A case of medicine in disguise: motion sickness patches sold as medical devices containing active pharmaceutical substances

INTRODUCTION

A case study is reported on anti-motion sickness transdermal patches sold in the Internet, claiming to contain only natural ingredients but, actually, containing undeclared medicinal active substances. The visual inspection of the samples evidenced many inconsistencies in secondary and primary packaging, missing of various legal information and a non-compliant "CE" mark.

METHODS

The qualitative analysis was performed by liquid chromatography - high resolution mass spectrometry and the quantitative by liquid chromatography with diode array detector.

RESULTS

The analyses evidenced the presence of the antihistaminic drug Diphenhydramine and of other active substances (Capsaicin, a transdermal absorption enhancer, and Diclofenac in traces, probably a contaminant from other productions of the same plant). Moreover, the presence of several trace elements, including those potentially toxic to humans, was assessed by ICP-MS analysis.

CONCLUSIONS

The case discussed is a new case of "medicines in disguise" never reported in literature, and shows the presence of tangible risks for public health.

Enantioselective HPLC analysis of Escitalopram oxalate and its impurities using a cellulose-based chiral stationary phase under normal- and green reversed-phase conditions

Normal-phase and reversed-phase high-performance liquid chromatography methods for the separation of the active pharmaceutical ingredient Escitalopram from its (R)-enantiomer impurity have been developed on the cellulose-based Chiralcel OJ-H chiral stationary phase. Both methods share two features: they use ethanol as a cosolvent and are able to give a complete enantioseparation without interference from other associated chiral impurities. With the green eluent mixture ethanol-water-diethylammine 70:30:0.1 (v/v/v) the resolution between escitalopram and (R)-enantiomer was 2.09 at 30°C. The limits of quantification for the (S) and (R) enantiomers were 4.5 μg mL^-1 and 3.8 μg mL^-1 , respectively. This article is protected by copyright. All rights reserved.

Nab-paclitaxel (Nab-P) and gemcitabine (G) first-line chemotherapy (CT) in patients (pts) with metastatic pancreatic cancer (mPC) who relapsed after adjuvant treatment (ADJ T): A “REAL LIFE” study

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Background: Nab-P and G represents a standard of care in first line mPC treatment. Only 5% of pts in Nab-P + G arm received ADJ T in the MPACT phase III trial. Accordingly, there is a lack of information about Nab-P + G benefit in this population. Aim of this analysis was to evaluate outcomes in mPC “real life” pts receiving first-line Nab-P + G after relapsing from ADJ T. Methods: Clinical records of 330 mPC pts receiving Nab-P + G with standard schedule as first line CT were retrospectively reviewed, investigating, efficacy (Progression Free Survival, PFS and Overall Survival, OS defined as time elapsed from the start of Nab-P + G to progression or death respectively) in pts treated with prior ADJ T. Analysis was then performed in ADJ T subgroup according disease free survival (DFS) cut-off ( ≤ 6 vs 6-12 vs ≥ 12 months). OS and PFS were estimated with Kaplan-Meyer method with 95% CI. Cox-regression model was applied to the data with univariate and multivariate approach. Results: At time of data analysis in the entire cohort median (m) OS was 11.3 months (95% CI 9.157-13.443); mPFS 7 months (95% CI 5.827-8.173). 90 out of 330 pts (27.3%) had received G-based ADJ T with mDFS of 29.2 months (95% CI 25.62-32.78). In the overall population at multivariate analysis, ADJ treatment was an independent prognostic factor related to better OS (HR 0.53, 95% CI 0.40-0.66; p < 0.001) and PFS (HR 0.69, 95% CI 0.49-0.89; p = 0.024). Median OS in ADJ T pts was significantly higher than pts who had not received ADJ T (15.0 vs 10.8 months respectively; p = 0.012). A similar trend in mPFS was observed in ADJ T versus non ADJ T pts (8.6 vs 6.9 months; p = 0.06). Pts with longer DFS after ADJ T showed major benefit in mOS (16.3 vs 13.1 vs 8.7 months in ≥ 12 vs 6-12 vs ≤ 6 months DFS respectively; p < 0.001). No significant differences in mPFS were observed in the three subgroups (p = 0.271). Conclusions: Nab-P + G is a standard of care also in pts treated with ADJ T. ADJ treatment is an independent prognostic factor related to better survival, maybe reflecting the effect of prior radical surgery. Pts who received G-based ADJ T may benefit of Nab-P+G combination with an increased survival in pts with longer DFS.

Chemotherapy rechallenge after regorafenib treatment in metastatic colorectal cancer: still hope after the last hope?

INTRODUCTION

The introduction of biological agents in cancer therapy is changing the progression of metastatic colorectal cancer. Currently, resistance to biological agents is an emerging problem; the progression of the disease is caused by the development of resistant clones. According to some authors, these clones can be re-sensitized to traditional and previously utilized chemotherapy agents. The results of the CORRECT study demonstrated the efficacy of regorafenib monotherapy in both KRAS wild type and mutant pretreated patients (pts). Two recent reports showed the potential of reintroduction of chemotherapy, even after treatment with regorafenib.

