Encorafenib plus cetuximab with or without binimetinib in patients with BRAF V600E-mutated metastatic colorectal cancer: real-life data from an Italian multicenter experience

Background

Encorafenib plus cetuximab with or without binimetinib showed increased objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) compared with chemotherapy plus anti-EGFR in previously treated patients with BRAF V600E-mutated (mut) metastatic colorectal cancer (mCRC). Although no formal comparison was planned, addition of binimetinib to encorafenib plus cetuximab did not provide significant efficacy advantage.

Patients and methods

This real-life study was aimed at evaluating safety, activity, and efficacy of encorafenib plus cetuximab with or without binimetinib in patients with BRAF V600E-mut mCRC treated at 21 Italian centers within a nominal use program launched in May 2019.

Results

Out of 133 patients included, 97 (73%) received encorafenib plus cetuximab (targeted doublet) and 36 (27%) the same therapy plus binimetinib (targeted triplet). Most patients had Eastern Cooperative Group Performance Status (ECOG-PS) of 0 or 1 (86%), right-sided primary tumor (69%), and synchronous disease (66%). Twenty (15%) tumors were DNA mismatch repair deficiency (dMMR)/microsatellite instability (MSI)-high. As many as 44 (34%) patients had received two or more prior lines of therapy, 122 (92%) were previously exposed to oxaliplatin, and 109 (82%) to anti-vascular endothelial growth factor (anti-VEGF). Most frequent adverse events were asthenia (62%) and anti-EGFR-related skin rash (52%). Any grade nausea (P = 0.03), vomiting (P = 0.04), and diarrhea (P = 0.07) were more frequent with the triplet therapy, while melanocytic nevi were less common (P = 0.06). Overall, ORR and disease control rate (DCR) were 23% and 69%, respectively, with numerically higher rates in the triplet group (ORR 31% versus 17%, P = 0.12; DCR 78% versus 65%, P = 0.23). Median PFS and OS were 4.5 and 7.2 months, respectively. Worse ECOG-PS, peritoneal metastases, and more than one prior treatment were independent poor prognostic factors for PFS and OS. Clonality of BRAF mutation measured as adjusted mutant allele fraction in tumor tissue was not associated with clinical outcome.

Conclusions

Our real-life data are consistent with those from the BEACON trial in terms of safety, activity, and efficacy. Patients in good general condition and not heavily pretreated are those more likely to derive benefit from the targeted treatment.

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Encorafenib plus cetuximab ± binimetinib is safe and effective for BRAF V600E mut mCRC even in the real-world setting.

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Median OS is slightly shorter than in the BEACON trial, probably due to less selected patients in real life.

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Patients deriving more benefit from targeted therapy are likely those in good general conditions and not heavily pretreated.

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BRAF adjusted MAF is worth further investigation to better characterize the genomic heterogeneity of BRAF V600E mut mCRC.

Stroke care in young patients

The aims of this study were (i) to evaluate the clinical features of a consecutive series of young patients with ischemic stroke and (ii) to assess the changes in the clinical management of these patients over the study period. All consecutive cases of young adults aged 16 to 44 years, with ischemic stroke, that were admitted between 2000 and 2005 in 10 Italian hospitals were included. We retrospectively identified 324 patients. One or more vascular risk factors were present in 71.5% of the patients. With respect to the diagnostic process, an increase in the frequency of cerebral noninvasive angiographic studies and a decrease in the use of digital subtraction angiography were observed (P < 0.001 and P = 0.03, resp.). Undetermined causes decreased over 5-year period of study (P < 0.001). The diagnosis of cardioembolism increased. Thrombolysis was performed for 7.7% of the patients. PFO closure (8%) was the most frequently employed surgical procedure. In conclusion, the clinical care that is given to young patients with ischemic stroke changed over the study period. In particular, we detected an evolution in the diagnostic process and a reduction in the number of undetermined cases.

Risk factors for the development of severe cisplatin neurotoxicity

Cisplatin sensory neuropathy is not equally severe in all patients and may progress even after drug withdrawal. A major goal in cisplatin chemotherapy would be the identification of early predictors of an unfavorable neurological outcome in order to adjust the schedules of administration. The final neurological outcome of 63 women treated with the same schedule of cisplatin (CDDP) was compared with the general demographic and oncological parameters and with the baseline neurological results. No definite association could be drawn between any of the parameters evaluated and peripheral neuropathy. Further studies are needed to investigate the individual factors which are at the basis of the remarkable variability of this severe side effect of CDDP.

