Phase II study of dacarbazine given with modern prophylactic anti-emetics and growth factor support to patients with metastatic, resistant soft tissue, and bone sarcoma

Historically, administration of dacarbazine to sarcoma patients was limited by frequent treat-ment-related nausea/vomiting and neutropenia. These toxicities are now largely preventable with contemporary antiemetics and growth factor support. In this single-arm, phase II study, dacarbazine 850 mg/m² was given on day 1 of each 3-week cycle until disease progression or intolerance with prophylactic serotonin-3 receptor, neurokinin-1 antagonists, corticosteroids, and pegfilgrastim. Coprimary endpoints included clinical benefit rate (CBR), and any grade of nausea/vomiting and/or grade 3–4 neutropenia. With a sample size of 80 patients, >24 patients with clinical benefit would indicate that the CBR exceeds the historical (<20%) [Power 0.80; alpha 0.05]. In addition, we hypothesized that the rates of nausea/vomiting would be 27% and grade 3–4 neutropenia would be 1% (historical: 90% and 36%, respectively) [power 0.95; alpha 0.05]. The CBR was 30% (24 patients: PR-2 and stable-22). The rate of nausea/vomiting was 37.5% (31 patients) and grades 3–4 neutropenia was 10% (8 patients). Median time-to-progression was 8.1 weeks (95% CI 8–9.7) and median overall survival was 35.8 weeks (95% CI 26.2–55.4). PET scans demonstrated no association with response. Modern prophylactic anti-emetics and pegfilgrastim given with dacarbazine reduced the rates of treatment related nausea/vomiting and serious neutropenia.

A randomized phase II trial of cabozantinib combined with PD-1 and CTLA-4 inhibition in metastatic soft tissue sarcoma

TPS11583

Background: Soft tissue sarcomas (STS) are rare malignancies with poor prognosis in the metastatic setting. Current standard therapy includes anthracycline based chemotherapy. Cabozantinib is a multikinase inhibitor that has demonstrated efficacy in solid tumors such as renal cell carcinoma (RCC) and hepatocellular carcinoma (HCC). A phase II study of cabozantinib in advanced STS is underway. Cabozantinib in combination with immune checkpoint blockade has shown clinical benefit in several tumor types including HCC, RCC, non-small cell lung cancer, and urothelial carcinoma. Since cabozantinib may alter PD-1 expression in regulatory T-cells and promote an immune permissive environment, we hypothesize that combining cabozantinib with immune checkpoint inhibition is a therapeutic strategy that will be more effective than cabozantinib alone. Additionally, the design of the trial will allow assessment of whether pretreatment with cabozantinib will enhance the efficacy of nivolumab and ipilimumab alone. Methods: This is an open label, multicenter, randomized phase II clinical trial of cabozantinib (60mg orally daily as a single agent, 40mg in combination) with or without combination Ipilimumab (ipi, 1mg/kg IV every 3 weeks for 4 doses) and Nivolumab (nivo, 3mg/kg IV every 3 weeks for four doses, then 480mg IV every 4 weeks) in patients (pts) with unresectable or metastatic STS refractory to up to two lines of chemotherapy. 105 pts with non-translocation driven sarcomas will be enrolled at three US sites and randomized 2:1 to the combination group. Pts will be stratified by prior pazopanib use and balanced for histologies. Patients who progress on arm A will cross over to combination therapy (arm B). The primary efficacy endpoint is objective response rate (ORR) by RECIST 1.1. 35 patients in Cohort A (cabozantinib alone) and 70 patients in Cohort B (cabozantinib plus ipi/nivo) will be required to detect an increase of the ORR from 10% in cohort A to 30% in cohort B with 81% power with a one-sided alpha level of 10%. Key eligibility criteria include: at least 18 years of age, ECOG performance status of 0 or 1, ≤2 prior lines of therapy and measurable disease. Exclusion criteria include: translocation-driven sarcoma except alveolar soft part sarcoma (ASPS), prior immunotherapy, and chronic use of corticosteroids or other immunosuppression. Secondary endpoints are safety, overall and progression free survival, disease control rate, and response rate to ipilimumab and nivolumab after cabozantinib pretreatment. Mandatory tumor biopsies pre-treatment and at 6 weeks will be obtained. Peripheral blood will be collected for circulating immune phenotyping. Enrollment will occur at 3 participating institutions and is expected to be completed in 2022. Clinical trial information: NCT04551430.

