PIPELINEs: Creating Comparable Clinical Knowledge Efficiently by Linking Trial Platforms

Adaptive, seamless, multisponsor, multitherapy clinical trial designs executed as large scale platforms, could create superior evidence more efficiently than single-sponsor, single-drug trials. These trial PIPELINEs also could diminish barriers to trial participation, increase the representation of real-world populations, and create systematic evidence development for learning throughout a therapeutic life cycle, to continually refine its use. Comparable evidence could arise from multiarm design, shared comparator arms, and standardized endpoints-aiding sponsors in demonstrating the distinct value of their innovative medicines; facilitating providers and patients in selecting the most appropriate treatments; assisting regulators in efficacy and safety determinations; helping payers make coverage and reimbursement decisions; and spurring scientists with translational insights. Reduced trial times and costs could enable more indications, reduced development cycle times, and improved system financial sustainability. Challenges to overcome range from statistical to operational to collaborative governance and data exchange.

Survival results with AP23573, a novel mTOR inhibitor, in patients (pts) with advanced soft tissue or bone sarcomas: Update of phase II trial

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Background: AP23573 is an mTOR inhibitor that has demonstrated single-agent activity in a broad range of sarcoma tumor types in phase I phase II trials. Overall survival (OS) was monitored to characterize OS in the treated population and in the subset of patients who achieved a clinical benefit response (CBR). Methods: Pts with advanced sarcomas, with no restrictions on prior therapies, were enrolled into 4 cohorts based on histologic subtype, in a phase 2, Simon's 2-stage trial. AP23573 (12.5 mg, i.v.) was administered daily × 5 every 2 wks. Efficacy was assessed using RECIST, with CBR defined as a complete or partial response or stable disease for at least 16 wks duration. OS was defined as the time from the first dose of AP23573 to the date of death from any cause. Kaplan-Meier estimates of the survival times of the population were calculated with OS time censored at the last date the pt was known to be alive when the confirmation of death is absent or unknown. Patients are continuing to be followed for OS in this ongoing trial. Results: 212 pts (105 M/107 F; median age, 50.6 yrs ([17–79 yrs]) were treated. Most pts (79%) had received =2 prior treatments, and over 90% of pts had disease progression at time of enrollment. The overall CBR rate was 29%, including 5 PRs (4 bone sarcoma, 1 MFH). The median OS was 40.1 wks for the entire study population. In the subset of patients achieving CBRs the median time to OS was 67.6 wks, suggesting that achievement of CBR, which is a measure of tumor control, correlates with extending OS. Conclusions: AP23573 exhibits single-agent activity in pts with advanced sarcomas as demonstrated by the CBR rate as a primary efficacy endpoint. The results of the OS analysis suggest that achieving a CBR in this pt population can result in prolonged survival. The consistency of this finding should be further examined with other pt factors that are also hypothesized to correlate for survival in this pt population.

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Levator claviculae muscle discovered during physical examination for cervical lymphadenopathy

During a routine physical examination of an adult female with a history of breast cancer and cervical lymphadenopathy, a mass was noted in the right supraclavicular region. The mass was unilateral and easily palpable along the superior border near the median aspect of the clavicle. Plain film radiography, performed to determine whether the mass represented an enlarged jugulo-omohyoid lymph node, revealed an elongated opaque mass in this region. Computed tomographic (CT) and magnetic resonance (MR) images were subsequently obtained. Sequential axial CT scans revealed a cylindrical mass that appeared to be independent of contiguous muscles, including the sternocleidomastoid, anterior, and middle scalene muscles. This mass attached inferiorly to the clavicle and superiorly to the transverse process of the sixth cervical vertebra. Sagittal, coronal, and axial MR scans confirmed the presence of a well-defined superficial mass. It is concluded that the mass represents a levator claviculae (cleidocervical) muscle. This observation underscores the importance of understanding soft tissue variants that may be encountered during a routine physical examination.

