Phase IB trial of pegylated arginine deiminase (ADI-PEG 20) plus radiotherapy and temozolomide in patients with newly diagnosed glioblastoma

2057

Background: ADI-PEG 20 exploits the different metabolic ability for synthesizing arginine (Arg) between normal and neoplastic cells to reduce tumor cell growth. Preclinical and clinical studies have shown that cancers which are either Arg auxotrophic, with silencing of argininosuccinate synthetase ( ASS1), or Arg non-auxotrophic, respond to ADI-PEG 20 monotherapy or ADI-PEG 20 combined with various chemotherapies, respectively. ADI-PEG 20 has shown efficacy as monotherapy in ASS1 negative mouse glioblastoma (GBM) models and the combination of ADI-PEG 20 with temozolomide (TMZ) and with radiation (RT) in both ASS1 negative and ASS1 positive mouse GBM models. Based on these rationales, ADI-PEG 20 was added to standard RT + TMZ in patients with newly diagnosed GBM. This is the first clinical trial combining ADI-PEG 20 with RT. Methods: This phase IB, open-label, single-arm, standard 3+3 dose escalation with a recommended phase 2 dose (RP2D) expansion study (NCT04587830) was initiated in June 2020. Weekly ADI-PEG 20 is added to concurrent RT + TMZ and to 6 cycles of adjuvant TMZ (Stupp protocol). ADI-PEG 20 could be continued for up to 2 years. RANO criteria are used to determine response by evaluating MRI at 1, 3 and 6 months after RT, and every 3 months thereafter. Major eligibility criteria are age 20-75 years with newly diagnosed, histologically confirmed GBM with Karnofsky performance status ≥ 60. Endpoints include safety, pharmacodynamics, immunogenicity, progression free survival (PFS) and overall survival (OS). Results: Cohorts 1 (18 mg/m2) and 2 (36 mg/m2) were completed without dose limiting toxicity (DLT). Enrollment to cohort 3 (RP2D phase, 36 mg/m2) is ongoing with 23/26 patients. The major adverse events (AEs) were fatigue (52%), constipation (39%) and neutrophil decrease (39%). Dermatologic or allergic reactions occurred in 12/23 (52%), and all were grade 1-2 except for anaphylactic shock in 1 and vasculitis/rash in 1. 22/23 are alive, with median PFS = 9.5 months. The first 6 study patients are all alive for at least 11 months, with the longest at 1.5 years. 10 are off treatment due to progressive disease in 6, severe AE in 2, consent withdrawal in 1, and medical decision in 1. Mean peripheral blood Arg levels were suppressed ( < 10uM) for 4-6 weeks in most subjects, with a reciprocal elevation of citrulline levels. Anti-ADI-PEG 20 antibodies tended to increase as peripheral Arg levels increased. Conclusions: The addition of ADI-PEG 20 to RT + TMX was safe, and no DLT was observed. The RP2D of ADI-PEG 20 was determined to be 36mg/m2. AEs were those typically seen with RT + TMZ, with perhaps an increase in rash reported with the addition of ADI-PEG 20. Anaphylaxis and vasculitis were seen (1 subject with each), and have been observed previously with ADI-PEG 20. The preliminary OS data are encouraging. A registration phase 2/3 trial of this triplet is being considered. Clinical trial information: NCT04587830.

Sinonasal renal cell-like adenocarcinoma: Easily misdiagnosed sinonasal tumor

BACKGROUND

Sinonasal renal cell-like adenocarcinoma is rare and exhibits unique pathological and clinical manifestations. Correct diagnosis and treatment of this newly described entity are challenging for both clinicians and pathologists.

METHODS

We report a female patient with sinonasal renal cell-like adenocarcinoma who initially presented with right intermittent epistaxis.

RESULTS

A 26-year-old woman presented with a 1-year history of right intermittent epistaxis and hyposmia. Nasal endoscopy revealed a reddish tumor in the right nasal cavity. An MRI revealed a hyperintense tumor arising from the right olfactory cleft accompanied by prominent feeding vessels originating from the anterior ethmoid artery (AEA). We performed a bicoronal incision with ligation of the AEA followed by endoscopic resection of the skull base tumor. The patient is currently free of recurrence.

CONCLUSION

This is the first study to review the clinical features of sinonasal renal cell-like adenocarcinoma. We recommend surgical resection as the mainstay of treatment.

Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage

BACKGROUND

Hydrocephalus following spontaneous aneurysmal sub-arachnoid hemorrhage (SAH) is often associated with unfavorable outcome. This study aimed to determine the potential risk factors and outcomes of shunt-dependent hydrocephalus in aneurysmal SAH patients but without hydrocephalus upon arrival at the hospital.

