Real-world outcomes of cisplatin, capecitabine, and gemcitabine with either epirubicin (PEXG) or docetaxel (PDXG) as first-line palliative treatment in metastatic or unresectable locally advanced pancreatic adenocarcinoma.

BACKGROUND: First-line palliative chemotherapy regimens in advanced pancreatic adenocarcinoma include triplet chemotherapy with 5-fluorouracil, oxaliplatin, and irinotecan, and the doublet of nab-paclitaxel plus gemcitabine. Use of triplet chemotherapy in real-world populations is limited by tolerability and nab-paclitaxel is not universally available. Regimens using the combination of cisplatin, capecitabine, gemcitabine, and either epirubicin or docetaxel may be better tolerated, more widely available, and similarly effective, but no published real-world data exist. METHODS: A retrospective cohort review of patients with metastatic or unresectable locally advanced pancreatic adenocarcinoma treated with first-line palliative cisplatin, capecitabine, gemcitabine, and either epirubicin or docetaxel chemotherapy at Auckland City Hospital between July 1, 2013 and July 30, 2020. The primary outcome was overall survival (OS). Secondary outcomes were rates of grade 3 or 4 hematological toxicity, rate of febrile neutropenia, number of cycles received, and reasons for discontinuation. RESULTS: Eighty-eight patients were included. Median age was 66 years (range 39-79), 28.4% had unresectable, locally advanced disease and 71.6% metastatic disease. Median OS was 8.5 months. Patients stopped treatment due to disease progression (53.4%), completing 12 cycles (19.3%), or toxicity (10.2%). Grade 4 neutropenia was experienced by 21.6%; 10.2% had febrile neutropenia. There were four treatment-related deaths. CONCLUSION: This retrospective study in a real-world population demonstrates that chemotherapy with cisplatin, capecitabine, and gemcitabine with epirubicin (PEXG) or docetaxel (PDXG) had similar effectiveness to more commonly used combination regimens. PDXG/PEXG are viable alternatives to nab-paclitaxel plus gemcitabine in countries that have restricted drug funding.

Corneal Nerve Changes Observed by In Vivo Confocal Microscopy in Patients Receiving Oxaliplatin for Colorectal Cancer: The COCO Study.

An objective method of early identification of people at risk of chemotherapy-induced peripheral neuropathy is needed to minimize long-term toxicity and maximize dose intensity. The aims of the study were to observe corneal nerve microstructure and corneal sensitivity changes and peripheral neuropathy in patients receiving oxaliplatin, and to determine its association with corneal parameters at different stages of treatment and assess utility as non-invasive markers to detect and monitor peripheral neuropathy. Twenty-three patients scheduled to receive oxaliplatin chemotherapy with intravenous 5-FU for gastro-intestinal cancer were recruited and followed up with for 12 months. Ocular examinations including corneal and retinal evaluations, alongside peripheral neuropathy assessment, were performed. The corneal nerve density did not show significant change after chemotherapy when measured with a widely used semi-automated program or an automated analysis technique. Macula and optic nerve function did not change during or after oxaliplatin chemotherapy. However, the corneal nerve density modestly correlated with clinical peripheral neuropathy after 20 weeks of chemotherapy (r = 0.61, p = 0.01) when peripheral neuropathy is typical most profound, and corneal nerve sensitivity correlated with neuropathy at 12 (r = 0.55, p = 0.01) and 20 weeks (r = 0.64, p = 0.006). In conclusion, corneal changes detected on confocal microscopy show moderate association with peripheral neuropathy, indicating their potential to identify the development of oxaliplatin-induced peripheral neuropathy. However, further studies are required to confirm these findings.

Pancreatic grade 3 neuroendocrine tumors behave similarly to neuroendocrine carcinomas following resection: a multi-center, international appraisal of the WHO 2010 and WHO 2017 staging schema for pancreatic neuroendocrine lesions.

BACKGROUND: In 2017, the WHO updated their 2010 classification of pancreatic neuroendocrine tumors, introducing a well-differentiated, highly proliferative grade 3 tumor, distinct from neuroendocrine carcinomas. The aim of this study was to investigate the clinical significance of this update in a large cohort of resected tumors. METHODS: Using a multicenter, international dataset of patients with pancreatic neuroendocrine lesions, patients were classified both according to the WHO 2010 and 2017 schema. Multivariable survival analyses were performed, and the models were evaluated for discrimination ability and goodness of fit. RESULTS: Excluding patients with a known germline MEN1 mutation and incomplete data, 544 patients were analyzed. The performance of the WHO 2010 and 2017 models was similar, however surgically resected grade 3 tumors behaved very similarly to neuroendocrine carcinomas. CONCLUSION: The addition of a grade 3 NET classification may be of limited utility in surgically resected patients, as these lesions have similar postoperative survival compared to carcinomas. While the addition may allow for a more granular evaluation of novel treatment strategies, surgical intervention for high grade tumors should be considered judiciously.

