Circulating tumour cells and PD-L1-positive small extracellular vesicles: the liquid biopsy combination for prognostic information in patients with metastatic non-small cell lung cancer.

BACKGROUND: Circulating tumour cells (CTCs), circulating tumour DNA (ctDNA), and extracellular vesicles (EVs) are minimally invasive liquid biopsy biomarkers. This study investigated whether they predict prognosis, alone or in combination, in heterogenous unbiased non-small cell lung cancer (NSCLC) patients. METHODS: Plasma samples of 54 advanced NSCLC patients from a prospective clinical trial. CtDNA mutations were identified using the UltraSEEK™ Lung Panel (MassARRAY® technology). PD-L1 expression was assessed in small EVs (sEVs) using an enzyme-linked immunosorbent assay. RESULTS: At least one ctDNA mutation was detected in 37% of patients. Mutations were not correlated with overall survival (OS) (HR = 1.1, 95% CI = 0.55; 1.83, P = 0.980) and progression-free survival (PFS) (HR = 1.00, 95% CI = 0.57-1.76, P = 0.991). High PD-L1+ sEV concentration was correlated with OS (HR = 1.14, 95% CI = 1.03-1.26, P = 0.016), but not with PFS (HR = 1.08, 95% CI = 0.99-1.18, P = 0.095). The interaction analysis suggested that PD-L1+ sEV correlation with PFS changed in function of CTC presence/absence (P interaction = 0.036). The combination analysis highlighted worse prognosis for patients with CTCs and high PD-L1+ sEV concentration (HR = 7.65, 95% CI = 3.11-18.83, P < 0.001). The mutational statuses of ctDNA and tumour tissue were significantly correlated (P = 0.0001). CONCLUSION: CTCs and high PD-L1+ sEV concentration correlated with PFS and OS, but not ctDNA mutations. Their combined analysis may help to identify patients with worse OS. TRIAL REGISTRATION: NCT02866149, Registered 01 June 2015, https://clinicaltrials.gov/ct2/show/study/NCT02866149 .

Programmed Cell Death Ligand 1-Expressing Circulating Tumor Cells: A New Prognostic Biomarker in Non-Small Cell Lung Cancer.

BACKGROUND: In non-small cell lung cancer (NSCLC), analysis of programmed cell death ligand 1 (PD-L1) expression in circulating tumor cells (CTCs) is a potential alternative to overcome the problems linked to the tumor biopsy spatiotemporal heterogeneity. However, the prognostic significance of PD-L1-positive [PD-L1(+)] CTCs remains controversial. METHODS: We prospectively evaluated the correlation with clinicopathological variables and prognostic value of PD-L1(+) CTCs, detected with the FDA-cleared CellSearch® system, in 54 patients with advanced NSCLC. RESULTS: We detected CTCs and PD-L1(+) CTCs in 43.4% and 9.4% of patients with NSCLC. PD-L1 expression concordance between tumor tissue and CTCs was low (54%). The presence of PD-L1(+) CTC correlated with the absence of gene alterations in tumor tissue and with poor prognosis-related biological variables (anemia, hyponatremia, increased lactate dehydrogenase). In univariate analysis, absence of gene alterations, number of metastatic sites, prior systemic therapies, and presence of CTCs and PD-L1(+) CTCs were associated with worse overall survival, whereas PD-L1 expression in tumor tissue was not. In multivariate analysis, squamous cell carcinoma histology, number of prior systemic treatments, and the presence of CTC were significantly associated with overall survival. Survival was worse in patients with PD-L1(+) CTCs than in patients with PD-L1-negative CTC or without any CTC. CONCLUSIONS: Our study suggests that the presence of PD-L1(+) CTCs is associated with poor prognosis in patients with advanced NSCLC. Studies with larger samples are needed to confirm our results and to determine how PD-L1(+) CTC detection could help to predict the response or resistance to anti-PD-1/PD-L1 therapies.Clinical trial registration NCT02866149.

Reducing malnutrition in Cambodia. A modeling exercise to prioritize multisectoral interventions.

