A Comparative Study Evaluating the Quality of Life and Survival Outcomes in Patients Receiving Chemotherapy Versus Oral Tyrosine Kinase Inhibitor in the Third Line and Beyond Setting for Advanced NSCLC

Introduction

The outcomes in advanced NSCLC have improved owing to the availability of more effective systemic and improved supportive care. This has increased the number of patients who seek treatment in the third line and beyond setting. We conducted this study to compare the quality of life (QoL), toxicity, and outcomes in patients receiving chemotherapy and EGFR tyrosine kinase inhibitors (TKIs) in this setting.

Methods

In this phase 3, randomized, open-label study, patients with stage III or IV NSCLC with disease progression on at least two prior lines of chemotherapy, with a life expectancy of at least 3 months, without prior EGFR TKI exposure, and stable brain metastases (if any) were included. Patients were randomized to receive chemotherapy (gemcitabine or docetaxel or paclitaxel or vinorelbine) or an EGFR TKI (erlotinib or gefitinib). The primary end point was the change in QoL at 8 to 10 weeks; the secondary outcomes were safety and overall survival (OS). Patients underwent clinical evaluation at every visit, and toxicity was assessed as per Common Terminology Criteria for Adverse Events version 4.03. A radiological tumor response assessment was done every 8 to 12 weeks from the start of therapy. The QoL was assessed using the EORTC QLQ C30 and LC13 questionnaires. The change in QoL scores was calculated as the difference between scores at baseline and scores at 8 to 10 weeks (Δ) for each QoL domain. The Mann-Whitney U test was used to compare the mean difference (Δ) for each domain. OS and progression-free survival (PFS) were determined using the Kaplan-Meier method and Cox proportional regression analysis.

Results

A total of 246 patients were enrolled in the study, with 123 in each arm. There was a male predominance with 69.1% male patients in the chemotherapy arm and 70.7% in the EGFR TKI arm. The median age of patients in the chemotherapy arm was 54 years and 55 years in the chemotherapy and EGFR TKI arms, respectively. There was no significant difference in the change in QoL at baseline and the second visit (Δ) in both arms in all domains of EORTC QLQ C30 except cognitive function (p = 0.0045) and LC13 except alopecia (0.01249). The mean Δ Global Health Status was -28 in the chemotherapy arm and -26.8 in the EGFR TKI arm; this was not statistically significant (p = 0.973). The median follow-up was 88.1 months (95% confidence interval [CI]: 39.04-137.15). On the intention-to-treat analysis, the median PFS was 3.13 months (95% CI: 2.15-4.11) in the chemotherapy arm and 2.26 months (95% CI: 2.1-2.43) in the EGFR TKI arm, with hazard ratio at 1.074 (95% CI: 0.83-1.38) (p = 0.58). There were 120 deaths in each arm. The median OS was 7.63 months (95% CI: 5.96-9.30) in the chemotherapy arm and 7.5 months in the EGFR TKI arm (95% CI: 5.85-9.14); hazard ratio at 1.033 (95% CI: 0.80-1.33) (p = 0.805). The toxicity profile was similar in both arms except for a significantly higher incidence of fatigue (p = 0.043), peripheral neuropathy (0.000), alopecia, hypokalemia (0.037), and pedal edema (0.007) in the chemotherapy arm and dry skin (p = 0.000) and skin rash (p = 0.019) in the EGFR TKI arm.

Conclusions

There was no significant difference in most QoL scales (except cognitive function and alopecia), OS, and PFS of patients with advanced NSCLC receiving an EGFR TKI as compared with chemotherapy TKI in the third-line setting. The toxicity profile is consistent with the known toxicities of the agents.

Study of Treatment Outcome in Adults with TFE-Related RCC

Introduction TFE Translocation renal cell carcinoma (TRCC) represents 1 to 5% of all cases of renal cell carcinoma, with the highest frequency among children and young adults. Management of these tumors is not very well defined in literature. Although in pediatric age group it has favorable prognosis, in adults it has an aggressive nature, with poor outcome. This is a retrospective analysis of treatment outcome in adult patient 18 years or above treated at our hospital between January 2013 and November 2018.

Material and Methods Clinical and pathological data of 26 patients from a single institution diagnosed with TRCC between January 2013 and November 2018 were retrospectively reviewed. All cases of TRCC were confirmed with immunohistochemistry or fluorescence in situ hybridization. We analyzed our data of patients treated with surgery only or who progressed after surgery and treated with systemic therapy or who presented with upfront unresectable or metastatic disease treated with systemic therapy with respect to event-free survival (EFS) and overall survival (OS).

Results Between January 2013 and November 2018, 26 adult patients who were treated at our center were eligible for this analysis as per our criteria. Out of 26 patients, 25 patients had radical surgery after evaluation and 1 had metastatic disease who was started on systemic therapy. Out 25 patients who were treated with radical surgery, 16 patients progressed and they were started on systemic therapy except for 1 patient who defaulted. Median time to start systemic therapy among patient treated with curative nephrectomy was 13 months. Median EFS and median OS among overall population were 22 and 30 months, respectively. Among 16 patients who were treated with systemic therapy, median EFS to first-line therapy was 8 months and to second-line therapy was 2.5 months. Median OS was 17 months in patients treated with systemic therapy.

