POS0088-PARE CHANGES IN PATIENT-REPORTED OUTCOME SCORES DURING COVID-19 PANDEMIC: DATA FROM THE ArthritisPower REGISTRY

Background

The COVID-19 pandemic causes concern among patients with autoimmune and rheumatic disease (ARD) due to increased risk of infection and heightened isolation from social distancing.1

Objectives

Examine how mean patient-reported outcome (PRO) scores for mental, social and physical health fluctuated after COVID-19 vaccine availability was widespread in US.

Methods

We conducted and reported on2 an initial analysis of January 2020 – April 2021 where US participants (pts) of the ArthritisPower (AP) registry completed PROMIS measures of physical health (Physical Function, Pain Interference, Fatigue, Sleep Disturbance), mental health (Anger, Anxiety, Depression) and social health (Social Isolation, Emotional Support). Follow-up analysis was conducted May – December 2021. Only pts from initial analysis were included in follow-up. Null hypothesis was no change in monthly average scores across 23-month pandemic period. Analysis of means compared monthly assessment mean scores to overall mean score for each measure during study period. Pts with < 2 assessment time points and osteoarthritis with no ARD were excluded from analysis.

Results

Total of 49,940 PRO scores were contributed by 2,266 pts during 23-month period, with 8,393 of the scores contributed from May – December 2021. Mean (standard deviation, SD) number of observations per pt was 5.6 (12.5). Pts were 87.6% female, 86.7% white, mean age of 52.1 (12.7) years. Rheumatoid arthritis (n=1,131, 49.9%) was the most common condition. Most commonly reported measures were Pain Interference, Fatigue, Sleep Disturbance and Physical Function, each with >11,000 total results (Table 1).

Table 1.

Avg assessment scores+ by month, mean (SD)

Pain Interf (n= 11536)Fatigue (n= 11591)Sleep Disturb (n= 11257)Physical Func (n= 11202)Depression (n=1489)Anxiety (n= 1066)Social Iso (n=698)Emot Support (n=578)Anger (n=523)Study Period^63.3 (7.8)62.6 (9.5)58.1 (9.0)37.7 (7.6)60.8 (9.2)62.4 (10.5)61.9 (10.2)40.8 (9.8)61.5 (12.8)May 202161.9 (8.2)*60.9 (9.7)*55.2 (8.8)*38.9 (8.5)59.5 (9.2)61.9 (9.8)60.2 (13.3)38.1 (8.3)59.6 (14.5)June61.6 (6.9)*60.9 (9.6)*54.8 (8.9)*38.3 (7.8)59.2 (7.0)60.6 (9.6)61.8 (12.0)39.3 (10.3)60.2 (10.9)July61.8 (7.4)*60.8 (10.2)*56.0 (8.6)*38.1 (7.9)61.0 (7.8)59.9 (12.1)66.8 (8.5)*39.4 (9.7)62.4 (9.7)Aug61.2 (8.5)*60.7 (10.4)*55.8 (9.6)*38.5 (8.5)57.7 (7.9)*58.2 (10.3)*57.2 (11.1)36.9 (12.2)53.3 (19.4)Sep62.4 (8.5)62.3 (10.0)56.2 (8.3)37.3 (7.6)58.7 (8.0)57.7 (11.3)*68.1 (12.8)36.7 (12.1)58.7 (12.0)Oct63.1 (8.4)63.3 (9.9)57.6 (8.6)37.3 (8.0)59.9 (9.9)62.3 (9.0)64.3 (10.3)37.3 (11.4)64.6 (10.2)Nov62.6 (6.8)63.2 (10.0)55.8 (8.6)*36.9 (7.0)59.1 (8.8)61.3 (6.8)61.4 (10.9)38.6 (11.7)60.3 (12.4)Dec62.9 (8.3)64.0 (9.6)56.5 (8.4)37.4 (8.1)60.7 (8.4)63.8 (5.3)65.1 (7.5)38.5 (13.5)68.6 (5.0)*

+PROMIS measures scored 0-100; mean 50 for general US population; 1SD = 10 points

^Study period: January 2020 – December 2021

. *Statistical significance (p<0.05); analysis of means (ANOM)

Pts’ mental and social health assessment scores improved then worsened during last 8 months of 2021 (Figure 1). Overall mean scores were: Anxiety 62.4 (12.5), Social Isolation 61.9 (10.5), and Anger 61.5 (12.8). From July – August, Social Isolation decreased by 1 SD. Compared to overall assessment mean, Anger declined by > ½ SD (53.3 [19.4]) in August and Anxiety declined by ½ SD (57.7 [11.3]) in September. By December, Anger rose by > ½ SD (68.6 [5.0]) of assessment mean. Pain Interference (mean: 63.3 [7.8]), Fatigue (62.6 [9.5]), and Sleep Disturbance (58.1 [9.0]) scores were significantly lower in May, June, July and August compared to the assessment mean, though none decreased by > ½ SD.

Conclusion

ARD members of AP had mental, social and physical health scores improve during summer of 2021, corresponding with widespread availability of vaccines. However mental and social health scores worsened by December as US faced new variants of the virus.

References

[1]George M, et al. Rheumatol. 2021;48:603-7.

[2]Gavigan K, et al. Arth Rheumatol. 2021;73(suppl 10).

Acknowledgements

This work was partially supported through a Patient-Centered Outcomes Research Institute (PCORI) award (PPRN-1306-04811). All statements in this poster, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee.

Disclosure of Interests

Kelly Gavigan: None declared, Esteban Rivera: None declared, Jeffrey R. Curtis Consultant of: Gilead, Novartis, and Samsung, Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB, Shilpa Venkatachalam: None declared, Laura Stradford: None declared, David Curtis: None declared, W. Benjamin Nowell Grant/research support from: William B. Nowell is the Principal Investigator on grants/contracts from AbbVie, Eli Lilly and Company, and PCORI, and an employee of the Global Healthy Living Foundation (GHLF). GHLF receives grants, sponsorships and contracts from pharmaceutical manufacturers and private foundations. A full list of GHLF funders is publicly available here: https://www.ghlf.org/our-partners/.