Mechanism and amelioration of recombinant human interleukin-11 (rhIL-11)-induced anemia in healthy subjects

Recombinant human interleukin-11 (rhIL-11), or Neumega rhIL-11 Growth Factor, is a recombinant cytokine that stimulates megakaryocytopoiesis, increases platelet production, and also has shown anti-inflammatory and immune-modulating activity. Mild, reversible anemia was the most common adverse event observed in clinical studies and was demonstrated to be related to hemodilution. The purpose of this study was to examine the renal mechanisms of the rhIL-11-induced volume retention and devise a possible therapeutic intervention to ameliorate this effect. Eighteen healthy volunteers (9 male and 9 female) on a controlled sodium (180 mEq/day) and potassium (120 mEq/day) diet were randomized to one of six treatment sequences in a three-period crossover design. Each subject received 25 micrograms/kg IL-11 s.c. once daily, 25 micrograms/kg IL-11 s.c. once daily + Maxzide-25 twice daily, or placebo for 7 days in a crossover design. There was a 14-day washout period between treatment periods. Renal clearance parameters indicated that mean sodium excretion was decreased compared to placebo within 8 hours after dosing with rhIL-11, with these results reaching statistical significance 8 to 16 hours postdose (p < 0.01). The cumulative sodium excretion (mEq +/- SD) over the 7-day treatment period for each respective treatment group was the following: rhIL-11 = 833 +/- 154, rhIL-11 + Maxzide-25 twice daily = 1114 +/- 178, and placebo = 982 +/- 193 (p < 0.01). Hemoglobin concentration and hematocrit values, used as indicators of hemodilution, decreased in the rhIL-11-treated group as compared to the baseline and placebo groups (p < 0.01). Concurrent dosing with Maxzide-25 twice daily reduced the rhIL-11-associated hemodilution by about 50%.

Hepatocellular adenomatosis associated with hereditary haemochromatosis

A young healthy man presented with abdominal pain following an accidental fall. Imaging studies and laparoscopy revealed multiple yellowish well-defined hepatic lesions. Liver biopsies showed hepatic adenomas and iron overload. Laboratory investigation confirmed a diagnosis of hereditary haemochromatosis. To our knowledge this represents the first report of an association of hepatic adenomatosis and primary haemochromatosis.

Skeletal metastases in colorectal carcinomas: a Saskatchewan profile

PURPOSE

Colorectal cancer is the third leading cause of cancer-related deaths in the world. Death is usually attributed to progress of the disease with recurrence and metastases. Skeletal metastases in primary colorectal cancer is an uncommon event. When such an event occurs, it is usually a late manifestation of the disease. In our study this phenomenon is analyzed in a population-based database.

METHODS

This report is a 25-year retrospective review that covers patients with skeletal metastases secondary to colorectal carcinomas registered at The Saskatchewan Cancer Foundation from 1970 to 1995. The latter is the sole registration agency of all cancers in the one million population base of the province of Saskatchewan.

RESULTS

A total of 5,352 cases of primary colorectal carcinomas were seen between 1970 and 1995. Of these, 355 had skeletal metastases. The incidence of osseous metastases in our institution is 6.6 percent. Among the latter, 60 cases (16.9 percent) had skeletal metastases only, whereas 295 cases (83.1 percent) had skeletal metastases in combination with lung, liver or brain metastases. This is in keeping with the fact that solitary skeletal metastases from a primary colonic carcinoma is a rare event, with an incidence of 1.1 percent in our institution. The disease-free interval from the time of diagnosis of the cancer to the onset of skeletal metastases ranged from 10 days to 5,309 days. Thirty-eight percent of the cases with skeletal metastases only were alive at the end of five years in comparison with 16 percent of the cases with skeletal and other metastases. However, there was no significant difference in the ten-year survival curves from the onset of osseous metastases in the two groups. The majority were diagnosed by a bone scan or plain radiography or both. Most cases in our institution received a multimodal treatment consisting of radiotherapy in conjunction with palliative surgery or chemotherapy or both. Radiotherapy was, however, the most effective therapy for painful skeletal metastases.

CONCLUSION

Skeletal metastasis is a rare event in primary colorectal carcinomas. Among these cases there is an emerging trend of a different clinical-biological behavior pattern between patients who develop solitary skeletal metastases vs. patients with skeletal and other organ metastases.

Dedifferentiated chondrosarcoma with features of telangiectatic osteosarcoma

We describe a 44-year-old female with a known history of a solitary osteochondroma of the scapula followed on X-ray for five years. She then presented with a rapidly growing lump. Imaging studies confirmed the presence of an aggressive looking lesion. Excision was performed and pathology showed a dedifferentiated chondrosarcoma with features of a telangiectatic osteosarcoma.

