Specificities of clinical research in radiotherapy

The aim of this review is to present the specificities of clinical research in radiation oncology. Objectives are similar to all research in oncology: to improve the efficacy and to decrease toxic effects. Phase III trials remain the main methodology to demonstrate an improvement in efficiency, but phase I-II and registers are also important tools to validate an improvement in the therapeutic index with new technologies. In this article we discuss the special features of end-points, selection of population, and design for radiation oncology clinical trials. Quality control of delivered treatments is an important component of these protocols. Financial issues are also discussed, in the particular context of France.

Abstract P3-14-01: High-dose vitamin D supplementation for the correction of vitamin D insufficiency in patients undergoing adjuvant chemotherapy for breast cancer, a phase II multicenter study

Background:Vitamin D (VitD) insufficiency affects most of patients with early breast cancer (EBC). Breast cancer treatment may lead to bone loss, due to premature ovarian failure or direct chemotherapy (CT) cytotoxic effects. These increase the risk of skeletal morbidity as compared to women without breast cancer history. We previously published the persistence of VitD insufficiency at the end of adjuvant CT despite an adapted dose supplementation. We report here the safety and efficacy analysis of a phase II trial evaluating a high-dose oral VitD supplementation regimen for correction of VitD insufficiency in insufficient EBC patients treated with adjuvant CT.

Material and methods: EBC patients with VitD insufficiency for whom adjuvant CT was planned were eligible for this study. They received one dose of 100,000 IU 25OH-vitamin D every 3 weeks from day 1 of cycle 1 to day 1 of cycle 5, except in case of clinical or biological adverse event related to vitamin D and calcium metabolism, leading to early discontinuation. The primary endpoint was the percentage of serum 25OH-vitamin D level normalization at day 1 of cycle 6 (D1C6). Secondary endpoints were the safety, the Vitamin D and calcium parameters (blood calcium, phosphorus and parathormone [PTH] levels, urinary calcium excretion) at baseline and the description of their evolution during adjuvant CT, as well as the evaluation of the predictive value of these biomarkers and baseline clinical factors on the percentage of VitD normalization at D1C6.

Results: Among 45 eligible patients, 44 were evaluable for the primary endpoint. Among them, 21 (47.7%; 95%CI: 33.0-62.8) achieved a 25OH-Vitamin D correction at D1C6. No clinical toxicity linked to the VitD treatment was reported. However, 13 patients (29.5%) presented an asymptomatic grade 1 hypercalciuria, possibly linked to the VitD treatment, without concomitant change in the kidney function, but which lead to the interruption of the high dose oral VitD supplementation in 10 of the 13 patients. VitD normalization rates at 6, 12, 18 and 24 months were 50, 28.9, 80 and 60.9%, respectively. No clinical or biological marker was found to significantly predict the 6-month 25OH vitamin D normalization.

Conclusions: A high-dose 25OH-vitamin D regimen allowed a high percentage of serum 25OHD level normalization at D1C6 in EBC patients undergoing adjuvant CT. An asymptomatic increase in urinary calcium excretion was observed in one third of the patients, without clinical consequences. The physiopathology of this urinary calcium increase warrants further evaluation, since it is a classical reason for VitD treatment interruption, leading to a lower rate of correction in this highly requiring clinical setting.

Citation Format: Jacot W, D'Hondt V, Touraine C, Chapelle A, Legouffe E, Metge M, Rifai L, Roca L, Pouderoux S, Romieu G. High-dose vitamin D supplementation for the correction of vitamin D insufficiency in patients undergoing adjuvant chemotherapy for breast cancer, a phase II multicenter study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-14-01.

Abstract P3-14-03: Changes in vitamin D and calcium metabolism markers in patients undergoing adjuvant chemotherapy for breast cancer

Background:Vitamin D (VitD) insufficiency affects the majority of patients with early breast cancer (EBC). Breast cancer treatment may lead to bone loss, due to premature ovarian failure or direct chemotherapy (CT) cytotoxic effects. These increase the risk of skeletal morbidity compared to women without breast cancer history. However, even if these evidences are well described, the evolution of calcium metabolism under CT is unknown in this population with a high cure rate. We report the evolution of VitD and calcium metabolism markers in patients undergoing adjuvant CT for EBC.