PATIENTS AND METHODS

We performed a retrospective review of clinical data from patients treated with regorafenib at our institution between March 2012 and March 2013. We analysed patient characteristics, KRAS/NRAS status, response to treatment (evaluated by RECIST v1.1 criteria) and survival.

RESULTS

Regorafenib was administered to 128 patients, and 11 (8.6%) received post-regorafenib therapy (to our knowledge). Seven (63.6%) patients were wild type for KRAS/NRAS. Post-regorafenib therapy represented for all the patients at least the fourth line: all the pts received both oxaliplatin- and irinotecan-based chemotherapy, all of them were treated with bevacizumab, and 7 patients also received cetuximab. Eight patients (72.7%) were treated with standard chemotherapy after regorafenib (irinotecan monotherapy, capecitabine plus oxaliplatin or irinotecan, dacarbazine or raltitrexed), while 3 patients received an experimental therapy (clinical trial). Nine of the 11 (81.8%) patients had PD and 2 patients had SD. The median progression-free survival was 1.6+ months (range 0.5-3.5), the median OS post-regorafenib was 2.1+ months (range 0.5-10.2) and the 6-month OS was 27.3%.

CONCLUSION

Our retrospective analysis showed that after regorafenib therapy, re-introduction of chemotherapy is possible. Unfortunately, we reported a high percentage of disease progression beyond regorafenib, which is likely due to the high percentage of heavily pretreated patients (some received four or five types of therapy before regorafenib). We think that regorafenib could represent a chemotherapy resensitizing agent; however, additional studies are needed in patients who have received less pretreatment.

Pancreatic cancer: New hopes after first line treatment

Pancreatic cancer is the fourth leading cause of cancer-related death worldwide. Extensive research has yielded advances in first-line treatment strategies, but there is no standardized second-line therapy. In this review, we examine the literature trying to establish a possible therapeutic algorithm.

TAS-102, the first "cardio-gentle" fluoropyrimidine in the colorectal cancer landscape?

Background

Cardiotoxicity in the form of cardiac arrhythmia, myocardial infarction, and angina-like symptoms are not rare complications of fluoropyrimidines as 5-Fluorouracil (5FU) and capecitabine.

Discussion

Tas-102, a novel oral fluoropyrimidine, was recently approved by FDA for the treatment of advanced and refractory colorectal cancer. Its unique mechanism of action doesn’t seem linked with cardiotoxicity in clinical trials reported so far.

Summary

TAS 102 may represent one of the drugs of choice for patients with advanced colorectal cancer with cardiac disease. This intriguing and clinically relevant issue is briefly examined.

GEMOX: An Active Regimen for the Treatment of Luminal and Human Epidermal Growth Factor Receptor 2-Positive Metastatic Breast Cancer

BACKGROUND

Pretreated metastatic breast cancer (MBC) remains a formidable challenge with unmet needs both in terms of prolonged survival and quality-of-life-related issues.

METHODS

We collected data from 27 MBC patients treated with gemcitabine and oxaliplatin (GEMOX) at our institution between June 2009 and April 2015. The patients were heavily pretreated, and all had previously been exposed to anthracyclines and taxanes.

RESULTS

We achieved a complete response in 1 patient (4%), a partial response in 7 patients (26%) and stable disease in 12 patients (44%), while 6 patients (22%) experienced progressive disease. The response of 1 patient (4%) could not be evaluated because she interrupted her treatment during the first cycle due to a major reaction to oxaliplatin. We observed grade 4 hypertransaminasaemia in only 1 patient (4%) and grade 2 neuropathy in 16 patients (59%). Grade 3 leuconeutropenia was observed in 5 patients (18%). The median progression-free survival was 5.9 months and the median overall survival was 9.6 months.

CONCLUSIONS

GEMOX is an efficient and well-tolerated salvage regimen for MBC patients.

The Modified Glasgow Prognostic Score and Survival in Colorectal Cancer: A Pooled Analysis of the Literature

BACKGROUND

It has been reported that the combination of inflammation parameters, such as albumin and C-reactive protein, in the modified Glasgow prognostic score (m-GPS) is a poor prognostic indicator in several malignancies. Here, we quantify the prognostic impact of this score and assess its value in colorectal cancer.

METHODS

A systematic review of electronic databases was conducted to identify publications exploring the association of m-GPS with outcome in colorectal cancer. Overall survival (OS) was the primary outcome, and cancer-specific survival (CSS), progression-free survival, and disease-free survival were secondary outcomes. Data from studies reporting a hazard ratio (HR) and 95% confidence interval (CI) were included in a metaanalysis. Pooled HRs were computed and weighted using generic inverse-variance and random effects modeling. All statistical tests were two-sided.

RESULTS

Nine studies, which included a total of 2,227 patients, were included in the analysis. Overall, according to multivariate analysis, m-GPS≥1 was independently associated with an HR for OS of 1.69 (95% CI=1.4-2.04; P<0.00001), an effect observed in all stages of disease. Six studies including a total of 1,751 patients reported HR for CSS. Overall, a high m-GPS was associated with an HR for CSS of 1.84 (95% CI=1.43-2.37; P<0.00001).

