The EMA review of trastuzumab emtansine (T-DM1) for the adjuvant treatment of adult patients with HER2-positive early breast cancer.

Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate of trastuzumab [a monoclonal antibody against human epidermal growth factor receptor 2 (HER2)] and DM1 (an inhibitor of tubulin polymerisation). It was initially approved in the European Union for the treatment of adult patients with HER2-positive unresectable locally advanced or metastatic breast cancer (BC) who had previously received trastuzumab and taxanes. On 18 December 2019, a variation of the marketing authorisation was approved extending this use to the adjuvant therapy of adult patients with HER2-positive early BC who have residual invasive disease in the breast and/or lymph nodes after neoadjuvant taxane-based and HER2-targeted therapy. A phase III randomised, multicentre, open-label trial compared T-DM1 with trastuzumab as adjuvant therapy in patients with HER2-positive early BC who had received preoperative chemotherapy and HER2-targeted therapy followed by surgery, with a finding of invasive residual disease in the breast and/or axillary lymph nodes. The study met its primary endpoint by showing an increased 3-year invasive disease-free survival rate in the T-DM1 arm (88.3%) compared with the trastuzumab arm (77.0%), with an unstratified hazard ratio of 0.50 (95% confidence interval: 0.39-0.64). There was a higher incidence of hepatotoxicity (37.3% versus 10.6%), thrombocytopenia (28.5% versus 2.4%), peripheral neuropathy (32.3% versus 16.9%), haemorrhage (29.2% versus 9.6%) and pulmonary toxicity (2.8% versus 0.8%) in the T-DM1 arm compared with the control arm. The aim of this manuscript was to summarise the scientific review of the application leading to regulatory approval of this additional indication in the European Union.

Short-term health effects in the general population following a major train accident with acrylonitrile in Belgium.

BACKGROUND: Following a train derailment, several tons of acrylonitrile (ACN) exploded, inflamed and part of the ACN ended up in the sewage system of the village of Wetteren. More than 2000 residents living in the close vicinity of the accident and along the sewage system were evacuated. A human biomonitoring study of the adduct N-2-cyanoethylvaline (CEV) was carried out days 14-21 after the accident. OBJECTIVES: (1) To describe the short-term health effects that were reported by the evacuated residents following the train accident, and (2) to explore the association between the CEV concentrations, extrapolated at the time of the accident, and the self-reported short-term health effects. METHODS: Short-term health effects were reported in a questionnaire (n=191). An omnibus test of independence was used to investigate the association between the CEV concentrations and the symptoms. Dose-response relationships were quantified by Generalized Additive Models (GAMs). RESULTS: The most frequently reported symptoms were local symptoms of irritation. In non-smokers, dose-dependency was observed between the CEV levels and the self-reporting of irritation (p=0.007) and nausea (p=0.007). Almost all non-smokers with CEV concentrations above 100pmol/g globin reported irritation symptoms. Both absence and presence of symptoms was reported by non-smokers with CEV concentrations below the reference value and up to 10 times the reference value. Residents who visited the emergency services reported more symptoms. This trend was seen for the whole range of CEV concentrations, and thus independently of the dose. DISCUSSION AND CONCLUSION: The present study is one of the first to relate exposure levels to a chemical released during a chemical incident to short-term (self-reported) health effects. A dose-response relation was observed between the CEV concentrations and the reporting of short-term health effects in the non-smokers. Overall, the value of self-reported symptoms to assess exposure showed to be limited. The results of this study confirm that a critical view should be taken when considering self-reported health complaints and that ideally biomarkers are monitored to allow an objective assessment of exposure.

Acrylonitrile exposure in the general population following a major train accident in Belgium: a human biomonitoring study.

BACKGROUND: On Saturday May 4, 2013, a train transporting chemicals derailed in the village of Wetteren (Belgium) and caused a leak of acrylonitrile (ACN). OBJECTIVES: To assess the human exposure to acrylonitrile in the local population with the highest suspected exposure. METHODS: Between May 18-25, 242 residents participated in the study. N-2-cyanoethylvaline (CEV), a biomarker that is highly specific for ACN exposure, was measured in the blood. To account for potential influence by smoking, cotinine was determined in the urine. Participants also filled in a short questionnaire. RESULTS: In the evacuated zone, 37.3% of the non-smokers and 40.0% of the smokers had CEV concentrations above the reference values of 10 and 200 pmol/g globin, respectively, at the time of the train accident. Spatial mapping of the CEV concentrations depending on the residential address showed a distribution pattern following the sewage system. DISCUSSION AND CONCLUSION: The train derailment resulted in a highly atypical sequence-of-events. In addition to exposure in the direct vicinity of the site of the train derailment, exposure also occurred via the sewage system, into which acrylonitrile had entered shortly after the accident.

Acrylonitrile exposure assessment in the emergency responders of a major train accident in Belgium: a human biomonitoring study.

BACKGROUND: On May 4, 2013, a train transporting chemicals derailed in Wetteren, Belgium. Several tanks loaded with acrylonitrile (ACN) exploded, resulting in a fire and a leakage of ACN. OBJECTIVES: To determine exposure to ACN and to assess discriminating factors for ACN exposure in the emergency responders involved in the on-site management of the train accident. METHODS: The study population consisted of 841 emergency responders. Between May 21 and June 28, they gave blood for the determination of N-2-cyanoethylvaline (CEV) hemoglobin adducts and urine for the measurement of cotinine. They also filled in a short questionnaire. RESULTS: 163 (26%) non-smokers and 55 (27%) smokers showed CEV concentrations above the reference values of 10 and 200 pmol/g globin, respectively. The 95th percentile in the non-smokers was 73 pmol/g globin and the maximum was 452 pmol/g globin. ACN exposure among the non-smokers was predicted by (1) the distance to the accident, (2) the duration of exposure, and (3) the occupational function. DISCUSSION AND CONCLUSION: Emergency responders involved in the on-site management of the train accident were clearly exposed to ACN from the accident. However, the extent of exposure remained relatively moderate with CEV concentrations staying within the ranges described in literature as background for a smoking population. Moreover, the exposure was less pronounced in the emergency responders as compared to that in the local population.

