Nivolumab plus cabozantinib versus sunitinib for first-line treatment of advanced renal cell carcinoma: extended follow-up from the phase III randomised CheckMate 9ER trial

BACKGROUND

Nivolumab plus cabozantinib (NIVO + CABO) was approved for first-line treatment of advanced renal cell carcinoma (aRCC) based on superiority versus sunitinib (SUN) in the phase III CheckMate 9ER trial (18.1 months median survival follow-up per database lock date); efficacy benefit was maintained with an extended 32.9 months of median survival follow-up. We report updated efficacy and safety after 44.0 months of median survival follow-up in intent-to-treat (ITT) patients and additional subgroup analyses, including outcomes by International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic risk score.

PATIENTS AND METHODS

Patients with treatment-naïve aRCC received NIVO 240 mg every 2 weeks plus CABO 40 mg once daily or SUN 50 mg for 4 weeks (6-week cycles), until disease progression/unacceptable toxicity (maximum NIVO treatment, 2 years). Primary endpoint was progression-free survival (PFS) per blinded independent central review (BICR). Secondary endpoints were overall survival (OS), objective response rate (ORR) per BICR, and safety and tolerability.

RESULTS

Overall, 323 patients were randomised to NIVO + CABO and 328 to SUN. Median PFS was improved with NIVO + CABO versus SUN [16.6 versus 8.4 months; hazard ratio (HR) 0.59; 95% confidence interval (CI) 0.49-0.71]; median OS favoured NIVO + CABO versus SUN (49.5 versus 35.5 months; HR 0.70; 95% CI 0.56-0.87). ORR (95% CI) was higher with NIVO + CABO versus SUN [56% (50% to 62%) versus 28% (23% to 33%)]; 13% versus 5% of patients achieved complete response, and median duration of response was 22.1 months versus 16.1 months, respectively. PFS and OS favoured NIVO + CABO over SUN across intermediate, poor and intermediate/poor IMDC risk subgroups; higher ORR and complete response rates were seen with NIVO + CABO versus SUN regardless of IMDC risk subgroup. Any-grade (grade ≥3) treatment-related adverse events occurred in 97% (67%) versus 93% (55%) of patients treated with NIVO + CABO versus SUN.

CONCLUSIONS

After extended follow-up, NIVO + CABO maintained survival and response benefits; safety remained consistent with previous follow-ups. These results continue to support NIVO + CABO as a first-line treatment for aRCC.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03141177.

Confirmatory validation analysis of the PROFFIT questionnaire to assess financial toxicity in cancer patients

BACKGROUND

The Patient Reported Outcome for Fighting FInancial Toxicity (PROFFIT) questionnaire was developed to measure financial toxicity (FT) and identify its determinants. The aim of the present study was to confirm its validity in a prospective cohort of patients receiving anticancer treatment.

PATIENTS AND METHODS

From March 2021 to July 2022, 221 patients were enrolled at 10 Italian centres. Selected items of the EORTC-QLQ-C30 questionnaire represented the anchors, specifically, question 28 (Q-28) on financial difficulties, and questions 29-30 measuring global health status/quality of life (HR-QOL). The study had 80% power to detect a 0.20 correlation coefficient (r) between anchors and PROFFIT-score (items 1-7, range 0-100, 100 indicating maximum FT) with bilateral alpha 0.05 and 80% power. Confirmatory factor analysis was conducted. FT determinants (items 8-16) were described.

RESULTS

Median age of patients was 65 years, 116 (52.5%) were females, 96 (43.4%) had low education level. Confirmatory factor analysis confirmed goodness of fit of the PROFFIT-score. Significant partial correlation of PROFFIT-score was found with Q-28 (r = 0.51) and HR-QOL (r = -0.23). Mean (SD) PROFFIT-score at baseline was 36.5 (24.9); it was statistically significantly higher for patients living in South Italy, those with lower education level, those who were freelancer/unemployed at diagnosis and those who reported significant economic impact from the COVID-19 pandemic. Mean (SD) scores of determinants ranged from 17.6 (27.1) for item 14 (support from medical staff) to 49.0 (36.3) for item 10 (expenses for medicines or supplements). PROFFIT-score significantly increased with worsening response to determinants.