Gingival Thickness and Outcome of Periodontal Plastic Surgery Procedures: A Meta-regression Analysis

OBJECTIVE

To evaluate the impact of soft tissue thickness (STT) on root coverage achieved with different periodontal plastic surgery procedures.

BACKGROUND

Gingival recession has been managed successfully through various surgical approaches, with great variability in outcomes. Anatomic characteristics of the recipient site and selected technique account in part for this variability. Gingival flap thickness is one of the most critical site-related characteristics.

METHODS

An electronic search was conducted on the major databases (PubMed, Embase, Web of Science). Human prospective studies with at least 6 mo of follow-up and with a numeric baseline measurement for gingival thickness were eligible. Only studies including nonsmoking patients were considered. Variables included surgical approach, participant characteristics, local anatomic factors, and follow-up time. Primary outcome was mean percentage root coverage (%RC) achieved, and complete root coverage was a secondary outcome.

RESULTS

A total of 42 studies were included (35 randomized controlled trials, 5 case series, 1 prospective cohort study, and 1 controlled clinical trial). Across studies, the pooled %RC was 81.9% (95% CI, 79.1% to 84.7%). The %RC was not significantly associated (P = 0.267) with baseline soft tissue thickness; however there was a significant (P = 0.031) inverse relationship between STT and %RC after 12-mo follow-up. Subgroup analysis showed that for no graft, there was a significant (P = 0.025) positive relationship between STT and %RC with the exclusion of the single outlier study based on STT.

CONCLUSIONS

STT plays a limited role in predicting root coverage across all approaches; when flaps are performed with no graft, the effect of STT is most critical. The length of time following surgery appears to influence outcomes, with 12-mo follow-up offering greater insight.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can suggest to clinicians which periodontal plastic surgery technique to employ when treating challenging cases. In particular, it can be helpful when selecting the treatment approach to treat thin phenotype sites. This study could help clinicians provide a more appropriate treatment decision in such cases.

Sonographic Measurement of the Patellar Tendon Should Predict Autograft Bone Patellar Tendon Bone (BPTB) Size: Comparison of Anatomical and Clinical Findings

The use of BPTB autograft is frequently used in ACL reconstruction, however, the risk of potential failure in patients with an anatomically unfavorable patellar tendon may predispose to reconstruction failure. Anatomical study of the extensor apparatus of the knee can provide knowledge about the best option obtain the graft and perform a better preoperative planning. Musculoskeletal ultrasound is a simple, reproducible, affordable technique that could be valid for patellar tendon evaluation. The objective of this study is to evaluate the reproducibility of the patellar tendon measurements by ultrasound and compare them with anatomical measurements, both in cadaver and patients undergoing ACLR. The study consists of two phases; first anatomical study in cadaver. The ultrasound measurement was performed by determining the length, width and thickness of the patellar tendon, both by ultrasound and anatomical dissection. The second phase is a cohort of 42 patients pending surgical ACLR. Previous ultrasound and intraoperative measurements were obtained. Regarding the anatomical study, statistical analysis did not show any differences comparing the measurements in length (p = ns) and thickness (p = ns) of the patellar tendon, although differences were obtained when comparing the results obtained for the width of the tendon after the ultrasound and anatomical measurement (p < 0.001). Same results were obtained in second phase of the study. The reproducibility of ultrasound measurements of the PT is comparable to intraoperatively measurements (without width measurement). These findings can be useful for preoperative planning in the reconstruction of ACL with BPTB Graft and to assess technical modifications prior to surgery.

Assessing long-term return to play after hip arthroscopy in football players evaluating risk factors for good prognosis

PURPOSE

Groin pain is the third most common disease in football players and has often been associated with hip pathology such as femoroacetabular impingement and labral lesions. Hip arthroscopy offers possibilities of function restoration via minimally invasive procedures. The aim of this study is to evaluate professional football player's injuries and their return to play after hip arthroscopy for FAI and labral injuries.

METHODS

Patients that underwent hip arthroscopy between 2009 and 2014 were selected retrospectively. From this population, only professional soccer players competing at national level were included (Tegner 10). Arthroscopic surgery was proposed in patients with persistent pain. All patients were assessed for VAS score preoperatively and at 3, 6, 12 and 24 months post-op. HOS (sport and DLA) and mHHS tests were performed at the same time periods.

RESULTS

All patients were men with a mean age of 26.5 ± 7.1 years old. Preoperative VAS (7.4 ± 1.3), HOS ADL (67.7 ± 5.5), HOS sport (37.6 ± 18.7) and mHHS (72.5 ± 8.8) showed improved scores during long-term follow-up. Time to return to play was 10.8 months (SD ± 4.3), with range between 4 and 20 months. Mean follow-up was 45.4 ± 15.6 months (range from 26 to 72 months). No differences were observed between non-active and active patients at final follow-up with respect to chondral lesions, but significant differences were observed with reference to management of the labrum (p = 0.031), where a higher rate of labrectomies existed among inactive patients and a higher rate of suture among active patients.

CONCLUSIONS

Hip arthroscopy is a safe procedure with very good return to play results, but for optimized return to football one should consider patient age at the time of surgery, the condition of the labrum and low scores on the Harris Hip Score (mHHS) and HOS (sport version) as predictive factors for poor prognosis. Level of evidence IV.

Laboratory Animal Legislation in Latin America

A review of existing legislation covering laboratory animals in Latin America is presented. The region presents a spectrum of economic development, political stability, and cultural diversity. With the exception of a few nations, there is a lack of regulations as well as minimal enforcement of existing laws pertaining to laboratory animals. Brazil, Mexico, and Uruguay stand out as the only nations in this region with specific legislation regulating laboratory animal care and use; the history and current status of regulations in these three nations is reviewed.