Material and methods: We evaluated the VitD and calcium parameters (blood calcium, phosphorus and parathormone [PTH] levels, urinary calcium excretion) in EBC patients treated with 6 cycles of adjuvant CT without high dose calcium and VitD treatment. Variables of interest were recorded at inclusion, then every 3 weeks, at each chemotherapy cycle initiation. Primary endpoint was the occurrence of a hypercalciuria during the course of adjuvant CT (between Day 1, Cycle 1 [D1C1] and Day 1, Cycle 6 [D1C6]).

Results: 82 patients were evaluable for the primary endpoint. The median age was 53 years (range 20-71). CT consisted of a sequential anthracyclines and taxane regimen in 96.3% of the cases. Eleven (26.8%) patients received adjuvant trastuzumab. Most patients (66, 80.5%) presented with baseline VitD insufficiency (<30 ng/mL). Median baseline VitD level was 20.65ng/mL (range 2.9-55). Nine patients (8 VitD insufficient, 1 VitD sufficient [calcium only]) received low-dose VitD and/or calcium supplementation during the CT cycles. No baseline clinical parameter was statistically predictive of a VitD baseline insufficiency, while baseline blood calcium level was statistically predictive of a VitD baseline insufficiency (p=0.051). 94% of the patients presented with VitD insufficiency at D1C6 (median VitD level 20ng/mL; 9-39). No case of hypercalcemia was recorded. 29 patients (35.4%; 95%CI: 25.6-46.5) developed hypercalciuria between D1C1 and D1C6, none clinically significant. This percentage was not significantly different between VitD insufficient patients and the others (34.8% vs. 37.5%), nor between supplemented and not supplemented patients (37.5% vs. 34.5%). In multivariate analysis, weight and BMI were significantly associated with the occurrence of a hypercalciuria, while a trend was detected for baseline VitD (p=0.085) and albumin blood level (p=0.072). Baseline PTH level was elevated in 12.7% of the VitD insufficient patients vs. none of the patients with a normal VitD level. These percentages increased to 52.5% and 50% respectively at D1C6.

Conclusions: We report here, to our knowledge, the first comprehensive study of the kinetics of VitD and calcium biomarkers during EBC adjuvant CT. This population appears highly VitD insufficient, with a compensatory elevation in blood PTH levels during the course of treatment. Hypercalciuria, while asymptomatic, is a highly prevalent abnormality in this setting, and must not be a limitation for high dose VitD supplementation.

Citation Format: Jacot W, Firmin N, Touraine C, Pouderoux S, Viala M, Metge M, Rifai L, Romieu G, Roca L, Guiu S, D'Hondt V. Changes in vitamin D and calcium metabolism markers in patients undergoing adjuvant chemotherapy for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-14-03.

Abstract P1-07-07: Overtime distribution and predictors of local recurrences (LRs) in patients with hormone receptor positive (HR+) and node positive (N+) breast cancers (BCs): 10 -year follow-up analysis of UNICANCER-PACS 01 and PACS04 trials

Purpose:Incidence of LRs in patients (pts) treated for HR+ HER2- localized BC and distribution overtime have not been described in recent years after introduction of new generation of adjuvant therapies and more extensive use of radiotherapy. We evaluated the incidence and distribution overtime of LRs in pts with HR+ HER2- N+ BCs who entered PACS 01 and PACS04 trials.

Patients and Methods: Data were analyzed from 2909 pts with HR+/HER2- BC out of 5008 included in both trials. Pts underwent mastectomy or lumpectomy plus axillary dissection for a localized N+ BC and, according to study design, were randomized to: 6 cycles of FE100C (standard arm) versus FE100C x 3 cycles followed by docetaxel 100 mg/m2 x 3 cycles (FEC-D) (PACS01) or 6 cycles of Epirubicin 75mg/m2 and Docetaxel 75 mg/m2 (ED75)(PACS04). Loco-regional radiotherapy was mandatory after lumpectomy and recommended in other cases. All pts received 5 years of hormone therapy (HT). A competing risk multivariate analysis was conduct using Fine and Gray model to identify risk factors associated to isolated LRs. Competing events were nodal recurrence, contralateral BC, distant metastasis and death. Cumulative incidence associated to each event was estimated by a Kablfleish-Prentice estimator.