Phase II trial of pegylated arginine deiminase in combination with gemcitabine and docetaxel for the treatment of soft tissue sarcoma

11508

Background: Soft tissue sarcoma (STS) is dependent on extracellular arginine as it often lacks expression of argininosuccinate synthase 1 (ASS1), the urea cycle enzyme needed to produce intracellular arginine. PEGylated arginine deiminase (ADI-PEG 20) is an extracellular arginine-degrading enzyme that causes ASS1 deficient tumors to enter the starvation state. Preclinical data demonstrated that addition of docetaxel (D) with ADI-PEG20 upregulates expression of the transporter for gemcitabine (G), overcoming transporter level resistance, and causing increased cell death. In vivo modeling demonstrated that the combination of ADI-PEG20 with G+D was superior to G+D alone. Therefore, we performed a phase 2 trial testing the addition of ADI-PEG20 to G+D. Methods: We performed an investigator-initiated, phase 2, multicenter, multi-arm clinical trial of ADI-PEG20 with G (90minute infusion)+D in STS, Ewing’s, osteosarcoma and small cell lung cancer. We are reporting Arm A, the STS arm. Eligible patients had STS that would be standardly treated with G+D that had progressed on at least one prior line of therapy with measurable disease by RECIST1.1 and had adequate organ function Based on a historic median PFS of 6.2 months for G+D, we targeted to enroll N = 75 patients in cohort A to detect a 2.8 month improvement with 80% power at a 5% alpha level. Primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), clinical benefit rate (CBR), safety, tolerability, cancer related mortality, and correlation with ASS1 expression by IHC. We evaluated PFS by Kaplan-Meier method and estimated overall response rate (ORR). Results: 75 patients were treated and deemed evaluable. The trial underwent two dose reductions by the data safety monitoring board due to prolonged neutropenia and thrombocytopenia preventing the use of day 8 G+D, consistent with preclinical mechanism of action data showing that ADI-PEG 20+D enhanced G uptake. Originally, the G dose was 900mg/m2 reduced first to 750mg/m2 then to 600mg/m2. D was dose reduced at the time of the second dose reduction from 75mg/m2 to 60mg/m2. ADI-PEG20 was given at a fixed intramuscular dose (36 mg/m2) weekly. The need for two dose reductions affected the PFS. The PFS/OS (months) were for the 600mg/m2 group (n = 31) was 6.0/N.D., leiomyosarcoma (LMS) (N = 33) 7.2/22.5, liposarcoma 5.1/17.4, and other (N = 36) 2.8/15.0. Responses were 8% complete (6/75) (3 LMS, 1 synovial and 2 angiosarcoma), 17% partial (13/75), and 43% stable disease (32/75), for an ORR of 25% (19/75) and CBR of 68% (51/75). There was a trend for ASS1 negative tumors to benefit more than ASS1 positive tumors. Conclusions: The combination of ADI-PEG20 with G+D can be safely and effectively given at a dose of 600mg/m2 G and 60mg/m2 D. Future randomized trials of ADI-PEG20 with G+D are planned. Clinical trial information: NCT03449901.

Adjustment to residential placement in Alzheimer disease patients: does premorbid personality matter?

AIM

To evaluate the influence of premorbid personality on adaptation to placement in a long-term care facility.

SUBJECTS

Twenty-eight persons with probable Alzheimer disease (AD) residing in an academically affiliated nursing home for 6-9 months.

METHODS

Premorbid personality was described retrospectively by two informants for each resident using the revised NEO Personality Inventory (NEO-PI-R). Standardized tests and rating scales were used on admission to the facility to assess cognition, mood state, physical dependency and general health. Nurses rated each AD resident's social behaviour, participation in activities and quality of sleep.