CONCLUSIONS

A high m-GPS is associated with poor OS in colorectal cancer. The m-GPS is a cheap and easily evaluable biomarker, and its incorporation into known prognostic scores for clinical decision making warrants further investigation in this setting.

Gemcitabine Plus Nab-Paclitaxel as Second-Line and Beyond Treatment for Metastatic Pancreatic Cancer: a Single Institution Retrospective Analysis

Metastatic pancreatic cancer still represent one of the most deadly disease for which there are few therapeutic options, especially in second line and beyond setting. Nabpaclitaxel plus gemcitabine activity was demonstrated in first line setting, but there are no clear evidence suggesting its use after that. We report a retrospective data analysis of 23 patients who received nab-paclitaxel plus gemcitabine after first line treatment at our Oncology Department. We observed a significant clinical benefit (43,5%) with a median overall survival of 5 months. In addition, manageable side effects were reported. Our data, despite the small sample, seem to indicate that nab- paclitaxel plus gemcitabine is an active and well tolerated regimen even in pretreated patients.

Health risks related to illegal and on-line sale of drugs and food supplements: results of a survey on marketed products in Italy from 2011 to 2013

OBJECTIVES

The increasing illegal and on-line market of medicines and food supplements is helping the widespread diffusion of harmful counterfeit and forbidden products among consumers of developed countries. The objectives of this survey were the description of the main frauds recognized by public officers and the detection of illegal or counterfeit drugs and food supplements.

METHODS

Medicines and food supplements found by Police forces on the illegal market or resulting from seizures made by Italian Customs authorities were visually inspected and analysed to evaluate their quality and the presence of other undeclared substances.

RESULTS

The visual inspection and the chemical analysis revealed unsuitable packaging (mostly lacking of adequate information for consumers), absence of the declared active substances and presence of undeclared active substances. Products containing doping agents, illegal substances and active ingredients requiring medical supervision were found.

CONCLUSION

The present work confirmed the health risk associated with assumption of medicines purchased on the Internet and from the illegal supply chain and evidenced a new threat to consumer safety related to the presence of pharmaceutical active ingredients in food supplements claiming to contain only "natural ingredients".

The Emerging Role of NRAS Mutations in Colorectal Cancer Patients Selected for Anti-EGFR Therapies

Colorectal cancer (CRC) is one of the most common cancers worldwide. Despite the improvement in overall survival (OS) due to new treatments and targeted therapies alone or in combination with chemotherapy up-to-date, little is known about cellular mechanisms, both of primary and acquired resistance of CRC to anti-Epidermal Growth Factor Receptor (EGFR) antibodies. EGFR is characterized by tyrosine kinase activity and occupies a key-role in the control of cellular transduction pathways. Its activation triggers both the RAS-RAF and PIK3CA pathways and is required to promote cell growth, differentiation, proliferation, and invasion. Cetuximab and panitumumab are both monoclonal antibodies (MoAbs) directed against the extracellular domain of EGFR, thus leading to inhibition of the downstream signaling pathways. Mutations in oncogene Kirsten-RAS (KRAS) are frequently associated with resistance to anti-EGFR therapy. However, a significant number of KRAS wild-type (WT) tumors fail to obtain disease control with anti-EGFR agents. Therefore, additional biomarkers of response/resistance to these drugs such as BRAF, NRAS, PIK3CA and PTEN have been investigated. This review will point attention on Neuroblastoma-RAS (NRAS) status in metastatic CRC (mCRC) patients (pts) selected for anti-EGFR therapy.

Pancreatic Cancer: Promises and Failures of Target Therapies

Currently, few efficient therapies are available to battle pancreatic cancer. Mechanisms underlying this cancer are not well known and researchers are trying to identify new therapeutic targets. Here, we present a review of new treatments and their results in recent years.

FOLFIRNOX for advanced pancreatic cancer (aPDAC) according to schedule and dose modifications: Clinical feasibility and impact of supportive care

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Background: Although FOLFIRINOX is considered one of the standards for aPDAC, concerns emerged with regard to the safety profile in clinical practice. Thus, we investigated the impact of dose/schedule modifications and additional supportive measures. Methods: The clinical charts of 292 aPDAC patients (pts) receiving classic (group 1) or modified (m)FOLFIRINOX (group 2) were retrieved at 8 Institutions. Results: Table summarizes pts’ characteristics;82/709 and 188/1127 pts/cycles were analyzed for groups 1 and 2, respectively. Overall toxicity was mild; significant differences in G2-4 toxicities between the two groups: asthenia (12.5% vs 6%, p<0.0001), anemia (6.1% vs 3.1%, p=0. 003), diarrhea (6.5% vs 4%, p=0.02), and thrombocytopenia (5.4% vs 0.5%, p<0.0001), favouring group 2, and neutropenia (4.7% vs 12.3%, p<0.0001), favouring group 1. G-CSF was used more frequently in group 1 (80% vs 36%, p<0.0001). Dose delays were comparable between the two groups; dose reductions were more common in group 2 (39% vs 28%, p<0.00001). No differences in the complete control of nausea/vomiting at cycle 1 (no N/V) with or without aprepitant were observed (50% vs 45%, respectively). The presence of a biliary stent did not appear to significantly worsen toxicity. Overall ORR and disease control rate (DCR: PR+SD) were 40% and 62%, respectively, without significant differences between the two groups. Median PFS was 7 mos for both groups. Median OS, however, was significantly longer in group 2 (12 vs 18 mos, respectively; p=0.01). Conclusions: Both schedulesare easily manageable and well tolerated and may be safely administered on an outpatient basis in pts carrying biliary stents as well. The minimal differences in toxicity and efficacy obtained with mFolfirinox require additional investigation. [Table: see text]

