CHARIOT: a phase I study of berzosertib with chemoradiotherapy in oesophageal and other solid cancers using time to event continual reassessment method.

BACKGROUND: Berzosertib (M6620) is a highly potent (IC50 = 19 nM) and selective, first-in-class ataxia telangiectasia-mutated and Rad3-related protein kinase (ATR) inhibitor. This trial assessed the safety, preliminary efficacy, and tolerance of berzosertib in oesophageal cancer (A1 cohort) with RT and advanced solid tumours (A2 cohort) with cisplatin and capecitabine. METHODS: Single-arm, open-label dose-escalation (Time-to-Event Continual Reassessment Method) trial with 16 patients in A1 and 18 in A2. A1 tested six dose levels of berzosertib with RT (35 Gy over 15 fractions in 3 weeks). RESULTS: No dose-limiting toxicities (DLTs) in A1. Eight grade 3 treatment-related AEs occurred in five patients, with rash being the most common. The highest dose (240 mg/m2) was determined as the recommended phase II dose (RP2D) for A1. Seven DLTs in two patients in A2. The RP2D of berzosertib was 140 mg/m2 once weekly. The most common grade ≥3 treatment-related AEs were neutropenia and thrombocytopenia. No treatment-related deaths were reported. CONCLUSIONS: Berzosertib combined with RT is feasible and well tolerated in oesophageal cancer patients at high palliative doses. Berzosertib with cisplatin and capecitabine was well tolerated in advanced cancer. Further investigation is warranted in a phase 2 setting. CLINICAL TRIALS IDENTIFIER: EU Clinical Trials Register (EudraCT) - 2015-003965-27 ClinicalTrials.gov - NCT03641547.

Dynamic optical coherence tomography shows characteristic alterations of blood vessels in malignant melanoma.

BACKGROUND: Dynamic optical coherence tomography (D-OCT) allows in vivo visualization of blood vessels in the skin and in malignant tumours. Vessel patterns in malignant melanoma may be associated with tumour stage. OBJECTIVE: The aim of this study was to describe blood vessel patterns in melanomas and to correlate them with stage. METHODS: One hundred fifty-nine malignant melanomas were assessed in a multicentre study. Every tumour was imaged using D-OCT prior to surgery and histologic evaluation. The tumour data such as thickness and ulceration as well as the staging at primary diagnosis and a follow-up of at least 40 months resulted in a stage classification. The vessel patterns were assessed according to predefined categories, compared with healthy adjacent skin, and correlated to stage. RESULTS: Melanomas contained more blood vessels in different patterns compared with healthy adjacent skin. In particular, irregular vascular shapes such as blobs, coils, curves and serpiginous vessels were more common in melanomas. In addition, these patterns were significantly more often found in high-risk and metastatic melanomas than in low-risk lesions. CONCLUSION: In melanomas, the density of the blood vessels is increased, and irregular vascular patterns are more frequent. At higher stages, especially in metastatic melanomas, these atypical vessels are significantly more common.

Single arm two-stage studies: Improved designs for molecularly targeted agents.

Mechanistic understanding of cancers and their potential interactions with molecularly targeted agents is driving the need for stratified medicine to ensure each participant receives the best possible care. This understanding, backed by scientific research, should be used to guide the design of clinical trials for these agents. The mechanism of action of a molecularly targeted agent often suggests that a biomarker can be used as a predictor of activity of the agent on the targeted disease. A biomarker driven trial is needed to confirm that the molecularly targeted agent stratifies the participant population with disease into high and low responder groups. We assume that the biomarker of interest can be dichotomised and propose a balanced parallel two-stage single-arm phase II trial that builds on existing two-stage single-arm designs. A single-arm trial cannot distinguish between a marker being predictive in the population as a whole and the agent causing an increased response in the marker positive group, but it is a first step. We compare this approach to the existing single-arm approaches, sequential enrichment, tandem two-stage, and parallel two-stage designs, and discuss the advantages and disadvantages of each design. We show that our design compares favourably to existing designs in the Bayesian framework, making a more efficient use of collected data. We recommend using the parallel two-stage balanced or sequential enrichment designs when randomisation is not practical in a phase II trial.