RESULTS

Poorer adjustment was associated with more severe dementia but better physical health. None of the NEO-PI-R domain scores predicted adjustment.

CONCLUSIONS

Contrary to popular belief, premorbid personality is relatively inconsequential for an AD patient's adaptation to a long-term care facility.

Hepatitis B immunisation coverage of infants born to chronic carrier mothers in Victoria

Infants born to HBsAg- (hepatitis B surface antigen) carrier mothers are highly likely to become chronic hepatitis B (HB) carriers themselves unless their status is recognised at birth and they are immunised with three doses of HB vaccine, the first within 48 hours of birth, concurrent with hepatitis B immune globulin (HBIG). This study was designed to determine how many infants born in Victoria to carrier mothers completed three doses of HB vaccine. We sent the names of all infants of HBsAg-carrier mothers notified in Victoria between 1.7.91 and 30.6.92 to the appropriate local government immunisation providers and requested information on how many doses of HB vaccine, DTP (diphtheria-tetanus-pertussis) or CDT (combined diphtheria-tetanus), and OPV (oral polio vaccine) they had received. The HBsAg-carrier prevalence of women giving birth in Victoria in 1991-92 was at least 0.52%. Of the 336 infants notified, 239 (71.1%) were recorded in local government records. Of these 239, 90.8% received at least two doses and 80.8% received at least three doses of hepatitis B vaccine. There was no significant difference in the number who received three doses of HB vaccine compared with three doses of DTP or CDT vaccine. Of the entire cohort of 336, only 57.4% were documented as being completely immunised against hepatitis B. HB immunisation coverage for these infants needs to be improved. The high rate of loss to follow-up, especially between the maternity hospital and the community, is disturbing. Mechanisms for intensive prospective follow-up of these infants should be developed to prevent loss to follow-up and to encourage full immunisation against HB. Improving HB immunisation coverage of infants in high HBsAg-prevalence ethnic groups and introduction of universal infant HB immunisation may lead to increased coverage of infants of carriers by serving as back-up mechanisms for those lost to follow-up.

Locally advanced head and neck cancer: combined chemotherapy and radical radiation therapy for organ and function preservation (interim report)

PURPOSE

This phase II study was performed to assess the feasibility of organ preservation after combined chemotherapy and radical radiation therapy in patients with resectable, locally advanced head and neck cancer.

MATERIALS AND METHODS

Twenty-four patients had surgically resectable stage III (n = 9) and stage IV (n = 15) squamous cell carcinoma of the head and neck. Initially, they received two to three courses of neoadjuvant chemotherapy (5-fluorouracil and cisplatin). Patients in whom response was seen were then treated definitively with two courses of cisplatin chemotherapy administered concomitantly with radical radiation therapy. Patients in whom no response was seen underwent salvage surgery or other standard therapy.

RESULTS

The response rate after induction chemotherapy was 84% (including 42% complete remission). Complete remission after concomitant chemotherapy and radical radiation therapy was 83%. After a median follow-up of 18 months (maximum, 3.5 years), 18 patients (75%) remained recurrence free. Grade 3 or 4 treatment-related toxicity was experienced, but there was no treatment-related mortality.

CONCLUSION

Combined chemotherapy and radical radiation therapy used in this study resulted in organ and function preservation in the majority of patients with resectable stage III and IV head and neck cancer.