Incidence and predictors of acute symptomatic seizures after stroke

OBJECTIVE

To assess incidence and predictors of acute symptomatic seizures in a prospective cohort of patients with first stroke.

METHODS

Patients with first stroke hospitalized in 31 Italian centers were recruited. Relevant demographic data, disease characteristics, and risk factors were collected. Acute symptomatic seizures (≤7 days) were recorded and correlated to age, gender, family history of epilepsy, and vascular risk factors.

RESULTS

A total of 714 patients (315 women, 399 men; age 27-97 years) were enrolled. A total of 609 (85.3%) had cerebral infarction (32 cerebral infarction with hemorrhagic transformation [CIHT]) and 105 (14.7%) primary intracerebral hemorrhage (PIH). A total of 141 (19.7%) had a large lesion (>3 cm) and 296 (41.5%) cortical involvement. Twelve patients reported family history of seizures. Forty-five patients (6.3%) presented acute symptomatic seizures, 24 with cerebral infarction (4.2%), 4 with CIHT (12.5%), and 17 (16.2%) with PIH. In multivariate analysis, compared to cerebral infarction, PIH carried the highest risk (odds ratio [OR] 7.2; 95% confidence interval [CI] 3.5-14.9) followed by CIHT (OR 2.7; 95% CI 0.8-9.6). Cortical involvement was a risk factor for PIH (OR 6.0; 95% CI 1.8-20.8) and for CI (OR 3.1; 95% CI 1.3-7.8). Hyperlipidemia (OR 0.2; 95% CI 0.03-0.8) was a protective factor for IPH.

CONCLUSION

The incidence of acute symptomatic seizures is the highest reported in patients with first stroke with prospective follow-up. Hemorrhagic stroke and cortical lesion were independent predictors of acute symptomatic seizures. Hyperlipidemia was a protective factor for hemorrhagic stroke.

Large Cryogenic Storage of Hydrogen in Carbon Nanotubes at Low Pressures

We report (6 wt %) storage of H2 at T=77 K in processed bundles of single-walled carbon nanotubes at P=2 atmospheres. The hydrogen storage isotherms are completely reversible. D2 isotherms confirm this anomalous low-pressure adsorption and further reveal the effects of quantum mechanical zero point motion. We propose that our post-synthesis treatment of the sample not only improves access for hydrogen to the central pores within individual nanotubes, but also may create a roughened tube surface with an enhanced binding energy for hydrogen. Such an enhancement is needed to understand the strong adsorption at low pressure. We obtain an experimental isosteric heat qst=125 ± 5 meV for processed SWNT materials.

[Drug use among workers: an update]

We present data coming from two years of surveillance of drug use among workers, as provided for by the recent law. Urine samples have been collected either by our lab or by the firm; procedures and investigated substances followed the law. Self-reported information on job duties and history of drug use have also been collected. Between September 2008 and April 2010, n = 2745 workers (age 40.5 +/- 9.5, 98% men, 43% handling workers) were screened, for a total number of 3002 urine samples. Among the samples with creatinine > = 20 mg/dl (n = 2878), 46 were positive (1.6%); no temporal trends were detected. Cannabis e cocaine were the two most spread substances. Positivity was associated with young age and presence of another positive sample in the same firm. Furthermore, we present the results of the analysis (urine and hair samples) on 146 suspected drug abuser selected by the SERT Varese in the same time period.

