SIRFLOX: Randomized Phase III Trial Comparing First-Line mFOLFOX6 (Plus or Minus Bevacizumab) Versus mFOLFOX6 (Plus or Minus Bevacizumab) Plus Selective Internal Radiation Therapy in Patients With Metastatic Colorectal Cancer

Purpose

SIRFLOX was a randomized, multicenter trial designed to assess the efficacy and safety of adding selective internal radiation therapy (SIRT) using yttrium-90 resin microspheres to standard fluorouracil, leucovorin, and oxaliplatin (FOLFOX)–based chemotherapy in patients with previously untreated metastatic colorectal cancer.

Patients and Methods

Chemotherapy-naïve patients with liver metastases plus or minus limited extrahepatic metastases were randomly assigned to receive either modified FOLFOX (mFOLFOX6; control) or mFOLFOX6 plus SIRT (SIRT) plus or minus bevacizumab. The primary end point was progression-free survival (PFS) at any site as assessed by independent centralized radiology review blinded to study arm.

Results

Between October 2006 and April 2013, 530 patients were randomly assigned to treatment (control, 263; SIRT, 267). Median PFS at any site was 10.2 v 10.7 months in control versus SIRT (hazard ratio, 0.93; 95% CI, 0.77 to 1.12; P = .43). Median PFS in the liver by competing risk analysis was 12.6 v 20.5 months in control versus SIRT (hazard ratio, 0.69; 95% CI, 0.55 to 0.90; P = .002). Objective response rates (ORRs) at any site were similar (68.1% v 76.4% in control v SIRT; P = .113). ORR in the liver was improved with the addition of SIRT (68.8% v 78.7% in control v SIRT; P = .042). Grade ≥ 3 adverse events, including recognized SIRT-related effects, were reported in 73.4% and 85.4% of patients in control versus SIRT.

Conclusion

The addition of SIRT to FOLFOX-based first-line chemotherapy in patients with liver-dominant or liver-only metastatic colorectal cancer did not improve PFS at any site but significantly delayed disease progression in the liver. The safety profile was as expected and was consistent with previous studies.

Observation of polarized positrons from an undulator-based source

An experiment (E166) at the Stanford Linear Accelerator Center has demonstrated a scheme in which a multi-GeV electron beam passed through a helical undulator to generate multi-MeV, circularly polarized photons which were then converted in a thin target to produce positrons (and electrons) with longitudinal polarization above 80% at 6 MeV. The results are in agreement with GEANT4 simulations that include the dominant polarization-dependent interactions of electrons, positrons, and photons in matter.

Anti-lactadherin antibodies in anti-angiogenic cancer therapy of breast cancer stem cells

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Background: Angiolix (Hu-Mc3) is a humanized monoclonal antibody that recognizes a migrating adhesion molecule called Lactadherin. This novel antibody has a high affinity for its antigen and recognizes an epitope on Lactadherin which interacts with the the ’RGD’- motif found on integrin receptors on newly formed endothelial cells. Lactadherin binding leads to signalling via a VEGF-independent integrin receptor signalling cascade leading to vascular endothelial cell profileration. Lactadherin binding may also increase the potency of VEGF-VEGF receptor signalling. Methods: We studied the expression of Lactadherin on breast cancer cell lines, the biodistribution of Angiolix in human breast cancer xeografts and its ability to inhibit tumor growth in vivo. Results: Our data show that tumor cells express lactadherin in vivo and that Angiolix could achieve more than 75% growth inhibition of human breast cancer growing as xenografts . Conclusions: In view of the recent finding that cancer stem cells can over-express the pro-angiogenic VEGF and make a major contribution to tumor vasculature proliferation leads to the possibility that Angiolix may be able to act to specifically target breast cancer stem cell and cause tumor regression by blocking the growth of tumor vasculature by its ability to neutralise Lactadherin-integrin receptor binding.

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Precision measurement of the weak mixing angle in Møller scattering

We report on a precision measurement of the parity-violating asymmetry in fixed target electron-electron (Møller) scattering: A(PV) = [-131 +/- 14(stat) +/- 10(syst)] x 10(-9), leading to the determination of the weak mixing angle sin2(thetaW(eff) = 0.2397 +/- 0.0010(stat) +/- 0.0008(syst), evaluated at Q2 = 0.026 GeV2. Combining this result with the measurements of sin2(thetaW(eff) at the Z0 pole, the running of the weak mixing angle is observed with over 6sigma significance. The measurement sets constraints on new physics effects at the TeV scale.