Preliminary evaluation of safety and activity of recombinant human interleukin 11 in patients with active Crohn's disease

BACKGROUND & AIMS

Recombinant human interleukin 11 (rhIL-11) is a cytokine with thrombocytopoietic activity and anti-inflammatory and mucosal protective effects. The objectives of this study were to investigate the safety and tolerability of rhIL-11 in patients with Crohn's disease and to explore the effects of dose and schedule on platelet count and Crohn's disease activity.

METHODS

A multicenter, double-masked, placebo-controlled, dose-escalation study of 76 patients with active Crohn's disease was performed. Patients were randomized to receive subcutaneous placebo or rhIL-11 at doses of 5, 16, or 40 microgram. kg-1. wk-1 given 2 or 5 times weekly for 3 weeks. Clinical and laboratory safety data were recorded, and disease activity was measured at each visit.

RESULTS

Subcutaneous injection of rhIL-11 generally was well tolerated. Significantly greater increases in platelet counts were found among patients receiving rhIL-11 40 microgram. kg-1. wk-1 as 2 or 5 weekly doses and 16 microgram. kg-1. week-1 as 5 weekly doses compared with patients receiving placebo (P < 0.05). Patients receiving 16 microgram. kg-1. wk-1 had the highest clinical response rates, with a response seen in 42% of patients (5/12) receiving 5 weekly doses and 33% of patients (4/12) receiving 2 weekly doses, compared with 7% of patients (1/15) receiving placebo.

CONCLUSIONS

Short-term treatment with rhIL-11 is well tolerated in patients with active Crohn's disease. The thrombocytopoietic effect of rhIL-11 seems to be both dose and schedule dependent and may be minimized with retained clinical benefit in Crohn's disease at 16 microgram. kg-1. wk-1 given in 2 equal doses.

A randomized trial of recombinant human interleukin-11 following autologous bone marrow transplantation with peripheral blood progenitor cell support in patients with breast cancer

This study assessed the safety and efficacy of recombinant human interleukin (rhIL)-11 in decreasing platelet transfusion requirements in patients with breast cancer who were undergoing autologous bone marrow transplantation (ABMT) with peripheral blood progenitor cell (PBPC) support. After high-dose therapy with cyclophosphamide, cisplatin, and carmustine, 80 patients were randomized to one of three treatment groups: placebo (26), 25 microg/kg of rhIL-11 (28), and 50 microg/kg of rhIL-11 (26). Of those randomized, 75 (94%) received at least one dose of the masked study drug and the remaining 5 (6%) withdrew consent before study drug administration. In the placebo group, each patient received an average 12.4 (+/-10.2) platelet transfusions vs. 9.2 (+/-5.0) in the 25-microg/kg rhIL-11 group (p = 0.17) and 9.9 (+/-3.5) in the 50-microg/kg rhIL-11 group (p = 0.34). There was no statistically significant difference between the rhIL-11 groups and the placebo group in the median number of days to platelet recovery. Neutrophil and red blood cell recovery were similar for all treatment groups. The imbalance in the number of patients already alloimmunized at study entry in the rhIL-11 groups (12) and in the placebo group (1) may have confounded the primary efficacy assessment. Most adverse events were related to the high-dose chemotherapy. Generally mild edema and minor conjunctival bleeding (grades 1 or 2) were statistically associated with rhIL-11 administration (p < 0.04). There was no association between rhIL-11 and the occurrence of atrial arrhythmias, although there was a suggestion of an association with rhIL-11, 5 of 50 cases vs. 1 of 25 in the placebo group. Two cardiovascular events, tachycardia and hypotension (grade 1 or 2), occurred in the 50-microg/kg rhIL-11 group. The number of patients who discontinued study drug dosing because of an adverse event was distributed across all treatment groups. In summary, rhIL-11 was safe and well tolerated in this study. The results did not demonstrate that rhIL-11 treatment significantly decreased platelet transfusion requirements after high-dose chemotherapy with ABMT and PBPC support.

Apophysial joint degeneration, disc degeneration, and sagittal curve of the cervical spine. Can they be measured reliably on radiographs?

STUDY DESIGN

Interexaminer reliability study.

OBJECTIVES

To determine the reliability of grading apophysial joint and disc degenerative changes and the reliability of measuring sagittal curves on lateral cervical spine radiographs.

