TTCC-2019-02: real-world evidence of first-line cetuximab plus paclitaxel in recurrent or metastatic squamous cell carcinoma of the head and neck

Objectives

The aim of this study was to confirm the efficacy of the ERBITAX scheme (paclitaxel 80 mg/m2 weekly and cetuximab 400 mg/m2 loading dose, and then 250 mg/m2 weekly) as first-line treatment for patients with recurrent/metastatic squamous cell carcinoma of the head and neck (SCCHN) who are medically unfit for cisplatin-based (PT) chemotherapy.

Materials and methods

This retrospective, non-interventional study involved 16 centers in Spain. Inclusion criteria were to have started receiving ERBITAX regimen from January 2012 to December 2018; histologically confirmed SCCHN including oral cavity, oropharynx, hypopharynx, and larynx; age ≥18 years; and platinum (PT) chemotherapy ineligibility due to performance status, comorbidities, high accumulated dose of PT, or PT refractoriness.

Results

A total of 531 patients from 16 hospitals in Spain were enrolled. The median age was 66 years, 82.7% were male, and 83.5% were current/former smokers. Patients were ineligible to receive PT due to ECOG 2 (50.3%), comorbidities (32%), PT cumulative dose ≥ 225 mg/m2 (10.5%), or PT refractoriness (7.2%). Response rate was 37.7%. Median duration of response was 5.6 months (95% CI: 4.4-6.6). With a median follow-up of 8.7 months (95% CI: 7.7-10.2), median PFS and OS were 4.5 months (95% CI: 3.9-5.0) and 8.9 months (95% CI: 7.8-10.3), respectively. Patients treated with immunotherapy after ERBITAX had better OS with a median of 29.8 months compared to 13.8 months for those who received other treatments. The most common grade ≥ 3 toxicities were acne-like rash in 36 patients (6.8%) and oral mucositis in 8 patients (1.5%). Five (0.9%) patients experienced grade ≥ 3 febrile neutropenia.

Conclusion

This study confirms the real-world efficacy and tolerability of ERBITAX as first-line treatment in recurrent/metastatic SCCHN when PT is not feasible. Immunotherapy after treatment with ERBITAX showed remarkable promising survival, despite potential selection bias.

Incidence, risk factors, and evolution of venous thromboembolic events in patients diagnosed with pancreatic carcinoma and treated with chemotherapy on an outpatient basis

BACKGROUND

Pancreatic carcinoma is one of the tumors associated with a higher risk for thromboembolic events, with incidence rates ranging from 5% to 41% in previous retrospective series.

PATIENTS AND METHODS

We conducted a retrospective study in eleven Spanish hospitals that included 666 patients diagnosed with pancreatic carcinoma (any stage) between 2008 and 2011 and treated with chemotherapy. The main objective was to evaluate the incidence of venous thromboembolic events (VTE) in this population, as well as potential risk factors for thrombosis. The impact of VTE on mortality was also assessed.

RESULTS

With a median follow-up of 9.3 months, the incidence of VTE was 22.1%; 52% were diagnosed incidentally. Our study was unable to confirm the ability of the Khorana score to discriminate between patients in the intermediate or high risk category for thrombosis. The presence of VTE proved to be an independent prognostic factor associated with increased risk of death (HR 2.39, 95% CI 1.96-2.92). Symptomatic events correlated with higher mortality than asymptomatic events (HR 1.72; 95% CI, 1.21-2.45; p = 0.002), but incidental VTE, including visceral vein thrombosis (VVT), negatively affected survival compared to patients without VTE. Subjects who developed VTE within the first 3 months of diagnosis of pancreatic carcinoma had lower survival rates than those with VTE after 3 months (HR 1.92, 95% CI 1.30-2.84; p<0.001).

CONCLUSIONS

Pancreatic carcinoma is associated with a high incidence of VTE, which, when present, correlates with worse survival, even when thrombosis is incidental. Early onset VTE has a particularly negative impact.