Feasibility study of respiratory questionnaire and peak flow recordings in autobody shop workers exposed to isocyanate-containing spray paint: observations and limitations

Diisocyanates, highly reactive monomers which cross-link polyurethane, are the most widely recognized causes of occupational asthma. Many exposed workers are end-users, including autobody spray painters who form a large population at risk. Neither the factors which determine incidence rate nor strategies for control have been adequately studied in this setting. We have conducted a cross-sectional survey of 23 (about one in five) autobody shops in the New Haven area to determine the feasibility of clinical epidemiological studies in this population. Among 102 workers, there was a high rate of airway symptoms consistent with occupational asthma (19.6%). Symptoms were most prevalent among those with the greatest opportunity for exposure (dedicated spray painters) and least among office workers; part-time painters had intermediate rates. Atopy was not associated with risk while smoking seemed to correlate with symptoms. Regular use of air-supplied respirators appeared to be associated with lower risk among workers who painted part- or full-time. We were unable to validate the questionnaire responses with peak expiratory flow record data attempted on a 1/3 sample of the workers. Despite intensive training and effort, subject compliance was limited. Among those who provided adequate data (24 of 38), only two demonstrated unequivocal evidence of labile airways; two others demonstrated lesser changes consistent with an occupational effect on flow rates. There was no clear association between these findings and either questionnaire responses or exposure classification. Overall, the survey suggests that there is a high prevalence of airway symptoms among workers in autobody shops, at least in part due to work-related asthma. However, there is need for both methodological and substantive research in this setting to document rates of occupational asthma and to develop a scientific basis for its effective control.

Australian Case-Control Study of Adverse Reactions to Japanese Encephalitis Vaccine

Background: Japanese encephalitis (JE) is widely distributed in Asia and is the world's most common aborviral encephalitis. An effective vaccine against JE has been used in Asia for decades without reports of serious adverse reactions. Since 1989, an apparent increase in frequency of allergic reactions to JE vaccine has been reported from a number of nonendemic countries, including Australia. The objective of this study was to evaluate possible risk factors for allergic reactions associated with Japanese encephalitis (JE) vaccine. Methods: A case-control study was carried out in Australia. Subjects were persons who had developed an allergic reaction (rash and/or edema) that had occurred within 1 week of a dose of Biken JE vaccine. All cases had been reported to the Australian Adverse Reactions Advisory Committee, and all could be accessed for purposes of this study. Three matched controls were recruited for each of five cases. Participants completed a questionnaire and had venous blood drawn. Results: Cases were significantly less likely than controls to give a history of contact with dogs (Fisher's exact test p =.03); were more likely than controls to have received other immunizations in the 1-9 days prior to, rather than on the same day, as the JE vaccine (chi-square test for independence p =.015); and were more likely than controls to have consumed more than usual quantities of alcohol in the 48 hours following the last dose of JE vaccine (Fisher's exact test p =.034). Conclusions: We recommend, where possible, that JE vaccine be administered concurrently with other vaccines, that recipients be advised to avoid more than usual alcohol intake after receiving JE vaccine, and that active surveillance of adverse events associated with JE vaccine be conducted.

Well-differentiated malignant cylindroma with partially preserved hyaline sheaths. A locally invasive neoplasm?

Light microscopic and ultrastructural features of a well-differentiated malignant cylindroma are described. The tumor was locally invasive but it neither recurred nor metastasized during the 3 years after surgery. This fact, together with the similar biologic behavior of two previously described, well-differentiated malignant cylindromas, suggests that these tumors possess either low or no metastatic potential.

Illness in returned travellers

International travel is an integral and increasing part of modern life. Travel-related illness is common, diverse and associated with varying incubation periods. A travel history should routinely be taken from every patient with a diagnostic problem, particularly if fever is present. This article focuses on common problems among returned Australian travellers.

A rare cause of reversible sensorineural hearing loss

A unilateral sensorineural hearing loss that acutely develops should raise suspicion. A thorough work-up is indicated as a few reversible causes exist. Drug therapy represents probably the most common cause of a reversible sensorineural hearing loss, with a few medical conditions contributing to the list of etiologic factors. We present a case of unilateral sensorineural hearing loss in an otherwise asymptomatic patient that was attributed to non-Hodgkin's lymphoma, which reversed following chemotherapy.

