Phase 3 RCT comparing docetaxel-platinum with docetaxel-platinum-5FU as neoadjuvant chemotherapy in borderline resectable oral cancer

BACKGROUND

Neoadjuvant chemotherapy (NACT) with TPF (docetaxel, cisplatin, and 5FU) is one of the treatment options in very locally advanced oral cancer with a survival advantage over PF (cisplatin and 5FU). TP (docetaxel and cisplatin) has shown promising results with a lower rate of adverse events but has never been compared to TPF.

METHODS

In this phase 3 randomized superiority study, adult patients with borderline resectable locally advanced oral cancers were randomized in a 1:1 fashion to either TP or TPF. After the administration of 2 cycles, patients were evaluated in a multidisciplinary clinic and further treatment was planned. The primary endpoint was overall survival (OS) and secondary endpoints were progression-free survival (PFS) and adverse events.

RESULTS

495 patients were randomized in this study, 248 patients in TP arm and 247 in TPF arm. The 5-year OS was 18.5% (95% CI 13.8-23.7) and 23.9% (95% CI 18.1-30.1) in TP and TPF arms, respectively (Hazard ratio 0.778; 95% CI 0.637-0.952; P = 0.015). Following NACT, 43.8% were deemed resectable, but 34.5% underwent surgery. The 5-year OS was 50.7% (95% CI 41.5-59.1) and 5% (95%CI 2.9-8.1), respectively, in the surgically resected versus unresected cohort post NACT (P < 0.0001). Grade 3 or above adverse events were seen in 97 (39.1%) and 179 (72.5%) patients in the TP and TPF arms, respectively (P < 0.0001).

CONCLUSION

NACT with TPF has a survival benefit over TP in borderline resectable oral cancers, with an increase in toxicity which is manageable. Patients who undergo surgery achieve a relatively good, sustained survival.

Low-cost oral metronomic chemotherapy versus intravenous cisplatin in patients with recurrent, metastatic, inoperable head and neck carcinoma: an open-label, parallel-group, non-inferiority, randomised, phase 3 trial

BACKGROUND

Regimens for palliation in patients with head and neck cancer recommended by the US National Comprehensive Cancer Network (NCCN) have low applicability (less than 1-3%) in low-income and middle-income countries (LMICs) because of their cost. In a previous phase 2 study, patients with head and neck cancer who received metronomic chemotherapy had better outcomes when compared with those who received intravenous cisplatin, which is commonly used as the standard of care in LMICs. We aimed to do a phase 3 study to substantiate these findings.

METHODS

We did an open-label, parallel-group, non-inferiority, randomised, phase 3 trial at the Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India. We enrolled adult patients (aged 18-70 years) who planned to receive palliative systemic treatment for relapsed, recurrent, or newly diagnosed squamous cell carcinoma of the head and neck, and who had an Eastern Cooperative Oncology Group performance status score of 0-1 and measurable disease, as defined by the Response Evaluation Criteria In Solid Tumors. We randomly assigned (1:1) participants to receive either oral metronomic chemotherapy, consisting of 15 mg/m² methotrexate once per week plus 200 mg celecoxib twice per day until disease progression or until the development of intolerable side-effects, or 75 mg/m² intravenous cisplatin once every 3 weeks for six cycles. Randomisation was done by use of a computer-generated randomisation sequence, with a block size of four, and patients were stratified by primary tumour site and previous cancer-directed treatment. The primary endpoint was median overall survival. Assuming that 6-month overall survival in the intravenous cisplatin group would be 40%, a non-inferiority margin of 13% was defined. Both intention-to-treat and per-protocol analyses were done. All patients who completed at least one cycle of the assigned treatment were included in the safety analysis. This trial is registered with the Clinical Trials Registry-India, CTRI/2015/11/006388, and is completed.