5HT2A receptor blockade in dorsomedial striatum reduces repetitive behaviors in BTBR mice

Restricted and repetitive behaviors are a defining feature of autism, which can be expressed as a cognitive flexibility deficit or stereotyped, motor behaviors. There is limited knowledge about the underlying neuropathophysiology contributing to these behaviors. Previous findings suggest that central 5HT_2A receptor activity is altered in autism, while recent work indicates that systemic 5HT_2A receptor antagonist treatment reduces repetitive behaviors in an idiopathic model of autism. 5HT_2A receptors are expressed in the orbitofrontal cortex and striatum. These two regions have been shown to be altered in autism. The present study investigated whether 5HT_2A receptor blockade in the dorsomedial striatum or orbitofrontal cortex in the BTBR mouse strain, an idiopathic model of autism, affects the phenotype related to restricted and repetitive behaviors. Microinfusion of the 5HT_2A receptor antagonist, M100907 into the dorsomedial striatum alleviated a reversal learning impairment and attenuated grooming behavior. M100907 infusion into the orbitofrontal cortex increased perseveration during reversal learning and potentiated grooming. These findings suggest that increased 5HT_2A receptor activity in the dorsomedial striatum may contribute to behavioral inflexibility and stereotyped behaviors in the BTBR mouse. 5HT_2A receptor signaling in the orbitofrontal cortex may be critical for inhibiting a previously learned response during reversal learning and expression of stereotyped behavior. The present results suggest which brain areas exhibit abnormalities underlying repetitive behaviors in an idiopathic mouse model of autism, as well as which brain areas systemic treatment with M100907 may principally act on in BTBR mice to attenuate repetitive behaviors.

Enhancement of the physicochemical properties of [Pt(dien)(nucleobase)]2+ for HIVNCp7 targeting

Physicochemical properties of coordination compounds can be exploited for molecular recognition of biomolecules. The inherent π-π stacking properties of [Pt(chelate)(N-donor)]²⁺ ([PtN₄]) complexes were modulated by systematic variation of the chelate (diethylenetriamine and substituted derivatives) and N-donor (nucleobase or nucleoside) in the formally substitution-inert PtN₄ coordination sphere. Approaches to target the HIV nucleocapsid protein HIVNCp7 are summarized building on (i) assessment of stacking interactions with simple tryptophan or tryptophan derivatives to (ii) the tryptophan-containing C-terminal zinc finger and (iii) to the full two-zinc finger peptide and its interactions with RNA and DNA. The xanthosine nucleoside was identified as having significantly enhanced stacking capability over guanosine. Correlation of the LUMO energies of the modified nucleobases with the DFT π-stacking energies shows that frontier orbital energies of the individual monomers can be used as a first estimate of the π-stacking strength to Trp. Cellular accumulation studies showed no significant correlation with lipophilicity of the compounds, but all compounds had very low cytotoxicity suggesting the potential for antiviral selectivity. The conceptual similarities between nucleobase alkylation and platination validates the design of formally substitution-inert coordination complexes as weak Lewis acid electrophiles for selective peptide targeting.

Overview of neuropathy associated with taxanes for the treatment of metastatic breast cancer

Taxanes are an established option in the standard treatment paradigm for patients with metastatic breast cancer (MBC). Neuropathy is a common, dose-limiting side effect of taxane therapy that is often managed by dose reductions and delays. The severity, time to onset, and improvement in neuropathy are important considerations for patient management and vary among currently approved taxanes. The rate of grade ≥3 neuropathy with taxanes has been shown to be dose and schedule dependent; however, time to improvement to grade ≤1 is typically shorter for nab-paclitaxel than for other taxanes in patients with MBC. Many tools for assessing patient-reported neuropathy exist. Because MBC is incurable and patient quality of life must be critically considered when making treatment decisions, there is a need for more prospective trials to assess patient-reported neuropathy. Validated predictors of taxane-related neuropathy may play an important role in treatment decisions in the future. This review will focus on the toxicity profile (i.e., neuropathy) of each of the taxanes used in the treatment of MBC, will provide updates on tools used for the assessment of neuropathy, and will highlight newly discovered predictors of taxane-related neuropathy.

A 15-year-old boy with abdominal pain, growth retardation, and anemia secondary to Helicobacter pylori-associated peptic ulcer

A 15-year-old boy with abdominal pain, growth retardation, and symptomatic anemia requiring blood transfusion was seen by a gastroenterologist and found to have a large ulcerated, fungating, and actively bleeding mass in his stomach. Initially, the patient was screened for Helicobacter pylori and found to be negative, so there was concern for malignancy after multiple endoscopic procedures. The patient did not respond to initial ulcer treatment and immediately prior to scheduled partial gastrectomy, additional tissue sections from the initial biopsy were stained for H. pylori and rare positive staining organisms were found. The test was positive, and the patient was started empirically on treatment to which he responded and ultimately recovered fully. Gastrectomy was not performed, and following treatment, the ulcer, anemia, and poor growth resolved.

Pilot study to assess toxicity and pharmacokinetics of docetaxel in patients with metastatic breast cancer and impaired liver function secondary to hepatic metastases

BACKGROUND

Limited clinical data are available regarding the safety of docetaxel in metastatic breast cancer patients with liver dysfunction.

METHODS

Eligible patients had breast cancer with impaired liver function secondary to hepatic metastases and were candidates for docetaxel therapy. They were assigned to one of five groups on the basis of total bilirubin, alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase levels. All other causes of liver dysfunction were excluded, and bile duct obstruction was corrected, if possible, prior to study entry. Patients received docetaxel every three weeks. The chemotherapy dose was chosen on the basis of the patient's level of hepatic dysfunction and escalated as tolerated. The primary outcome of this study was safety. The secondary outcomes were pharmacokinetic data and efficacy in terms of time to disease progression.

RESULTS

Twenty-three patients were enrolled. No unexpected toxicities occurred. Grade 3/4 fatigue (65%), neutropenia (30%), myalgias (26%), neutropenic fever (26%), vomiting (9%), and rash (9%) were the most common serious adverse events. The median time to progression was three months (range 1-18 months). Pharmacokinetic results indicated that patients with more severe hepatic dysfunction may have been underdosed based on our conservative dosing strategy.