Comparative HPLC and ELISA studies for CDT isoform characterization in subjects with alcohol related problems. Prospective application in workplace risk-prevention policy

Serum carbohydrate-deficient transferrin (CDT) is the most specific marker of chronic alcohol abuse so far. The performance of commercial HPLC over the ELISA method for measurement of CDT was evaluated on a series of 105 serum samples obtained from subjects referred to the Toxicology Laboratory of Salvatore Maugeri Hospital for alcohol-related problems. Compared to ELISA, HPLC analysis was more valuable for determining alcohol-related patterns of CDT isoforms and quantifying serum levels of disialotransferrin that better reflect chronic heavy drinking. Other significant advantages of the HPLC method included reproducible separation and easier detection of glycoform types and genetic transferrin variants that are known to cause falsely high or low results in sera examined by immunoassay. Current scientific evidence indicates that disialotransferrin is the target analyte for CDT determination and HPLC the current CDT analysis reference method. Systematic studies for early assessment of excessive alcohol intake or abuse of alcoholic substances in workers are recommended by the Italian legislation in accordance with the European Alcohol Action Plan (EAAP) launched by the WHO Regional Committee for Europe. These studies are advisable given their potential role in preventing negative effects of alcohol abuse in workplace. A research strategy combining CDT and other laboratory markers with questionnaire and physician interview is recommended for examining subjects with alcohol related problems and the diagnosis of alcoholism. This approach can be applied for alcohol abuse in workplace surveillance.

[Diagnostic agreement between two different analytic methods for in vitro measurement of specific IgE and comparison with clinical evaluation and in vivo test for ubiquitarian and professional allergens]

This study surveys the diagnostic agreement between two different analytic systems for the measurement of serum specific IgE (sLgE), Immulite 2000 (IML) and ImmunoCap (CAP), with clinic evaluation and in vivo test. Our sample is represented by 33 adults (27 females and 6 males), with suspect of immediate allergic disease and suspect of sensitization to at least one allergen of the study panel (18 allergens: inhalant, alimentary and professional). All patients have been subjected to Skin Prick Test (SPT) for all the studied allergens, therefore sIgE measurement with IML and CAP systems has been executed (twice for each method) only for the allergens which resulted positive to the diagnostic suspect and to SPT, and for an equal number of allergens chosen by bound randomisation. In vitro methods (IML and CAP), evaluated by K Cohen statistics, give good diagnostic agreement. In the same way, the diagnostic agreement of the used analytic systems both with clinical suspect and with in vivo test is satisfying, with higher K values for IML.

Dizziness and vertigo: an epidemiological survey and patient management in the emergency room

Dizziness and vertigo are frequent causes of presentation at the emergency room, with an incidence in the Vimercate district, Italy, close to 3.5%. The basic management of the "dizzy" patients in the emergency room includes a detailed history and an accurate physical/neurological examination, with the aim to identify "at risk" patients who require further diagnostic procedures and/or immediate admission to the hospital.

Thrombolysis for acute ischemic stroke: the patient's point of view

BACKGROUND

The use of thrombolytic therapy for acute ischemic stroke is still controversial. A major problem is balancing the improvement in functional ability against the risk of early death from cerebral hemorrhage. Our aim was to assess whether patients who have had a stroke, and their proxies, would give consent to thrombolysis if this therapy were introduced into clinical practice for acute ischemic stroke in Italy.

METHODS

A 10-item questionnaire was administered by personnel not directly involved in the care of patients in 12 Italian hospitals. Interviews were carried out with at least 10 consecutive stroke inpatients per center in the postacute phase and to their proxies.

RESULTS

There were 685 responders (377 female), median age 58 years (range 18-98); 332 were patients and 353 proxies. Responders were representative of the Italian population as a whole as regards mean age and sex, education and marital status; 59% of responders (95% confidence interval 55-62%) would agree to thrombolysis in the case of stroke. There was more uncertainty among proxies than patients, especially when the decision had to be taken for a relative (41 vs. 17% could not decide, p < 0.001). The preference for thrombolysis was higher among more educated people (p = 0.001) and was not influenced by sex, age and marital status. Overall, 81% of responders would prefer to risk dying rather than remain severely disabled.

CONCLUSION

Thrombolytic therapy is feasible in Italy as there is ample willingness to trade off a better functional outcome with a higher risk of death. Education is the main sociodemographic determinant of independent decision-making, as only those with an adequate cultural level are able to discriminate between one treatment option and another. The proxy's uncertainty about how to interpret a patient's preference regarding consent to thrombolytic therapy should be tackled, since proxies play a key role in making patients' preferences known in case of incompetence after an acute stroke.