Nab-paclitaxel (Nab-P) and gemcitabine (G) as first-line chemotherapy (CT) in advanced pancreatic cancer (APDAC) elderly patients (pts): A “real-life” study

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Background: Nab-P and G represents a standard of care in first line APDAC treatment. Neverthless, activity, efficacy and safety of Nab-P + G have not been established in elderly pts and clinical trials on APDAC treatment contain fewer elderly pts compared with everyday clinical practice. Aim of this analysis is to evaluate outcomes and toxicities of elderly pts treated with first line Nab-P + G in a “real world” population. Methods: Clinical records of APDAC pts receiving Nab-P 125 mg/m2 and G 1000 mg/m2on days 1,8 and 15 of a 28 day cycle as first line CT were retrospectively reviewed, investigating activity (Disease Control Rate, DCR: Stable Disease + Partial Response + Complete Response, SD+PR+CR), efficacy (Progression Free Survival, PFS and Overall Survival, OS) and safety. Analysis was then performed in ≥ 70 years group of pts. OS and PFS were estimated with Kaplan-Meyer method with 95% CI. Cox-regression model was applied to the data with univariate and multivariate approach. Results: 105 pts (M/F:58/47), median age 64 (range 37-77) ECOG Performance Status of 0/1/2: 46/41/17 respectively were included in our analysis. 37 pts (35%) were ≥ 70 years old. In overall population Nab-P+G was administered for a median number of 6 cycles (range 1-12). 4 CR, 24 PR and 28 SD were observed (DCR: 53%), median PFS was 7 months (95% C.I. 5.93 - 8.08) and median OS was 11 months (95% C.I. 9.58 – 12.41). Pts aged ≥ 70 received a median number of 5 cycles (range 1 - 10). DCR was 48% (9 PR + 9 SD) with no differences in PFS (6.5 months, 95%C.I. 5.36 – 7.64, p=0.49) and OS (10 months, 95% C.I. 8.53 – 11.47 p=0.67) with < 70 years old pts. Treatment was mildly tolerated and toxicity profile appeared to be different in elderly pts than younger ones with more G3-4 non-haematological (27% vs 15% p=0.03) and fewer haematological (12% vs 29% p=0.004) events respectively. Conclusions: These data, evaluated under daily practice conditions, in absence of clinical trials on APDAC elderly pts, show that pts aged ≥ 70 may benefit of first-line Nab-P and G combination, as well as younger ones, both in terms of response and survival experiencing a tolerable, but significantly different toxicity profile.

Analysis of prognostic factors in advanced pancreatic cancer (APDAC) patients (pts) undergoing to first-line nab-paclitaxel (Nab-P) and gemcitabine (G) treatment

412

Background: Nab-P + G combination represents an optimal first line therapeutic option in APDAC. Actually we have no parameters to predict prognosis in pts receiving this regimen. Here we present data of a multicentre retrospective analysis evaluating prognostic impact of clinical or biological factors in a cohort of APDAC pts treated with Nab-P + G first line CT. Methods: Clinical records of 118 APDAC pts receiving first line Nab-P + G were retrospectively reviewed. Overall survival (OS) and progression free survival (PFS) were evaluated with Kaplan Meier method with 95% CI and curves were compared with log-rank test. Cox-regression model was applied to the data with univariate and multivariate approach. Variables included in analysis were age, gender, ECOG PS, primary tumor site, liver metastases, multiple metastatic sites, baseline CA19-9, bilirubin levels, neutrophil/lymphocyte ratio (NLR), CA19-9 decrease > 50%, biliary stent and symptomatic disease. Results: Median age was 66 (37 - 83), M/F:65/53, ECOG PS 0/1/2: 51/46/21 respectively. 4 complete and 27 partial responses were observed with 26% response rate (RR). Median OS and PFS were 11 months (95% CI 9.58 – 12.41) and 7 months ( 95% CI 5.96 – 8.03) respectively. When considered at univariate analysis primary tumor location to the head, ECOG PS of 2, bilirubin levels higher than median and NLR ≥ 5 had a bad prognostic impact both on PFS and OS. Differently, CA19-9 decrease > 50% was considered a positive prognostic factor for PFS and OS. Multivariate analysis confirmed the negative role of NLR ≥ 5 respect of PFS (HR 3.21; 95%CI 1.61 – 5.68, p = 0.002) and OS (HR 3.38; 95%CI 1.88 – 5.79, p = 0.001) and positive impact of CA19-9 decrease > 50% on PFS (HR 0.37; 95% CI 0.11 – 0.68, p=0.006) and OS (HR 0.53; 95% CI 0.15 – 0.97, p=0.005), as independent prognostic factors. Conclusions: This analysis suggest that in APDAC pts receiving first line Nab-P + G, high NLR value (≥5) could be considered an easy detectable, independent parameter to predict poor outcomes in terms of PFS and OS. Furthermore CA19-9 reduction > 50% from baseline may be, in absence of other clinical and molecular parameters, an early marker of good prognosis.