Dynamic optical coherence tomography of skin blood vessels - proposed terminology and practical guidelines.

BACKGROUND: Dynamic optical coherence tomography (D-OCT) has recently been introduced in dermatology. In contrast to 'Standard' OCT imaging, which exclusively relies on the morphological analysis of the tissue, D-OCT allows the in vivo visualization of blood flow. Preliminary D-OCT data showed differences in the vascularization of nevus to melanoma transition, suggesting that this technology may help to differentiate between benign and malignant lesions. OBJECTIVE: Several factors may influence the quality of D-OCT imaging. Therefore, standard operating procedures as well as a common terminology are required for better validation and comparison of the images. METHODS: Here, we present practical guidelines for optimal image acquisition and a proposed terminology on vascular patterns observed by D-OCT. RESULTS: Dynamic OCT allows the morphologic distinction of different vascular shapes (e.g. dots, blobs, curves, lines), their distribution and organization within skin lesions. CONCLUSION: D-OCT adds functional information on skin microvasculature and the vascular networks within lesions.

Optical coherence tomography for margin definition of basal cell carcinoma before micrographic surgery-recommendations regarding the marking and scanning technique.

BACKGROUND/PURPOSE: Mohs Micrographic Surgery (MMS) is the preferred therapeutic treatment for high-risk basal cell carcinoma (BCC). Optical Coherence Tomography (OCT) is a non-invasive imaging technique that enables the diagnosis of BCC. We thought to determine the margins of BCCs with OCT, prior to MMS, to reduce the number of surgical steps. METHODS: Different permanent markers were tested on the skin regarding line width, resistance against disinfection and brightness in the OCT image. The visible tumor margins of BCCs were defined by dermoscopy, adding a safety margin of 2 mm and labeled using the selected pen, causing a signal shadow in OCT. Scans of the center and of entire margin were performed. If parts of the BCC were visible outside the margin, another 2 mm were added and the scan was repeated until the tissue outside the labeling looked tumor free. RESULTS: Eight out of ten BCCs were totally excised in a single stage when margin delineation was done by OCT. Macroscopic margins were enlarged after OCT scanning in four patients, saving further stages of MMS. CONCLUSION: OCT may help to better define the microscopic dimensions of BCCs and therefore reduce the number of stages of MMS.

Optical coherence tomography of basal cell carcinoma: influence of location, subtype, observer variability and image quality on diagnostic performance.

BACKGROUND: We previously described the principal results from an observational, prospective, multicentre, clinical trial of the diagnostic value of optical coherence tomography (OCT) for basal cell carcinoma (BCC) in a clinical setting. In this trial, much additional useful information was gathered that warranted further analysis, presented here. OBJECTIVES: To investigate the influence of candidate diagnostic criteria, OCT image quality, lesion location, and observer confidence and interobserver variability on the diagnostic performance of OCT, and to assess its potential use for diagnosis of BCC subtypes. METHODS: A total of 234 clinically unclear 'pink lesions' were evaluated in three steps: after clinical examination, after adding dermoscopy and after adding OCT. In addition to the diagnoses (including lesion subtype), observers recorded which of 15 diagnostic criteria the OCT image contained, their confidence in the diagnoses, the OCT image quality and the anatomical location of the lesion. RESULTS: Diagnostic performance of OCT did not depend on the lesion's anatomical location. Good OCT image quality was correlated with improved diagnostic performance, but diagnostic performance for lesions with mediocre image quality was still better than by clinical and dermoscopic examination. The main reason for reduced image quality was superficial scales and crusting. Observer confidence in diagnosis was correlated with diagnostic performance. Interobserver diagnostic performance was consistently higher than clinical examination and dermoscopy across all sites. BCC subtype could be determined with moderate accuracy, but further independent image markers are required. CONCLUSION: OCT is useful in the diagnosis of BCC.