Randomised phase 2 trial of SIR-Spheres plus fluorouracil/leucovorin chemotherapy versus fluorouracil/leucovorin chemotherapy alone in advanced colorectal cancer

PURPOSE

Selective internal radiation therapy (SIRT) with SIR-Spheres(R) is a new technique for selectively targeting high doses of radiation to tumours within the liver. The primary objectives of this randomised trial were to compare the response rate, time to progressive disease (PD), and toxicity of a regimen of systemic fluorouracil/leucovorin chemotherapy versus the same chemotherapy plus a single administration of SIR-Spheres in patients with advanced colorectal liver metastases. The trial was designed to presage a larger trial that would have survival as the primary outcome.

PATIENTS AND METHODS

Twenty-one patients with previously untreated advanced colorectal liver metastases, with or without extrahepatic metastases, were randomised into the study.

RESULTS

Using RECIST criteria, the response rate for 11 patients receiving the combination treatment was significantly greater than for 10 patients receiving chemotherapy alone (First Integrated Response; 10 PR, 1 SD vs. 0 PR, 6 SD, 4 PD, P < 0.001 and Best Confirmed Response; 8 PR, 3 SD vs. 0 PR, 6 SD, 4 PD P < 0.001). The time to PD was greater for patients receiving the combination treatment (18.6 months vs. 3.6 months, P < 0.0005). Median survival was significantly longer for patients receiving the combination treatment (29.4 months vs. 12.8 months, P = 0.02). One patient in the combination arm died from chemotherapy induced neutropenic sepsis after the fourth chemotherapy cycle. There were more Grade 3 and 4 toxicity events in patients receiving the combination treatment. There was no difference in quality-of-life over a 3 month period between the two treatments when rated by patients (P = 0.96) or physicians (P = 0.98).

CONCLUSIONS

This small phase 2 randomised trial demonstrated that the addition of a single administration of SIR-Spheres to a regimen of systemic fluorouracil/leucovorin chemotherapy significantly increased both treatment related response, time to PD, and survival with acceptable toxicity. The combination of SIR-Spheres plus systemic chemotherapy is now the subject of ongoing trials to further define patient benefit.

Epididymal sarcoidosis

Sarcoidosis is a multisystem disorder that rarely involves the genitourinary tract. To date only 28 cases of histologically proved sarcoidosis involving the epididymis have been described in the literature. Although uncommon, sarcoidosis should be considered in any differential diagnosis of testicular lesions. We present 2 cases of epididymal sarcoidosis. A 27-year-old asymptomatic black man had multiple nontender scrotal nodules on routine physical examination. A 34-year-old black man was initially diagnosed with sarcoidosis by transbronchial biopsy. He received 10 months of prednisone therapy before noticing a mass in the right testicle. Surgical exploration of both patients demonstrated noncaseating granulomatous inflammation consistent with sarcoidosis.

Comparison of "direct" and "indirect" radionuclide cystography

Thirty children were studied using both direct (catheter) and indirect techniques of radionuclide cystography. Of 54 ureters able to be compared, six showed vesico-ureteric reflux (VUR) on the direct study but were read as negative on the indirect cystogram, and five showed no reflux on the direct cystogram but were read as positive for VUR on the indirect study. (Sensitivity of 68% and specificity of 86%). Regarding ureters read as true positives on indirect study, if that ureter has ever shown reflux at any time, or if it drained a scarred kidney specificity was improved to 97% without changing the sensitivity. Concerns about the validity of indirect cystogram results and the ease of assessment and low radiation dose from the direct cystogram has made direct cystography our preferred technique.

Acute chromium poisoning in a 2 year old child

Sodium dichromate ingestion in children is uncommon and potentially lethal. The most appropriate management is uncertain because of the lack of sound data contained in the few reports of successfully treated patients. Immediate treatment should include urgent induction of emesis, administration of ascorbic acid as an antidote, followed by supportive treatment.