FINDINGS

Between May 16, 2016, and Jan 17, 2020, 422 patients were randomly assigned: 213 to the oral metronomic chemotherapy group and 209 to the intravenous cisplatin group. All 422 patients were included in the intention-to-treat analysis, and 418 patients (211 in the oral metronomic chemotherapy group and 207 in the intravenous cisplatin group) were included in the per-protocol analysis. At a median follow-up of 15·73 months, median overall survival in the intention-to-treat analysis population was 7·5 months (IQR 4·6-12·6) in the oral metronomic chemotherapy group compared with 6·1 months (3·2-9·6) in the intravenous cisplatin group (unadjusted HR for death 0·773 [95% CI 0·615-0·97, p=0·026]). In the per-protocol analysis population, median overall survival was 7·5 months (4·7-12·8) in the oral metronomic chemotherapy group and 6·1 months (3·4-9·6) in the intravenous cisplatin group (unadjusted HR for death 0·775 [95% CI 0·616-0·974, p=0·029]). Grade 3 or higher adverse events were observed in 37 (19%) of 196 patients in the oral metronomic chemotherapy group versus 61 (30%) of 202 patients in the intravenous cisplatin group (p=0·01).

INTERPRETATION

Oral metronomic chemotherapy is non-inferior to intravenous cisplatin with respect to overall survival in head and neck cancer in the palliative setting, and is associated with fewer adverse events. It therefore represents a new alternative standard of care if current NCCN-approved options for palliative therapy are not feasible.

FUNDING

Tata Memorial Center Research Administration Council.

TRANSLATIONS

For the Hindi, Marathi, Gujarati, Kannada, Malayalam, Telugu, Oriya, Bengali, and Punjabi translations of the abstract see Supplementary Materials section.

Treatment and outcome of patients with uterine carcinosarcoma: Data from developing world

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Background: To evaluate the clinicopathological factors, outcome and prognostics factors of uterine carcinosarcoma. Methods: All patients of uterine carcinosarcoma treated between January 2013 and December 2018 were identified and their clinical, laboratory and imaging details were retrieved from electronic medical record. Details of the treatment received, toxicity profile and outcome were recorded and analyzed. Patients (including stage I) were considered for four cycles of chemotherapy (Paclitaxel +Carboplatin) followed by radiation (EBRT to pelvis with vaginal brachytherapy). Survival analysis was done using the Kaplan–Meier method and compared between treatment groups using the Log-rank test. Results: Of 81 cases, 48 % presented with early stage disease (FIGOI-II) and 52 % with late stage (FIGO III-IV) disease. Median age was 58 years (30-80 years). Most women (83%) were postmenopausal and 80% of them presented with postmenopausal bleeding. Six patients developed carcinosarcoma on adjuvant tamoxifen (given for breast cancer) after a median drug intake of 8 years. In early stage, 10% patients received only surgical treatment; 46% received both chemotherapy (CT) and radiation therapy (RT) while 33 % received RT alone. In advanced stage, 31% received only CT, 14 % received only RT and 33% received both CT and RT after surgery. About 8% of patients had myelosuppression(grade I/II), 10 % had peripheral neuropathy (grade I/II) and 11% had electrolyte imbalance. At a median follow up of 2 years (1- 80 months), median DFS and OS in early stage group was 28.5 months and 31.0 months while in advanced stage group it was 13.0 months and 15.0 months respectively. Distant metastasis (omentum, peritoneum and lung being the common site) were seen in 30% of patients while local relapse was seen in 5 % cases. On univariate analysis stage of disease and receipt of adjuvant therapy were the factors found to be significantly associated with improved OS (p < 0.001) and adjuvant RT alone was associated with improved DFS (p < 0.023). Conclusions: Adjuvant treatment (chemotherapy and or radiation therapy) is associated with improved overall survival in uterine carcinosarcoma, irrespective of stage at presentation.

Prevalence, clinical features, and diagnosis of Trichomonas vaginalis among female STI clinic attendees in Trinidad

Background

Trichomonas vaginalis (TV) is one of the most common pathogens causing sexually transmitted infections (STIs) in both men and women. Since there are no accurate prevalence data available on TV infection among women for Trinidad and Tobago and in the Caribbean region, there is a great need for research to study the dynamics of the infection and its transmission.

Objectives

To determine the prevalence and diagnose TV infection in women attending the STI clinic and to provide recommendations for control and prevention of trichomoniasis in the community.

Study Design

A cross-sectional study was designed after obtaining the informed consent. Following a routine clinical examination, vaginal swabs were collected - one for wet mount preparation, one for InPouch culture, and other two for OSOM rapid test/and fluorescent antibody testing. Cotton swabs and Dacron swabs were used for testing.