Thyroid carcinoma showing thymus-like differentiation: Case presentation of a young man

Ectopic thymic tissue can be present in the thyroid gland and a carcinoma showing thymus-like differentiation (CASTLE) may arise from such tissue. We are reported the case of a 26-year-old man with CASTLE, with cervical subcutaneous nodules relapse, who showed a good response to treatment with surgery, chemotherapy and radiotherapy. The problematic aspect of this case was the diagnosis; only on review were we able to make a final diagnosis. CASTLE is a very rare neoplasm. It is important to differentiate this cancer from others tumors such as primary or metastatic squamous cell carcinoma of the head and neck or squamous cell thyroid carcinoma, because the therapy and prognosis are different. Diagnosis is complicated and requires careful histological analysis (CD5- and P63-positive with presence of Hassall’s corpuscles); unfortunately there is no gold standard treatment so, in this case, we administered a sandwich of chemotherapy and radiotherapy.

Oxaliplatin-induced hypersensitivity reaction: underlying mechanisms and management

Hypersensitivity reactions are rare but feared drugs adverse effect. These reactions are not uncommon with anticancer drugs, such as taxanes, monoclonal antibodies, and platinum compounds. Oxaliplatinum, a third-generation platinum compound, one of the mainstay drugs in the treatment of many gastrointestinal cancers, can give rise to hypersensitivity reactions, sometimes with fatal outcomes. In this paper, we reviewed the incidence and mechanisms underlying the occurrence of this event, highlighting the most recent advances concerning the pathogenesis of the reaction and also reporting possible risk factors identified and the most effective treatment in preventing the onset of this event.

Tyrosine Kinase Inhibitors in EGFR-Mutated Large-Cell Neuroendocrine Carcinoma of the Lung? A Case Report

Large-cell neuroendocrine carcinoma (LCNEC) of the lung is a high-grade carcinoma belonging to the neuroendocrine tumors of the lung and is different from typical lung large-cell carcinoma. It represents about 3% of all pulmonary malignancies and is characterized by neuroendocrine cytologic features. The treatment usually is platinum-based chemotherapy, however the outcome remains poor. Therefore new therapeutic options are needed. Tyrosine kinase inhibitors have demonstrated greater efficacy and better tolerability than standard chemotherapy in non-small-cell lung cancer harboring epidermal growth factor receptor (EGFR) mutations. EGFR gene mutations were also rarely identified in LCNEC. We report a patient with lung LCNEC activating EGFR mutations who showed an impressive response to gefitinib.

Blind Snipers: Relevant Off Target Effects of Non-chemotherapeutic Agents in Oncology: Review of the Literature

In recent years an increasing attention is focused on the potential effects of drugs on cancer incidence and/or cancer survival. Many medications of common use, developed for a variety of medical non-cancer situations, have been found to have potential anti- cancer effects. In this article, we performed an overview of the literature evidence for several commonly used non-cancer medications, such as aspirin, beta-blockers, metformin and other anti- diabetics, cardiac glycosides, anticoagulant heparin, statins, psychotropic drugs, vitamins, calcium and estrogens which have been shown to have anticancer effects, in observational and experimental studies. A huge amount of data supports the idea that a few of these commonly used medicines could decrease cancer death-rate, particularly aspirin, statins and metformin, crosswise different types of cancer. To date, no mature data are available from randomized and prospective trials; perhaps, the results of some studies underway will allow us to answer some questions on the possible use of these drugs in our clinical practice in primary and secondary prevention, or even in adjuvant setting.

Natural history of malignant bone disease in gastric cancer: final results of a multicenter bone metastasis survey

Background

Bone metastasis represents an increasing clinical problem in advanced gastric cancer (GC) as disease-related survival improves. In literature, few data on the natural history of bone disease in GC are available.

Patients and Methods

Data on clinicopathology, skeletal outcomes, skeletal-related events (SREs), and bone-directed therapies for 208 deceased GC patients with evidence of bone metastasis were statistically analyzed.

Results

Median time to bone metastasis was 8 months (CI 95%, 6.125–9.875 months) considering all included patients. Median number of SREs/patient was one. Less than half of the patients (31%) experienced at least one and only 4 and 2% experienced at least two and three events, respectively. Median times to first and second SRE were 2 and 4 months, respectively. Median survival was 6 months after bone metastasis diagnosis and 3 months after first SRE. Median survival in patients who did not experience SREs was 5 months. Among patients who received zoledronic acid before the first SRE, the median time to appearance of first SRE was significantly prolonged compared to control (7 months vs 4 months for control; P: 0.0005).