Gemcitabine-erlotinib versus gemcitabine-erlotinib-capecitabine in the first-line treatment of patients with metastatic pancreatic cancer: Efficacy and safety results of a phase IIb randomised study from the Spanish TTD Collaborative Group

BACKGROUND

Gemcitabine and erlotinib have shown a survival benefit in the first-line setting in metastatic pancreatic cancer (mPC). The aim of this study was to assess whether combining capecitabine (C) with gemcitabine + erlotinib (GE) was safe and effective versus GE in patients with mPC.

PATIENTS AND METHODS

Previously untreated mPC patients were randomised to receive G (1000 mg/m², days 1, 8, 15) + E (100 mg/day, days 1-28) + C (1660 mg/m², days 1-21) or GE, q4 weeks, until progression or unacceptable toxicity. Primary end-point: progression-free survival (PFS); secondary end-points: overall survival (OS), response rate, relationship of rash with PFS/OS and safety.

RESULTS

120 patients were randomised, median age 63 years, ECOG status 0/1/2 33%/58%/8%; median follow-up 16.5 months. Median PFS in the gemcitabine-erlotinib-capecitabine (GEC) and GE arms was 4.3 and 3.8 months, respectively (hazard ratio [HR]: 0.88, 95% confidence interval [CI]: 0.58-1.31; p = 0.52). Median OS in the GEC and GE arms was 6.8 and 7.7 months, respectively (HR: 1.09, 95% CI: 0.72-1.63; p = 0.69). Grade 3/4 neutropenia (GEC 43% versus GE 15%; p = 0.0008) and mucositis (GEC 9% versus GE 0%; p = 0.03) were the only statistically significant differences in grade 3/4 adverse events. PFS and OS were significantly longer in patients with rash (grade ≥1) versus no rash (grade = 0): PFS 5.5 versus 2.0 months (HR = 0.39, 95% CI: 0.26-0.6; p < 0.0001) and OS: 9.5 versus 4.0 months (HR = 0.51, 95% CI: 0.33-0.77; p = 0.0014).

CONCLUSION

PFS with GEC was not significantly different to that with GE in patients with mPC. Skin rash strongly predicted erlotinib efficacy. The study was registered with ClinicalTrials.gov: NCT01303029.

Use of an autologous bioengineered composite skin in extensive burns: Clinical and functional outcomes. A multicentric study

OBJECTIVE

We report clinical and functional outcomes obtained after application of an autologous bioengineered composite skin (ABCS) produced in a single Spanish tissue-engineering unit.

MATERIALS/METHODS

Twenty-five burned patients treated with ABCS from 1999 to 2007 in five burn centres were included in the study. Mean age was 29 years (SD 11), with mean total body surface area (TBSA) burned being 74% (SD 17) and mean full-thickness injury of 61% (SD 19) of TBSA.

RESULTS

The mean area initially engrafted with ABCS was 24% (SD 13) of TBSA, with a final take of 49% (SD 30, range 0-100%). ABCS achieved permanent coverage of a mean of 11% (SD 8) of TBSA. In subset analyses, lack of pre- and post-application wound bed infection and lack of serious acute systemic complications at the time of engraftment were significantly associated with better ABCS take.

CONCLUSIONS

Final take obtained with ABCS could be improved with the use of non-cytotoxic topical antibiotics following engraftment. The use of plasma to prepare ABCS reduces production costs: cost-effectiveness ratio is not a limitation for its use. In terms of patient satisfaction, cosmetic/functional outcomes (general appearance, texture, flexibility, sensitivity and colour) of ABCS and split-thickness autografts are not different statistically.