In vivo microvascular imaging of cutaneous actinic keratosis, Bowen's disease and squamous cell carcinoma using dynamic optical coherence tomography.

BACKGROUND: A clear distinction between actinic keratosis (AK), Bowen's disease (BD) and squamous cell carcinoma (SCC) cannot reliably be made by clinical and dermoscopic evaluation alone. Dynamic optical coherence tomography (D-OCT) is a novel angiographic variant of OCT that allows for non-invasive, in vivo evaluation of the cutaneous microvascular morphology. OBJECTIVE: To investigate the microvascular structures of AK, BD and invasive SCC using D-OCT in order to gain insights into the microvascular morphology of lesions in the spectrum of keratinocyte skin cancers. METHODS: Forty-seven patients with a total of 54 lesions (18 AK, 12 BD and 24 SCC) were included in the study. D-OCT still images of AK, BD and SCC at three predefined skin depths were prepared and randomized, creating a study set of 162 D-OCT images. Three observers performed blinded evaluations of the randomized study set assessing multiple parameters including the different types of vascular morphology. Non-blinded quantitative measurements of vascular diameter were also performed. RESULTS: The blinded observer analysis suggests that D-OCT evaluation of the vascular morphology may aid in distinguishing AK, BD and SCC lesions. We identified two vascular shapes that presented significantly differently across the lesion types, namely 'blobs' and 'curves'. A strong presence of blobs at 300 µm skin depth was characteristically seen in a third of BD cases, while not or only slightly present in AK and SCC lesions. Vascular curves were predominantly present in AK lesions. CONCLUSION: We identified various vascular D-OCT features that may aid in non-invasively differentiating subtypes within the keratinocyte skin cancer spectrum.

Statistical controversies in clinical research: publication bias evaluations are not routinely conducted in clinical oncology systematic reviews.

Background: Publication bias is an over-representation of statistically significant results in the published literature and may exaggerate summary effect estimates in oncology systematic reviews. Omitting non-significant results in systematic reviews may therefore affect clinical decision-making. We investigate ways that systematic reviewers attempted to limit publication bias during the search process as well as the statistical methods used to evaluate it. For a subset of reviews not reporting publication bias evaluations, we carried out our own assessments for publication bias to determine its likelihood among these reviews. Design: We examined systematic reviews from the top five highest impact factor oncology journals published between 2007 and 2015. Systematic reviews were screened for eligibility and qualifying reviews (n = 182) were coded for relevant publication bias study characteristics by two authors. A re-analysis of reviews not initially evaluating for publication bias was carried out using Egger's regression, trim-and-fill, and selection models. Results: Of the 182 systematic reviews, roughly half carried out a hand search to locate additional studies. Conference abstracts were the most commonly reported form of gray literature, followed by clinical trials registries. Fifty-one reviews reported publication bias evaluations. The most common method was the funnel plot (80%, 41/51) followed by Egger's regression (59%, 30/51) and Begg's test (43%, 22/51). Our publication bias evaluations on non-reporting reviews suggest that the degree of publication bias depends on the method employed. Conclusion: Our study shows publication bias assessments are not frequently used in oncology systematic reviews. Furthermore, evidence of publication bias was found in a subset of non-reporting reviews. Systematic reviewers in oncology are encouraged to conduct such analyses when appropriate and to employ more robust methods for both mitigating and evaluating publication bias.

Temporal electronic phenotyping by mining careflows of breast cancer patients.

In this work we present a careflow mining approach designed to analyze heterogeneous longitudinal data and to identify phenotypes in a patient cohort. The main idea underlying our approach is to combine methods derived from sequential pattern mining and temporal data mining to derive frequent healthcare histories (careflows) in a population of patients. This approach was applied to an integrated data repository containing clinical and administrative data of more than 4000 breast cancer patients. We used the mined histories to identify sub-cohorts of patients grouped according to healthcare activities pathways, then we characterized these sub-cohorts with clinical data. In this way, we were able to perform temporal electronic phenotyping of electronic health records (EHR) data.