Toxic shock syndrome -- some new features

A thirty-year-old female presented with a high fever, conjunctivitis, confusion, vomiting, watery diarrhoea, diffuse erythroderma, shock and oliguric renal failure. Staphylococcus aureus phage 29/52 (Group 1) was isolated from a high vaginal swab. In addition to all the previously reported features which defined toxic shock syndrome, there were pustular skin vesicles, altered red cell morphology, and severe myocardial involvement. Treatment with fluid replacement, cloxacillin, haemodialysis, positive inotropic agents, and supportive measures resulted in a full recovery.

Massive hemoptysis: control by transcatheter bronchial artery embolization

Massive hemoptysis (600 ml in 48 hours) has an ominous prognosis with a mortality of 50 to 100% in medically treated patients and up to 35% in patients undergoing operation. Surgical resection has been the procedure of choice in patients with massive hemoptysis. Those with a contraindication to operation present a particularly frustrating problem. We have treated 7 such patients with massive hemoptysis by transcatheter bronchial artery embolization. In all 7, the bleeding was arrested. Two patients died of recurrent hemoptysis, 1 ten days and the other 2 months following embolization, and 5 are well 1 month to one year later. Transcatheter bronchial artery embolization is a valuable therapeutic modality in patients with massive hemoptysis. However, the procedure is palliative, and, therefore, elective resection must be considered as definitive treatment in those patients who have no contraindication to operation.

Studies of the glomerular mesangium and the juxtaglomerular apparatus in the genetically diabetic mouse

Intact and uninephrectomized genetically diabetic (db/db) mice (C57BL/KsJ) and their nondiabetic littermates (dm/m) had renal biopsies performed at 6 months of age. Renal tissues were studied by regular light microscopy and by a variety of immunohistochemical techniques. Intact db/db mice had peripheral mesangial thickening as compared to db/m mice. This thickening, predominantly due to increased mesangial matrix material, extended to the glomerular hilum and the extraglomerular mesangium of the juxtaglomerular apparatus. This abnormality was markedly increased an uninephrectomized db/db mice (db/db-UN) compared to intact db/db mice. Db/m-UN animals had slightly greater mesangial thickness than intact db/mice but less than that of db/db mice. Intact db/db mice had increased mesangial IgM staining compared to db/m mice and these differences were magnified by uninephrectomy. The IgM staining, especially in the diabetic mice, involved the peripheral mesangium and the glomerular hilum extending into extraglomerular mesangium and the distal tubule at the level of the macula densa. The tubular staining in the region of the juxtaglomerular apparatus was between the tubular basement membrane and the epithelial cells and between epithelial cells. The distal tubular epithelial cell cytoplasm also showed increased staining for IgM as the tubule coursed away from the glomerulus. These studies amplify the argument that alterations in glomerular hemodynamics influence the rate of development of diabetic glomerular lesions. Further, these diabetic mice appear to represent an important model for the study of mesangial macromolecular processing mechanisms.

Membranoproliferative glomerulonephritis type 1: comparison of natural history in children and adults

Clinical, laboratory and pathological data on 46 patients (29 children and 17 adult) with Type 1 membranoproliferative glomerulonephritis (MPGN) were reviewed in order to compare the natural history of the disease in two age groups. The nephrotic syndrome was the most common presenting clinical feature in both age groups. Established renal failure at time of biopsy was seen in adult males only. All the adults males, but none of the women, were either dead or in renal failure after a mean duration of diseases of 17.7 months. In contrast 43% of the children (both sexes) were in renal failure after a mean duration of disease of 51.6 months. Statistical analysis disclosed that only up to 48 months was there a significant difference in survival between the two age groups (P less than .01). Beyond this time the difference was not statistically significant. The difference in behaviour of MPGN in the two age groups is similar to that observed in other glomerulonephropathies.

Effects on small-intestinal function and structure induced by feeding a deconjugated bile salt

Feeding sodium deoxycholate orally to rats for three days caused inhibition of small-intestinal active sugar transport and ouabain-sensitive, sodium-potassium-dependent adenosine triphosphatase activity. At the same time, there was evidence of extensive ultrastructural damage to the microvillar and intracellular compartments of the small-intestinal epithelium while its light microscopic appearance was essentially normal. These functional and morphological changes reverted towards normal over the subsequent four days when a normal diet, without added bile salt, was reintroduced.