METHODS

One hundred and sixty-eight aneurysmal SAH patients were evaluated. Using functional scores, those without hydrocephalus upon arrival at the hospital were compared to those already with hydrocephalus on admission, those who developed it during hospitalization, and those who did not develop it throughout their hospital stay. The Glasgow Coma Score, modified Fisher SAH grade, and World Federation of Neurosurgical Societies grade were determined at the emergency room. Therapeutic outcomes immediately after discharge and 18 months after were assessed using the Glasgow Outcome Score.

RESULTS

Hydrocephalus accounted for 61.9% (104/168) of all episodes, including 82 with initial hydrocephalus on admission and 22 with subsequent hydrocephalus. Both the presence of intra-ventricular hemorrhage on admission and post-operative intra-cerebral hemorrhage were independently associated with shunt-dependent hydrocephalus in patients without hydrocephalus on admission. After a minimum 1.5 years of follow-up, the mean Glasgow outcome score was 3.33 ± 1.40 for patients with shunt-dependent hydrocephalus and 4.21 ± 1.19 for those without.

CONCLUSIONS

The presence of intra-ventricular hemorrhage, lower mean Glasgow Coma Scale score, and higher mean scores of the modified Fisher SAH and World Federation of Neurosurgical grading on admission imply risk of shunt-dependent hydrocephalus in patients without initial hydrocephalus. These patients have worse short- and long-term outcomes and longer hospitalization.

Management of middle cerebral artery dissecting aneurysm

BACKGROUND

Dissecting aneurysms of the intracranial carotid circulation were previously thought to occur primarily in young people presenting with cerebral infarction caused by arterial stenosis and occlusion. The appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also present with cerebral infarction. However, recent studies have reported better outcomes for patients with middle cerebral artery (MCA) dissecting aneurysms involving surgically treated subarachnoid hemorrhage (SAH). The purpose of this study is to describe a case of spontaneous SAH from rupture of a dissecting aneurysm in the M2 segment observed in a 79-year-old man with no sign of an ischemic neurological deficit, and also to review the clinical and radiological features of cases reported since 1990.

METHODS

Our review of the literature identified 24 cases of MCA dissecting aneurysms after 1990.

RESULTS

Of the patients in these cases, 15 (63%) presented with pure bleeding and 7 (29%) with ischemia, and two were detected incidentally. Our review also found that the outcome of patients presenting with pure bleeding differed from those with ischemia. Patients with an MCA dissecting aneurysm who presented with pure bleeding showed better outcomes if they had surgery than if they did not. In contrast, the appropriate management of patients with a dissecting aneurysm who present with ischemia remains controversial.

CONCLUSION

Our review found that the clinical course of patients presenting with ischemia differed from that of patients presenting with pure bleeding. Most of the patients with ischemia underwent progressive deterioration. However, while the outcome for patients with ischemia treated surgically was relatively good, it remained poor compared to the outcome for patients who had been bleeding.

Infected spinal dermal sinus tract with meningitis: a case report

PURPOSE

Congenital dermal sinus tract (DST), an uncommon entity of cranial or spinal dysraphism, occurs along the midline neuraxis that may arise from nasion and occiput down to the lumbar and sacral region. It is often diagnosed in infants and children for skin signs, neurological deficits, local infection, meningitis, or abscess. For spinal DST, there is a paucity of case or series report in Taiwan.

CASE REPORT

In this paper, we report a case in a 6-year-old girl. The girl presented with midline lumbar skin dimple, hypertrichosis, and history of bacterial meningitis. She was successful treated by surgical excision of the DST with local infection that ended within the subarachnoid space between L2-3 vertebrae.

CONCLUSION

This case highlights the importance of a thorough examination of the midline craniospinal axis in children with meningitis or history of meningitis.

Cerebellar bacterial brain abscess: report of eight cases

PURPOSE

To analyze the clinical characteristics and therapeutic outcome of patients with solely cerebellar bacterial brain abscess (BBA).