CONCLUSIONS

Docetaxel can be administered to patients with metastatic breast cancer and liver dysfunction after dose attenuation. However, because of a narrow therapeutic index in this clinical setting, therapy should be closely monitored with subsequent dose escalation when possible.

Abstract OT3-3-01: Eniluracil + 5-fluorouracil + leucovorin (EFL) vs. capecitabine phase 2 trial for metastatic breast cancer

Based on a modified dosing protocol designed to optimize efficacy, an open-label EFL vs. capecitabine (4:3 randomization) Phase 2 trial for metastatic breast cancer is in progress. Eniluracil inactivates dihydropyrimidine dehydrogenase, thereby preventing the formation of α-fluoro-β-alanine, and conferring 100% oral bioavailability and a 5 hr half-life on 5-fluorouracil (5-FU). Study drugs are administered orally for 1st- or 2nd-line treatment for metastatic disease in patients previously treated with an anthracycline and a taxane. Arm 1: eniluracil (40 mg) taken 11–16 hr before 5-FU (30 mg/m2); leucovorin (30 mg) taken with 5-FU and the next day. The regimen is administered once/week for 3 weeks/4 weeks. Arm 2: capecitabine (1000 mg/m2) taken bid for 14 days/21days. Arm 2 patients with disease progression could crossover to take EFL in Arm X. Two sites in the USA and 19 in Russia are enrolling. Currently, 115 patients (21% are 1st-line, 70% had previous 5-FU treatment) are enrolled and 83 have had tumor assessments. EFL was well tolerated with no unexpected toxicities. As of May 2012, there were 11, 7, & 1 partial responses in Arms 1, 2, & X, respectively. The primary endpoint, progression-free survival, will be determined approximately 7.5 months after the trial is enrolled with 140 evaluable patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-3-01.

A phase 1 study of weekly everolimus (RAD001) in combination with docetaxel in patients with metastatic breast cancer

BACKGROUND

Inhibition of mammalian target of rapamycin with everolimus may improve the efficacy of taxanes. Everolimus and docetaxel are both metabolized by CYP3A4, which could result in a pharmacokinetic (PK) interaction.

METHODS

Fifteen patients with metastatic breast cancer were treated with docetaxel (doses of 40-75 mg/m(2) intravenously on day 1 of a 21-day cycle) in combination with everolimus (doses ranging from 20 to 50 mg orally on days 1 and 8 of a 21-day cycle) in a phase 1 trial using the continuous reassessment method to determine maximum tolerated dose. The first 2 patients developed a dose-limiting toxicity (neutropenic infection), prompting a mandatory dose reduction and PK evaluation of both everolimus and docetaxel for patients enrolled in subsequent dosing cohorts.

RESULTS

Fifteen patients were treated. Dose-limiting toxicity included grade 3 mucositis (n = 1), prolonged grade 4 neutropenia (n = 1), and grade 3 infection/febrile neutropenia (n = 3). Day 8 of everolimus was commonly held for neutropenia despite a dose reduction in docetaxel to 40 mg/m(2). Eleven patients underwent complete PK evaluation for everolimus, and 9 patients underwent complete PK evaluation for both everolimus and docetaxel. Widely variable changes in clearance were seen for both drugs, and the study was terminated because of lack of efficacy and concerns regarding toxicity seen with the combination.

CONCLUSIONS

Weekly everolimus in combination with docetaxel every 3 weeks was associated with excessive neutropenia and variable clearance of both drugs, making combination therapy unpredictable, even at low doses of both drugs.

Short-term biomarker modulation prevention study of anastrozole in women at increased risk for second primary breast cancer

The selective estrogen receptor modulators (SERM), Tamoxifen and raloxifen reduce risk breast cancer. Patient acceptance of SERMs for breast cancer prevention is low due to toxicities. New agents with a better toxicity profile are needed. Aromatase inhibitors (AI) reduce the risk of contralateral breast cancer and risk of new breast cancer in high risk women. However, the mechanism by which AIs reduce breast risk is not known. Surrogate biomarkers are needed to evaluate the effect of preventive agents. The objective of this prospective short-term prevention study was to evaluate the effect of anastrozole on biomarkers in breast tissue and serum of women at increased risk for developing a contralateral breast cancer. Women with a history of stage I, II breast cancer who started anastrozole for standard adjuvant treatment were eligible. Patients underwent baseline fine needle aspiration of the unaffected breast and serum collection for biomarker analysis before starting anastrozole at 1 mg per oral/day and again at 6 months. Biomarkers included changes in cytology, insulin-like growth factor 1 (IGF-1), IGF-binding protein 1 (IGFBP-1), and IGFBP-3. Thirty-seven patients were enrolled. There was a significant modulation in serum IGFBP-1 levels between pre- and postsamples (P = 0.02). No change was observed in IGF-1, IGFBP-3, and breast cytology.We showed a significant modulation of IGFBP-1 levels with six months anastrozole. Anastrozole is currently being studied as a prevention agent in a large phase III trial and our results provide support for continued evaluation of IGFBP-1 as a surrogate endpoint biomarker in prospective breast chemoprevention studies.

Comparison of MammaPrint, BluePrint, and TargetPrint with clinical parameters in patients with breast cancer: Findings from a prospective United States cohort

47

Background: MammaPrint (MP) is a powerful predictor of disease outcome in early stage breast cancer. In addition, TargetPrint (TP), a microarray-based test that measures the mRNA expression level of ER, PR and HER2 and an 80 gene expression Molecular Subtyping profile BluePrint (BP) were developed. In the present study, MP, BP and TP were measured in a prospective U.S. breast cancer patient cohort.

Methods: MP results were evaluated in fresh tumor samples from 127 breast cancer patients (T1-4N0-2; median age 62 [39-97 yr]) collected by core needle biopsy or from a surgical specimen between July 2008 and January 2011. We compared treatment advice as recommended by NCCN guidelines and classification according to MP. In addition, we compared IHC/FISH ER, PR and HER2 assessments with TP. The MP and BP results were used to subtype the patients into molecular subgroups.