Conclusions

To our knowledge, this retrospective analysis is the largest multicenter study to demonstrate that bone metastases from GC are not so rare, are commonly aggressive and result in relatively early onset of SREs in the majority of patients. Indeed, our large study, which included 90 patients treated with ZOL, showed, for the first time in literature, a significant extension of time to first SRE and increase in the median survival time after diagnosis of bone metastasis. Taken together, these data may support the beneficial effects of ZOL in GC patients.

Correlation among Streptococcus bovis, endocarditis and septicemia in a patient with advanced colon cancer: a case report

INTRODUCTION

One of the bacterial agents that has been found to be associated with colorectal cancer is Streptococcus bovis, with 13% of infective endocarditis cases caused by this pathogenic species.

CASE PRESENTATION

We describe the case of a 57-year-old Caucasian man with infiltrating and ulcerating metastatic adenocarcinoma of the sigmoid colon. The patient was receiving second-line chemotherapy treatment and, on the eighth day of the second cycle, he developed a grade IV pancytopenia. We diagnosed a severe sepsis with positive blood cultures for Streptococcus bovis/gallolyticus with a secondary endocarditis.

CONCLUSIONS

A recent study suggests that the majority of patients affected by colonic cancer have a Streptococcus bovis/gallolyticus colonization that becomes apparent as an overt infection only when immunosystem disorders or cardiac valve lesions occur. This correlation is important for involving more specialists in a correct and early diagnosis of this rare, but potentially fatal, complication.

Management of potentially resectable colorectal cancer liver metastases

Colorectal cancer is a very common malignancy worldwide and development of liver metastases, both synchronous or metachronous, is a common event. Of all patients with metastatic colorectal cancer, up to 77% have a liver-only disease and approximately 10%-20% of patients with colorectal liver metastases are considered resectable at the time of diagnosis. Surgical resection of liver metastases remains the best treatment option and it is associated with a survival plateau and a 20%-25% of long-term survivors. Perioperative chemotherapy for resectable liver metastases may improve resecability of liver metastases and disease free survival, but its impact on overall survival is still unclear and more studies are needed. Moreover, preoperative chemotherapy can increase postoperative complications. Further studies are needed to define the role of adjuvant chemotherapy after a R0 resection of liver metastases and to define the criteria for a better selection of patients candidate to hepatectomy. New strategies such as targeted therapies are emerging with promising results. Optimal management requires a multidisciplinary approach, local and systemic, but it is a still pending question. Colorectal liver metastases represent a major challenge for oncologists and surgeons. In this review will be analyzed available data about assessment and management of the patients with potentially resectable colorectal liver metastases.

Targeted therapies (TT) in metastatic renal cell carcinoma (mRCC): An Italian survey of 902 pts

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Background: TT have improved the outcome in mRCC; however, definite data regarding their efficacy when used in the community setting are still insufficient. This survey was aimed to evaluate survival in subsequent lines of treatment (tx) in mRCC pts treated outside clinical trials. Methods: Individual data from the clinical records of 902 pts treated with TT from mid 2007 to December 2012 were obtained from 28 Italian Institutions, through a questionnaire sent after approval by local ethical committees. Results: Median follow up was 26 mo (range 1-85), median age was 60 yrs (range 25-89), 75% were male. At onset metastatic sites were lung (62%), lymph nodes (38%), bone (31%); each of the other sites <10%. Median overall survival (mOS) was 24 mo (range 1-85) without statistical difference among the various centres. Sunitinib was the 1stline tx in 693 pts (76.6%), sorafenib in 124 (13.7%) , temsirolimus in 35 (4%), bevacizumab in 26 (3%), pazopanib in 19 (1.5%), others 5. Median PFS of 1stline (mPFS1) sunitinib was 11 mo and that of sorafenib 7 mo. Type of response: CR 32 (3.5%), PR 274 (30%), SD 275 (30%); PD 265 (29%), not evaluable 33 (3.5%), tx ongoing 23 (2.5%). Dose reduction of sunitinib and sorafenib was required in 49% and 39% of the cycles administered, respectively; 137 pts (15%) received only 1 cycle of sunitinib mostly for rapid progression and/or deterioration. 2ndline tx was performed in 46% of the pts: sorafenib 143 (16%), everolimus 121 (13%), sunitinib 100 (11%), temsirolimus 25 (3%), chemo-immunotherapy 26 (3%), others 1%. mPFS2 was 6 mo with sunitinib and about 4 mo with the other tx (p=0.001). 155 pts (17%) received 3 lines of tx: mOS of TKI-TKI-mTOR (A), TKI-mTOR-TKI (B) and other (C) triplets were 48, 37 and 33 mo, respectively; A vs B p= 0.06; A vs C p= 0.01. Overall PFS3 was 6 mo. Conclusions: i) This survey shows that data of clinical trials were reproduced in the real world setting; ii) a good proportion of pts achieved long OS after subsequent lines of tx; iii) on the other hand, a similar percentage of pts experienced rapid progression; iv) further studies are needed to better identify the different subsets of pts in order to improve the efficacy of TT.