SUMMARY OF BACKGROUND DATA

Several authors have proposed that the presented of degenerative changes and the absence of lordosis in the cervical spine are indicators of poor recovery from neck injuries caused by motor vehicle collisions. The validity of those conclusions is questionable because the reliability of the methods used in their studies to measure the presence of degenerative changes and the absence of lordosis has not been determined.

METHODS

Kellgren's classification system for apophysial joint and disc degeneration, as well as the pattern and magnitude of the sagittal curve on 30 lateral cervical spine radiographs were assessed independently by three examiners.

RESULTS

Moderate reliability was demonstrated for classifying apophysial joint degeneration with an intraclass correlation coefficient of 0.45 (95% confidence interval, 0.09-0.71). Classifying degenerative disc disease had substantial reliability, with an intraclass correlation coefficient of 0.71 (95% confidence interval, 0.23-0.88). Measuring the magnitude of the sagittal curve from C2 to C7 had excellent interexaminer agreement, with an intraclass correlation coefficient of 0.96 (95% confidence interval, 0.88-0.98) and an interexaminer error of 8.3 degrees.

CONCLUSIONS

The classification system for degenerative disc disease proposed by Kellgren et al and the method of measurement of sagittal curves from C2 to C7 demonstrated an acceptable level of reliability and can be used in outcomes research.

Value of three-dimensional gradient-echo magnetic resonance cholangiography in diagnosing choledocholithiasis

OBJECTIVE

To evaluate the role of magnetic resonance cholangiography (MRC) in patients with suspected choledocholithiasis.

PATIENTS AND METHODS

Twenty-six consecutive patients with suspected choledocholithiasis (11 men and 15 women ranging in age from 25 to 81 years) underwent three-dimensional gradient-echo MRC; each patient also underwent endoscopic retrograde cholangiography or operative cholangiography. Each set of images for each patient was reviewed independently by a radiologist who was unaware of the results of the other type of imaging.

RESULTS

Diagnostic-quality MRC images were obtained for 17 of the patients. Of these, 13 had stones in the common bile duct, as confirmed by another imaging method, and MRC indicated the presence of these stones in all 13 patients. In the other four patients bile duct obstruction was due to either acute pancreatitis (in three) or cholangiocarcinoma (in one). For seven of the nine nondiagnostic-quality MRC studies, the bile duct was not obstructed, so there was no bile stasis and the MRC images could not be obtained. Motion artifacts due to inability to hold the breath were the limiting factors in the other two patients.

CONCLUSION

Although MRC has some limitations, this new noninvasive technique may be used as a screening test in selected patients with suspected choledocholithiasis.

A phase I trial of recombinant human interleukin-11 (neumega rhIL-11 growth factor) in women with breast cancer receiving chemotherapy

We performed a phase I trial of recombinant human interleukin-11 (rhIL-11) in women with breast cancer. Cohorts of three to five women were accrued to five dosage levels of rhIL-11 (10, 25, 50, 75, and 100 micrograms/kg/d). rhIL-11 alone was administered by a daily subcutaneous injection for 14 days during a 28-day prechemotherapy "cycle 0." Patients (pts) subsequently received up to four 28-day cycles of cyclophosphamide (1,500 mg/m2) and doxorubicin (60 mg/m2) chemotherapy followed by rhIL-11 at their assigned dose (days 3 through 14). Sixteen pts (13 stage IV, 3 stage IIIB) were accrued to this study. Median age was 53 years and median Eastern Cooperative Oncology Group Performance Status was 0. A grade 3 neurologic event was seen in 1 pt at 100 micrograms/kg. Because of the degree of grade 2 constitutional symptoms (myalgias/arthralgias and fatigue) at 75 micrograms/kg, dose escalation was stopped and 75 micrograms/kg was the maximally tolerated dose. No other grade 3 or 4 adverse events related to rhIL-11 were seen. The administration of rhIL-11 was not associated with fever. Reversible grade 2 fatigue and myalgias/arthralgias were seen in all pts at 75 micrograms/kg. Weight gain of 3% to 5% associated with edema was seen at doses > 10 micrograms/kg but a capillary leak syndrome was not seen. rhIL-11 alone was associated with a mean 76%, 93%, 108%, and 185% increase in platelet counts at doses of 10, 25, 50, and 75 micrograms/kg, respectively. No significant changes in leukocytes were seen. A mean 19% decrease in hematocrit was observed. Acute-phase proteins increased with treatment at all doses. Compared with patients at the 10 micrograms/kg dose, patients receiving doses > or = 25 micrograms/kg experienced less thrombocytopenia in the first two cycles of chemotherapy. We conclude that rhIL-11 has thrombopoietic activity at all doses studied, is well tolerated at doses of 10, 25, and 50 micrograms/kg, and at doses > or = 25 micrograms/kg has the potential to reduce chemotherapy-induced thrombocytopenia in this model.