Results

A prevalence of 16% of trichomoniasis out of 422 females was recorded. In all, 65 (65%) were in the age range of 15-29 years and peak of 30% in the age group of 20-24 years. Vaginal discharge was a common complaint (83%); 75.6% had foul odor and only 9.8% had typical fishy odor. The majority of them (87%) had whitish-yellow colored discharge.

Conclusion

Prevalence of trichomoniasis is significant in the female population attending STI clinic. Targeting high-risk age group between 15 and 29 years for control and prevention would be beneficial. Prompt and accurate diagnosis using appropriate laboratory test is recommended.

Growth, spectral, optical, thermal, surface analysis and third order nonlinear optical properties of an organic single crystal: 1-(2-Methyl-6-nitro-4-phenyl-3-quinolyl) ethanone

Single crystal of 1-(2-Methyl-6-nitro-4-phenyl-3-quinolyl) ethanone was grown using slow evaporation solution growth technique. Single crystal X-ray diffraction study reveals the lattice parameters of the grown crystal. The modes of vibration of different molecular groups present in 2M6NQE were identified by FTIR spectral analysis. Its optical behavior was examined through UV-vis-NIR absorption and PL emission spectrum. They signify that the crystal has transparency in the region between 383 and 1100 nm. The PL spectrum of the title compound shows green emission in the crystal. From the thermal analysis, 2M6NQE has found to be thermally stable up to 263°C, and the melting point of the material is 170°C. The estimations of third order non-linear optical properties like non-linear absorption coefficient (β), non-linear refractive index (n2) and susceptibility [χ(3)] were calculated using Z-scan technique. It has observed that, crystal exhibits reverse saturation absorption and self-defocusing performance. Etching study was carried out for the grown crystal using different solvents.

Synthesis, characterization of (3E)-1-(6-chloro-2-methyl-4-phenyl quinolin-3-Yl)-3-aryl prop-2-en-1-ones through IR, NMR, single crystal X-ray diffraction and insights into their electronic structure using DFT calculations

3E-1-(6-Chloro-2-methyl-4-phenylquinolin-3-yl)-3-arylprop-2-en-1-ones were synthesized and characterized by FTIR, (1)H NMR, (13)C NMR, HSQC, DEPT-135. In addition the compound 3E-1-(6-chloro-2-methyl-4-phenylquinolin-3-yl)-3-(2,5-dimethoxyphenyl)prop-2-en-1-one was subjected to the single crystal X-ray diffraction studies. Density functional theory calculations were carried out for this chalcone and its derivatives to investigate into their electronic structure, chemical reactivity, linear and non-linear optical properties. The structure predicted from DFT for chalcone is in good agreement with the structure from XRD measurement.

Generation and characterization of neutralizing monoclonal antibodies against baculo-expressed HPV 16 VLPs

Human papillomavirus (HPV) is the well-known second most cause of cervical cancer in women worldwide. According to the WHO survey, 70% of the total cervical cancers are associated with types HPV 16 and 18. Presently used prophylactic vaccine for HPV contains mainly capsid protein of L1 virus like particles (VLPs). Correct folding of VLPs and display of neutralizing epitopes are the major constraint for VLP-based vaccines. Further, monoclonal antibodies (mAbs) play a vital role in developing therapeutics and diagnostics. mAbs are also useful for the demonstration of VLP conformation, virus typing and product process assessment as well. In the present study, we have explored the usefulness of mAbs generated against sf-9 expressed HPV 16 VLPs demonstrated as type-specific and conformational dependent against HPV 16 VLPs by ELISA. High affinity and high pseudovirion neutralization titer of mAbs indicated their potential for the development of prophylactic vaccines for HPV. Also, the type-specific and conformational reactivity of the mAbs to HPV 16 VLPs in sf-9 cells by immunofluorescence assay proved their diagnostic potential.

Lupus nephritis: a 15-year multi-centre experience in the UK

OBJECTIVES

Our aim was to audit the outcome of lupus nephritis (LN) at three East Midlands centres.