Targeting VEGF-VEGFR Pathway by Sunitinib in Peripheral Primitive Neuroectodermal Tumor, Paraganglioma and Epithelioid Hemangioendothelioma: Three Case Reports

Sunitinib malate (Sutent^TM; Pfizer Inc., New York, N.Y., USA) is a small molecule kinase inhibitor with activity against a number of tyrosine kinase receptors, including vascular endothelial growth factor receptors, stem-cell factor receptor, and platelet-derived growth factor receptors alpha and beta. Sunitinib, registered for the treatment of renal cell carcinoma and gastrointestinal stromal tumors, has recently been approved for the treatment of patients with advanced pancreatic neuroendocrine tumors. Peripheral primitive neuroectodermal tumor (pPNET), paraganglioma (PGL) and epithelioid hemangioendothelioma (EHE) are rare tumors in which there is an overexpression of pro-angiogenic factors and in which a high intratumoral microvessel density is a significant poor prognostic factor. On the basis of this preclinical rationale and the lack of effective treatments in pre-treated advanced stages of these rare diseases, we report our interesting experience of pPNET, PGL and EHE treatment with sunitinib.

Hydrate modifications of the non-steroidal anti-inflammatory drug diclofenac sodium: Solid-state characterisation of a trihydrate form

Diclofenac sodium is a non-steroidal anti-inflammatory drug widely used in painful and inflammatory diseases. It can exist in different hydrate phases. By exposure to different conditions of temperature and relative humidity can be isolated a trihydrate form never described in literature. The methods of preparation of the trihydrate form (named DSH3) were described and its physico-chemical properties were investigated. Data from FTIR spectroscopy, X-ray powder diffraction and thermal analysis were used for identification and characterisation of DSH3 in comparison with the anhydrous form (DS, the commercial form) and the hydrate form DSH (obtained by exposure of DS to relative humidity even below 60% and already described and characterised in a previous article of the same authors). Intrinsic dissolution studies were performed to compare the pharmaceutical properties of DS and DSH with DSH3, since this form was accidentally found on the Italian market as active pharmaceutical ingredient (API). This work stresses the importance of assessing the correct crystalline form also in API of well-established use to guarantee quality, safety and efficacy of the final dosage form. Furthermore, this study suggests that isomorphic hydrate forms with a different dislocation of water within the crystal structures can exist.

Medicines informal market in Congo, Burundi and Angola: counterfeit and sub-standard antimalarials

Background

The presence of counterfeits and sub-standards in African medicines market is a dramatic problem that causes many deaths each year. The increase of the phenomenon of pharmaceutical counterfeiting is due to the rise of the illegal market and to the impossibility to purchase branded high cost medicines.

Methods

In this paper the results of a quality control on antimalarial tablet samples purchased in the informal market in Congo, Burundi and Angola are reported. The quality control consisted in the assay of active substance by means of validated liquid chromatographic methods, uniformity of mass determination, disintegration and dissolution tests. Moreover, a general evaluation on label and packaging characteristics was performed.

Results

The results obtained on thirty antimalarial tablet samples containing chloroquine, quinine, mefloquine, sulphadoxine and pyrimethamine showed the presence of different kinds of problems: a general problem concerning the packaging (loose tablets, packaging without Producer name, Producer Country and sometimes without expiry date); low content of active substance (in one sample); different, non-declared, active substance (in one sample); sub-standard technological properties and very low dissolution profiles (in about 50% of samples). This last property could affect the bioavailability and bioequivalence in comparison with branded products and could be related to the use of different excipients in formulation or bad storage conditions.

Conclusion

This paper evidences that the most common quality problem in the analysed samples appears to be the low dissolution profile. Here it is remarked that the presence of the right active substance in the right quantity is not a sufficient condition for a good quality drug. Dissolution test is not less important in a quality control and often evidences in vitro possible differences in therapeutic efficacy among drugs with the same active content. Dissolution profile can be dramatically affected by the choice of excipients in the oral solid formulation and, in many cases, is out of specifications due to the absence of formulation studies by producers of developing countries.

Development and validation of a reversed-phase LC method for analysing potentially counterfeit antimalarial medicines

Pharmaceutical counterfeiting is more and more a public health problem, especially in developing countries where the most counterfeit drugs are antibiotics, antimalarials and other life-saving drugs. The evaluation of the phenomenon extent is of great concern to the World Health Organization for carrying out a global strategy to combat the phenomenon. To this purpose, a reversed-phase liquid chromatographic method to perform the separation and simultaneous determination of three different kinds of antimalarial drugs (chloroquine, quinine and mefloquine) was developed. The method was validated by using both commercial and in-laboratory produced tablets and was then verified on various in-laboratory produced formulations differing in excipient composition. Finally, the method was successfully applied to the analysis of medicinal samples purchased from the informal market in Congo, Burundi and Angola.