Pathological ribonuclease H1 causes R-loop depletion and aberrant DNA segregation in mitochondria.

The genetic information in mammalian mitochondrial DNA is densely packed; there are no introns and only one sizeable noncoding, or control, region containing key cis-elements for its replication and expression. Many molecules of mitochondrial DNA bear a third strand of DNA, known as "7S DNA," which forms a displacement (D-) loop in the control region. Here we show that many other molecules contain RNA as a third strand. The RNA of these R-loops maps to the control region of the mitochondrial DNA and is complementary to 7S DNA. Ribonuclease H1 is essential for mitochondrial DNA replication; it degrades RNA hybridized to DNA, so the R-loop is a potential substrate. In cells with a pathological variant of ribonuclease H1 associated with mitochondrial disease, R-loops are of low abundance, and there is mitochondrial DNA aggregation. These findings implicate ribonuclease H1 and RNA in the physical segregation of mitochondrial DNA, perturbation of which represents a previously unidentified disease mechanism.

Natural and unnatural oil slicks in the Gulf of Mexico.

When wind speeds are 2-10 m s-1, reflective contrasts in the ocean surface make oil slicks visible to synthetic aperture radar (SAR) under all sky conditions. Neural network analysis of satellite SAR images quantified the magnitude and distribution of surface oil in the Gulf of Mexico from persistent, natural seeps and from the Deepwater Horizon (DWH) discharge. This analysis identified 914 natural oil seep zones across the entire Gulf of Mexico in pre-2010 data. Their ∼0.1 µm slicks covered an aggregated average of 775 km2. Assuming an average volume of 77.5 m3 over an 8-24 h lifespan per oil slick, the floating oil indicates a surface flux of 2.5-9.4 × 104 m3 yr-1. Oil from natural slicks was regionally concentrated: 68%, 25%, 7%, and <1% of the total was observed in the NW, SW, NE, and SE Gulf, respectively. This reflects differences in basin history and hydrocarbon generation. SAR images from 2010 showed that the 87 day DWH discharge produced a surface-oil footprint fundamentally different from background seepage, with an average ocean area of 11,200 km2 (SD 5028) and a volume of 22,600 m3 (SD 5411). Peak magnitudes of oil were detected during equivalent, ∼14 day intervals around 23 May and 18 June, when wind speeds remained <5 m s-1. Over this interval, aggregated volume of floating oil decreased by 21%; area covered increased by 49% (p < 0.1), potentially altering its ecological impact. The most likely causes were increased applications of dispersant and surface burning operations.

Is intermittent exotropia a curable condition?

Surgical treatment of childhood intermittent exotropia (XT) is associated with high recurrence rates. In addition, the natural history of intermittent XT has not been rigorously studied and, anecdotally, some cases resolve without surgery. We compared long-term cure rates in children with surgically and non-surgically managed intermittent XT. Children undergoing surgery for intermittent XT who had 5 years follow-up were retrospectively identified. A non-surgical cohort of comparable children was selected by matching each surgical patient for age at onset and age at the 5-year examination. Cure was defined as no manifest tropia on examination or by history, no new monofixation (stereoacuity subnormal for age), and no additional surgery. Each group had 33 children (total follow-up from presentation 7.2±2.6 years in the surgical group vs 6.8±2.3 years). There were no significant differences between groups for age at onset, age at presentation, or distance or near angle of deviation at presentation (all P≥0.4). The cure rate at 5 years was 30% in the surgical group and 12% in the non-surgical group (P=0.1; difference 18%, 95% CI -1 to 37%). Only a small proportion of surgical and non-surgical patients met our definition of cure, with the vast majority demonstrating a constant or intermittent manifest deviation after an average of 7 years follow-up. In childhood intermittent XT, long-term cure is difficult to achieve with surgical intervention, and in some patients managed non-surgically the intermittent XT will spontaneously resolve.