Results: Pts' median age was 50 (22-65); 67.2% underwent lumpectomy, 32.8% mastectomy; 67.6% had 1 to 3 N+, 32.4% more than 3 N+; 45.7% had lymphovascular invasion; 49.5% received FE100C, 35.8% ET75, 14.7% had FEC-D; while radiotherapy was given to 97.3% and HT to 92.2%, of whom 90.5% received tamoxifen. At a median follow-up of 9.1 years, 60 pts (2.1%) experienced LR as first event. The 5-year and 10-year cumulative incidence of LRs were 1.04% and 2.53%, respectively. The cumulative incidence of LRs increased from the 5th year, and the annual risk tended to remain constant over time. Multivariate analysis of competing risk showed that younger age, conservative surgery and omission of HT (not prescribed or non-adherence) were independently associated with risk of developing LRs.

Table 1. Multivariate analysis on competing risk of predictors of LRsVariablesHR 95%CIP valueAge at entry (<35 years, ≥ 35)*0.95 [0.92; 0.99]0.009Mastectomy, lumpectomy0.39 [0.17; 0.86]0.020> 20mm, ≤20 mm0.68 [0.37; 1.24]0.203N+ >3, 1-31.73 [0.99; 3.02]0.055Grade II/III, I1.06 [0.50; 2.24]0.885PR+,PR-1.78 [0.70; 4.53]0.223Type of chemotherapy 3FEC-3D, 6FEC/6ET1.32 [0.65; 2.69]0.446Number of cycles 6, <60.71 [0.17; 0.75]0.630Hormone therapy Yes,No0.36 [0.17; 0.75]0.006*treated as continuous variable

Conclusion: Our analysis showed that incidence of LRs in pts with HR+ N+ BCs treated within PACS trials were considerably lower as compared to earlier studies. These findings may reflect differences in treatment era, as the more extensive use of radiotherapy and new generation of adjuvant chemotherapy. Despite current adjuvant strategies, young age at diagnosis and omission of HT remain independent risk factors of LRs.

Citation Format: Pistilli B, Filleron T, Mazouni C, Zingarello A, Lacroix-Triki M, Rivera S, Coudert B, Serin D, Canon J-L, Campone M, Bachelot T, Goncalves A, Levy C, Cottu P, Petit T, Eymard J-C, Tunon De Lara C, Roché H, Roca L, Lemonnier J, Delaloge S. Overtime distribution and predictors of local recurrences (LRs) in patients with hormone receptor positive (HR+) and node positive (N+) breast cancers (BCs): 10 -year follow-up analysis of UNICANCER-PACS 01 and PACS04 trials [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-07.

Predictions for the [Formula: see text] decay

We calculate the shape of the [Formula: see text] and [Formula: see text] invariant mass distributions in the [Formula: see text] and [Formula: see text] decays that are dominated by the [Formula: see text] resonance. The weak interaction part is the same for both processes and the hadronization into the different meson-baryon channels in the final state is given by symmetry arguments. The most important feature is the implementation of the meson-baryon final-state interaction using two chiral unitary models from different theoretical groups. Both approaches give a good description of antikaon-nucleon scattering data, the complex energy shift in kaonic hydrogen and the line shapes of [Formula: see text] in photoproduction, based on the two-pole scenario for the [Formula: see text]. We find that this reaction reflects more the higher mass pole and we make predictions of the line shapes and relative strength of the meson-baryon distributions in the final state.

Abstract P6-09-10: Impact of a tailored oral vitamin D supplementation regimen on serum 25-hydroxy vitamin D levels in early breast cancer patients: A randomized phase III study

Purpose: Only a minority of patients with early breast cancer (EBC) treated with adjuvant or neoadjuvant chemotherapy have sufficient baseline vitamin D. The current recommendations regarding daily vitamin D supplementation appears too low to correct this deficiency in this population. Optimal vitamin D dosing has yet to be determined in this setting. The current randomized phase III study address the issue of the effectiveness and safety of a tailored high dose oral vitamin D supplementation as a means for restoring normal 25-hydroxy vitamin D (25OHD) levels in a large population of chemotherapy-treated EBC patients.

Methods: Chemotherapy-treated EBC patients were stratified according to the degree of Vitamin D deficiency, time between chemotherapy initiation and inclusion (0 to 6 months versus 6 to 12 months), hormone receptors status and menopausal status. Participants were randomly assigned to receive a 6-months conventional (C) vitamin D and calcium supplementation or a 6-months high dose oral vitamin D regimen tailored on the degree of deficiency (T) associated with a conventional calcium supplementation. Primary endpoint was the efficacy (6-months percentage of 25OHD serum levels normalization) in the T arm compared with the C arm. Statistical analyses were performed on an intent to treat basis.