Undernutrition is a major contributor to child morbidity and mortality and poses a large burden to the economy, in Cambodia. This study explored factors contributing to child stunting and wasting and their regional inequalities among 1,938 Cambodian children aged 6-23.9 months. Data were drawn from a longitudinal study (year 2017) conducted in six districts of two north-eastern provinces and the capital and used as cross-sectional. Socio-demographic and household characteristics, children's feeding practices during the previous 24 hr, and children's length and weight measurements were collected. Gradient boosting models were used to calculate the contribution of determinants to child undernutrition whereas concentration index was used to assess the impact of those determinants on stunting and wasting inequalities among socioeconomic groups. It was found that low-household wealth could predict 21% to 45% of child stunting and 23% to 36% of wasting across regions. After wealth, source and treatment of drinking water were found the second major predictor for stunting (15%) and wasting (21%). Combining child nutrition and household water, sanitation and hygiene indicators predicted around 30% of child undernutrition, either in the form of stunting or wasting. Mothers' education predicted >30% of stunting in the north-eastern region. Results highlight that a complex interplay of factors contributes to child stunting and wasting. An integrated, intersectoral, equity-focused approach that addresses children's dietary quality, household's water, sanitation and hygiene conditions, mother's education, and poverty is likely to yield the highest impact in achieving further gains in nutritional status among Cambodian children.

Regorafenib plus FOLFIRINOX as first-line treatment for patients with RAS-mutant metastatic colorectal cancer (FOLFIRINOX-R trial): a dose-escalation study.

PURPOSE: The combination of bevacizumab and FOLFIRINOX is used in patients with RAS-mutant metastatic colorectal cancer (RASm-mCRC). Regorafenib, an oral multi-tyrosine kinase inhibitor, has antiangiogenic properties, cytostatic effects and also true cytotoxic effects, unlike bevacizumab. The aim of this study was to determine the maximum tolerated dose (MTD) and the recommended phase 2 dose (RP2D) of the regorafenib-FOLFIRINOX combination in patients with RASm-mCRC. METHODS: The FOLFIRINOX-R trial was a phase 1/2 study where the dose-escalation part (3 + 3 design with three dose levels, DLs) was completed before its early termination. FOLFIRINOX (14-day cycle) included oxaliplatin (standard dose), folinic acid, fluorouracil and irinotecan (150 or 180 mg/m²). Regorafenib (120 or 160 mg daily) was given from day 4 to day 10 of each cycle. Dose-limiting toxicity (DLT) was studied in the first three cycles. Eligibility criteria included ECOG performance status ≤ 1 and not previously treated RASm-mCRC. RESULTS: Thirteen patients (median age: 65 years; min-max: 40-76) were enrolled. DLT could not be evaluated in one patient (DL3) due to poor observance. The median treatment duration and median follow-up were 6.2 (min-max: 2.3-10) and 13.4 (min-max: 3.8-18.0) months, respectively. Dose was modified in 12/13 (92%) patients. One grade 3 hypokalemia occurred at DL2. MTD was not reached at DL3. Grade 3 diarrhea was recorded in 7/13 patients (13 events) equally distributed in all DLs. CONCLUSION: The RP2D for this regorafenib-FFX combination could not be determined due to a high prevalence of grade 3 diarrhea related to treatment as advised by our Independent Data Monitoring Committee. TRIAL REGISTRATION NUMBERS: ClinicalTrials.gov : NCT03828799.

Hepatitis B prevalence and associated factors in adults presenting for infection screening in northern Thailand.