Results: For the group of patients (n=59) for which NCCN recommends the use of a multi-gene signature for determining chemotherapy treatment recommendations, 42 patients were classified as High Risk and 17 as Low Risk by MP. Comparison of TP with IHC/FISH indicated a concordance of 98% for ER, 94% for PR, and 98% for HER2. For a subgroup of 53 patients combined MP and BP results were available; 18 patients were Luminal-type/MP Low Risk, 27 patients were Luminal-type/MP High risk, 1 patient was Her2-type/MP Low Risk, 1 patient was Her2-type/MP High Risk and 6 patients were Basal-type/MP High Risk.

Conclusions: Adding the multi-gene signature MammaPrint, as well as BluePrint and TargetPrint provides additional information for treatment guidance. By combining MammaPrint with the BluePrint molecular subtyping profile, specific groups of patients can be recognized that are at high risk of recurrence and that would possibly benefit from specific treatment. This study shows that TargetPrint provides high quality second opinion for local IHC/FISH assessment.

Chemotherapy resistance in metastatic breast cancer: the evolving role of ixabepilone

Resistance to chemotherapy is a major obstacle to the effective treatment of many tumor types. Although many anticancer therapies can alter tumor growth, in most cases the effect is not long lasting. Consequently, there is a significant need for new agents with low susceptibility to common drug resistance mechanisms in order to improve response rates and potentially extend survival. Approximately 30% of the women diagnosed with early-stage disease in turn progress to metastatic breast cancer, for which therapeutic options are limited. Current recommendations for first-line chemotherapy include anthracycline-based regimens and taxanes (paclitaxel and docetaxel). They typically give response rates of 30 to 70% but the responses are often not durable, with a time to progression of 6 to 10 months. Patients with progression or resistance may be administered capecitabine, gemcitabine, vinorelbine, albumin-bound paclitaxel, or ixabepilone, while other drugs are being evaluated. Response rates in this setting tend to be low (20 to 30%); the median duration of responses is <6 months and the results do not always translate into improved long-term outcomes. The present article reviews treatment options in taxane-resistant metastatic breast cancer and the role of ixabepilone in this setting.

Phase II Trial of Anastrozole Plus Goserelin in the Treatment of Hormone Receptor–Positive, Metastatic Carcinoma of the Breast in Premenopausal Women

Purpose

To explore the antitumor activity of the aromatase inhibitor, anastrozole, in the treatment of premenopausal women with hormone receptor–positive, metastatic breast cancer who have been rendered functionally postmenopausal with the use of the luteinizing hormone-releasing hormone agonist, goserelin.

Patients and Methods

Premenopausal women with estrogen and/or progesterone receptor–positive, metastatic or recurrent breast cancer were enrolled in this prospective, single-arm, multicenter phase II trial. Patients were treated with goserelin 3.6 mg subcutaneous monthly and began anastrozole 1-mg daily 21 days after the first injection of goserelin. Patients continued on treatment until disease progression or unacceptable toxicity.

Results

Thirty-five patients were enrolled of which 32 were evaluable for response and toxicity. Estradiol suppression was assessed, with mean estradiol levels of 18.7 pg/mL at 3 months and 14.8 pg/mL at 6 months. One participant (3.1%) experienced a complete response, 11 (34.4%) experienced partial response, and 11 (34.4%) experienced stable disease for 6 months or longer for a clinical benefit rate of 71.9%. Median time to progression was 8.3 months (range, 2.1 to 63+) and median survival was not been reached (range, 11.1 to 63+). The most common adverse events were fatigue (50%), arthralgias (53%), and hot flashes (59%). There were no grade 4 to 5 toxicities.

Conclusion

The combination of goserelin plus anastrozole has substantial antitumor activity in the treatment of premenopausal women with hormone receptor–positive metastatic breast cancer.

Kinetic evaluation and performance of pilot-scale fed-batch aerated lagoons treating winery wastewaters

Winery wastewater was treated in two pilot-scale aerated lagoons operating in fed-batch mode. A first lagoon of 27.2m(3) working volume was gradually filled with wastewater with an average COD content of 8700mg/L. Given that with the flow-rate used (790L/day) this first lagoon completed its working volume after 30days of starting, part of the liquid contained in the first lagoon was transferred to another adjacent second lagoon of 10.8m(3) working volume. Therefore, the experiment continued in the second lagoon for another additional 24days using an influent with a COD content of 18,700mg/L at a flow-rate of 170L/day. After the 21st day, a maximum COD removal efficiency of 91% was achieved, and this value was maintained virtually constant until the end of the experiments. A mathematical model based on three differential equations solved simultaneously allowed the kinetic parameters of the system to be obtained.

Implications of anthracycline-resistant and taxane-resistant metastatic breast cancer and new therapeutic options

Patients with advanced or metastatic breast cancer commonly develop disease resistant to chemotherapy (typically anthracyclines and taxanes), which presents a major obstacle to therapy and leaves few effective treatment options. Drug resistance can occur due to various mechanisms including modification of drug efflux membrane transporters such as P-glycoprotein, as well as alterations in beta-tubulin. The novel epothilone B analog, ixabepilone, which has low susceptibility to various drug-resistance mechanisms, has demonstrated preclinical activity in drug-resistant breast cancer. The clinical activity of ixabepilone was evaluated in metastatic breast cancer patients with highly pretreated and/or resistant/refractory disease. Results were reviewed from three phase II trials in which ixabepilone was administered as monotherapy and one phase III trial that evaluated ixabepilone in combination with capecitabine. As a single agent, ixabepilone demonstrated activity in women who were heavily pretreated and resistant to an anthracycline, a taxane, and/or capecitabine. The combination of ixabepilone and capecitabine was significantly more active than capecitabine alone in patients with prior treatment or resistance to anthracyclines and taxanes. Treatment-related adverse events were generally low grade except for grade 3/4 toxicities, including neutropenia (53-54%) and reversible peripheral sensory neuropathy (14-16%). Ixabepilone has significant activity in patients with heavily pretreated metastatic breast cancer who are disease resistant or refractory to anthracyclines and taxanes. Further clinical evaluation of this agent in patients with drug-resistant breast cancer and in specific patient subsets is warranted.