Resistance to clethodim in Italian ryegrass (Lolium perenne ssp. multiflorum) from Mississippi and North Carolina.

BACKGROUND: Clethodim, an acetyl-CoA carboxylase (ACCase)-inhibiting herbicide, is one of the few postemergence chemical control options available to growers of Mississippi to manage glyphosate and/or other herbicide resistant Italian ryegrass populations. Recently, clethodim failed to adequately control Italian ryegrass populations across Mississippi. A sethoxydim, also an ACCase inhibitor, -resistant Italian ryegrass population from North Carolina was cross-resistant to clethodim. This research characterized the magnitude and mechanisms of clethodim resistance in the Mississippi and North Carolina Italian ryegrass populations via whole-plant herbicide dose response, cross resistance, and metabolism studies, and molecular analysis. RESULTS: Two clethodim-resistant biotypes from Mississippi, MS24 and MS37, were 10- and 4-fold resistant, respectively, relative to a susceptible (SUS1) biotype. A North Carolina biotype, NC21, was 40-fold resistant to clethodim compared to SUS1. Two additional biotypes from North Carolina, NC22 and NC 23, recorded shoot dry weight reduction of only 17-30% of nontreated at the highest clethodim dose of 2.17 kg ha-1 , (8×). The NC22 biotype was cross-resistant to sethoxydim, fluazifop, quizalofop, and pinoxaden. Metabolic inhibitors such as piperonyl butoxide and 4-chloro-7-nitrobenzofurazan did not affect resistance of MS37, MS51, and NC22 biotypes to fenoxaprop, clethodim, or pinoxaden. The MS37 biotype had three target site mutations, I2041N, C2088R, and G2096A. Another clethodim-resistant biotype from Mississippi, MS51, had only the C2088R substitution. The NC22 and NC23 biotypes had I1781L, I2041N, and D2078G replacements. CONCLUSION: This study shows that the mechanism of resistance to clethodim in Italian ryegrass from Mississippi and North Carolina is due to target site modifications in the ACCase gene leading to broad cross-resistance to other ACCase-inhibiting herbicides. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.

Mapping a route to Indigenous engagement in cancer genomic research.

Precision oncology guided by genomic research has an increasingly important role in the care of people with cancer. However, substantial inequities remain in cancer outcomes of Indigenous peoples, including Indigenous Maori in Aotearoa New Zealand (New Zealand). These inequities will be perpetuated unless deliberate steps are taken to include Indigenous peoples in all parts of cancer research-as research participants, in research leadership, and in research governance. This approach is especially important when there have been historical breaches of trust that have discouraged their participation in health research. This Personal View describes a precision oncology research roadmap for neuroendocrine tumour research, which seeks to reflect the values of New Zealand's Indigenous Maori people. This roadmap includes facilitating ongoing dialogue, Maori leadership, reciprocity, agreed kawa (guiding principles), tikanga (cultural protocols), and honest monitoring of what is and what is not being achieved. We challenge cancer researchers worldwide to generate locally appropriate roadmaps that honestly assess their practices to benefit Indigenous people internationally.

Patient characteristics and clinical outcomes following initial surgical intervention for MEN1 associated pancreatic neuroendocrine tumours: A systematic review and exploratory meta-analysis of the literature.