CONCLUSIONS

External validation of PROFFIT-score in an independent sample of patients was successful. The instrument is now being used in clinical studies.

An Italian multicenter retrospective real-life analysis of patients with brain metastases from renal cell carcinoma: the BMRCC study

BACKGROUND

The treatment of patients with brain-spread renal cell carcinoma (RCC) is an unmet clinical need, although more recent therapeutic strategies have significantly improved RCC patients' life expectancy. Our multicenter, retrospective, observational study investigated a real-world cohort of patients with brain metastases (BM) from RCC (BMRCC).

PATIENTS AND METHODS

A total of 226 patients with histological diagnosis of RCC and radiological evidence of BM from 22 Italian institutions were enrolled. Univariate and multivariate models were performed to investigate the impact of clinicopathological features and multimodal treatments on both overall survival (OS) from the BM diagnosis and intracranial progression-free survival (iPFS).

RESULTS

The median OS from the BM diagnosis was 18.8 months (interquartile range: 6.2-43 months). Multivariate analysis confirmed the following as positive independent prognostic factors: a Karnofsky Performance Status >70% [hazard ratio (HR) = 0.49, 95% confidence interval (CI) 0.26-0.92, P = 0.0026] and a single BM (HR = 0.51, 95% CI 0.31-0.86, P = 0. 0310); in contrast, the following were confirmed as worse prognosis factors: progressive extracranial disease (HR = 1.66, 95% CI 1.003-2.74, P = 0.00181) and only one line of systemic therapy after the BM occurrence (HR = 2.98, 95% CI 1.62-5.49, P = 0.029). Subgroup analyses showed no difference in iPFS according to the type of the first systemic treatment [immunotherapy (IT) or targeted therapy (TT)] carried out after the BM diagnosis (HR = 1.033, 95% CI 0.565-1.889, P = 0.16), and revealed that external radiation therapy (eRT) significantly prolonged iPFS when combined with IT (10.7 months, 95% CI 4.9-48 months, P = 0.0321) and not when combined with TT (9.01 months, 95% CI 2.7-21.2 months, P = 0.59).

CONCLUSIONS

Our results suggest a potential additive effect in terms of iPFS for eRT combined with IT and encourage a more intensive multimodal therapeutic strategy in a multidisciplinary context to improve the survival of BMRCC patients.

A conserved glutathione binding site in poliovirus is a target for antivirals and vaccine stabilisation

Strategies to prevent the recurrence of poliovirus (PV) after eradication may utilise non-infectious, recombinant virus-like particle (VLP) vaccines. Despite clear advantages over inactivated or attenuated virus vaccines, instability of VLPs can compromise their immunogenicity. Glutathione (GSH), an important cellular reducing agent, is a crucial co-factor for the morphogenesis of enteroviruses, including PV. We report cryo-EM structures of GSH bound to PV serotype 3 VLPs showing that it can enhance particle stability. GSH binds the positively charged pocket at the interprotomer interface shown recently to bind GSH in enterovirus F3 and putative antiviral benzene sulphonamide compounds in other enteroviruses. We show, using high-resolution cryo-EM, the binding of a benzene sulphonamide compound with a PV serotype 2 VLP, consistent with antiviral activity through over-stabilizing the interprotomer pocket, preventing the capsid rearrangements necessary for viral infection. Collectively, these results suggest GSH or an analogous tight-binding antiviral offers the potential for stabilizing VLP vaccines.

Production and Characterisation of Stabilised PV-3 Virus-like Particles Using Pichia pastoris

Following the success of global vaccination programmes using the live-attenuated oral and inactivated poliovirus vaccines (OPV and IPV), wild poliovirus (PV) is now only endemic in Afghanistan and Pakistan. However, the continued use of these vaccines poses potential risks to the eradication of PV. The production of recombinant PV virus-like particles (VLPs), which lack the viral genome offer great potential as next-generation vaccines for the post-polio world. We have previously reported production of PV VLPs using Pichia pastoris, however, these VLPs were in the non-native conformation (C Ag), which would not produce effective protection against PV. Here, we build on this work and show that it is possible to produce wt PV-3 and thermally stabilised PV-3 (referred to as PV-3 SC8) VLPs in the native conformation (D Ag) using Pichia pastoris. We show that the PV-3 SC8 VLPs provide a much-improved D:C antigen ratio as compared to wt PV-3, whilst exhibiting greater thermostability than the current IPV vaccine. Finally, we determine the cryo-EM structure of the yeast-derived PV-3 SC8 VLPs and compare this to previously published PV-3 D Ag structures, highlighting the similarities between these recombinantly expressed VLPs and the infectious virus, further emphasising their potential as a next-generation vaccine candidate for PV.