CASE REPORT

Eight patients with solely cerebellar BBA, collected during a period of 23 years from 210 BBA patients, were included in this study. The eight patients were five men and three women, aged 5-54 years (mean, 36.6 years). Six of them were adults, one was a child, and one was an adolescent. Six patients had underlying medical/surgical problems. Of the clinical presentations, dizziness was the most common (87.5%, 7/8), followed by headache (62.5%, 5/8), altered consciousness (62.5%, 5/8), fever (50%, 4/8), ataxia (25%, 2/8), hearing impairment (12.5%, 1/8), dysarthria (12.5%, 1/8), and hemiparesis (12.5%, 1/8). The Image Severity Index (ISI) scores of these eight patients ranged from 6 to 12 points. All eight patients received both medical and surgical treatment. One patient died owing to a complication in the neurosurgical procedure and the remaining patients survived. The therapeutic outcome was quantified one month after discharge by modified Rankin scale (mRS) and the result showed six of the seven survivors had good outcomes, while the other one had a poor outcome (ataxic gait).

CONCLUSION

Cerebellar BBA accounted for 3.8% (8/210) of the overall BBA. In cerebellar BBA, dizziness is a frequent symptom. Early diagnosis and a combination of antimicrobial and neurosurgical intervention is important for its treatment. The small case number is a limitation of this study; therefore, further large-scale study of cerebellar BBA is needed for better delineation of the clinical characteristics, therapeutic outcome, and prognostic factors.

Supratentorial deep-seated bacterial brain abscess in adults: clinical characteristics and therapeutic outcomes

PURPOSE

Supratentorial deep-seated bacterial brain abscess (BBA) in adults is rarely examined solely in the literature. This retrospective study is conducted to examine the clinical characteristics and therapeutic outcome of this specific group of BBA.

METHODS

Eight adult patients with supratentorial deep-seated BBA, collected during a study period of 14 years (1994-2007), were enrolled. Their microbiological data derived from cerebrospinal fluid (CSF), blood or pus cultures, clinical features and therapeutic outcome were analyzed.

RESULTS

The eight adult cases were six men and two women, aged 41 to 80 years (mean=61). Preceding medical conditions were found in five of these eight cases, while preceding neurosurgical event was found in one. Of the clinical presentations, hemiparesis (6) was the most common, followed by fever (5), altered consciousness (4), headache (3), septic shock (1), and seizure (1). The main locations of the BBA were the left basal ganglia in five, the left thalamus in two, and the right basal ganglia in one. Causative pathogens were found in six cases and the isolated pathogens were all cultured from CSF specimens. Positive bacteremia which grew K. pneumoniae was found in one case. Seven of these eight cases contracted the infection in a community-acquired state. Besides antibiotic treatment, seven of them received a neurosurgical intervention (stereotactic aspiration and/or ventriculoperitoneal shunt). The therapeutic result showed six cases survived and two expired. Five of the six survivors had variable degree of neurologic deficits.

CONCLUSIONS

Besides the common clinical features of BBA, supratentorial deep-seated BBA has a high incidence of hemiparesis in the early stages of disease. Most of the involved patients have community-acquired infections and are preceded by a medical condition. Stereotactic aspiration for therapeutic and diagnostic purposes, as well as shunting surgery, is the most common neuro-surgical procedures used for treatment. But despite therapeutic efforts, high mortality and morbidity remain.

Predictors and long-term outcome of seizures after bacterial brain abscess

BACKGROUND

Seizures are one of the most important neurological complications of bacterial brain abscesses. A better understanding of the risk factors of seizures following bacterial brain abscesses is needed to predict those who will require treatment.

METHODS

A total of 205 patients were enrolled in this 22-year retrospective study. Prognostic variables were analysed based on Cox's proportional hazards model after a minimum of 18 months of follow-up.

RESULTS

Seizures occurred in 48 patients who had bacterial brain abscesses, including acute symptomatic seizures in 17% (35/205) and unprovoked seizures in 6.4% (13/205). Altogether, 27 patients had early seizures and 21 had late seizures. The overall mortality rate in the seizure patients was 23% (11/48) and seven patients progressed to epilepsy.

CONCLUSION

Cox's proportional hazards model demonstrated that valvular heart diseases as the underlying diseases and the presence of a fronto-parietal distribution of bacterial brain abscess were independently predictive of seizures, and the presence of late seizures was predictive of developing epilepsy. Most first seizures occurred within 3 y after bacterial brain abscesses.

Atorvastatin does not affect insulin sensitivity and the adiponectin or leptin levels in hyperlipidemic Type 2 diabetes

BACKGROUND

In addition to lipid lowering, further pleotropic effects of statins have been postulated. We aimed to study if the various pleotropic effects are due indirectly to the modulation of adipocytokines.

MATERIALS AND METHODS

We studied the effect of atorvastatin on insulin sensitivity and the plasma adiponectin and leptin concentrations. Our randomized open labeled study had 29 hyperlipidemic Type 2 diabetic patients (14 females, 15 males, mean age 60.0+/-2.2 yr). They were randomized into three 12-week atorvastatin intervention types. Each day patients were given either 10 mg (no.=10), 20 mg (no.=10) or 40 mg (no.=9). Evaluations were performed before and after intervention.