Quality of life and psychometric functionality in patients with differentiated thyroid carcinoma

We studied the psychological performance and the quality of life in patients with differentiated thyroid carcinoma, either during treatment with chronic suppressive doses of levothyroxine, or during the withdrawal of levothyroxine needed to perform whole-body scanning with radioactive iodine, with those of appropriate healthy controls. Eighteen women with differentiated thyroid carcinoma and 18 euthyroid age-matched healthy women were recruited. Patients were studied the day before levothyroxine withdrawal (when in chronic mild or subclinical hyperthyroidism), 4-7 days later (when most patients had normal serum free thyroxine and free triiodothyronine levels), and the day before scanning (when in profound hypothyroidism). Controls were studied at one time point. When compared with controls, patients presented with impairment of several indexes during chronic suppressive levothyroxine therapy (total score, emotional, sleep, energy and social of the Nottingham Health Profile; mental health, general health and social function of the SF-36, and total score on Wais Digit Span; P<0.05 for all comparisons). Also, quality of life indexes (19 of 21 scores), cognitive tests (6 of 12 scores), and affective and physical symptoms visual mental scales (18 of 19) worsened during profound hypothyroidism (P<0.05 for all comparisons). Quality of life and cognitive performance were almost comparable with those of euthyroid controls when most patients had normal free thyroxine and triiodothyronine levels. In conclusion, quality of life and psychometric functionality in patients with differentiated thyroid carcinoma is not only affected by withdrawal of levothyroxine but also by long-term treatment with supraphysiological doses of levothyroxine.

[Comparative analysis of the clinical history and polysomnography in sleep disorders. Diagnostic relevance of polysomnography]

INTRODUCTION

The incidence of associate pathologies has been studied during the sleep, as well as the diagnostic efficiency of the clinical history.

PATIENTS AND METHODS

Patients (n = 136) remitted by diverse services, have been studied. It has been carried out a complete polysomnography, as well as other supplementary studies (anxiety and depression tests, excessive daytime sleepiness Epworth's test, EEG and sleep notebook).

RESULTS

The most common symptom turned out to be the primary snores, followed by the excessive daytime sleepiness and apneas. The results of the excessive daytime sleepiness Epworth's test and the anxiety and depression tests were not useful to differ among pathologies, not even between pathologies and patients with normal sleep. The percentage of diagnosis of suspicion confirmed by the polysomnography was of 39.7%, while in 11% of the total of patients it was observed the existence of more than a pathology of the sleep. In 49.3% of the cases the polysomnographic diagnosis was completely different from the diagnosis of suspicion. Among the patients with clinic suspicion of apnoea, in 48.3% of the cases the existence of the same one was verified, although in 14.6% it was associated with other pathologies. In 51.7% of the patients it was not possible to confirm this pathology.

CONCLUSIONS

The clinical history is not enough for the diagnosis of the pathologies of the sleep. On the other hand, the existence of associate pathologies diminishes the value of several 'screening-methods'. Therefore, it is fundamental to carry out a complete polysomnography in all the patients that present any sleep disorder on the part of doctors that approach the problem of the sleep in a global way and not only thinking in the possible existence of syndrome of sleep apnoea.

[Behavior disorders during REM sleep. Two clinical cases]

INTRODUCTION

The behavior disorder occurring during REM (Rapid Eye Movement) sleep is a parasomnia characterized by absence of atonia typical of this phase of sleep, although the other characteristics are maintained, namely rapid eye movements and desynchronization of cortical electrical activity. Clinically it is accompanied by abrupt, often violent movements, which may involve a limb or the trunk in relation to dreams typical of this phase of sleep, and which may interrupt sleep. Many pathological processes have been described, including: the Shy-Dragger syndrome, Parkinson's disease, olivopontocerebellar atrophy, multisystemic atrophy, in relation to certain antidepressant drugs, and most frequently the idiopathic form.

CLINICAL CASES

We present two cases, one diagnosed as olivopontocerebellar atrophy and another in which there were no pathological findings. Both were referred to our department for the study of possible sleep disorders. In both cases neurophysiological studies, basically polysomnography with monitorization of various muscle groups and video, led to the diagnosis.

CONCLUSIONS

We discuss the diagnostic and physiological criteria, and physiopathological explanations of each case, with special reference to N-Methyl-D-Aspartate (NMDA) and non-N-Methyl-D-Aspartate (non-NMDA) receptors. Finally we consider the pharmacological treatment of this disorder.