Background and aims: Hepatitis B is a leading cause of morbidity and mortality worldwide. In view of the World Health Organization 2030 targets, effective screening of chronic infection is crucial. We have assessed the prevalence and risk factors of hepatitis B surface antigen in adults presenting for screening. Methods: Free-of-charge and anonymous services for simultaneous hepatitis B, hepatitis C, human immunodeficiency virus and syphilis screening and counseling were provided in four facilities in northern Thailand. Analyses were performed separately in clients born before integration into the 1992 hepatitis B vaccine Thailand's Expanded Program on Immunization and in clients born afterwards. Results: Between October 2015 and August 2020, hepatitis B surface antigen prevalence was 7.2 % (185/2578) in clients born before 1992 (95 % confidence interval [CI] = 6.2%-8.2 %). In the multivariable analysis, characteristics independently associated with a higher risk of infection were being born male (adjusted odds ratio [aOR] = 1.49, 95 % CI = 1.10-2.01) and being part of a hill tribe (aOR = 1.65, 95 % CI = 1.01-2.70). Forty-two percent were unaware of their infection. In clients born in 1992 or afterwards, prevalence was 1.5 % (43/2933) (95 % CI = 1.1%-2.0 %) and characteristics independently associated with a higher risk were being born between 1992 and 1995 (aOR = 1.90, 95 % CI = 1.00-3.61), being born male (aOR = 2.60, 95 % CI = 1.34-5.07), being part of a hill tribe (aOR = 5.09, 95 % CI = 2.52-10.26) and having ever injected drugs (aOR = 4.33, 95 % CI = 1.23-15.24). Conclusions: Risk factor-based screening would miss many chronic hepatitis cases. Screening all adults once in their lifetime may be beneficial until the second generation of immunized infants have reached adult age.

Stereotactic MR-Guided Radiotherapy for Liver Metastases: First Results of the Montpellier Prospective Registry Study.

Liver stereotactic body radiotherapy (SBRT) is a local treatment that provides good local control and low toxicity. We present the first clinical results from our prospective registry of stereotactic MR-guided radiotherapy (MRgRT) for liver metastases. All patients treated for liver metastases were included in this prospective registry study. Stereotactic MRgRT indication was confirmed by multidisciplinary specialized tumor boards. The primary endpoints were acute and late toxicities. The secondary endpoints were survival outcomes (local control, overall survival (OS), disease-free survival, intrahepatic relapse-free survival). Twenty-six consecutive patients were treated for thirty-one liver metastases between October 2019 and April 2022. The median prescribed dose was 50 Gy (40-60) in 5 fractions. No severe acute MRgRT-related toxicity was noted. Acute and late gastrointestinal and liver toxicities were low and mostly unrelated to MRgRT. Only 5 lesions (16.1%) required daily adaptation because of the proximity of organs at risk (OAR). With a median follow-up time of 17.3 months since MRgRT completion, the median OS, 1-year OS and 2-year OS rates were 21.7 months, 83.1% (95% CI: 55.3-94.4%) and 41.6% (95% CI: 13.5-68.1%), respectively, from MRgRT completion. The local control at 6 months, 1 year and 2 years was 90.9% (95% CI: 68.3-97.7%). To our knowledge, we report the largest series of stereotactic MRgRT for liver metastases. The treatment was well-tolerated and achieved a high LC rate. Distant relapse remains a challenge in this population.

Pharmacokinetic Variability Drives Palbociclib-Induced Neutropenia in Metastatic Breast Cancer Patients: Drug-Drug Interactions Are the Usual Suspects.

Palbociclib is a good candidate for therapeutic drug monitoring (TDM) due to its narrow therapeutic range and frequency of toxicities, particularly high-grade neutropenia. In this prospective, bicentric clinical trial, we evaluated the palbociclib exposure−toxicity relationship and determined the relevant sources of palbociclib pharmacokinetic variability, including drug−drug interactions (DDI). We followed 58 patients (mean age: 62.9 years) for 1 year. The geometric median of palbociclib plasma trough concentration (Ctrough) was 74.1 ng/mL. Neutropenia occurred in 70.7% of patients (high grade in 67.2% of patients). High-grade neutropenia occurrence during the first two palbociclib cycles was higher in patients with lower neutrophil count at initiation (p = 0.002). Palbociclib plasma Ctrough was correlated with high-grade neutropenia occurrence during the first two cycles (p = 0.024, OR 5.51). Co-treatment with agents that may interfere with palbociclib PK significantly influenced palbociclib Ctrough (p < 0.05). CYP3A4/P-glycoprotein inhibitors increased by 25% palbociclib Ctrough (p = 0.035), while antacids reduced it by 20% (p = 0.036). However, DDI did not have any significant effect on high-grade neutropenia occurrence (p > 0.05). This study confirms the major role of TDM to manage palbociclib safe use from the first week of treatment, particularly the significant incidence of hematological toxicity. Moreover, this first dedicated prospective study confirmed the importance of characterizing co-treatments to limit the DDI risk with oral-targeted therapies.