OS07.4.A Regorafenib in recurrent glioblastoma patients: a multicentric real-life study

Background

Few options are still available for recurrent glioblastoma (GBM). In the Italian phase 2 REGOMA trial, regorafenib improved overall survival, as compared to lomustine, for GBM patients at first progression after chemoradiation. Here, we present the results of a real-life multicentre study that analysed clinical and radiological features, response to treatments, tolerability, and outcome of a cohort of GBM patients treated with regorafenib at first tumour progression.

Patients and Methods

We enrolled GBM patients at first tumour progression in three Italian Institutions (Turin, Treviso, Bari). Regorafenib was administered following an escalation dose protocol (1st cycle: 80 mg/day for 2 weeks, then 120 mg/day for one week; 2nd cycle: 120 mg/day for 2 weeks, then 160 mg/day for one week; 160 mg/day from the 3rd cycle). MRI scans were obtained at baseline and every 3 months. Progression-free survival (PFS) and overall survival (OS) were defined as time from regorafenib initiation and disease progression or death.

Results

From January 2020 to January 2022, 66 GBM patients were included. Median age was 60.0 years. MGMTp methylation was found in 30 patients (45.5%). First-line treatment consisted in chemoradiation in 61 (92.4%), in upfront TMZ (3, 4.5%) or RT alone followed by TMZ (2, 3.0%). Median dose was 120 mg/day 21q28 day, which was lower than that used in REGOMA trial (149 mg). Median PFS (mPFS) was 2.7 months (2.4 - 3.0 95% CI) and median OS (mOS) 7.1 months (5.4 - 8.9 95% CI). Best RANO response to regorafenib was partial response (PR) in 10 (15.1%), stable disease in 14 (21.2%), and progressive disease in 42 (63.7%) patients. All PRs were observed within the first three months of treatment. Patients who completed treatment up the 6th, 9th, and 12th cycles were 20, 3 and 2, respectively. Forty-six (69.7%) patients presented adverse events of any grade, and 21 (31.8%) grade III-IV toxicity. The most frequent adverse events were fatigue (33.3%), hand-foot syndrome (27.3%), and liver enzymes increase (15.2%). Two patients only (3.0%) interrupted regorafenib due to toxicity.In a multivariable analysis, factors significantly associated with disease progression were higher age (p = 0.035) and absence of MGMTp methylation (p = 0.024).

Conclusion

In this real-life study on 66 patients, mPFS and mOS were similar to those of the 59 patients enrolled in the regorafenib arm of REGOMA trial (2.7 vs 2.0 months; 7.1 vs 7.4 months, respectively). However, we observed a higher rate of PRs as compared to REGOMA (15% versus 3.0%). Type and severity of adverse events were similar between the two studies. Moreover, we had a lower incidence of discontinuations of regorafenib due to toxicity, maybe attributable to the lower dose intensity.We are further analysing the data of MRI-perfusion, with the aim to explore whether it can predict an early response or progression in comparison to standard MRI.

P-206 Could day 7 embryo culture become standard practice to improve patients’ treatment and outcome?

Study question

What are the clinical outcomes following transfer of day 7 embryos; could day 7 embryo culture become part of standard embryology practice?

Summary answer

Although clinical outcomes remain low, success has been seen following transfer of day 7 embryos. Extended culture plays an important role in standard embryology practice.

What is known already

In vitro culture conditions and cryopreservation techniques have improved greatly in recent years, allowing for extended culture, and freezing of embryos at the blastocyst stage. Optimally, embryos should develop to the blastocyst stage on day 5, however deviation from normal development can sometimes occur due to problems in either the embryonic intrinsic factors or imprinting timings. Live births have been reported from slower developing day 7 embryos. Extended culture to day 6 is standard practice in most IVF laboratories, however the aim of this study is to investigate the outcomes following prolonged embryo culture to day 7.