[Neurophysiological study in Alpers syndrome]

INTRODUCTION

Infantil progressive polydystrophy was described by Alpers in a child with psychomotor retardation, crises which were resistant to treatment and diffuse loss of cortical neurons.

OBJECTIVE

The aim of this study was to review the neurophysiological aspects of Alpers syndrome and their clinical correlation.

MATERIAL AND METHODS

We present three children with subacute encephalopathy, progressive psychomotor retardation, myoclonic epilepsy which was resistant to treatment and crises of apnea, who had degeneration of the cerebral grey matter. Serial EEG, polysomnographs, auditory evoked potentials of the brain stem and visual evoked potentials were done.

RESULTS

The electroencephalogram findings showed the presence of complex bursts of acute waves, small many-pointed or slow waves of great amplitude which were irregular and arrhythmical, lasting one to five seconds, separated by periods of inactivity on the tracing which lasted from three to ten seconds. The EEG was distinctive, changing over the course of the illness, and with increasing numbers and duration of the bursts of suppression of cerebral bioelectric activity. Polysomnography showed cerebral bioelectric activity which was markedly unstructured and with little difference between the tracings when asleep and when awake, together with a large number of apneas of obstructive and mixed types. The PEAT showed reduced amplitude and altered morphology in all the waves, and even absence of some of them. The visual evoked potentials were asymmetrical and with delay in the latency of the P100 wave.

CONCLUSIONS

Although definite diagnosis of progressive neurone degeneration requires post mortem examination of the brain, clinico-pathological studies, including electrophysiological, radiological and biochemical studies are sufficiently characteristic to suggest the diagnosis during life.

[Neurophysiological aspects of Proteus syndrome]

INTRODUCTION

The Proteus Syndrome was defined in 1983 by Wiedeman. However, the first case mentioned in the literature was that of Joseph Merrick, the Elephant Man, presented by Sir Frederick Treves in 1884. It is a rare pathological condition. Its multiple clinical features include; partial gigantism of hands and/or feet, pigmented nevi, hemihypertrophy of the body, tumors, skeletal anomalies, growth disorders and visceral anomalies. Hereditary transmission has not been clearly defined. Diagnosis and treatment require the participation of experts from several medical and surgical specialties.

CLINICAL CASE

We present a case sent to our hospital for the surgical correction of cranio-facial malformations. Epileptic crises post-operatively indicated the need for neurological and neuro-physiological study. This was done by means of conventional electro-encephalography: brainstem, somato-sensorial and visual auditory evoked potentials, together with imaging techniques which showed the structural and functional asymmetry of the central nervous system at both cerebral and brainstem levels.

CONCLUSIONS

Few neuro-physiological studies are included in the literature we reviewed for this paper. Therefore we do not know whether the functional anomalies of the central nervous system which we describe should be considered to be part of the syndrome.

[Clinical and urodynamic study of enuresis in a juvenile male population]

We carried out a clinical and urodynamic assay of 100 cases of enuresis of a male population of ages ranging from 17 to 25. 64% displayed urodynamic alterations and these were significantly greater (p less than 0.005) amongst those suffering from nocturnal enuresis with diurnal symptoms (90%) than amongst those suffering from nocturnal enuresis only (59%). 36% of the patients did not display any urodynamic alteration. The urodynamic dysfunction most commonly displayed was vesical instability (46%). The other urodynamic dysfunctions found were 18% of the total, and detrusor contraction alteration constituted 10% of these (2 of the cases corresponded to vesical-urethral neurogenic dysfunction). The presence of minimum latent rachichisis was accompanied by urodynamic alterations in a significantly larger proportion (p less than 0.005) than in individuals not displaying this. The three case of wide-scale rachischisis were accompanied by urodynamic alterations corresponding to vesico-urethral neurogenic dysfunction. The case of secondary enuresis displayed neither urodynamic nor radiological alterations. Juvenile age enuresis displayed similar characteristics to infantile enuresis, although the percentage of vesical instability was lower. However, detrusor contraction alterations increased and the presence of previously non diagnosed vesico-urethral neurogenic dysfunctions was displayed.