Phase I trial of escalating doses of weekly everolimus (RAD001) in combination with docetaxel for the treatment of metastatic breast cancer (MBC)

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Background: Inhibition of mTOR with everolimus (E) may improve efficacy in combination with docetaxel (D), but both drugs are metabolized by CYP3A4, thus a pharmacokinetic (PK) interaction may also exist. Methods: 15 patients (pts) with MBC were treated with docetaxel and everolimus using the continuous reassessment method (CRM) to determine maximum tolerated dose (MTD). Docetaxel doses were 40–75 mg/m2 IV on day 1 of a 21 day cycle. Everolimus doses were 20–50 mg PO on days 1 and 8 of a 21 day cycle (except cycle 2, where only day 8 was given to allow single agent PK analyses of both drugs). Response was measured every 2 cycles using RECIST. Results: Median age= 58 years and 77% of pts had >2 prior chemotherapies for MBC. Initially 2 of 2 pts treated (D= 75 mg/m2, E= 30 mg) developed DLT (neutropenic fever/infection), prompting a mandatory PK evaluation for all pts enrolled in subsequent cohorts. A second cohort of 3 patients (D=60 mg/m2, E=20mg) had no DLT, but no pts received day 8 of E due to grade 3–4 neutropenia. PK analyses demonstrated a 42% lowered (-42%) D clearance at the 60 mg/m2 in the presence of E (n=1). Subsequent cohorts were accrued at D=40 mg/m2 with escalating doses of E (Table). For the entire group, an 18% decrease (-18%) in D clearance was observed when D was administered concomitantly with E. High interpatient variability of D clearance was observed (range +16% to -135%). No pts had CR/PR, but 6 had SD>4 cycles and 2 had SD=8 cycles. Conclusions: Weekly everolimus appears to cause widely variable and unpredictable changes in docetaxel clearance making this combination unfeasible.

[Table: see text]

No significant financial relationships to disclose.

Luxación recidivante postraumática del tendón extensor carpi ulnaris (ECU) en la muñeca: a propósito de un caso

La luxación o subluxación del tendón del extensor carpi ulnaris es uno de los diagnósticos diferenciales, a tener en cuenta, ante la existencia de dolor en el lado cubital de la muñeca, siendo rara su lesión aislada, por lo que su diagnóstico, puede pasar, con frecuencia, desapercibido.

La lesión ocurre durante una hipersupinación del antebrazo, desviación cubital y flexión palmar de la muñeca. Manifestando el paciente la sintomatología dolorosa tras la reducción del tendón con la pronación, dolor que puede llegar a ser muy incapacitante, con disminución del movimiento de pronosupinación de la muñeca, y disminución de fuerza. Debido a su mecanismo de producción y aparición de los síntomas, el diagnóstico es clínico, pues las pruebas complementarias pueden ser normales. La luxación del tendón, sólo ocurre, ante la ruptura o desinserción de su vaina osteofibrosa propia, o capa profunda del sexto compartimento extensor, a pesar de que el ligamento anular dorsal, o capa superficial del retináculo extensor, permanezca intacto. El tratamiento ha de ser quirúrgico, para reconstruir la vaina o corredera osteofibrosa, obteniéndose resultados satisfactorios.

Clinicopathologic characteristics and prognostic factors in 420 metastatic breast cancer patients with central nervous system metastasis

BACKGROUND

Breast cancer is the second most common cause of central nervous system (CNS) metastases. Several risk factors for CNS metastases have been reported. The objective of the current study was to describe clinicopathologic characteristics and prognostic factors in breast cancer patients with CNS metastases.

METHODS

The authors retrospectively evaluated clinical data from 420 patients who had been diagnosed with breast cancer and CNS metastasis between 1994 and 2004 at the University of Texas M. D. Anderson Cancer Center.

RESULTS

The median age of the patients at the time of diagnosis of breast cancer was 45 years (range, 25-77 years). Premenopausal and postmenopausal patients were distributed equally. Most patients had invasive ductal histology (91.2%), grade 3 tumors (81.4%) (using the modified Black nuclear grading system), T2 tumor classification (40.1%), and N1 lymph node status (59.7%) diagnosis. Forty percent of patients had estrogen receptor (ER)-positive disease, and 34% had progesterone receptor-positive disease. HER-2/neu status was recorded for only 248 patients, and 39% of the patients in that group had HER-2/neu-positive disease. The most common sites of first metastasis were liver, bone, and lung. CNS metastasis was the site of first recurrence in 53 patients (12%). In total, 329 patients had received either neoadjuvant treatment (113 patients) or adjuvant chemotherapy (216 patients). The majority of those patients (74.4%) had received anthracycline-based regimens. Metastasis was solitary in 111 patients (26.4%), and 29 patients had only leptomeningeal metastases. The median time from breast cancer diagnosis to CNS metastasis was 30.9 months (range, from -5 months to 216.7 months). The median follow-up after a diagnosis of CNS metastasis was 6 months (range, 7-95.9 months). In all, 359 patients died, and the overall median survival was 6.8 months. Only age at diagnosis and ER status were associated significantly with overall survival in the multivariate analysis.

CONCLUSIONS

The current results indicated that the prognosis remains patients with breast cancer metastatic to the CNS. More effective treatment approaches are needed for patients with CNS metastases, even for those with favorable prognostic factors, such as ER-positive tumors or younger age.