Study design, size, duration

This is a retrospective analysis study of 47 patients who underwent frozen embryo transfers (FETs) with a cryopreserved day 7 embryo at a UK licensed centre between 2017-2021. Patients were split into two groups: those transferring untested (non-PGT-A) day 7 embryos, and those transferring euploid PGT-A tested day 7 embryos. Clinical pregnancy (CPR) was analysed to study the clinical outcome of day 7 embryo culture followed by a frozen transfer.

Participants/materials, setting, methods

All patients who had FET with a day 7 embryo between 2017-2021 were included in this study. A total of 49 FETs (48 eSET,1 DET) involving 47 patients took place: 38 with untested embryos and 11 with euploid embryos. Clinical pregnancy rate (CPR) and live birth (LBR) was analysed to study the efficacy in transfer of day 7 embryos and the two groups of patients (untested and PGT-A tested) were compared.

Main results and the role of chance

The overall CPR per embryo transfer was 8% (47 patients, 49 ETs, 50 embryos transferred) and the LBR per embryo transfer was 4%. In the PGT-A group, a total of 201 day 7 embryos were biopsied over the 5-year study period; 28 were euploid following testing (14% euploidy rate). Of these, 11 have been transferred; 4 resulted in a pregnancy and 2 in a live birth. (LBR 18%) There is a significant difference in CPR between the PGT-A group (11 patients, 11 FETs; 11 embryos transferred, 4 foetal hearts seen, CPR=36%) and the untested group (36 patients, 38 ETs; 39 embryos transferred, CPR=0%) Chi square test performed and confirmed (p < 0.001). The mean age of the patient at the time of embryo transfer was 38.6 ± 0.5 and the mean age of the embryo transferred was 35.6± 0.5 (this was the patient’s age at the time of embryo freezing).

Limitations, reasons for caution

Limiting factors include the retrospective study design and the small sample size. It is also worth noting the high number of day 7 embryos required to undergo PGT-A testing to result in a low number of euploid embryos suitable for embryo transfer.

Wider implications of the findings

This study indicates the value of day 7 embryo culture as it has resulted in some patients achieving an ongoing pregnancy and a live birth. However, care must be taken to counsel patients appropriately around the chance of success when transferring day 7 embryos, particularly patients using untested embryos.

Trial registration number

Not Applicable

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with renal cell carcinoma

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of renal cell carcinoma was published in 2019 with an update planned for 2021. It was therefore decided by both the ESMO and the Singapore Society of Oncology (SSO) to convene a special, virtual guidelines meeting in May 2021 to adapt the ESMO 2019 guidelines to take into account the ethnic differences associated with the treatment of renal cell carcinomas in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with renal cell carcinoma representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate.

P14.86 Predictive value of MGMT promoter (pMGMT) methylation status on pseudoprogression (PsP) and survival analysis in Glioblastoma (GBM) patients: a retrospective single institutional analysis

BACKGROUND

Glioblastoma is the most common and aggressive primary brain tumor. Conventional therapies, such as maximal extension of surgery followed by radiotherapy (RT) and chemotherapy with Temozolomide (TMZ) have not resulted in major improvements in terms of patients’ outcome, overall survival (OS) still remaining poor. In this context, radiological response assessment after radiotherapy remains challenging due to the potential effect of radionecrosis, often mimicking tumor progression. Differentiation between PsP and true progression is required to avoid further unnecessary surgeries, or the premature discontinuation of TMZ. It is known that pMGMT methylated patients respond better to chemotherapy than unmethylated counterpart, so, tumor cells necrosis can be enhanced in this setting. The aim of the study is to observe the correlation between pMGMT methylation status with the incidence of PsP in GBM patients at the first radiological evaluation after RT.

MATERIALS AND METHODS

Patients with histologically diagnosis of GBM from 2017 to 2021 and availability of pMGMT methylation status were enrolled. PsP was radiologically defined at first brain MRI after RT in case of increasing size of the enhancing component and of peritumoral oedema that remain stable or decrease after antioedema therapy, such as a clinical improvement was observed.

RESULTS

We analysed 55 GBM patients, 35 (64%) displayed pMGMT methylation whereas 20 (36%) resulted pMGMT unmethylated. PsP was evident in 29 patients (53%), all of them showed methylation of pMGMT. In our analysis, none of pMGMT unmethylated patients experienced PsP. Regarding survival outcome for pMGMT methylated patients, our analysis shows a mPFS of 8.7 (95% CI: 5–10) months versus 9.3 (95%CI: 4.6–12.3) months in methylated and unmethylated respectively (p=0.87).