Conclusion TRCC is rare in adult population but carries significant risk of disease progression even after initial curative treatment with potential response to targeted therapy for short duration.

Extraction of Metal Ions Using Chemically Modified Silica Gel Covalently Bonded with 4,4'-Diaminodiphenylether and 4,4'-Diaminodiphenylsulfone-salicylaldehyde Schiff Bases

Two new chelating materials (Si-DDE-o-HB, and Si-DDS-o-HB) were synthesized by modifying the activated silica gel phase with Schiff bases of 4,4'-diaminodiphenylether (DDE)/4,4'-diaminodiphenylsulfone (DDS) and o-hydroxybenzaldehyde (o-HB). The synthesized materials were characterized by FTIR and BET surface area measurement techniques. The extraction of metal ions such as Zn2+, Mn2+ and Cr3+ by the chelating material Si-DDE-o-HB was found to be higher than that by Si-DDS-o-HB. The order of metal sorption was found to be Zn2+ > Mn2+ > Cr3+. The correlation coefficients for Freundlich and Langmuir adsorption isotherms were compared for the sorption of Zn2+ onto the chelating material. The loading and elution of the metal ion solution was examined at optimum pH 7.5 and 0.5 cm3 min-1 flow rate of the solution using a column technique. The preconcentration factor for the elution of Zn2+ using dilute HNO3 was found to be 66.2 with a breakthrough volume of 15 cm3. The data obtained for the preconcentration of Zn2+ by the column technique suggested that the material Si-DDE-o-HB can find industrial applications.

Primary amyloidosis presenting with predominant lymphnodal masses

A 50 year young farmer presented with clinical features of bilateral carpal tunnel syndrome and generalized lymphadenopathy including paratracheal and retroperitoneal lymphodes. The histological diagnosis confirmed primary amyloidosis of lymphnodes. Presentation of primary amyloidosis as lymphnodal mass with deposition of amyloid in carpal tunnel is extremely rare and can only be diagnosed by histochemistry. The clinical response to drugs is variable and needs surgical intervention for decompressive therapy which can improve the symptoms of carpal tunnel syndrome.

Germ cell mutagenicity of phthalic acid in mice

Mutagenicity of phthalic acid was evaluated by employing dominant lethal mutation and sperm head abnormality assays in male Swiss albino mice. For the dominant lethal mutation assay, adult male mice received a single intraperitoneal (i.p.) injection of either 40 mg or 80 mg/kg b.w. of phthalic acid for 5 consecutive days. For the sperm head abnormality assay, the mice were treated with 50, 100, 150, 200 and 300 mg/kg b.w. as a single i.p. injection. Treatment of adult male mice with phthalic acid resulted in induction of dominant lethal mutations and abnormal sperm heads. The results obtained indicate that phthalic acid is a germ cell mutagen.

Clastogenicity of lanthanides: induction of chromosomal aberration in bone marrow cells of mice in vivo

Clastogenic properties of two lanthanide elements praseodymium (Pr) and neodymium (Nd) were evaluated by employing mouse in vivo chromosomal aberrations (CAs) assay. Praseodymium oxide (Pr6O11) and neodymium oxide (Nd2O3) administered intraperitoneally to Swiss albino mice in vivo induced significant increase in the frequency of CAs in bone marrow cells, when compared to negative control. The number of CAs/cell and percent aberrant cells increased with an increase in the concentration and period of treatment. The effect was maximum when the cells were analysed 12 h after treatment, as compared to 6 and 24 h. This is the first report on the clastogenicity of these elements in mouse in vivo.

Clastogenicity of lanthanides--induction of micronuclei in root tips of Vicia faba

The clastogenic property of two lanthanides, Praseodymium and Neodymium, was evaluated by scoring the frequencies of micronucleated cells in the interphase and chromosome/chromatid aberrations at ana-telophases in root tips of Vicia faba L. The significant increase in the frequency of micronucleated cells coupled with the increase in the frequency of chromosome/chromatid bridges and lagging chromosomes/chromatids suggest that these two are clastogenic for Vicia faba root cells.

The power of the optimal asymptotic tests of composite statistical hypotheses

The easily computable asymptotic power of the locally asymptotically optimal test of a composite hypothesis, known as the optimal C(alpha) test, is obtained through a "double" passage to the limit: the number n of observations is indefinitely increased while the conventional measure xi of the error in the hypothesis tested tends to zero so that xi(n)n((1/2)) --> tau not equal 0. Contrary to this, practical problems require information on power, say beta(xi,n), for a fixed xi and for a fixed n. The present paper gives the upper and the lower bounds for beta(xi,n). These bounds can be used to estimate the rate of convergence of beta(xi,n) to unity as n --> infinity. The results obtained can be extended to test criteria other than those labeled C(alpha). The study revealed a difference between situations in which the C(alpha) test criterion is used to test a simple or a composite hypothesis. This difference affects the rate of convergence of the actual probability of type I error to the preassigned level alpha. In the case of a simple hypothesis, the rate is of the order of n(-(1/2)). In the case of a composite hypothesis, the best that it was possible to show is that the rate of convergence cannot be slower than that of the order of n(-(1/2)) ln n.