BACKGROUND: This systematic review aimed to define the outcomes of different pancreatic resection procedures for multiple endocrine neoplasia type 1 (MEN1) associated pancreatic neuroendocrine neoplasms (pNENs). METHODS: A search of PubMed, MEDLINE and SCOPUS databases were performed in accordance with PRISMA guidelines. RESULTS: Twenty-seven studies including 533 patients undergoing initial pancreatic resection for MEN1 associated pNENs were included in this systematic review. Three hundred and sixty-six (68.7%) distal pancreatectomies (DP), 120 (22.5%) sole enucleations (SE) and 47 (8.8%) pancreaticoduodenectomies (PD) were identified. SE was associated with a higher rate of recurrence than DP (25/67, 37% vs 40/190, 21% respectively, P = 0.008) but a lower rate of endocrine insufficiency than PD (1/20, 5% vs 8/21, 38% respectively, P = 0.010). A meta-analysis of major pancreatic resections (PD or DP) vs SE in 15 studies showed that SE is associated with an increased rate of recurrence (Major resection 42/184, 23% vs SE 20/53, 38% RR 0.65 CI 0.43-0.96 P = 0.032) but reduced rate of postoperative endocrine insufficiency (Resection 37/93, 40% vs SE 0/24, 0% RR 7.37 CI 1.57-34.64 P = 0.008). Similarly, insulinomas and functional pNENs overall had lower rates of recurrence and reoperation with major resection. There was no difference in the reoperation rates or survival outcomes after SE compared with major pancreatic resections at follow-up (pooled overall mean duration: 85 months). CONCLUSION: Major pancreatic resections for MEN1 associated pNENs have a lower risk of recurrence and a higher risk of postoperative endocrine insufficiency when compared to sole enucleation, but a similar rate of reoperation and survival.

The diversity and commonalities of gastroenteropancreatic neuroendocrine tumors.

BACKGROUND: Recent data demonstrate that the incidence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has increased exponentially (overall ~500%) over the last three decades, thus refuting the erroneous concept of rarity. GEP-NETs comprise 2% of all malignancies and in terms of prevalence, are the second commonest gastrointestinal malignancy after colorectal cancer. Diagnosis is usually late since there is no biochemical screening test and symptoms are protean and overlooked. As a consequence, 60-80% exhibit metastases with a consequent suboptimal outcome. DISCUSSION: The gastrointestinal tract and pancreas exhibit ~17 different neuroendocrine cell types, but neither the cell of origin nor the biological basis of GEP-NETs is understood. This review examines GEP-NETs from the cellular and molecular perspective and addresses the distinct patterns of functional tumor biology pertinent to clinicians. Although grouped as a neoplastic entity (NETs), each lesion is derived from distinct cell precursors, produces specific bioactive products, exhibits distinct chromosomal abnormalities and somatic mutation events and has uniquely dissimilar clinical presentations. GEP-NETs demonstrate very different survival rates reflecting the intrinsic differences in malignant potential and variations in proliferative regulation. Apart from the identification of the inhibitory role of the somatostatin receptors, there is limited biological knowledge of the key regulators of proliferation and hence a paucity of successful targeted therapeutic agents. IGF-I, TGFß and a variety of tyrosine kinases have been postulated as key regulatory elements; rigorous data is still required to define predictably effective and rational therapeutic strategy in an individual tumor. A critical issue in the clinical management of GEP-NETs is the need to appreciate both the neuroendocrine commonalities of the disease as well as the unique characteristics of each tumor. The further acquisition of a detailed biological and molecular appreciation of GEP-NETs is vital to the development of effective management strategy.

A nomogram to assess small-intestinal neuroendocrine tumor ('carcinoid') survival.

Neuroendocrine tumors (NETs) are a heterogeneous group of cancers of which the commonest site is the small intestine (SI). Most information available to determine tumor behavior reflects univariate assessment of factors or is anecdotal or experience based. There currently exists no objective multivariate analysis of indices that defines SI NET prognosis. A key unmet need is the lack of a rigorous mathematical-based tool - a nomogram - for the assessment of parameters that define progress, determine prognosis and can guide therapy. Since prediction of NET behavior is a critical criterion in determining clinical strategy, we constructed a NET nomogram (Modlin Score) for prognosis prediction, patient group comparisons and a guide for stratification of treatment and surveillance. We used hazard ratio (HR), Cox analysis and Kaplan-Meier analysis of published data and the current Surveillance, Epidemiology and End Results (SEER) database (approx. 20,000 patients) to develop a nomogram from 15 variables demonstrated to provide significant multivariate HRs. These included age, gender, ethnicity, symptoms, urinary 5-hydroxyindoleacetic acid, plasma chromogranin A, liver function tests, tumor size, invasion, metastasis, histology, Ki-67 index, carcinoid heart disease and therapy (surgery or long-acting somatostatin analogs). Internal validation was assessed using 33 SI NET patients. A NET nomoscore (Modlin Score) was developed by HR weighting and stratification into low (<75), medium (75-95) and high risk (>95). This identified significant differences (p <0.03, Kaplan-Meier) in survival (15.5 ± 4.3, 9.7 ± 2.5 and 6.4 ± 1.1 years, respectively). The Modlin Score was significantly elevated (p <0.01) in deceased compared to alive patients. This nomogram represents an optimized construct based upon currently analyzable data, and application will facilitate accurate stratification for comparison in clinical trials. External validation and amplification by identification of additional indices, e.g. molecular biomarkers, are necessary. The development of a mathematically validated nomogram provides a platform for objective assessment of SI NET disease, a finite basis for precise prognostication and a tool to guide management strategy.