CONCLUSIONS

Methylation status of pMGMT showed to be predictor of PsP in GBM patients. If validated, this information could be very useful to guide clinicians in differentiating PsP from true progression. To date, our survival analysis regarding PFS showed no statistical difference among methylated patients with respect to the presence or absence of PsP. Thus, PsP seems not to be a marker of responsiveness to common treatment. Further data are needed to validate our results.

P–226 Failure of blastocoele expansion within the first two hours post thawing could halve the chances of implantation

Study question

The aim of this study was to evaluate the influence of blastocoele re-expansion time of warmed vitrified blastocysts on clinical pregnancy outcome.

Summary answer

Clinical pregnancy rate was significantly higher after transfer of warmed vitrified blastocysts that were fully expanded within 2 hours post thaw.

What is known already

The number of blastocysts being vitrified worldwide has increased dramatically over recent years. A combination of factors has led to this including the introduction of vitrification, an increase in freeze-all policies, single embryo transfer and an increase in preimplantation genetic testing. Currently, blastocyst re-expansion after thawing is used to indicate the survival status of the blastocyst and when combined with the morphology of blastocyst can predict its reproductive potential. While time taken for blastocoele re-expansion has been proposed to be a biomarker of viability, its value in clinical practice remains unclear.

Study design, size, duration

This retrospective study analysed outcomes in patients who had frozen embryo transfers between June-December 2020. 233 embryos were reviewed with time-lapse to assess their blastocoele expansion post-warming and three groups were identified. The first included fully expanded blastocysts post-warming. The second group included partially expanded blastocysts and the third non-expanded blastocysts. In addition, the groups were subcategorised into two further categories depending on whether they took less or more than 2 hours to complete expansion.

Participants/materials, setting, methods

233 vitrified/warmed embryos from 216 patients were analysed using time-lapse incubators. The first group included 134 blastocysts, of which 70 were fully expanded within 2 hours and 64 after 2 hours post thaw. The second group had 70 embryos of which 45 expanded partially within 2 hours and 25 after 2 hours. The third had 28 embryos that had no expansion within the first 2 hours (n = 20) or after 2 hours (n = 8).

Main results and the role of chance

Blastocysts were collapsed by laser prior to vitrification. Single blastocyst transfer was performed for all patients. The mean transferred embryo age was 32.1± 5.5 and the recipient’s was 37.5± 5.9. Fully expanded blastocysts (n = 70) within 2 hours demonstrated a clinical pregnancy rate (CPR) of 57% compared with 38% from those that expanded fully after 2 hours (n = 64) (p = 0.02). Blastocysts with some form of expansion (full or partial) within 2 hours post-warming (n = 115) were associated a significantly higher CPR compared to those expanding after 2 hours (n = 89). The CPR was 55% and 39% respectively (p = 0.02). Embryos that showed no expansion (n = 20) within the first 2 hours post thaw resulted in CPR of 28%. Interestingly, embryos that showed no expansion after 2 hours resulted in no pregnancy. When combining morphology as a selection criterion, expansion within 2 hours of thawing was associated with a CPR of 62.5% for ≥4AB embryos, 50% for BB embryos and 45% for poorer embryos ≤CB.In conclusion, failure of blastocoele expansion post 2 hours reduced by half the chances of clinical pregnancy (p = 0.03). Combination of the degree of re-expansion and embryo morphology is an important predictor tool to improve clinical outcomes in frozen embryo transfers.

Limitations, reasons for caution

This study uses a small sample size of patients. The data are observational and were retrospectively analysed so unknown confounders could not be assessed. The addition of more cycles and further multivariate analysis, is essential for confirmation of the findings. However, initial results are very reassuring.