RESULTS

All baseline characteristics were statistically identical in the 3 groups. Drop in total cholesterol, LDL-cholesterol, and triglyceride levels were measured at the end. With 10 mg the drop was 30%, 37%, and 30%. The 20 mg group was 43%, 54%, and 34%. The 40 mg group was 42%, 51%, and 27%. Groups had no significant change of body mass index, HDLcholesterol, and glycated hemoglobin levels. Also, levels of insulin, adiponectin, leptin, homeostasis model assessment index (HOMA) and Quantitative Insulin Sensitivity Check Index (QUICKI) stayed the same. Pooled parameters of all 29 patients showed no difference in levels of insulin, adiponectin, leptin, HOMA, and QUICKI before and after treatment.

CONCLUSIONS

Atorvstatin does not affect insulin sensitivity and the adiponectin or leptin levels in hyperlipidemic Type 2 diabetes.

Cold-induced ependymin expression in zebrafish and carp brain: implications for cold acclimation

Cold acclimation has been suggested to be mediated by alternations in the gene expression pattern in the cold-adapted fish. To investigate the mechanism of cold acclimation in fish brain at the molecular level, relevant subsets of differentially expressed genes of interest were identified and cloned by the PCR-based subtraction suppression hybridization. Characterization of the selected cold-induced cDNA clones revealed one encoding ependymin. This gene was shown to be brain-specific. The expression of ependymin was induced by a temperature shift from 25 degrees C to 6 degrees C in Cyprinus carpio or 12 degrees C in Danio rerio. Activation of ependymin was detected 2 h after cold exposure and peaked at more than 10-fold at 12 h. This peak level remains unchanged until the temperature returns to 25 degrees C. Although the amount of soluble ependymin protein in brain was not changed by cold treatment, its level in the fibrous insoluble polymers increased 2-fold after exposure to low temperature. These findings indicate that the increase in ependymin expression is an early event that may play an important role in the cold acclimation of fish.

Characterization of Methanosarcina mazei N2M9705 isolated from an aquaculture fishpond

A new methanogenic isolate, designated as strain N2M9705 (=OCM 668), was isolated from an aquaculture fishpond near Wang-gong, Taiwan. This strain grew on trimethylamine and methanol, but it did not catabolize H2-CO2, acetate, or formate. The cells were stained Gram-negative, nonmotile, irregular coccus 0.6-0.8 micrometer in diameter. Gas vacuoles were observed and cell aggregated to form various sizes of granules. Cells grew optimally at 32 degrees -37 degrees C with 1% NaCl. The pH range of growth was 6.2-7.4, and higher pH inhibited the cell growth. The cells grew well in minimal medium, but growth was greatly stimulated by yeast extract and peptone. A comparison of 16S rDNA sequences of this organism phylogenetically related to Methanosarcina mazei. This is the first report of methyltrophic methanogenic isolated from an aquaculture fishpond.

Regulatory factors associated with synthesis of the osmolyte glycine betaine in the halophilic methanoarchaeon Methanohalophilus portucalensis

The halophilic methanoarchaeon Methanohalophilus portucalensis can synthesize de novo and accumulate beta-glutamine, Nepsilon-acetyl-beta-lysine, and glycine betaine (betaine) as compatible solutes (osmolytes) when grown at elevated salt concentrations. Both in vivo and in vitro betaine formation assays in this study confirmed previous nuclear magnetic resonance 13C-labelling studies showing that the de novo synthesis of betaine proceeded from glycine, sarcosine, and dimethylglycine to form betaine through threefold methylation. Exogenous sarcosine (1 mM) effectively suppressed the intracellular accumulation of betaine, and a higher level of sarcosine accumulation was accompanied by a lower level of betaine synthesis. Exogenous dimethylglycine has an effect similar to that of betaine addition, which increased the intracellular pool of betaine and suppressed the levels of Nepsilon-acetyl-beta-lysine and beta-glutamine. Both in vivo and in vitro betaine formation assays with glycine as the substrate showed only sarcosine and betaine, but no dimethylglycine. Dimethylglycine was detected only when it was added as a substrate in in vitro assays. A high level of potassium (400 mM and above) was necessary for betaine formation in vitro. Interestingly, no methylamines were detected without the addition of KCl. Also, high levels of NaCl and LiCl (800 mM) favored sarcosine accumulation, while a lower level (400 mM) favored betaine synthesis. The above observations indicate that a high sarcosine level suppressed multiple methylation while dimethylglycine was rapidly converted to betaine. Also, high levels of potassium led to greater amounts of betaine, while lower levels of potassium led to greater amounts of sarcosine. This finding suggests that the intracellular levels of both sarcosine and potassium are associated with the regulation of betaine synthesis in M. portucalensis.