Effect of education on the recording of medicines on admission to hospital.

BACKGROUND: The inaccurate recording of medicines on admission to hospital is an important cause of medication error. Medication reconciliation has been used to identify and correct these errors. OBJECTIVE: To determine if a multimodal intervention involving medication reconciliation with real-time feedback and education would reduce the number of errors made by medical staff when recording medicines at the time of admission to hospital. DESIGN: Observational study. PARTICIPANTS: Patients admitted to the general medical wards of a teaching hospital were studied prospectively. Patients > or =75 years of age and on > or =5 medications were identified as the 'target group.' INTERVENTION: After admission, a second medication history was taken, and discrepancies were identified and communicated to the medical teams. An educational intervention to encourage prescribers to obtain accurate medication histories was conducted at the same time. MEASUREMENTS: The discrepancy rate was measured before and after the intervention. MAIN RESULTS: There were 470 admissions in the 'target group.' Three hundred and thirty-eight of the admissions (71.9%) had one or more unintentional discrepancies. Although many discrepancies had little potential to cause harm, 33% were rated as clinically significant. During the study the discrepancy rate (prior to reconciliation) fell from 2.6 (SD 2.6) to 1.0 (SD 1.1) per admission (p < 0.0001). This decline in discrepancy rate remained significant (p = 0.001) even when only clinically important discrepancies were included. The proportion of admissions with one or more clinically important discrepancies also decreased during the study from 46% to 24% (p = 0.023). CONCLUSIONS: Errors in the recording of medicines at the time of hospital admission are common. Combining the feedback provided by medication reconciliation with prescriber education reduced the error rate. This approach may be useful when the resources are not available to perform medication reconciliation for all patients admitted to hospital.

Modeling nutrient consumptions in large flow-through bioreactors for tissue engineering.

Flow-through bioreactors are utilized in tissue regeneration to ensure complete nutrient distribution and apply defined hydrodynamic stresses. The fundamental concepts in designing these bioreactors for regenerating large high aspect ratio tissues (large surface area relative to the thickness of the matrix such as skin, bladder, and cartilage) are not well defined. Further, tissue regeneration is a dynamic process where the porous characteristics change due to proliferation of cells, de novo deposition of matrix components, and degradation of the porous architecture. These changes affect the transport characteristics and there is an imminent need to understand the influence of these factors. Using computational fluid dynamic tools, changes in the pressure drop, shear stress distribution and nutrient consumption patterns during tissue regeneration were assessed in rectangular and circular reactors described by Lawrence et al. [Biotechnol Bioeng 2009;102(3):935-947]. Further, six new designs with different inlet and outlet shapes were analyzed. The fluid flow was defined by the Brinkman equation on the porous regions using the pore characteristics of 85 microm and 120 pores/mm(2). The minimum flow requirements to satisfy nutrient (oxygen and glucose) requirements for three different cell types (SMCs, chondrocytes, and hepatocytes) was evaluated using convective diffusion equation. For consumption reaction, the Michaelis-Menten rate law was used, with constants (k(m) and v(m) values) extracted from literature. Simulations were performed by varying the flow rate as well as the cell number. One of the circular reactors with semicircular inlet and outlet shape decreased (i) non-uniformity in hydrodynamic stress within the porous structure and (ii) non-uniform nutrient distribution. All cell types showed increased consumption of oxygen than glucose. Hepatocytes needed a very high flow rate relative to other cell types. Increase in cell number suggested a need for increasing the flow in circular reactors.

Flow dynamics in bioreactors containing tissue engineering scaffolds.