Stereotactic MR-Guided Adaptive Radiotherapy for Pancreatic Tumors: Updated Results of the Montpellier Prospective Registry Study.

Introduction: Stereotactic MR-guided Adaptive RadioTherapy (SMART) is a novel process to treat pancreatic tumors. We present an update of the data from our prospective registry of SMART for pancreatic tumors. Materials and methods: After the establishment of the SMART indication in a multidisciplinary board, we included all patients treated for pancreatic tumors. Primary endpoints were acute and late toxicities. Secondary endpoints were survival outcomes (local control, overall survival, distant metastasis free survival) and dosimetric advantages of adaptive process on targets volumes and OAR. Results: We included seventy consecutive patients in our cohort between October 2019 and April 2022. The prescribed dose was 50 Gy in 5 consecutive fractions. No severe acute SMART related toxicity was noted. Acute and late Grade ≤ 2 gastro intestinal were low. Daily adaptation significantly improved PTV and GTV coverage as well as OAR sparing. With a median follow-up of 10.8 months since SMART completion, the median OS, 6-months OS, and 1-year OS were 20.9 months, 86.7% (95% CI: (75−93%), and 68.6% (95% CI: (53−80%), respectively, from SMART completion. Local control at 6 months, 1 year, and 2 years were, respectively, 96.8 % (95% CI: 88−99%), 86.5 (95% CI: 68−95%), and 80.7% (95% CI: 59−92%). There was no grade > 2 late toxicities. Locally Advanced Pancreatic Cancers (LAPC) and Borderline Resectable Pancreatic Cancers (BRPC) patients (52 patients) had a median OS, 6-months OS, and 1-year OS from SMART completion of 15.2 months, 84.4% (95% CI: (70−92%)), and 60.5% (95% CI: (42−75%)), respectively. The median OS, 1-year OS, and 2-year OS from initiation of induction chemotherapy were 22.3 months, 91% (95% CI: (78−97%)), and 45.8% (95% CI: (27−63%)), respectively. Twenty patients underwent surgical resection (38.7 % of patients with initially LAPC) with negative margins (R0). Conclusion: To our knowledge, this is the largest series of SMART for pancreatic tumors. The treatment was well tolerated with only low-grade toxicities. Long-term OS and LC rates were achieved. SMART achieved high secondary resection rates in LAPC patients.

Stunting, Beyond Acute Diarrhoea: Giardia Duodenalis, in Cambodia.

BACKGROUND: The adverse outcomes of malnutrition on the development of a child are well acknowledged as are the broad variety of contextual factors that may impact child nutritional status. Adequate nutrient intake and the adoption of appropriate water, sanitation and hygiene measures are largely documented for their positive influence on health. Improved sanitation and protection from human feces can significantly lower the incidence of diarrhea and environmental enteropathy. However, the impact of excessive exposure to animal feces on child health is less well documented. OBJECTIVES: This study tests the hypothesis that there is a positive association between exposure to animal feces, morbidity and anthropometric outcomes in children under 5 years of age, in Cambodia. It aims to improve insights that can contribute to discerning high-impact policies that promote children can develop to their full potential. METHODS: Data for this study was drawn from the third follow-up round of the MyHealth project cohort study that is conducted in six districts of three Cambodian provinces (Phnom Penh, Kratie and Ratanak Kiri). The analysis included a sample of 639 children under 5 years of age. RESULTS: The presence of livestock and more particularly, pigs near the main household dwelling was found a risk factor associated with Giardia duodenalis infection (23%). Giardia duodenalis infection was found to be a protective factor for acute diarrhea, yet, associated with stunting in the univariate model. CONCLUSIONS: Preventive measures that protect from extensive exposure to animal feces may be most effective to prevent infection with Giardia duodenalis and consequent stunting, thereby improving the potential for a healthy development in young Cambodian children. The results support the need for cross-sector policy measures that reinforce comprehensive early childhood interventions towards improving nutritional status as part of a wider set of child welfare and development measures.

Diets and Feeding Practices during the First 1000 Days Window in the Phnom Penh and North Eastern Districts of Cambodia.