Ciguatera and mannitol: experience with a new treatment regimen

Ciguatera is a distressing, hitherto-untreatable and not rare disease which results from the eating of ciguatoxin-contaminated fish from tropical and subtropical waters. We report here the results of a pilot study to assess the efficacy of mannitol therapy in ciguatera poisoning. Twelve adult patients (six men) have been treated, five of whom--who were ill acutely--experienced a significant benefit from this therapy, in three cases, with a hitherto-unexperienced dramatic reversal of symptoms. We conclude that an intravenous infusion of 1.0 g/kg of mannitol which is given over 45 minutes, after rehydration if required, can be of significant benefit to at least some acutely intoxicated victims. We postulate either a reduction of axonal oedema, or a scavenger effect, or both, as the mechanism of the beneficial effects of mannitol. Ciguatoxin is rich in hydroxyl groups, and causes microscopic oedema of neural tissue. If our conclusion of the beneficial effects of mannitol therapy is confirmed, this will offer the first effective therapy for acute phases of this disease, and has promise of preventing much long-term morbidity.

Rhinoscleroma

We have described a case of rhinopharyngeal rhinoscleroma, and reviewed the clinical behavior and management of this disease. Selective long-standing antibiotic treatment was successful in halting the process. Treatment of the advanced cicatrix with carbon-dioxide laser vaporization yielded excellent results.

Oral dantrolene sodium for tonsillectomy pain: a double-blind study

Tonsillectomy in adults and older children is typically accompanied by 7 to 14 days of pain. On the basis of clinical observations of patients treated perioperatively with dantrolene sodium for malignant hyperthermia, we hypothesized that pharyngeal muscle spasms are a major factor in tonsillectomy pain. We entered 113 patients, 11 years of age and older, into a double-blind, placebo-controlled study to evaluate the effectiveness of dantrolene sodium in reduction of tonsillectomy pain. Patients were randomly assigned either dantrolene (1.5 mg/kg per day) or placebo orally four times a day for 5 days postoperatively. On a standardized questionnaire, the patient recorded pain, diet, activity level, analgesics, and side effects, daily for 2 weeks. Also, alkaline phosphatase (alk phos) and serum aspartate aminotransferase (SGOT) levels were determined before the operation and 2 weeks after. Patients who received dantrolene had no significant differences in subjective pain, diet, or activity level scores from those of patients who received placebo. Dantrolene patients did, however, require significantly less analgesic use than placebo patients (p = 0.034, 0.015, and 0.005 for postoperative days 2, 3, and 4, respectively). There was no significant difference in side effects or changes in liver enzyme between the dantrolene and placebo groups. We conclude that dantrolene sodium, given in the dosage noted, is effective in reduction of analgesic requirements after tonsillectomy.

Carcinoma of the oral cavity and oropharynx

A high index of suspicion in smokers, coupled with inspection and palpation, is necessary for early diagnosis of cancer of the oral cavity and the oropharynx. Surgery or radiotherapy, or a combination of those modalities, is usually successful, except in advanced cases of cancer of the tongue base and the oropharynx.

Sarcoidosis of the larynx treated with CO2 laser

A case of sarcoidosis of the larynx is described. The definitive treatment consisted of transoral partial supraglottic resection using the CO2 laser. Longterm follow-up results are shown by a photograph.

Atypical facial pain and orbital cancer

A patient complaining of facial pain was found to have primary squamous cell cancer of the orbit. The treatment included surgery and radiotherapy. The patient having this extremely rare disease has been followed up for seven years with no evidence of recurrence.

Surgery of the head and neck in the older patient

While threatening in appearance, head and neck surgery is well tolerated by most elderly patients. Most surgery on the nose, sinuses, ears, and salivary glands is performed for benign conditions. Malignant disease is more common in the oral cavity, pharynx, and larynx.

Adenocarcinoma of the para-nasal sinuses

1. Adenocarcinoma in this series is commoner than squamous cell carcinoma. 2. Adenocarcinoma is a disease mainly affecting the ethmoid sinuses whereas squamous cell carcinoma is a disease mainly affecting the maxillary sinuses. 3. Patients with adenocarcinoma survive longer than those with squamous cell carcinoma. 4. Death from adenocarcinoma usually results from intra-cranial infiltration and therefore widespread resection with the assistance of a neuro-surgeon may be needed.