Is captopril-induced improvement of insulin sensitivity mediated via endothelin?

Angiotensin-converting enzyme (ACE) inhibitors have been reported to improve insulin sensitivity during either short-term or long-term administration. Recent studies indicate that endothelin-1 (ET-1) has potent glycogenolytic effects in rat hepatocytes and may cause insulin resistance in rat adipocytes. In addition, ET may also have a role in stimulation of the hypothalamic-pituitary-adrenal axis. To test the hypothesis that part of the effect of captopril in enhancing insulin sensitivity may be mediated via ET and/or by glucocorticoids, we measured 24-h urinary excretion of ET and free cortisol before and after short-term treatment with captopril. The 24-h urinary immunoreactive endothelin (IR-ET) excretion decreased significantly (p < 0.05) from 65 +/- 4 ng at baseline to 42 +/- 3 ng after captopril treatment, whereas no significant change in the 24-h urinary free cortisol excretion was observed. Moreover, no significant change in the 24-h urinary IR-ET and free cortisol excretions was noted in the placebo-treated group. We speculate that ACE inhibitors may exert their effect on insulin sensitivity not only by blocking the renin-angiotensin and kinin systems but also by inhibiting production and/or release of ET.

Parathyroid hormone and parathyroid hormone related protein assays in the investigation of hypercalcemic patients in hospital in a Chinese population

There are many pathological causes and potential mechanisms for hypercalcemia. We measured intact parathyroid hormone (PTH) and parathyroid hormone related protein (PTHrP) in the hypercalcemic in-patients and attempted to evaluate the roles of PTH and PTHrP in hypercalcemia due to malignancy. We performed a prospective study of 178 patients with corrected serum calcium concentrations greater than 2.74 mmol/l in a hospital over a 3-year period. We measured calcium and albumin using a Hitachi 747 autoanalyzer, and we measured PTH and PTHrP by two-site immunoradiometric assays (IRMA). Hypercalcemia was attributed to malignancy alone in 93 patients (52.3%), primary hyperparathyroidism (HPT) alone in 28 patients (15.7%), uremia with hemodialysis in 23 patients (12.9%), unknown in 16 patients (9%), primary HPT coexisting with malignancy in 7 patients (3.9%) and other rare causes (6.2%). Plasma PTHrP levels were elevated in 71/93 (76.3%) patients with hypercalcemia due to malignancy, but the elevated PTHrP percentage differed for each kind of tumor. PTHrP levels were elevated in 100% of patients with squamous carcinomas (CA) in the lung, esophagus, skin, cholangiocarcinoma of liver, and breast CA. The positive bony metastatic rate was 44.1% (41/93). There was no correlation between high PTHrP and bony metastasis. There was a good correlation between the corrected serum calcium and PTHrP levels (r = 0.476, p < 0.001), but no correlation between survival time and serum calcium level or PTHrP level. There was no significant difference in life expectancy after cancer diagnosis between the high PTHrP group and normal PTHrP group, and there was no significant difference in life expectancy after the first occurrence of hypercalcemia between the two groups. Measurement of both PTH and PTHrP levels led to a change in the initial diagnosis in 7 patients. In routine practice, measurement of serum PTH alone is not enough. This study suggests that the appropriate combination of PTH and PTHrP assays results in a more accurate diagnosis of the hypercalcemic causes. In addition, especially high PTHrP levels should be screened for malignancy. However, the prognosis in cancer patients after hypercalcemia with high PTHrP group, as compared to those with the normal PTHrP group is not significantly different.

Somatic embryogenesis and plant regeneration in callus culture derived from immature seeds and mature zygotic embryos of Dysosma pleiantha (Hance) Woodson

Callus was induced on the wounded immature seeds and mature zygotic embryos of Dysosma pleiantha (Hance) Woodson (Berberidaceae) on a medium based on Murashige and Skoog's (1962) formula supplemented with 1 mg/l 2,4-dichlorophenoxy-acetic acid (2,4-D). Spontaneous embryoid formation occurred on the media containing low concentrations of 2,4-D (0.1-0.5 mg/l). These embryoids germinated in either MS or B5 medium containing 1 mg/l N(6)-benzyladenine and 1 mg/l gibberellic acid. The regenerated plantlets were successfully transferred to soil.