Bioreactors are widely used in tissue engineering as a way to distribute nutrients within porous materials and provide physical stimulus required by many tissues. However, the fluid dynamics within the large porous structure are not well understood. In this study, we explored the effect of reactor geometry by using rectangular and circular reactors with three different inlet and outlet patterns. Geometries were simulated with and without the porous structure using the computational fluid dynamics software Comsol Multiphysics 3.4 and/or ANSYS CFX 11 respectively. Residence time distribution analysis using a step change of a tracer within the reactor revealed non-ideal fluid distribution characteristics within the reactors. The Brinkman equation was used to model the permeability characteristics with in the chitosan porous structure. Pore size was varied from 10 to 200 microm and the number of pores per unit area was varied from 15 to 1,500 pores/mm(2). Effect of cellular growth and tissue remodeling on flow distribution was also assessed by changing the pore size (85-10 microm) while keeping the number of pores per unit area constant. These results showed significant increase in pressure with reduction in pore size, which could limit the fluid flow and nutrient transport. However, measured pressure drop was marginally higher than the simulation results. Maximum shear stress was similar in both reactors and ranged approximately 0.2-0.3 dynes/cm(2). The simulations were validated experimentally using both a rectangular and circular bioreactor, constructed in-house. Porous structures for the experiments were formed using 0.5% chitosan solution freeze-dried at -80 degrees C, and the pressure drop across the reactor was monitored.

Multilayer composite scaffolds with mechanical properties similar to small intestinal submucosa.

Use of biodegradable scaffolds to engineer new tissues has become an attractive option in various transplantation protocols. In particular, small intestinal submucosa (SIS) has generated immense interest in various tissue engineering applications because of its diverse favorable properties. However, it is a natural matrix, which leads to problems in large-scale preparations and contains sample to sample heterogeneity. In this study, we explored the formation of synthetic matrix mimicking the characteristics of the SIS. Three-dimensional composite structures were developed by sandwiching 50:50 PLGA film between porous chitosan matrices. The outer chitosan layers provide biological activity while the inner PLGA layer provides mechanical strength. PLGA films were initially perforated at 1 cm distance, and the porous chitosan matrix was formed sequentially on each side by controlled rate freezing and lyophilization technique at -80 degrees C. Scanning electron microscopy analysis showed a layered microarchitecture with chitosan filling the perforations of PLGA membrane. Urea permeability studies confirmed that the perforations were filled (negligible urea transfer across composite over 8 h). Tensile strength analysis showed that the matrices formed using 160 kDa PLGA had sufficient break stress ( approximately 4.5 MPa). Degradation analysis over 8 weeks in the presence of 10 mg/L lysozyme showed a 50% decrease in total weight and an 80% decrease in PLGA molecular weight. When cellular adhesion and actin distribution of mouse embryonic fibroblasts were evaluated, for 7 days, cells showed their typical spindle shape and redistribution of actin fibers on composite matrices. Viability studies and MMP-2/MMP-9 activity showed that the cells were viable and functional, similar to tissue culture plastic. Further, canine bladder smooth muscle cells also showed similar cell adhesion and spreading on the composite matrix. In summary, composite structures mimicking SIS were constructed and show potential as a tissue engineering material.

The incorporation of poly(lactic-co-glycolic) acid nanoparticles into porcine small intestinal submucosa biomaterials.

Small intestinal submucosa (SIS) derived from porcine small intestine has been intensively studied for its capacity in repairing and regenerating wounded and dysfunctional tissues. However, SIS suffers from a large spectrum of heterogeneity in microarchitecture leading to inconsistent results. In this study, we introduced nanoparticles (NPs) to SIS with an intention of decreasing the heterogeneity and improving the consistency of this biomaterial. As determined by scanning electron microscopy and urea permeability, the optimum NP size was estimated to be between 200 nm and 500 nm using commercial monodisperse latex spheres. The concentration of NPs that is required to alter pore sizes of SIS as determined by urea permeability was estimated to be 1 mg/ml 260 nm poly(lactic-co-glycolic) acid (PLGA) NPs. The 1mg/ml PLGA NPs loaded in the SIS did not change the tensile properties of the unmodified SIS or even alter pH values in a cell culture environment. More importantly, PLGA NP modified SIS did not affect human mammary endothelial cells (HMEC-1) morphology or adhesion, but actually enhanced HEMC-1 cell growth.

Cell colonization in degradable 3D porous matrices.

Cell colonization is an important in a wide variety of biological processes and applications including vascularization, wound healing, tissue engineering, stem cell differentiation and biosensors. During colonization porous 3D structures are used to support and guide the ingrowth of cells into the matrix. In this review, we summarize our understanding of various factors affecting cell colonization in three-dimensional environment. The structural, biological and degradation properties of the matrix all play key roles during colonization. Further, specific scaffold properties such as porosity, pore size, fiber thickness, topography and scaffold stiffness as well as important cell material interactions such as cell adhesion and mechanotransduction also influence colonization.