Postoperative computed tomography scan study of the pterygomaxillary separation during the Le Fort I osteotomy using a micro-oscillating saw

PURPOSE

The objective of the study was to evaluate the type of pterygomaxillary separation that occurs with use of a micro-oscillating saw.

PATIENTS AND METHODS

Sixteen patients underwent a postoperative computed tomography scan.

RESULTS

Ideal or near-ideal separations occurred on 26 of 32 sides (81%), while low-level fractures occurred in 6 of 32 sides (19%). No high-level fractures of the pterygoid plates, or fractures extending to the base of the skull or orbit, were seen. There was a striking difference in the number of ideal separations on the right-hand side (94%), compared with the left-hand side (50%), probably because of the greater difficulty of a right-handed surgeon positioning the saw blade correctly on the left side without bending the thin flexible saw blade backward.

CONCLUSION

In view of the high percentage of ideal pterygomaxillary separations achieved using a micro-oscillating saw, and the absence of high-level pterygoid plate fractures extending to the base of the skull, this technique is recommended for the pterygomaxillary dysjunction.

Outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer

BACKGROUND

Hospitalization and intravenous (IV) broad-spectrum antibiotics are the standard of care for all febrile neutropenic patients with cancer. Recent work suggests that a low-risk population exists who might benefit from an alternate approach.

METHODS

A prospective randomized clinical trial was performed comparing oral ciprofloxacin 750 mg plus clindamycin 600 mg every 8 hours with IV aztreonam 2 g plus clindamycin 600 mg every 8 hours for the empiric outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer.

RESULTS

The oral regimen cured 35 of 40 episodes (88% response rate), whereas the IV regimen cured 41 of 43 episodes (95% response rate, P = 0.19). Although the cost of the oral regimen was significantly less than that of the IV regimen (P < 0.0001), it was associated with significant renal toxicity (P < 0.05), which led to early termination of the study. Overall, combining its safety and efficacy, the IV regimen was superior (P = 0.03).

CONCLUSIONS

This prospective study suggested that outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients with cancer is safe and effective. Better oral regimens are needed.

Outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer

BACKGROUND

Hospitalization and intravenous (IV) broad-spectrum antibiotics are the standard of care for all febrile neutropenic patients with cancer. Recent work suggests that a low-risk population exists who might benefit from an alternate approach.

METHODS

A prospective randomized clinical trial was performed comparing oral ciprofloxacin 750 mg plus clindamycin 600 mg every 8 hours with IV aztreonam 2 g plus clindamycin 600 mg every 8 hours for the empiric outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer.

RESULTS

The oral regimen cured 35 of 40 episodes (88% response rate), whereas the IV regimen cured 41 of 43 episodes (95% response rate, P = 0.19). Although the cost of the oral regimen was significantly less than that of the IV regimen (P < 0.0001), it was associated with significant renal toxicity (P < 0.05), which led to early termination of the study. Overall, combining its safety and efficacy, the IV regimen was superior (P = 0.03).

CONCLUSIONS

This prospective study suggested that outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients with cancer is safe and effective. Better oral regimens are needed.

Ventilation scintigraphy with submicronic radioaerosol as an adjunct in the diagnosis of congenital lobar emphysema

When clinical examination and routine chest x-ray do not adequately explain neonatal respiratory distress, lung scintigraphy using a submicronic aerosol particle may be most helpful. Three cases illustrating this point are presented. Discussion centers around the diagnosis of an atypical case of congenital lobar emphysema (CLE), and differentiating between CLE, foreign body aspiration and compensatory hyperinflation in neonates with respiratory distress. Conservative and surgical treatment options for CLE are also illustrated.