Rational use of EEG in adults in clinical practice

The electroencephalogram (EEG) is still widely used for the diagnosis of several clinical conditions and symptoms. To assess the information provided by the EEG in relation to its duration, and to identify the shortest recording providing a conclusive report, the tracing was tested in 290 adult patients seen in a hospital neurophysiology unit for epilepsy (definite or uncertain), headache, head trauma, fainting, syncope, undefined loss of consciousness, vertigo, and cerebrovascular disease. Two neurophysiologists participating in the study read the same EEG independently. The record was based on a standardized timed sequence of montages. At each step any changes from the previous step were noted. Sixty-seven percent of the EEGs were coded as normal or aspecific, 24.1% were slow, and 8.6% were epileptiform. Normal tracings ranged from 38.8% (definite epilepsy) to 87.5% (vertigo), and epileptiform EEG from 0 (uncertain epilepsy) to 28.6% (definite epilepsy). The final report was clear in 80% of cases at the end of a 2-minute reading and almost 90% after 4 minutes. Hyperventilation and intermittent photic stimulation contributed little to the final report. Only for definite epilepsy were there changes along the whole sequence of montages. Thus, only for epilepsy need the EEG recordings last more than 20 minutes, whereas for the other clinical indications the total recording time could be limited to 4 minutes at most.

Neurotoxicity and ototoxicity of cisplatin plus paclitaxel in comparison to cisplatin plus cyclophosphamide in patients with epithelial ovarian cancer

PURPOSE

To compare the neurotoxicity and ototoxicity of combination cisplatin plus paclitaxel versus cisplatin plus cyclophosphamide using extensive clinical and instrumental evaluation.

PATIENTS AND METHODS

Forty-six of 51 consecutive patients affected by-epithelial ovarian cancer seen in our institution between October 1994 and August 1995 entered the study. After randomization, they were assigned to receive cisplatin 75 mg/m2 every 3 weeks associated with cyclophosphamide 750 mg/m2 (CC group, n = 22) or paclitaxel 175 mg/m2 over a 3-hour infusion (CP group, n = 24). Treatment was repeated six times in 43 patients and nine times in 25. Before treatment and after three, six, and nine courses of chemotherapy, patients underwent clinical and instrumental neurologic and otologic examinations.

RESULTS

Mild sensory impairment was evident even after only three courses of both treatments and signs and symptoms were more severe at the end of treatment. On clinical grounds only, it was possible to demonstrate after six and nine courses a difference between CC and CP treatment, due to the involvement in some CP patients of pain and thermal sensory modalities. However, the overall severity of the neuropathy was similar. Audiometric parameters demonstrated a more negative outcome after treatment in CC compared with CP patients. However, the different severity of the involvement was closely correlated to this initial difference in audiologic performance.

CONCLUSION

Up to nine courses of chemotherapy, the CC and CP schedules are similar in terms of severity of neurotoxicity and ototoxicity when patients are evaluated during and immediately after treatment. With the doses used in our study, these toxicities are not dose-limiting. Our results suggest that most of the toxic effects observed during the treatment were due to cisplatin.

Cryoglobulinaemic neuropathy: lack of progression in patients with good haematological control

Nine consecutive patients with essential mixed cryoglobulinaemia type II (EMCII) were investigated by a follow-up study of 3-6 years (mean 5.3), to verify the long-term outcome of the peripheral nerve involvement in the disease. At the beginning of the study, a peripheral neuropathy, mild or moderate, mainly sensory, was present approximately in 50% of cases. All patients maintained good general conditions, low-staging of EMCII, were well controlled by therapy or did not need any medical treatment. During the neurological follow-up all patients had regular controls, usually at 1-year intervals, and only slight changes were seen with respect to the first evaluation. Therefore, we conclude that peripheral neuropathy during EMCII is less progressive that it can be thought at least in patients with benign course of the disease.

Epilepsy and psychiatric disturbance. A cross-sectional study

One hundred patients with cryptogenic epilepsy and normal intelligence and 100 age- and sex-matched controls were submitted to psychiatric interview using the Clinical Interview Schedule. Nineteen patients and 15 controls were identified as having psychiatric disorders. Anxiety and depression were the predominating diagnoses in both groups. Personality disorders were occasionally present in subjects with epilepsy. The study shows that patients with cryptogenic epilepsy and normal neuropsychological abilities should not be considered at any higher risk of psychiatric disturbance than a non-neurological patient population.