Wider implications of the findings: The degree of speed of re-expansion post warming should be used as a predictor for prioritisation of embryos for transfer. Owing to these preliminary findings there is rationale for a larger scale study combining other morphological indicators that could further assess implantation indicators and assist patient counselling

Trial registration number

Not applicable

First-line treatment of metastatic clear cell renal cell carcinoma: a decision-making analysis among experts

BACKGROUND

The treatment landscape of metastatic clear cell renal cell carcinoma (mccRCC) has been transformed by targeted therapies with tyrosine kinase inhibitors (TKI) and more recently by the incorporation of immune checkpoint inhibitors (ICI). Today, a spectrum of single agent TKI to TKI/ICI and ICI/ICI combinations can be considered and the choice of the best regimen is complex.

MATERIALS AND METHODS

We performed an updated decision-making analysis among 11 international kidney cancer experts. Each expert provided their treatment strategy and relevant decision criteria in the first line treatment of mccRCC. After the collection of all input a list of unified decision criteria was determined and compatible decision trees were created. We used a methodology based on diagnostic nodes, which allows for an automated cross-comparison of decision trees, to determine the most common treatment recommendations as well as deviations.

RESULTS

Diverse parameters were considered relevant for treatment selection, various drugs and drug combinations were recommended by the experts. The parameters, chosen by the experts, were performance status, International Metastatic renal cell carcinoma Database Consortium (IMDC) risk group, PD-L1 status, zugzwang and contraindication to immunotherapy. The systemic therapies selected for first line treatment were sunitinib, pazopanib, tivozanib, cabozantinib, ipilimumab/nivolumab or pembrolizumab/axitinib.

CONCLUSION

A wide spectrum of treatment recommendations based on multiple decision criteria was demonstrated. Significant inter-expert variations were observed. This demonstrates how data from randomized trials are implemented differently when transferred into daily practice.

Mammalian expression of virus-like particles as a proof of principle for next generation polio vaccines

Global vaccination programs using live-attenuated oral and inactivated polio vaccine (OPV and IPV) have almost eradicated poliovirus (PV) but these vaccines or their production pose significant risk in a polio-free world. Recombinant PV virus-like particles (VLPs), lacking the viral genome, represent safe next-generation vaccines, however their production requires optimisation. Here we present an efficient mammalian expression strategy producing good yields of wild-type PV VLPs for all three serotypes and a thermostabilised variant for PV3. Whilst the wild-type VLPs were predominantly in the non-native C-antigenic form, the thermostabilised PV3 VLPs adopted the native D-antigenic conformation eliciting neutralising antibody titres equivalent to the current IPV and were indistinguishable from natural empty particles by cryo-electron microscopy with a similar stabilising lipidic pocket-factor in the VP1 β-barrel. This factor may not be available in alternative expression systems, which may require synthetic pocket-binding factors. VLPs equivalent to these mammalian expressed thermostabilized particles, represent safer non-infectious vaccine candidates for the post-eradication era.

Repeat partial nephrectomy for recurrence of Von Hippel-Lindau-related renal cell carcinoma in an autotransplanted kidney

Von Hippel-Lindau disease predisposes to develop renal cell carcinoma (RCC). Treatment is frequently challenging due to presence of bilateral tumors and high risk of recurrence. We present the case of a VHL-patient with bilateral recurrence of clear-cell RCC after bilateral partial nephrectomy and autotransplantation on one side. Recurrence on the transplanted kidney was treated with repeat partial nephrectomy with good oncological and functional outcomes. This approach is feasible in centres with wide experience in partial nephrectomy and renal transplantation when minimally invasive tumor ablation is not indicated.

Universal detection of foot and mouth disease virus based on the conserved VP0 protein

Background: Foot and mouth disease virus (FMDV), a member of the picornaviridae that causes vesicular disease in ungulates, has seven serotypes and a large number of strains, making universal detection challenging. The mature virion is made up of 4 structural proteins, virus protein (VP) 1 – VP4, VP1-VP3 of which form the outer surface of the particle and VP4 largely contained within. Prior to mature virion formation VP2 and VP4 occur together as VP0, a structural component of the pre-capsid which, as a result of containing the internal VP4 sequence, is relatively conserved among all strains and serotypes. Detection of VP0 might therefore represent a universal virus marker. Methods: FMDV virus protein 0 (VP0) was expressed in bacteria as a SUMO fusion protein and the SUMO carrier removed by site specific proteolysis. Rabbit polyvalent sera were generated to the isolated VP0 protein and their reactivity characterised by a number of immunoassays and by epitope mapping on peptide arrays. Results: The specific VP0 serum recognised a variety of FMDV serotypes, as virus and as virus-like-particles, by a variety of assay formats. Epitope mapping showed the predominant epitopes to occur within the unstructured but highly conserved region of the sequence shared among many serotypes. When immunogold stained VLPs were assessed by TEM analysis they revealed exposure of epitopes on the surface of some particles, consistent with particle breathing hitherto reported for some other picornaviruses but not for FMDV. Conclusion: A polyvalent serum based on the VP0 protein of FMDV represents a broadly reactive reagent capable of detection of many if not all FMDV isolates. The suggestion of particle breathing obtained with this serum suggests a reconsideration of the FMDV entry mechanism.