Expressive writing as a presurgical stress management intervention for breast cancer patients

This study evaluated whether expressive writing (EW) was an effective stress management intervention for breast cancer patients. Women were recruited at the end of neoadjuvant chemotherapy and assigned to write about their cancer experience (EW group; n = 24) or neutral topics (neutral writing [NW] group; n = 25). Women were asked to write for 20 minutes a day for a total of four writing sessions that were completed over a 7-day period. Participants were reassessed approximately 3 days before and 2 weeks after surgery. The intervention did not significantly decrease women's distress, perceived stress, sleep disturbance, or pain. There was some evidence that the EW group used more sleep medication at the presurgical assessment than the NW group. Social constraints moderated the effect of the intervention. Among women with high social constraints, the EW group reported lower average daily pain than the NW group. Among women with low social constraints, the EW group reported higher average daily pain than the NW group. EW was not broadly effective as a stress management intervention for women with breast cancer. These data do not support the use of EW as a presurgical mind-body complementary medicine program for this population.

Comparison of Ductal Lavage and Random Periareolar Fine Needle Aspiration as Tissue Acquisition Methods in Early Breast Cancer Prevention Trials

PURPOSE

Short-term phase I and phase II breast cancer prevention trials require tissue acquisition at baseline and after intervention to evaluate modulation of potential biomarkers. Currently used tissue acquisition methods include ductal lavage (DL), random periareolar fine needle aspiration (RPFNA), and core needle biopsy. The optimum method to retrieve adequate samples and the most accepted method by study participants is not known.

EXPERIMENTAL DESIGN

We compared RPFNA and DL as breast tissue acquisition methods for short-term breast cancer prevention trials by evaluating sample adequacy and tolerability in subjects who participated in two prospective phase II breast cancer prevention trials. Eighty-six women at increased risk for breast cancer were included in this study and underwent baseline DL and RPFNA. High risk was defined as having a 5-year Gail score of >1.67% or a history of atypical hyperplasia (AH), lobular carcinoma, or breast cancer.

RESULTS

Median age was 54.5 years (range, 39-75 years); 75% of the women were postmenopausal. About 51% of the women yielded nipple aspiration fluid, and breast fluid samples via DL were retrieved in 73% of these subjects. Of these samples, 71% were adequate samples (greater than 10 epithelial cells). However, when the entire cohort was considered, only 31% of the subjects had adequate samples. RPFNA was also attempted in all subjects, and sample retrieval rate was 100%. Out of these, 96% of the subjects had adequate samples. In DL samples, AH rate was 3.7% was and hyperplasia (H) rate was 11.1%. In RPFNA samples, AH rate was 12.9%, and H rate was 24.7%. Cytology findings in RPFNA samples correlated with age, menopausal status, and breast cancer risk category (previous history of lobular carcinoma in situ). Both procedures were well tolerated, and no complications occurred among participants.

CONCLUSIONS

Considering that the main end point for short-term prevention trials is the modulation of biomarkers, it is important to optimize adequate sample acquisition; therefore, RPFNA is a more practical option for future phase I and II breast cancer prevention trials compared with DL.

Phase II Clinical Trial of Ixabepilone (BMS-247550), an Epothilone B Analog, in Patients With Taxane-Resistant Metastatic Breast Cancer

Purpose

Ixabepilone (BMS-247550) is an epothilone analog that optimizes the properties of naturally occurring epothilone B. Natural epothilones and their analogs promote tumor cell death by binding to tubulin and stabilizing microtubules, causing apoptosis. This international phase II trial assessed the activity of ixabepilone in patients with metastatic breast cancer (MBC) that was resistant to taxane therapy.

Patients and Methods

MBC patients, who had experienced disease progression while receiving or within 4 months of taxane therapy (6 months if adjuvant taxane only), and who had a taxane as their last regimen, received ixabepilone (1- or 3-hour infusion of 50 mg/m2 or 3-hour infusion of 40 mg/m2 every 3 weeks).

Results

Of 49 patients treated with 40 mg/m2 ixabepilone during 3 hours, 35 (73%) had experienced disease progression within 1 month of their last taxane dose. The response rate was 12% (95% CI, 4.7% to 26.5%). All responses (n = 6) were partial; five of six patients had not responded to prior taxane therapy. In responders, the median response duration was 10.4 months. In 20 patients (41%), stable disease was the best outcome. Median time to progression was 2.2 months (95% CI, 1.4 to 3.2 months); median survival was 7.9 months. For treated patients across all cohorts (intent-to-treat population), the response rate was also 12% (eight of 66). Treatment-related adverse events in the study were manageable and primarily grade 1/2. Treatment-related neuropathy was mostly sensory and mild to moderate.

Conclusion

Ixabepilone (40 mg/m2 as a 3-hour infusion every 3 weeks) demonstrates promising antitumor activity and an acceptable safety profile in patients with taxane-resistant MBC.

Dose-seeking study of the combination of GM-CSF with pegfilgrastim plus CHOP-rituximab in patients with aggressive non- Hodgkin lymphoma (NHL)

18501

Background: Therapy for aggressive B cell NHL includes CHOP-rituximab (CHOP-R)q 14 days with G-CSF support. We are now investigating CHOP-R plus pegfilgrastim (Neulasta [N]) and low dose GM-CSF (Leukine). The rationale for low dose GM-CSF is based on its stimulation of ADCC which appears to be the most important mechanism of action of R and upregulation of CD20 on B cells, in addition, to other immunomodulating effects. Some of these are seen at lower levels of GM-CSF and appear to be lost at higher doses. N is given in order to allow delivery of chemotherapy q. 2 weeks. Methods: The goal was to determine the optimal dose of GM-CSF needed to support absolute neutrophil count (ANC) recovery >1,000 by day 14 without inducing marked leucocytosis when combined with N. R is given on day 1, CHOP on day 2 and growth factors start on day 3. We used a single fixed low dose of N 3 mg s.c. on day 3 and an escalating dose of GM-CSF starting at 75 mcg s.c. on day 3. GM-CSF was repeated every Monday, Wednesday and Friday. Results: So far we have delivered 65 evaluable courses to 18 pts (16 evaluable) whose median age was 58 (range 26–87). The plan was to escalate GM-CSF as necessary to support ANC recovery by day 14 without inducing severe leucocytosis. GM-CSF was to be escalated in cohorts of 5 patients at: 75, 125 and 250 mcg. The first cohort of 5 was treated at 75 mcg and all 5 recovered their ANC to >1,000 by day 14 and none exceeded ANC >50,000 before day 14. Therefore the next cohort of 5 received the same dose of 75 and all 5 were able to recover by day 14. Subsequently the next 6 were also treated at the same dose of 75 mcg. During 65 total courses, all but 3 pts recovered ANC to >1,000 before day 14. Chemotherapy doses were not reduced unless severe infection (i.e. septic shock or bilateral pneumonia). Because of prolonged or severe neutropenia, intrapatient dose escalations of GM-CSF were done in 2 pts (to 125 mcg) during the 2nd course and to 250 mcg in 1 pt during the 3rd. Conclusions: GM- CSF 75 mcg on Mondays, Wednesdays and Fridays is adequate and safe to support ANC recovery if combined with 3 mg N. However, in view of encouraging data of McLaughlin et al with 250 mcg of Leukine plus R in indolent NHL, in the next study we will attempt to escalate Leukine to 250 mcg.