Sural nerve bioptic findings in essential cryoglobulinemic patients with and without peripheral neuropathy

Peripheral neuropathy often occurs in cryoglobulinemia but the pathogenesis of the peripheral nerve involvement is not completely understood, so that the relation between the reported endoneural changes and neuropathy is not clear. In this study we compared the sural nerve biopsies of 6 cryoglobulinemic patients with or without signs of peripheral neuropathy and all affected by the essential mixed type II form (ECII) and, moreover, of 8 age-matched controls. We found that in all the patients with neuropathy, axonopathy occurred and it was invariably associated with endoneural vessel damage. Moreover, the fiber losses were patchily distributed within the nerve fascicles. On the contrary both nerve fibers and vessels were normal in the patients without clinical and neurophysiological evidence of neuropathy and in controls. Our results support the hypothesis that the endoneural damage observed during ECII is not simply coincidental, but is relevant in the pathogenesis of cryoglobulinemic neuropathy. They also favor the assumption that ischemic damage of the nerve fibers occurs during ECII.

A survey of the necessity of the hospitalization day in an Italian teaching hospital

To assess the extent of inappropriate hospital use in an adult in-patients population we used a modified version of the Appropriateness Evaluation Protocol (A.E.P.) to evaluate retrospectively a cross-section of 273 patient-days in a large teaching hospital in the Greater Milan area. Overall, 41% were judged to represent inappropriate hospital use on the basis of the protocol's criteria. The rate of inappropriate hospital use was significantly associated with admitting specialty, ranging from 12% for surgery, to 20% for cardiology and to about 60% in psychiatric, geriatrics and neurology departments (p less than 0.01). Hospital days of patients with longer stays were more frequently inappropriate: a statistically significant trend of inappropriateness emerged ranging from 30% among patients with total length of stay (LOS) of 1-10 days to 60% among those with LOS greater than 30 days (p less than 0.01). This study confirms that there is a substantial rate of unnecessary use of hospitals but that such inappropriateness does not seem in most cases to be easily modifiable through "simple" organizational changes.

A clinico-pathological and follow up study of 10 cases of essential type II cryoglobulinaemic neuropathy

Ten patients with essential cryoglobulinaemia type II were examined for peripheral nerve damage. In six cases distal symmetrical nerve involvement was present, while in three other cases abnormalities restricted to single nerves were found. Electrophysiological and morphological data were consistent with axonal damage, the larger myelinated fibres being most affected. Although active signs of vasculitis and immunoperoxidase staining for immunoglobulins were not present, endoneurial vessels were widely damaged, with abnormally thick endothelial cells and redundant basal membranes. These findings, together with a patchy distribution of myelinated fibre loss, suggest ischaemia as a cause of peripheral neuropathy during essential cryoglobulinaemia type II. A follow up examination, performed one year after haematologial remission, revealed that no further peripheral nerve damage had occurred.

Hypothyroidism and polyneuropathy

The prevalence and characteristics of polyneuropathy were assessed using standard clinical and electrophysiological criteria in 39 consecutive outpatients with primary hypothyroidism, 15 of whom were previously untreated. Subjective complaints, mainly paraesthesiae, were recorded from 25 cases (64%) and objective findings supporting a clinical diagnosis of polyneuropathy were present in 13 (33%). Using standard electrophysiological criteria, a definite diagnosis of polyneuropathy was made in 28 cases (72%). The commonest sites of abnormal nerve conduction were the sensory nerves, especially the sural nerve. Polyneuropathy was generally mild. None of the clinical and biochemical indicators of hypothyroidism were significantly correlated with the electrophysiological signs of peripheral nerve impairment or the diagnosis of polyneuropathy.

Intracerebral hemorrhage following intravenous administration of epinephrine

We report a case of intracerebral hemorrhage (ICH) in a young man following intravenous self-administration of epinephrine. Arteriography evidenced normal intracranial vessels, and namely excluded the presence of vascular malformations which could have been implicated in the pathogenesis of ICH. We believe that the main pathogenetic agent in this case was the sudden rise in arterial blood pressure. This report aims at underlying the severe implications of non-medical use of sympathomimetic drugs.