Final report of the phase I/II clinical trial of the E75 (nelipepimut-S) vaccine with booster inoculations to prevent disease recurrence in high-risk breast cancer patients.

BACKGROUND: E75 (nelipepimut-S) is a human leukocyte antigen (HLA)-A2/A3-restricted immunogenic peptide derived from the HER2 protein. We have conducted phase I/II clinical trials vaccinating breast cancer patients with nelipepimut-S and granulocyte-macrophage colony-stimulating factor (GM-CSF) in the adjuvant setting to prevent disease recurrence. All patients have completed 60 months follow-up, and here, we report the final analyses. PATIENTS AND METHODS: The studies were conducted as dose escalation/schedule optimization trials enrolling node-positive and high-risk node-negative patients with tumors expressing any degree of HER2 (immunohistochemistry 1-3+). HLA-A2/3+ patients were vaccinated; others were followed prospectively as controls. Local and systemic toxicity was monitored. Clinical recurrences were documented, and disease-free survival (DFS) was analyzed by Kaplan-Meier curves; groups were compared using log-rank tests. RESULTS: Of 195 enrolled patients, 187 were assessable: 108 (57.8%) in the vaccinated group (VG) and 79 (42.2%) in the control group (CG). The groups were well matched for clinicopathologic characteristics. Toxicities were minimal. Five-year DFS was 89.7% in the VG versus 80.2% in the CG (P = 0.08). Due to trial design, 65% of patients received less than the optimal vaccine dose. Five-year DFS was 94.6% in optimally dosed patients (P = 0.05 versus the CG) and 87.1% in suboptimally dosed patients. A voluntary booster program was initiated, and among the 21 patients that were optimally boosted, there was only one recurrence (DFS = 95.2%). CONCLUSION: The E75 vaccine is safe and appears to have clinical efficacy. A phase III trial evaluating the optimal dose and including booster inoculations has been initiated. CLINICAL TRIALS: NCT00841399, NCT00584789.

Downregulation of interleukin-18-mediated cell signaling and interferon gamma expression by the hepatitis B virus e antigen.

UNLABELLED: The mechanisms by which hepatitis B virus (HBV) establishes and maintains chronic hepatitis B infection (CHB) are poorly defined. Innate immune responses play an important role in reducing HBV replication and pathogenesis. HBV has developed numerous mechanisms to escape these responses, including the production of the secreted hepatitis B e antigen (HBeAg), which has been shown to regulate antiviral toll-like receptor (TLR) and interleukin-1 (IL-1) signaling. IL-18 is a related cytokine that inhibits HBV replication in hepatoma cell lines and in the liver through the induction of gamma interferon (IFN-γ) by NK cells and T cells. We hypothesized that HBV or HBV proteins inhibit IFN-γ expression by NK cells as an accessory immunomodulatory function. We show that HBeAg protein inhibits the NF-κB pathway and thereby downregulates NK cell IFN-γ expression. Additionally, IFN-γ expression was significantly inhibited by exposure to serum from individuals with HBeAg-positive but not HBeAg-negative chronic HBV infection. Further, we show that the HBeAg protein suppresses IL-18-mediated NF-κB signaling in NK and hepatoma cells via modulation of the NF-κB pathway. Together, these findings show that the HBeAg inhibits IL-18 signaling and IFN-γ expression, which may play an important role in the establishment and/or maintenance of persistent HBV infection. IMPORTANCE: It is becoming increasingly apparent that NK cells play a role in the establishment and/or maintenance of chronic hepatitis B infection. The secreted HBeAg is an important regulator of innate and adaptive immune responses. We now show that the HBeAg downregulates NK cell-mediated IFN-γ production and IL-18 signaling, which may contribute to the establishment of infection and/or viral persistence. Our findings build on previous studies showing that the HBeAg also suppresses the TLR and IL-1 signaling pathways, suggesting that this viral protein is a key regulator of antiviral innate immune responses.