Although several health and development indicators have improved significantly in Cambodia, inadequate breastfeeding and inappropriate complementary feeding practices leave many children at high risk of malnutrition during the early stages of life. In 2014, the prevalence of wasting and stunting among Cambodian children under 5 were 10% and 32%, respectively. Thus, a strong focus on improving feeding practices within the first 1000 days window to reduce child malnutrition prevalence in Cambodia is needed. This cross-sectional study assessed the current feeding practices among of women of reproductive age, pregnant women, lactating women and children less than 24 months living in six districts from Phnom Penh and two rural provinces in the North East of Cambodia. The nutritional status of pregnant women was poor, with 21.4% having a Middle Upper arm circumference below 23 cm. While breastfeeding was predominant within the first 6 months of age in every district, feeding practices of pregnant women and children were a concern, as >70% of the children were not meeting the minimum acceptable diet, and most of the women did not improve their diet during pregnancy. Inadequate nutrition during the first 1000 days is highly prevalent in Cambodia. A comprehensive national Mother, Infant and Young Child Nutrition strategy needs to be developed and operationalized to improve feeding practices of Cambodian women and children.

Identification of Acute Malnutrition in Children in Cambodia Requires Both Mid Upper Arm Circumference and Weight-For-Height to Offset Gender Bias of Each Indicator.

Malnutrition remains a serious health problem in Cambodia with over 10% of children less than five years of age suffering from acute malnutrition. In addition to the presence of nutritional edema, two indicators are recommended by the World Health Organization for the diagnosis of acute malnutrition: weight-for-height Z-scores (WHZ; with acute malnutrition defined as WHZ < −2 Z-score) and mid-upper arm circumference (MUAC, with acute malnutrition defined as MUAC < 12.5 cm). Earlier, we showed that WHZ and MUAC identified different subgroups of children with acute malnutrition. To explore factors associated with both indicators of acute malnutrition, we analyzed baseline data from a longitudinal study in three provinces in Cambodia: Phnom Penh (capital, urban environment), Kratie (rural province), and Ratanakiri (hilly, rural province). Data was available for 4381 children below 30 months of age. Malnutrition rates were higher in the two rural provinces than in the capital. Although both MUAC and WHZ showed gender bias, with MUAC identifying more girls, and WHZ identifying more boys with acute malnutrition, the gender effect was strongest for MUAC. The gender bias of MUAC diminished with older age, but remained significant up to 30 months of age. Only using both MUAC and WHZ as indicators resulted in gender neutral identification of acute malnutrition. WHZ alone always identified more children with acute malnutrition than MUAC alone. In Phnom Penh, MUAC alone identified only 11% with acute malnutrition in addition to WHZ. To conclude, both MUAC and WHZ showed gender bias in this cohort of Cambodian children. In Cambodia, implementation of a MUAC-only or a WHZ-only program for the identification of acute malnutrition would be unethical as it will lead to many children remaining undiagnosed.

The unfinished health agenda: Neonatal mortality in Cambodia.