Results: The trial accrued 215 patients, among which 197 patients presented with vitamin D deficiency, and randomized 195 patients (T, 100; C, 95) from July 2011 to January 2013. The groups were well balanced in regard to the stratification characteristics, as well as in regard of median weight and neoadjuvant or adjuvant chemotherapy status. Compliance to the daily oral supplementation was low in both arms, 64% of the patients in both arms taking less than 80% of the planned oral supplementation dose. Compliance to the tailored high dose vitamin D schedule appeared better (78%). After 6 months of treatment, at the primary endpoint analysis time, significantly more patients in the T arm presented with normalised serum vitamin D levels compared to the C arm (30% vs. 12.6%; p = 0.003). Vitamino-calcic supplementation was well tolerated, with no difference in the treatment-related toxicity between the 2 arms.

Conclusion: In this randomized phase III study, a tailored high dose oral vitamin D supplementation allowed a statistically higher percentage of serum 25OHD levels normalization compared to a conventional regimen, without any increase in side effects, in a large population of chemotherapy-treated EBC patients. Observance of a daily oral supplementation remains poor in this setting, advocating for an adaptation of the schedule and dosage of this supplementation in a population of patients subject to chemotherapy-induced emesis.

Clinical trial number NCT01480869.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-09-10.

Abstract P1-13-04: Optimal duration of adjuvant chemotherapy for high risk node negative breast cancer patients: 6-year results of the prospective randomized phase III trial PACS 05

BACKGROUND: In 2000, the NIH Consensus meeting concluded that 4 to 6 cycles of adjuvant chemotherapy appeared to provide an optimal benefit; So, we underwent a prospective randomized trial comparing 4 and 6 cycles of FEC 100 (JCO 2005; 23: 2686–2693) for high risk node negative breast cancer patients.

METHODS: This study enrolled 18–65 y women with operable breast cancer, without axillary lymph node involvement, or presence of isolated tumor cells, with size superior to 1 cm and another poor prognostic factor: T > 2 cm, HR –, SBR grade II or III, age < 35 y.

After adequate breast surgery and axillary lymph node dissection or sentinel node technique, they were randomized between arm A, 6 cycles of FEC 100, and arm B, 4 cycles, every three weeks. The local regional treatment was completed following usual recommendations. All HR+ patients received hormonal therapy for 5 years. After August 2005, patients with HER2+ tumors were excluded from this study.

The primary end point was PFS at 5 years. This study was powered to detect a 6% difference in favour of 6 cycles.

Between August 2002 and September 2006, 1516 patients were randomized; 1515 are analysed in ITT. Three patients in the B group did not receive any chemotherapy. There is no significant difference between the two arms for tumor and patient characteristics.

RESULTS At a median follow-up of 73 months we observed regarding PFS a low event rate, 197 for the entire population (13%) 91 in arm A median PFS, vs. 106 in arm B median PFS, without any difference between the two groups for DFS, DDFS, local relapse, overall survival. There was no unexpected toxicity. In the arm A we observed more grade III and IV neutropenia, without congestive heart failure.

CONCLUSION At a follow-up of 73 months, we observed a low relapse rate, with no significant difference between the two arms. Duration of FEC100 does not induce different outcomes in this population. Question of length of adjuvant treatment is still open with and without taxanes.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-13-04.

OT2-04-03: Uptake of a Randomized Breast Cancer Prevention Trial Comparing Letrozole to Placebo in BRCA1/2 Mutations Carriers: The FNCLCC ONCO-03/LIBER Trial

Background: Women with germline BRCA1or BRCA2 (BRCA1/2) mutations are an extreme risk population for developing breast cancer, with a life-time risk of 56–80%. Prophylactic mastectomy provides a valid option to reduce such risk, but it considerably affects the quality of life. Medical prevention by aromatase inhibitor that has been recently shown to have preventive effect may thus be an alternative. LIBER is an ongoing, double-blind, randomized phase III trial to evaluate the efficacy of five-years letrozole versus placebo to decrease breast cancer incidence in post-menopausal BRCA1/2 mutation carriers (NCT00673335). We present data on the uptake of this trial. Methods: To evaluate theoretical feasibility, we compared inclusion criteria of women in the LIBER trial (n=113) to characteristics of women entered in the prospective ongoing national GENEPSO cohort (n=1505). Uptake was evaluated through a survey sent to all active centres, with responses obtained from 17 of the 20 (85%) centres. Results: According to characteristics of the women included in GENEPSO cohort (n=1505) and the survey, approximately one third of BRCA1/2 mutation carriers are eligible for this study. From november 2009 to may 2010, 534 women eligible from chart review have been informed by mail of the trial and were invited to an oral information by participating centres. Of them, 44% of women came to the dedicated medical visit. Uptake of drug prevention trial was 32 % of orally informed women and 15 % of overall eligible women. Main reasons of refusal were: potential side effects, probability to receive the placebo and lack of support from the women's physicians. Prior prophylactic oophorectomy and history ***of previous unilateral breast cancer were more frequent in women enrolled in the ONCO-03/LIBER trial than in the French cohort (93% versus 60% and 50 % versus 39 %, respectively), suggesting a higher motivation for medical prevention in these subgroups of patients.