Ataxic hemiparesis syndrome: sensory disturbances and somatosensory evoked potentials

26 patients with ataxic hemiparesis syndrome (AHS), due to acute ischemic cerebrovascular disease, have been submitted to clinical and electrophysiological evaluation, in order to assess the frequency of sensory disturbances in this condition. Sensory impairment were present in 78% and SEP abnormalities in 54% of the patients, while they were entirely absent in 23% of them. Lesions responsible for AHS, detected by CT scan, were mainly located in the thalamus, capsula interna, subcortical white matter, centro parietal cortex; sensory and SEP changes were more frequent in gross infarct involving the cortex and in smaller infarcts involving the thalamus, less frequent in the lacunar infarcts of the capsula interna and subcortical white matter, relatively rare in patients with CT scan without hypodense lesions. Although a statokinesthesic defect and/or major SEP abnormalities were often present (38% of patients), our findings do not support the view that they are involved in the pathogenesis of the ataxia, which may rather be attributed to a derangement of cerebro-cerebellar and cerebello-cerebral connections.

Anticonvulsant drugs and bone metabolism

The influence of chronic antiepileptic treatment on bone metabolism has been investigated in 52 adult epileptics, who had normal dietary intake, sunlight exposure and daily living activities. None of the patients had symptoms or signs suggestive of osteomalacia. Serum phosphate levels were significantly decreased and serum alkaline phosphatase levels were significantly increased in the patients compared with matched controls. Calcitonin values and bone mineral content, measured by single photon absorptiometry, were significantly lower among anticonvulsant users. Calcium metabolism impairment grossly correlated to the number of drugs concurrently used by the patient but not to the types, to the relative plasma concentrations or to the overall duration of the treatment. Our findings indicate that in ambulatory patients with adequate diet and outdoor activities in Italy present with clinically irrelevant impairment of bone metabolism.

Trithiozine polyneuropathy: clinical, neurophysiological and histopathological study of three cases

3 peptic ulcer patients, treated for a few weeks with Trithiozine, developed polyneuropathy. The histopathological patterns in the 2 patients in whom sural nerve biopsy was done presented wallerian degeneration of the axons of the myelinated fibers, especially those of larger caliber. The evidence for a iatrogenic toxic etiology is discussed.

Circadian rhythm in human nerve conduction velocity

Motor and sensory nerve conduction velocity was determined bilaterally, evry 4 h, in 6 healthy volunteers. A circadian rhythm was demonstrated in 18 nerves out of 24. A rhythm for both motor and sensory groups could also be determined. The two rhythms differ significantly.

Electrophysiological findings in workers exposed to N-heptane fumes

Electrophysiological examination of the peroneal nerve was performed in a group of individuals exposed for professional reasons to vapours of n-heptane. The results suggest a probably specific role of this hydrocarbon compound in provoking "minimal" peripheral nerve damage.

Amplitude desynchronisation of evoked compound muscle action potentials in normal and uraemic subjects

Compound muscle action potentials of the extensor digitorum brevis were obtained in two groups of normal and uraemic subjects by stimulating the deep peroneal nerve at the ankle and at the capitulum fibulae. Particular attention was drawn to the index of desynchronisation supplied by the amplitude change in the muscle potential evoked by distal and proximal stimulation of the same nerve. Statistical studied confirmed the soundness of this index in the normal and in the pathological condition, and showed a significant increase of the values found in uraemic patients. The complex of the data pointed out the advantage of integrating the usual motor conduction velocity determination with the mentioned desynchronisation index.

F-wave velocity in motor neurone disease

The F-wave velocity in the central segment (axilla to spinal cord) was studied employing the "collison technique" described by Kimura (1974), and compared with the conduction velocity obtained with the usual methods. In 25 normal subjects the F-wave velocity increased proceeding proximally, reaching the maximum values in the central tract (64.86 +/- 2.23 m/sec in ulnar nerve). In 11 patients affected by motor neurone disease and 11 patients affected by amyotrophic lateral sclerosis the F-wave velocity decreased significantly proceeding proximally and the minimum values were found in the central tract (52.51 +/- 2.15 m/sec in MND and 48.64 +/- 5.60 m/sec in ALS). We therefore suggest the use of F-wave velocity as a more complete element for precise localization of the lesion in the central segment when the motoneurone is primarily involved.