Evaluation of ozonated olive oil with or without adjunctive application of calcium sodium phosphosilicate on post-surgical root dentin hypersensitivity: a randomized, double-blinded, controlled, clinical trial.

AIM: This study was conducted to evaluate the efficacy of ozonated olive oil with or without adjunctive application of mineral wash containing calcium sodium phosphosilicate on the reversal of post-surgical root dentin hypersensitivity. METHODS: A double-blinded, randomized controlled clinical trial was conducted on 51 participants with root dentin hypersensitivity (RDH). Participants were randomLy assigned to 4 groups: Group A, ozonated olive oil (OZO): Group B, ozonated olive oil and mineral wash: Group C, placebo olive oil (PPO) and mineral wash: Group D, placebo olive oil only. Active treatment was carried out in-clinic and followed by at-home care with a remineralising paste. The response to various pain stimuli was periodically assessed with a visual analogue scale. Additionally, scanning electron microscopic study assessed the dentinal tubule occlusion and change in tubular surface area after treatment. RESULTS: The group B participants showed a significant decrease in tooth level and global sensitivity over the period (P<0.001). Moreover, the intergroup comparison also revealed a significant result (P<0.001). Similarly, participants of group C also showed a significant reduction in sensitivity over the period (P<0.001). Whereas, no significant (P>0.05) difference was detected between group A and group D for tooth level and global sensitivity analysis. The SEM study result showed a significantly (P<0.001) enhanced tubule occlusion and decreased tubular surface area in group B specimens compared to other group specimens. CONCLUSION: OZO, as a mono-therapy is not efficient in reducing post-surgical RDH. However, the adjunctive application of mineral wash containing calcium sodium phosphosilicate has positive impact on the reversal of post-surgical root dentin hypersensitivity.

Effect of subgingival application of topical ozonated olive oil in the treatment of chronic periodontitis: a randomized, controlled, double blind, clinical and microbiological study.

AIM: The aim of this paper was to evaluate the efficacy of ozonated olive oil as a monotherapy and an adjunct to scaling and root planing in the treatment of chronic periodontitis METHODS: A split mouth, double-blinded, randomized controlled clinical trial was conducted on 20 subjects diagnosed with chronic periodontitis. Quadrants of each subject were randomly assigned to four groups and treated accordingly: Group A, scaling and root planing (SRP): Group B, topical ozonated olive oil (OZO) as an adjunct to scaling and root planing: Group C, topical ozonated olive oil as a monotherapy and: Group D, topical chlorhexidine gel as a monotherapy. The quadrants were analyzed clinically by plaque index, gingival index, sulcus bleeding index, probing pocket depth, and clinical attachment level at baseline, 2, 4, 6 and 8 weeks of time intervals. The subjects were also analyzed for perceived pain, discomfort or tooth hypersensitivity (quadrant wise) on a Visual Analogue Scale (VAS). Additionally, subgingival plaque samples were collected from the two predetermined sites of each quadrant at baseline, 4 and 8 weeks for the analysis of total bacterial counts (TBCs) and the detection of frequency of eight putative periodontopathogens by polymerase chain reaction (PCR) method. RESULTS: The adjunctive use of the OZO with SRP resulted in a significant improvement (P<0.001) of clinical parameters as well as microbiological parameters over the time and in comparison to the control groups. The OZO as monotherapy also showed a significant improvement (P<0.001) in clinical parameters as well as microbiological parameters over the time without any documented side effects. However, there was a significant increase (P<0.05) in dentinal hypersensitivity following OZO as an adjunct to scaling and root planing therapy. CONCLUSION: The OZO, as an adjunctive therapy as well as a mono-therapy is efficient in improving periodontal conditions.