Conclusion: One third of women with a BRCA1/2 mutation are eligible to the ONCO-03/LIBER prevention trial. 32 % of orally informed women and, only 15% of overall eligible women entered the trial. To reach accrual objective (n=308), a greater information of the trial should be offered to women with BRCA1/2 mutation and the trial has been proposed to other countries.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-04-03.

P5-18-04: Safety Profile of Ixabepilone as Adjuvant Treatment for Poor Prognosis Early Breast Cancer: First Results of the Unicancer-PACS 08 Trial

Purpose: PACS 01 trial demonstrated that the sequential adjuvant chemotherapy with FEC100 followed by docetaxel (D) significantly improves disease-free and overall survival in node-positive(N+) early breast cancer (BC). However, Triple negative (TN) and ER+/ PR-/HER2− subgroups are significantly associated to a worse prognosis even after adjunction of D. As Ixabepilone (Ixa) has notable preclinical and clinical activity in these subgroups, the PACS 08 trial aims to compare standard FEC100-D regimen to 3 cycles of FEC100 followed by 3 cycles of Ixa. We report the preliminary results of the toxicity profile.

Patients and methods: Patients (pts) had localized resectable unilateral ER-/PR-/HER2− or ER+/PR-/HER2− BC. Main inclusion criteria were: age<70 years, normal cardiac, hepatic, haematological and renal functions. Arm A: pts received 3 cycles of FEC100 (F and C, each at 500 mg/m2, E 100 mg/m2, every 3 weeks) followed by 3 cycles of D (100 mg/m2 every 3 weeks); Arm B, Ixa 40 mg/m2 replaced D. Radiotherapy was mandatory after conservative surgery and endocrine therapy was given to ER+ pts. A 5% absolute difference in disease-free survival at 5 years is the main statistical end-point. Results: Between October 2007 and September 2010, 762 pts with TNBC or ER+/PR-/HER2− BC were enrolled. Recruitment was interrupted due to BMS decision to stop Ixa development in adjuvant setting. Main pts characteristics were well balanced between the 2 arms: median age 53 years, postmenopausal 57.8%, conservative surgery 68.4%, node positive 59.5%. A total of 755 pts were evaluable for safety. Treatment was completed for 93.4% and 86.1% of pts in arms A and B, respectively. During FEC100 sequence, toxicities were well balanced between the two arms. From cycle 4, whereas Gr3/4 sensory neurotoxicity (12pts; 3.5%) and thrombopenia (7pts; 2%) were reported in Ixa arm, none of these toxicities was reported in the D arm (p0.001). There were significantly more Gr3/4 neutropenia on day 21 in Ixa arm (13pts, 6.6% vs 4pts, 1.9%; p<10.005). No significant difference was observed for febrile neutropenia. Fewer cutaneous toxicities were observed in Ixa arm (2pts, 0.6% vs 10pts, 2.6%; p<0.05). No significant difference was observed neither for motor neurotoxicity or hepatic function between two arms. More pts discontinued treatment in Ixa arm compared to D arm (49pts (13%) vs 26pts (7%), p<0.05). Main reasons were Gr3/4 haematological adverse events (AE) and Gr3/4 neurotoxicities for Ixa arm and due to GR3/4 haematological AE for D arm. One non expected Gr4 bullous dermatitis was reported during the first Ixa cycle. 2 deaths due to septic shock occured in Ixa arm (both at cycle 4 for a 56- and a 66-year-old woman). However, according to the IDMC no obvious precipitating factor questioning the Ixa arm was identified.

Conclusion: Our results indicate that D arm is more often associated to significant haematological toxicities, whereas both neurotoxicities and haematological toxicities are reported in the Ixa arm. Although significantly more pts discontinued treatment due to adverse events in Ixa arm compared to D arm, Ixa may still represent a promising therapeutic option for pts in the adjuvant setting especially for poor prognosis BC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-04.