METHODS

We undertook a retrospective review of all biopsy-proven LN types III-V 1995-2010.

RESULTS

In total, 61 patients with LN were identified, with a median follow-up of 68 months. LN was present at the time of systemic lupus erythematosus (SLE) diagnosis in 20 patients. The median time from SLE diagnosis to the first LN episode was 5.3 years. Some 35 patients received IV cyclophosphamide and 17 received mycophenolate mofetil (MMF) as induction therapy; 81.8% of those treated with cyclophosphamide and 81.3% with MMF had at least 'improved' according to the ACR-response criteria 6 months from induction; 33.3% and 37.5%, respectively, had a 'complete' response. MMF and azathioprine were the most frequently used maintenance therapy. We found that 32.8% experienced a flare after a mean post-induction time of 3.5 years, irrespective of the maintenance therapy used, and 43.8% of partial responders flared compared with 4.8% of complete responders. End-stage renal failure developed in 8.2%.

CONCLUSIONS

Overall, outcomes (response, flare-rate, end-stage renal failure) were comparable with European clinical studies. Partial responders are more likely to flare compared with complete responders. The results highlight that LN can occur, and flare, after many years of SLE, emphasizing the importance of continued vigilance for LN in all patients.

Model alternative strategies for tuberculosis and Human immune deficiency virus case-finding in hard-to-reach populations in rural Eastern Nigeria

BACKGROUND

Since roughly half of all cases of active tuberculosis (TB) and Human immune deficiency virus (HIV) infection currently go undetected, there is a compelling need to pursue research aimed at improving case-finding, particularly among hard-to-reach populations.

OBJECTIVE

To identify and simplify TB/HIV case finding in Eastern Nigeria.

METHODS

This study involved an extensive pre-intervention Knowledge, Aptitude, Behavioural, Practice (KABP) Survey which revealed the specific limitations to TB/HIV case-finding using semi-structured questionnaires, key informant interviews and focus group discussions. The second component investigated the role of existing strategies and resources in the study area, and identified ways of optimizing these strategies and also provided alternative strategies. The third phase evaluated the performance of the different strategies and the most effective methods of optimizing their use.

RESULTS

The pre- intervention KABP Survey showed that the majority of the population could ill afford the costs imposed by delays in TB/HIV diagnosis and treatment. Most of the patients dropped out completely at any stage on the path to successful treatment due to several reasons. Working at motor parks, accepted stop points and several other ways were found as effective methods of reaching the hard-to-reach population.

CONCLUSION

Findings from this study can be used for designing appropriate TB/HIV management and case- finding training materials for the training and use of TB/HIV health workers as well as providing information on TB/HIV case finding for National policy. Thorough consideration of the findings and subsequent implementation of them are highly recommended.

Psoas abscess: diagnosis and treatment

Psoas abscess is an uncommon presentation on the acute medical take. However recognition and appropriate treatment is essential. This review is designed to highlight the clinical features, microbiology, diagnostic tests and treatment for this condition. In order to illustrate some of the pitfalls and complexities in the management of psoas abscess we have included a case history of a patient who was recently treated in our department.

Tuberculous peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients

Among 155 patients who were initiated on continuous ambulatory peritoneal dialysis (CAPD), 4 patients (2 men, 2 women) developed tuberculous peritonitis. They had been on PD for between 2 months and 84 months when they developed the peritonitis. The Mantoux test was negative in all of them. The diagnosis was made by a variety of means in the various cases: demonstration of Mycobacterium tuberculosis in the peritoneal cavity; presence of caseating granuloma in a peritoneal biopsy; Mycobacterium tuberculosis in a cold abscess adjacent to the peritoneal cavity; and demonstration of IS6110 and MPB64 genes of Mycobacterium tuberculosis by polymerase chain reaction (PCR) technique. Two of the patients developed ultrafiltration failure. Among 3 patients who were switched to hemodialysis, 2 died and 1 continues on maintenance dialysis. The last patient, whose catheter was removed, was reimplanted with a new catheter and continues on PD without ultrafiltration failure. Any patient with peritonitis unresponsive to conventional therapy should be investigated for tuberculous peritonitis. Institution of chemotherapy without delay will preserve peritoneal membrane integrity.