and multiple dose pharmacokinetics and indices of antiviral pharmacodynamics were assessed during weeks 1 and 6, along with safety assessments during the study. RESULTS The range of mean ribavirin terminal phase half-lives after single doses was 44-49 h. Comparison of week 1 and week 6 AUC(0,12h) values showed accumulation in plasma of approximately 6-fold. The range of mean washout half-lives after week 6 was 274-298 h, reflecting release of ribavirin from deep compartment stores. The range of single and multiple dose IFN terminal phase half-lives was 5-7 h. IFN demonstrated an increase in bioavailability (approximately 2-fold) upon multiple dose administration. Ribavirin and IFN pharmacokinetic parameters for combined ribavirin and IFN were similar to those during monotherapy with either compound, although the power of this study to detect differences was low. Serum HCV-RNA titers and ALT concentrations were reduced by IFN alone, ribavirin alone reduced ALT concentrations only, and combined IFN plus ribavirin produced numerically greater falls in both measurements than either treatment alone. Serum concentrations of neopterin and activity of 2',5'-oligoadenylate synthetase (2'5'-OAS) were increased by IFN alone and in combination with ribavirin, whereas serum 2'5'-OAS activity was decreased and neopterin concentrations unaltered by ribavirin monotherapy. IFN and ribavirin monotherapy produced characteristic changes in safety laboratory tests (IFN--reductions in white cells, neutrophils and platelets; ribavirin--reduced haemoglobin) and characteristic adverse event profiles (IFN--headache, flu-like symptoms, fatigue, anorexia, nausea, myalgia, and insomnia; ribavirin--headache, fatigue, myalgia, and pruritus). There was no additive effect of combination therapy on safety laboratory tests or reported adverse events. All changes were fully reversible upon treatment cessation. CONCLUSIONS There was no evidence of pharmacokinetic interactions between IFN and ribavirin in this study. There were numerical trends indicating that the combination of IFN and ribavirin reduced titers of HCV-RNA to a greater extent than did either treatment alone, and the safety profile of combination therapy was similar to those of both monotherapy treatments.
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Akwagyriam I, Goodyer LI, Harding L, Khakoo S, Millington H. Drug history taking and the identification of drug related problems in an accident and emergency department. J Accid Emerg Med 1996; 13:166-8. [PMID: 8733649 PMCID: PMC1342679 DOI: 10.1136/emj.13.3.166] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine the incidence of drug related problems that fail to be noted on casualty cards in patients subsequently admitted, and to compare medication histories as recorded by accident and emergency (A&E) senior house officers (SHOs) and a pharmacist. METHODS An initial retrospective survey of 1459 acute inpatient admissions through A&E over a three month period was followed by a prospective study of 33 elderly patients. RESULTS In the retrospective survey, 52 medication related problems were confirmed after examination of the medical records, of which only 16 were identified in A&E. In the prospective study, 125 currently prescribed items were identified by the pharmacist compared to 77 by A&E SHOs; 66% of the missed information was clinically relevant. Of 17 previous adverse drug reactions identified by the pharmacist only six were also recorded by the A&E officer. Only four over the counter medicines were identified by the A&E SHOs compared to 30 by the pharmacist. CONCLUSIONS More accurate recording of drug history on casualty cards should be undertaken, particularly in respect of over the counter medication and the identification of drug related problems.
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el-Refaie A, Savage K, Bhattacharya S, Khakoo S, Harrison TJ, el-Batanony M, Nasr S, Mokhtar N, Amer K, Scheuer PJ, Dhillon AP. HCV-associated hepatocellular carcinoma without cirrhosis. J Hepatol 1996; 24:277-85. [PMID: 8778193 DOI: 10.1016/s0168-8278(96)80005-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/AIMS Hepatocellular carcinoma is an aggressive malignancy and carries a poor prognosis. Hepatitis B and C virus infection, cirrhosis and aflatoxin B1 exposure are considered major risk factors. The role of hepatitis C virus in the causation of hepatocellular carcinoma has been debated. It is a positive, single-stranded RNA virus without a DNA intermediate in its replicative cycle, so that integration of hepatitis C virus nucleic acid sequences into the host genome seems unlikely. The most plausible explanation of hepatitis C virus-associated hepatocellular carcinoma so far is that the virus causes necroinflammatory hepatic disease with vigorous regeneration, fibrosis, and eventually cirrhosis. The aim of this study was to examine the relationship of hepatitis C, cirrhosis and hepatocellular carcinoma. METHODS Sixty-six consecutive patients with hepatocellular carcinoma undergoing resection or transplantation at the Royal Free Hospital were reviewed. A combination of serological data and polymerase chain reaction assay was used to assign hepatitis C virus and hepatitis B virus infection. RESULTS We found four HCV-RNA positive patients with hepatocellular carcinoma without cirrhosis. All four cases were positive for HCV-RNA and negative for all markers of hepatitis B virus infection. CONCLUSIONS These four cases show that hepatocellular carcinoma may develop in patients with hepatitis C virus without pre-existing cirrhosis. However, the precise role of hepatitis C virus in hepatocarcinogenesis, the carcinogenic potential of the different genotypes and whether this role is influenced by other risk factors still have to be clarified.
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Affiliation(s)
- A el-Refaie
- University Department of Histopathology, Royal Free Hospital and School of Medicine, London, United Kingdom
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Affiliation(s)
- G M Dusheiko
- University Department of Medicine, Royal Free Hospital School of Medicine, London
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