Two bi-institutional prospective studies using intraperitoneal oxaliplatin with or without irinotecan during HIPEC following complete cytoreductive surgery for colorectal carcinomatosis

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Background: In treatment of peritoneal carcinomatosis (PC) of colorectal origin, studies combining cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) have shown encouraging survival results. Intraperitoneal drugs usually used are mitomycin C or oxaliplatin in monotherapy. The aim of this study was to assess long-term survival in patients treated with a new combination of oxaliplatin and irinotecan (ox-irino) and to compare it with that obtained with oxaliplatin alone (ox-alone).

Methods: Two bi-institutional prospective studies were carried out. All patients with PC who had undergone CRS with HIPEC using either ox-alone 460 mg/m2 or ox-irino (ox: 300 mg/m2 and irino: 200 mg/m2) from January 1998 to December 2007 were included.

Results: 146 patient underwent CRS + HIPEC for PC from colorectal carcinoma. 103 patients received ox-irino and 43 patients received ox-alone HIPEC. The overall mortality rate was 4.1%. The overall morbidity rate was 47.2%. It was significantly lower in the ox-alone group compared to the ox-irino group (34.9% vs. 52.4%, p =0.05). After a median follow-up of 48.5 months, (95%CI 41.0-56.3), the median OS was 41 months (95%CI 32-60) and the median RFS was 15.7 months (95%CI 12-18). The median RFS of the ox-alone group was 16.8 months (95%CI 11-25) and was not significantly different from that of ox-irino group (15.7 months, 95%CI 11-18, p = 0.93). There was no significant difference between the median OS of the ox-alone group (40.83 months, 95%CI 29–61) and the ox-irino group (47 months, 95%CI 32-61, p = 0.94). At 5 years, the OS and the RFS rates were respectively 41.8% (95% CI 25.20-57.58) and 13.8% (95% CI 4.66-27.84) in the ox-alone group and 42.4% (95% CI 28.52-56.09) and 14.2% (95% CI 6.27-25.20) in the ox-irino group.

Conclusions: This study confirms the interesting survival results of CRS + HIPEC to treat colorectal PC. 460 mg/m2 of oxaliplatin alone HIPEC is as efficient as 300 mg/m2 of oxaliplatin associated with 200 mg/m2 of irinotecan, but with lower morbidity. Ox-alone HIPEC, should remain the current gold standard.

No significant financial relationships to disclose.

Beam-helicity asymmetries in double-pion photoproduction off the proton

Beam-helicity asymmetries have been measured at the MAMI accelerator in Mainz in the three isospin channels gamma[over -->]p-->pi(+)pi(0)n, gamma[over -->]p-->pi(0)pi(0)p, and gamma[over -->]p-->pi(+)pi(-)p. The circularly polarized photons, produced from bremsstrahlung of longitudinally polarized electrons, were tagged with the Glasgow magnetic spectrometer. Charged pions and the decay photons of pi(0) mesons were detected in a 4pi electromagnetic calorimeter which combined the Crystal Ball detector with the TAPS detector. The precisely measured asymmetries are very sensitive to details of the production processes and are thus key observables in the modeling of the reaction dynamics.

Radiofrequency radiation (900 MHz) induces Egr-1 gene expression and affects cell-cycle control in human neuroblastoma cells

Many environmental signals, including ionizing radiation and UV rays, induce activation of Egr-1 gene, thus affecting cell growth and apoptosis. The paucity and the controversial knowledge about the effect of electromagnetic fields (EMF) exposure of nerve cells prompted us to investigate the bioeffects of radiofrequency (RF) radiation on SH-SY5Y neuroblastoma cells. The effect of a modulated RF field of 900 MHz, generated by a wire patch cell (WPC) antenna exposure system on Egr-1 gene expression, was studied as a function of time. Short-term exposures induced a transient increase in Egr-1 mRNA level paralleled with activation of the MAPK subtypes ERK1/2 and SAPK/JNK. The effects of RF radiations on cell growth rate and apoptosis were also studied. Exposure to RF radiation had an anti-proliferative activity in SH-SY5Y cells with a significant effect observed at 24 h. RF radiation impaired cell cycle progression, reaching a significant G2-M arrest. In addition, the appearance of the sub-G1 peak, a hallmark of apoptosis, was highlighted after a 24-h exposure, together with a significant decrease in mRNA levels of Bcl-2 and survivin genes, both interfering with signaling between G2-M arrest and apoptosis. Our results provide evidence that exposure to a 900 MHz-modulated RF radiation affect both Egr-1 gene expression and cell regulatory functions, involving apoptosis inhibitors like Bcl-2 and survivin, thus providing important insights into a potentially broad mechanism for controlling in vitro cell viability.