Colon Cancer in Pregnancy: Report of a Case and Review of the Literature

Most colon cancer cases occur in patients over 50 years of age, although about 3% of colorectal cancer patients are younger than 40. During pregnancy the incidence of this neoplasm is estimated to be 0.002%. To date only 32 cases of colonic cancer arising above the peritoneal reflection during pregnancy have been described in the literature. We report another such case, stressing the need for constant alertness on the part of physicians in the presence of abdominal pain and/or distension, a palpable abdominal mass, rectal bleeding and/or weight loss during pregnancy. In fact, the reportedly poorer prognosis of this cancer in pregnant patients is mainly due to the fact that the initial symptoms of the malignancy are usually attributed by the patient, but also by physicians, to normal pregnancy.

Thrombotic Thrombocytopenic Purpura Resistant to Plasma-exchange: Salvage Treatment with High-dose IgG or Vincristine

Even though plasmaexchange (PE), either alone or combined with cortisone or platelet anti-aggregating substances is the treatment of choice for TTP, 10-15% of patients is resistant to treatment. Since immunoglobulin (IgG) infusion was reported to cure the clinical symptoms of PE-resistant TTP, and vincristine (VCR) has been recently successful in treating TTP, we reviewed the results obtained with both drugs in 20 PE-resistant patients. Of 12 patients receiving IgG and 8 receiving VCR, 3 (25%) and 4 (50%), respectively, achieved complete remission. Even though no conclusions can be drawn from such results, if complete remission can be achieved in a however small number of PE-resistant patients, the use of these drugs is suggested as a salvage treatment for TTP.

Integrated cardiovascular/respiratory control in type 1 diabetes evidences functional imbalance: Possible role of hypoxia

BACKGROUND

Cardiovascular (baroreflex) and respiratory (chemoreflex) control mechanisms were studied separately in diabetes, but their reciprocal interaction (well known for diseases like heart failure) had never been comprehensively assessed. We hypothesized that prevalent autonomic neuropathy would depress both reflexes, whereas prevalent autonomic imbalance through sympathetic activation would depress the baroreflex but enhance the chemoreflexes.

METHODS

In 46 type-1 diabetic subjects (7.0±0.9year duration) and 103 age-matched controls we measured the baroreflex (average of 7 methods), and the chemoreflexes, (hypercapnic: ventilation/carbon dioxide slope during hyperoxic progressive hypercapnia; hypoxic: ventilation/oxygen saturation slope during normocapnic progressive hypoxia). Autonomic dysfunction was evaluated by cardiovascular reflex tests.

RESULTS

Resting oxygen saturation and baroreflex sensitivity were reduced in the diabetic group, whereas the hypercapnic chemoreflex was significantly increased in the entire diabetic group. Despite lower oxygen saturation the hypoxic chemoreflex showed a trend toward a depression in the diabetic group.

CONCLUSION

Cardio-respiratory control imbalance is a common finding in early type 1 diabetes. A reduced sensitivity to hypoxia seems a primary factor leading to reflex sympathetic activation (enhanced hypercapnic chemoreflex and baroreflex depression), hence suggesting a functional origin of cardio-respiratory control imbalance in initial diabetes.