[Table: see text]

Goserelin plus anastrozole in the treatment of premenopausal hormone receptor positive, recurrent or metastatic breast cancer

1030

Background: Aromatase inhibitors (AIs) are highly active in postmenopausal women with hormone receptor positive breast cancer. However, the AIs do not suppress ovarian estrogen synthesis and are not effective in premenopausal women. This phase II study was initiated to estimate the activity of anastrozole when given with ovarian suppression by goserelin in premenopausal women with ER and/or PgR positive metastatic breast cancer. Methods: Premenopausal women with measurable recurrent or metastatic, ER and/or PgR positive breast cancer; no prior AI or LH-RH agonist/antagonist; no adjuvant chemotherapy within 6 months; ECOG performance status of 0–2; adequate organ function; and who provided signed, informed consent were eligible. A 2 stage phase II design was utilized. Treatment was with goserelin 3.6 mg SQ q4wk and anastrozole 1 mg/day begun on day 22 of protocol treatment. Treatment was continued to disease progression. Results: 35 patients (pts) were enrolled. Three were excluded from analysis for the following: 1 postmenopausal, 1 consent withdrawal, 1 early oophorectomy. Of the remaining 32 pts, median age was 43 yrs (range 26–51 yrs), 18 (56%) had prior chemotherapy, and 9 (28%) had prior SERM. Pts were Asian/Middle Eastern 22%, Caucasian 62%, Black 13%, Hispanic 3%. Disease sites were lymph node 50%, breast 44%, bone 81%, lung 41%, liver 22%, pleural effusion 6% and soft tissue 6%. Receptor status was ER+/PgR+ 75%, ER+/PgR- 22% and ER-/PgR+ 3%. Response: Treatment resulted in complete response (CR) in 1(3%), partial response (PR) in 11(34%), stable disease 6+ mos (SD) in 11(34%), and clinical benefit (CR+PR+SD) 23 (72%). Median TTP was 8 mos (range 2 - 63+ mos); median OS was 26 mos (range 11 - 63+ mos). Estradiol levels were detectable in 30/31 pts at baseline (median 56 pg/ml, range <10 - 273 pg/ml). Mean estradiol levels (pg/ml) were 75 at baseline, 21 at 1 mos, 19 at 3 mos, and 15 at 6 mos. TOXICITY: One grade 3 weight loss. All other toxicities were grade 1–2. Conclusions: Ovarian suppression with goserelin in combination with anastrozole is well tolerated and highly active in the treatment of premenopausal, hormone receptor-positive metastatic breast cancer. Support provided by AstraZeneca Pharmaceuticals

No significant financial relationships to disclose.

Actions of a novel therapeutic formulation: Zn, Se and Mn plus Lachesis Muta venom (O-LM) on radiation deleterious immune effects

14116

Background: We have previously reported that O-LM inhibits malignant cell proliferation and increases survival in rodent tumor models (Int J Cancer S13:183, 2002). Molecular and immunological basis of O-LM action were reported (J Clin Oncol 24:18S, 2006). As O- LM selectively protects normal tissues from high doses of ionizing radiation (Proc Int Cancer Congress,1495–9, 1998), we here investigated O- LM protective action upon radiation effects on immune cells. Methods: Balb/c mice (n=15 each group) were employed: control (C); 2Gy whole body irradiated (IR); treated with O-LM (Zn, Se, Mn 4μg/ml each; L. Muta 4 ng/ml; 0.1 ml/day, sc) for 15 days and 2Gy irradiated (O-LM+IR). Mice were sacrificed at day 3, 7 or 15 post-irradiation (PI). Proliferation was evaluated in lymphocytes by [3H]- Thymidine incorporation after T- or B selective mitogen stimulation. In cell-free supernatants (SN) from mitogen-stimulated cultures cytokines involved in lymphocyte regulation and/or inflammation were determined by ELISA. Results: Irradiation induced a decrease in T lymphocyte proliferation at 3 and 7 days PI (% of decrease in IR: 47.6±9.0, p<0.05; 42.0±7.2, p<0.02 respectively). Pretreatment with O-LM recovered proliferation to basal values (day 3 PI 93.4±10.2%; day 7 PI 130.9±15.3%, O-LM+IR vs. C; p=NS). No modifications were observed in B cells. At day 3 PI, a marked decrease in IFN? levels was obtained in SN of IR mice that was reverted by O-LM treatment (pg/ml: IR 1653±419; C 10884±2783, p<0.02; O-LM+IR 16924±4284, p<0.05 vs C). Also, at day 7 PI, an important increase in TNFa was observed in IR mice, that were reverted by O-LM (pg/ml: IR: 300.7±62.3 vs O-LM+IR: 28.7±2.3, p<0.02). No differences were found in IL-2 levels. Conclusions: The therapeutic action of O-LM is based on its ability of targeting simultaneously multiple pathways involved in cancer development. Present data demonstrate that O-LM protects animals from irradiation by recovering the immune function, improving T lymphocyte activity and modulating the production of key cytokines as IFN? and TNFa. The reported effect may represent a potential benefit for cancer patients undergoing radiotherapy.

No significant financial relationships to disclose.