Safety analysis from PACS 04—A phase III trial comparing 6 cycles of FEC100 with 6 cycles of ET75 for node-positive early breast cancer patients, followed by sequential trastuzumab in HER2+ patients: Preliminary results

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Background: Following the BCIRG 001, PACS 01 and HERA trials, this randomised, multicentre, open-label, Phase III trial was designed to demonstrate the benefit of concomitant docetaxel and epirubicin versus anthracyclines, and evaluate the use of sequential trastuzumab. Methods: Patients (pts) with localised, resectable, unilateral breast cancer who met the following criteria were eligible: age <65 years, ≥1 positive node, M0, adequate heart and organ functions. Pts were randomised to receive either 6 cycles of 5-fluorouracil-epirubicin-cyclophosphamide (FEC100: F and C, 500 mg/m2, E 100 mg/m2) (Arm A) or epirubicin-docetaxel (ET75: E 75 mg/m2, T 75 mg/m2) (Arm B). Primary prophylaxis with G-CSF was not planned. Radiotherapy was mandatory after conservative surgery and tamoxifen was required in pts with hormone receptor-positive tumours. Pts with HER2-positive disease were then further randomised to observation only or to 1 year of trastuzumab monotherapy (6 mg/kg iv every 3 weeks). In HER2-positive pts receiving trastuzumab, left ventricular ejection fraction (LVEF) was determined at Cycles 2, 4, 8, 13, 18 and after 2 years. Otherwise, LVEF was determined at baseline and at 1 year post-surgery. Results: Of the 3010 pts recruited (2622 evaluable for safety to date), 1518 received FEC100 and 1492 received ET75 after the first randomisation. Haematologic toxicity was the most frequent toxicity in both arms. Grade 3–4 toxicities were similar for Arms A and B, except febrile neutropenia (10.3% and 31.4%, respectively) and nausea/vomiting (13.2% and 7.5%, respectively). Grade 2 clinical cardiac toxicity (decreased LVEF) was observed in 4 pts in Arm A and 5 in Arm B, with median LVEF scores of 63% in both arms at the end of chemotherapy. HER2-positive pts (n=500) were then randomised to either receive trastuzumab (n=259) or observation only (n=241). Conclusions: These preliminary safety data indicate that FEC100 and ET75 were both well tolerated, with acceptable cardiac safety values. The trial is ongoing and further analysis regarding the use of trastuzumab in this setting will be presented.

[Table: see text]

[Cardiac primary lymphoma]

The primary cardiac lymphoma is extremely rare. A case is presented of a 60 year old female patient with non-Hodgkin lymphoma of probable primary cardiac localization and with subsequent extension to peripheral lymph nodes. She had had a febrile syndrome for 8 months. Two two-dimensional echocardiograms gave negative results. Due to a syncope with atrial fibrillation, a transesophageal echocardiogram was carried out, which showed tumors in both atria, interatrial septum and right ventricle. The later appearance of right preauricular lymph nodes and left supraclavicular nodes led to a biopsy which confirmed a diagnosis of diffuse non-Hodgkin lymphoma with large immunoblastic cells. The patient died 15 months after the first symptoms, having undergone 6 chemotherapy cycles. The autopsy showed remission of the macroscopic lesions but presence of microscopic lesions in the cardiac chambers with histology and phenotypic markers identical to the ones found in the lymph nodes.

Structure and polymorphism of the upstream region of the pfg27/25 gene, transcriptionally regulated in gametocytogenesis of Plasmodium falciparum

Transcription of the early gametocyte-specific gene pfg27/25, and genomic structure and polymorphism of its upstream region were studied in the human malaria parasite Plasmodium falciparum. The upstream genomic sequence of the pfg27/25 gene is characterised by a repetitive region that contains five direct and one inverted repeats of a unit constituted by a perfectly conserved sequence flanked by a poly-dT and a poly-d(AT) tract. Sequences further upstream from the repetitive region are polymorphic in distantly related parasite lines. Nuclear 'run off' experiments indicated that transcription of pfg27/25 is developmentally regulated. Transcription of the gene, undetectable in asexual parasites, is activated at the onset of gametocytogenesis. Te gene is transcribed in a 2.5 kb mature mRNA for the first 2-3 days of sexual differentiation, while transcription is down-regulated in more mature gametocytes.