Physico-chemical characterisation and intrinsic dissolution studies of a new hydrate form of diclofenac sodium: comparison with anhydrous form

Diclofenac sodium is a non-steroidal anti-inflammatory drug widely used in painful and inflammatory diseases. In standard conditions, by exposure to relative humidity even below 60% at 25 degrees C, the anhydrous form DS gives rise to a hydrate species DSH, a tetrahydrate form different from that obtained by crystallisation from water and previously described. The method of preparation and the physico-chemical properties of the hydrate form were investigated. Data from FTIR spectroscopy, X-ray powder diffraction and thermal analysis were used for the identification and the characterisation of DSH. DS and DSH were easily differentiated by their IR spectra, X-ray patterns and thermal behaviour. DSH stability was followed at room temperature over a period of 1 year and under different conditions of temperature to verify the tendency to solid-solid transition and to study its existence range. Solubility and intrinsic dissolution studies were performed to compare the physico-chemical properties of DS and DSH. Differences in solubility and intrinsic dissolution rates were pointed out: these studies showed that DS dissolved faster than DSH. Storage under uncontrolled environmental conditions or contact with water vapour during manufacturing process could thus influence the performance of the final dosage form.

Focused microwave-assisted extraction and LC determination of the active ingredient in naproxen-based suppositories

A simple and rapid open-vessel focused microwave-assisted extraction (FMAE) method followed by LC analysis was developed for the determination of naproxen in suppositories. Parameters which might affect the FMAE method, such as nature and volume of the extraction solvent, temperature and extraction time were optimized. The extraction solvent consisted of methanol/sodium hydrogen carbonate (pH 8.7; 0.1 M) (50:50, v/v). Extractions were performed by reaching the target temperature of 70 degrees C in a 7 min linear ramp and then maintaining the target temperature for 3 min. Chromatographic analysis was performed on a Discovery RP-Amide C16 column (250 mm x 4.6 mm i.d., 5 microm particle size). The mobile phase consisted of acetonitrile/potassium dihydrogenphosphate (pH 3.0; 25 mM) (40:60, v/v). The complete analytical procedure was validated with regard to limit of quantification, linearity, precision and accuracy. The advantages of the proposed method in comparison to conventional methods are decreased extraction time, reduced solvent consumption and no further sample clean-up steps required before liquid chromatographic analysis.

Diclofenac sodium multisource prolonged release tablets—a comparative study on the dissolution profiles

The aim of this work was to compare the dissolution behaviour of six diclofenac sodium prolonged release tablets of different brands obtained from the national market. The formulations contain the same amount of drug substance but different types and/or amount of excipients. The influence of these differences in formulation on the release characteristics of the dosage forms was evaluated on the European Pharmacopoeia apparatus 2 (paddle) employing eight different dissolution media in the pH range 1.2-8. Friability and hardness were tested too according to the European Pharmacopoeia. Dissolution profiles obtained from the studied formulations showed that the release characteristics vary considerably among different manufacturers and that even identical formulations show rather dissimilar release profiles in all the studied media. Use of both SIF without pancreatin and SIF without pancreatin containing 1% (w/v) Tween 20 resulted in strong discrimination among products. A correlation between friability and hardness and in vitro dissolution was evidenced for two formulations having identical excipient composition.

Effects induced by hydroxyl radicals on salmon calcitonin: a RP-HPLC, CD and TEM study

The effects of hydroxyl radical attack on a peptidic drug were studied in vitro. Different chemico-physical techniques were used to investigate structural damage induced by oxidative stress conditions in salmon calcitonin (sCT), a peptide hormone used in treating osteoporosis. Reversed-phase liquid chromatography (RP-HPLC), circular dichroism (CD) and transmission electron microscopy (TEM) were applied to measure formation of oxidation/degradation products and to reveal the conformational and ultrastructural modifications in the presence of OH. free radicals. Hydroxyl radicals were obtained from ferrous sulfate and ascorbic acid mixtures. The RP-HPLC results revealed the formation of new chromatographic peaks indicating a number of degradation/oxidation products formed in the presence of OH. free radicals. CD spectra showed slight protein conformational modifications as well as aggregation. TEM confirmed sCT aggregation and suggested the formation of fibrillar aggregates.

RP-HPLC study of the degradation of diclofenac and piroxicam in the presence of hydroxyl radicals

The effect of hydroxyl radical attack on two non-steroidal anti-inflammatory drugs (NSAIDs) was studied in vitro. Diclofenac and piroxicam were analysed by RP-HPLC after reaction with OH* free radicals to detect newly formed oxidation and/or degradation products. OH* free radicals were obtained by means of ferrous sulphate and ascorbic acid mixtures. During the reaction the mixtures were exposed to irradiation by a tungsten lamp to obtain an increased and more reproducible formation of hydroxyl radicals. The chromatographic profiles showed the formation of several new peaks for both diclofenac and piroxicam due to the presence of a number of degradation/oxidation products formed in the presence of OH* radicals.