BACKGROUND: Reduction of neonatal and under-five mortality rates remains a primary target in the achievement of universal health goals, as evident in renewed investments of Sustainable Development Goals. Various studies attribute declines in mortality to the combined effects of improvements in health care practices and changes in socio-economic factors. Since the early nineties, Cambodia has managed to evolve from a country devastated by war to a nation soon to enter the group of middle income countries. Cambodia's development efforts are reflected in some remarkable health outcomes such as a significant decline in child mortality rates and the early achievement of related Millennium Development Goals. An achievement acknowledged through the inclusion of Cambodia as one of the ten fast-track countries in the Partnership for Maternal, Newborn and Child Health. This study aims to highlight findings from the field so to provide evidence for future programming and policy efforts. It will be argued that to foster further advances in health, Cambodia will need to keep neonatal survival and health high on the agenda and tackle exacerbating inequities that arise from a pluralistic health system with considerable regional differences and socio-economic disparities. METHODS/FINDINGS: Data was drawn from Demographic Health Surveys (2000, 2005, 2010, 2014). Information on a series of demographic and socio-economic household characteristics and on child anthropometry, feeding practices and child health were collected from nationally representative samples. To reach the required sample size, live-births that occurred over the past 10 years before the date of the interview were included. Demographic variables included: gender of the child, living area (urban or rural; four ecological regions (constructed by merging provinces and the capital), mother's age at birth (<20, 20-35, 35+), birth interval (long, short) and birth order (1st, 2-3, 4-6, 7+). Socio-economic variables included: mother education level (none, primary, secondary+) and household wealth (asset-based index). Data on antenatal care, tetanus injection and skilled assistance at birth were used for the mother's last child. Between 2000 and 2014, Cambodia achieved a considerable reduction in neonatal mortality (46% reduction rate). By 2014, gender inequities became almost non-existent (for all measures of equality); inequity related to mother's education decreased for all time periods; improvements were observed for differences in neonatal mortality by preceding birth interval; and a reduction in neonatal mortality rates could be noted among all the regional subgroups. Inequities increased between mothers who had limited antenatal care and those who received more than four antenatal care visits. In most scale indicators, the Slope Index of Inequality and Relative Index of Inequality estimates for all four rounds of the survey suggest inequity exacerbated in deprived communities. Also, wealth and residence (urban/rural divide) continued to be major determinants in neonatal mortality rates and related inequity trends. CONCLUSION: Analysis highlighted some of the complex patterns and determinants of neonatal mortality, in Cambodia. There has been a considerable decline in neonatal mortality which echoes global trends. Our analysis reveals that despite these advances, additional socio-economic and demographic characteristics considerably affected neonatal mortality rates and its inequities. There continue to be pockets of vulnerable groups that are lagging behind. This analysis highlights the determinants along the urban-rural and rich-poor divides in neonatal mortality inequities and how these affect access to and utilization of quality basic health services. This calls for future policy and programming efforts to be deliberate in their equity approach. Quality improvements in health services and targeted interventions for specific socio-economic groups will be required to further accelerate progress in reducing neonatal mortality and address Cambodia's pressing unfinished agenda in health.

Correction: Greffeuille, V.; et al. Persistent Inequalities in Child Undernutrition in Cambodia from 2000 Until Today. Nutrients 2016, 8, 297.

We would like to submit the following as a correction to our recently published paper [1] because of the use of the wrong cut-off for overweight.[...].

Inequalities in Nutrition between Cambodian Women over the Last 15 Years (2000-2014).

This study aimed to describe the trends over four nationally representative Demographic Health Surveys (2000, 2005, 2010, and 2014) of the nutritional status of women of reproductive age in Cambodia and to assess the main factors of inequality with regards to nutrition. The prevalence of undernutrition and over-nutrition evolved in opposite trends from 2000 to 2014, with a significant decrease in underweight and a significant increase in overweight women. This results in a shift, with overweight prevalence in women being higher than underweight for the first time in 2014. Anemia was constantly high and still affected 45% of women in 2014. Multivariate analysis showed that age, wealth index, maternal education, number of children, year of survey, and anemia were contributing factors for being underweight. Being overweight was positively related to increase in age, wealth index, number of children, and year of survey; and negatively related to anemia and increase in education level. The risk of anemia was higher in the poorest households and for less-educated women and women living in rural areas. Consequently, policies should target the most vulnerable women, especially the youngest, and support integrated interventions in the health, social, and agriculture sectors to reduce inequalities in nutrition between women.

Persistent Inequalities in Child Undernutrition in Cambodia from 2000 until Today.

The study assessed the trends of nutritional status of children under age five in Cambodia over four DHS surveys from 2000 to 2014 and the contribution of socioeconomic and demographic factors to its changes. Undernutrition was a public health problem in all surveys. Despite consistent improvement over the years, stunting still affected 32.5% of children in 2014. Wasting prevalence did not improve since 2005 and affected 9.6% of children under five in 2014. Low wealth and mother education; and rural residence contributed to undernutrition. In 2014; wealth status was the main socioeconomic factor associated with undernutrition and the nutritional status of children was strongly related to that of their mothers. Anemia prevalence was high and after a decrease between 2000 and 2005 remained at 45%. The prevalence of overweight was less than 10% and did not change over the years despite an increasing trend in the richest households of urban areas. Persistent inequalities in child undernutrition call for action, giving priority to the most vulnerable households to ensure availability and access to nutrient-rich foods for women and children through nutrition-sensitive and nutrition-specific programs. The recent increase of overweight in the richest populations must also be considered in Cambodian health policies.