Plasmodium falciparum: parasites defective in early stages of gametocytogenesis

Some molecular characteristics of Plasmodium falciparum lines which do not produce gametocytes are described. Parasites carrying a subtelomerically deleted chromosome 9 cannot form even the earliest forms of gametocytes, detectable with antibodies against the gametocyte-specific antigen Pfg27. In a parasite culture of clone HB3, in which both intact and deleted forms of chromosome 9 are present, full-length chromosome 9 molecules are retained mainly in gametocytes. These data suggest that the subtelomeric portion of chromosome 9 is required at an early stage of gametocytogenesis. Parasite subclones derived from gametocyte producing clone 3D7, which completely lost ability to produce gametocytes, are also described. Unlike the previous gametocyteless lines, these parasites stably maintain a full-length chromosome 9 and the ability to cytoadhere to C32 melanoma cells after prolonged asexual propagation. Their defect in sexual development is therefore genetically and functionally distinct from that of parasites carrying a deleted chromosome 9. Gametocyteless subclones derived from 3D7 do not produce any Pfg27 mRNA, while this gene is anomalously expressed in asexual stage parasites of two lines of a different genetic background, 1776sel8 and C10, one able and the other unable to produce gametocytes.

Subtelomeric structure of Plasmodium falciparum chromosomes

Previous studies of subtelomeric regions in Plasmodium berghei led to the identification of subtelomeric repeats (2.3kb long) present in a variable number at many chromosomal ends. Both loss and increase in 2.3kb-repeat copy number are involved in chromosome-size polymorphisms. Subtelomeric losses leading to chromosome-size polymorphisms have been described by several authors in P.falciparum where the structure of subtelomeric regions is not known in detail. We therefore undertook their characterisation, by means of chromosome walking and jumping techniques, starting from the telomere-flanking sequence present in pPftel.1, the P.falciparum telomeric clone described by Vernick and McCutchan (1988). The results indicate that at least 20 (out of 28) chromosomal ends in P.falciparum 3D7 chromosomes share a subtelomeric region, about 40kb long, covering (but not limited to) the Rep20 region. Non repetitive, AT-rich portions flanking the Rep20 region on both sides are also conserved at most chromosomal ends.

Chromosomal polymorphism and sexual differentiation in Plasmodium

The correlation observed in several instances between the loss of ability to produce gametocytes and chromosomal rearrangements, prompted us to investigate in further detail the molecular bases of chromosomal polymorphism in Plasmodium. Generation of polymorphic karyotypes in Plasmodium involves important rearrangements, mostly occurring in subtelomeric position. Detailed analysis on the organisation of these regions have been carried out on the rodent malaria P. berghei and the human malaria P. falciparum. A 2.3kb sequence, tandemly organised in long clusters is shared by many P. berghei chromosomal ends. Variations in the copy number of this "module" account for most of the observed polymorphisms. In a P. falciparum cloned line (3D7) a common region spanning at least 40 kb, is present. It does not contain any repetitive structure other than the rep20 cluster, that appears to be completely contained within the common region. Notwithstanding the structural differences, human and rodent Plasmodia share the common feature of possessing long subtelomeric regions showing, thus, a homology between the different chromosomes.

Thermal properties of red blood cells infected by malaria parasites

Three membrane thermotropic transitions at 8, 20, and 40 degrees C have been detected in human red blood cells (RBC) by using spin-labeled stearic acids. Red blood cells infected in vitro by Plasmodium falciparum showed the disappearance of the 8 degrees C transition and a lowering of the 40 degrees C transition to 32 degrees C. The disappearance of the 8 degrees C transition was observed in synchronized cultures of P. falciparum trophozoites as well as in mouse RBC infected in vivo by an asynchronous population of P. berghei. Furthermore, erythrocytes infected by P. falciparum showed an increase in the phosphorylation of protein 4.1. This protein was shown previously to be involved in the 8 degrees C transition, (T. Forte, T. L. Leto, M. Minetti, and V. T. Marchesi, Biochemistry 24, 7876-7880 (1985). Our results suggest that the malaria parasite invasion produces a disorganization of the protein 4.1-membrane interaction.