Structure-based energetics of protein interfaces guides foot-and-mouth disease virus vaccine design

Virus capsids are primed for disassembly, yet capsid integrity is key to generating a protective immune response. Foot-and-mouth disease virus (FMDV) capsids comprise identical pentameric protein subunits held together by tenuous noncovalent interactions and are often unstable. Chemically inactivated or recombinant empty capsids, which could form the basis of future vaccines, are even less stable than live virus. Here we devised a computational method to assess the relative stability of protein-protein interfaces and used it to design improved candidate vaccines for two poorly stable, but globally important, serotypes of FMDV: O and SAT2. We used a restrained molecular dynamics strategy to rank mutations predicted to strengthen the pentamer interfaces and applied the results to produce stabilized capsids. Structural analyses and stability assays confirmed the predictions, and vaccinated animals generated improved neutralizing-antibody responses to stabilized particles compared to parental viruses and wild-type capsids.

Sunitinib administered on 2/1 schedule in patients with metastatic renal cell carcinoma: the RAINBOW analysis

BACKGROUND

First-line sunitinib is recommended in metastatic renal cell carcinoma (mRCC), but it is frequently associated with relevant toxicities and subsequent dose reductions. Alternative schedules, such as 2-week-on treatment and 1-week-off (2/1 schedule), might improve tolerability. We evaluated the safety and outcomes of this schedule in a large multicenter analysis.

PATIENTS AND METHODS

Retrospective, multicenter analysis of mRCC patients treated with first-line sunitinib on a 2/1 schedule. Data of 249 patients were reviewed: 208 cases who started sunitinib on the 4/2 schedule (full dosage: 188/208, 90.4%) and thereafter switched to the 2/1 schedule for toxicity (group 4/2 → 2/1) and 41 patients who started first-line sunitinib with the 2/1 schedule because of suboptimal clinical conditions (group 2/1). A total of 211 consecutive patients treated with the 4/2 schedule in another institution served as external controls. Safety was the primary end point. Treatment duration (TD), progression-free survival (PFS) and overall survival (OS) were also analyzed.

RESULTS

In group 4/2 → 2/1, the overall incidence of grade ≥ 3 toxicities was significantly reduced (from 45.7% to 8.2%, P < 0.001) after the switch to 2/1 schedule. This advantage was maintained also in the 106/188 cases (56.4%) who maintained the full dosage. Fatigue, hypertension, hand-foot syndrome and thrombocytopenia were less frequent. The incidence of grade ≥ 3 adverse events in the negatively selected group 2/1 (only 73.2% starting at full dose) was 26.8%, similar to what observed in the external control group (29.4%). Median TD was 28.2 months in the 4/2 → 2/1 group (total time spent with both schedules), 7.8 months in the 2/1 group and 9.7 months in external controls. Median PFS was 30.2, 10.4 and 9.7 months, respectively. Median OS was not reached, 23.2 and 27.8 months, respectively.

CONCLUSIONS

mRCC patients who moved to a modified 2/1 schedule of sunitinib experience an improved safety profile compared with that observed during the initial 4/2 schedule.

Final results from the large sunitinib global expanded-access trial in metastatic renal cell carcinoma

BACKGROUND

We report final results with extended follow-up from a global, expanded-access trial that pre-regulatory approval provided sunitinib to metastatic renal cell carcinoma (mRCC) patients, ineligible for registration-directed trials.

METHODS

Patients ⩾18 years received oral sunitinib 50 mg per day on a 4-weeks-on-2-weeks-off schedule. Safety was assessed regularly. Tumour measurements were scheduled per local practice.

RESULTS

A total of 4543 patients received sunitinib. Median treatment duration and follow-up were 7.5 and 13.6 months. Objective response rate was 16% (95% confidence interval (CI): 15-17). Median progression-free survival (PFS) and overall survival (OS) were 9.4 months (95% CI: 8.8-10.0) and 18.7 months (95% CI: 17.5-19.5). Median PFS in subgroups of interest: aged ⩾65 years (33%), 10.1 months; Eastern Cooperative Oncology Group performance status ⩾2 (14%), 3.5 months; non-clear cell histology (12%), 6.0 months; and brain metastases (7%), 5.3 months. OS was strongly associated with the International Metastatic Renal-Cell Carcinoma Database Consortium prognostic model (n=4065). The most common grade 3/4 treatment-related adverse events were thrombocytopenia (10%), fatigue (9%), and asthenia, neutropenia, and hand-foot syndrome (each 7%).

CONCLUSION

Final analysis of the sunitinib expanded-access trial provided a good opportunity to evaluate the long-term side effects of a tyrosine kinase inhibitor used worldwide in mRCC. Efficacy and safety findings were consistent with previous results.