Risk ranking priority of carcinogenic and/or genotoxic environmental contaminants in food in Belgium.

This paper focuses on the risks of environmental carcinogenic and/or genotoxic contaminants in food. It describes, for each contaminant studied, the carcinogenicity and genotoxicity, the toxicological reference values, the exposure and the risk characterisation. The compounds studied were classified into 3 categories based on a risk assessment. Effects others than carcinogenicity and/or genotoxicity (e.g. endocrine disruption activity) were also taken into account for the classification. Given the low margin of exposure values for arsenic and lead, these two compounds are classified as priority 1 (high concern) for food safety and as a first priority to take actions to reduce exposure. Cadmium, methylmercury, dioxins and dioxin-like polychlorinated biphenyls (PCB), non-dioxin-like PCB and toxaphene are classified as priority 2 (medium concern). Polybrominated biphenyls, chlordane, heptachlor, dichlorodiphenyltrichloroethane (DDT) and metabolites, hexachlorobenzene, hexachlorocyclohexane (lindane included), polychlorophenols and their salts are classified as priority 3 (low concern).

Cytogenetic biomonitoring of a population of children allegedly exposed to environmental pollutants. Phase 2: Results of a three-year longitudinal study.

Our previous cytogenetic biomonitoring of a group of inhabitants in a village (Mellery, Belgium) where exposure to a mixture of toxic environmental pollutants, (probably originating from a neighbouring chemical waste disposal site) was suspected, showed that difference in the SCE and HFC bioassays was more pronounced for children. The results of follow-up study in 1992 confirmed this surprising conclusion by an even higher incidence. As very few studies have been performed on the levels of children's biomarkers, this group of exposed populations needed to be explored further. Do children residing in the vicinity of hazardous waste sites indeed represent a population at higher risk? In the present study, we compare the performance of various bioassays (SCE, HFC, SSB and MN) in extended exposed and reference children's groups. Simultaneously, in the exposed group, we followed variation in the lymphocyte SCE frequencies as a function of time. Reversibility of the latter biomarker was ascertained subsequent to a preliminary technical remediation of the disposal site. We compared these data with those obtained from a synchronous cross-sectional study on a group of children living near a similar chemical disposal site. The two exposed populations did not differ from the reference population regarding to the SCE and HFC mean levels. Comparisons of the mean levels of the two other biomarkers, SSB and MN, showed no difference between the Mellery exposed children and the reference group from Wavre whereas significant differences appeared when the Hensies group is compared either to the Mellery or to the Wavre reference group.

Cytogenetic monitoring of a village population potentially exposed to a low level of environmental pollutants. Phase 1:SCE analysis.

By analogy to the techniques applied for monitoring biological effects of exposure to genotoxic agents in occupational populations, we have carried out cytogenetic monitoring in a group of inhabitants of a village (Mellery, Belgium) suspected to have been exposed to a variety of toxic environmental pollutants. These pollutants probably originated from a neighboring chemical wastes site. A group of 51 environmentally exposed and 52 reference persons (including children) were examined for the frequency of sister-chromatid exchanges (SCE) in their peripheral blood lymphocytes. The technique was further refined by using a high frequency cells (HFC) analysis. Analysis of the reference subgroups showed a significant difference between non-smoking adults and children. The influence of tobacco was clear, too. In the exposed group, no significant differences could be demonstrated between either the smokers or the non-smokers or the children. Furthermore, not only were the mean frequencies of SCE higher than in the respective reference subgroups but comparison between the two groups also showed a higher number of individuals presenting a HFC level above the background in the exposed group. Surprisingly, the difference was more pronounced for the children. A follow-up of the same exposed population carried out 18 months later and after remediation of the atmospheric chemical release, the previously observed tendencies in the exposure parameter remained unmodified.

Genotoxic effects of glycidyltrimethylammonium chloride.

Evaluation of the genotoxicity of epoxides is best carried out on a case by case basis. Although glycidyltrimethylammonium chloride (GTAC) is widely used in several industrial applications, its genotoxicity is poorly documented. Therefore, we have evaluated GTAC in a battery of 4 in vitro short-term tests for genotoxicity. We report here that GTAC mediates the induction of base-pair substitutions in S. typhimurium, gene conversion in S. cerevisiae (D7), chromosomal aberrations in CHO cells and viral DNA amplification in Chinese hamster CO6O cells. In view of these results, it is advisable to consider GTAC a potential carcinogen.

Induction of microchromosomes by chemical carcinogens correlates with SV40-DNA amplification in SV40-transformed Chinese hamster cells.

Radiations and chemical carcinogens induce the amplification of viral DNA inserts and of their cellular flanking sequences in SV40-transformed Chinese hamster embryo cells. In the cell line CO60, the phenomenon is easily measured by in situ hybridization using SV40-DNA as a probe. We found that the appearance of microchromosomes (MC) in CO60 metaphases correlated well with the induction of SV40-DNA amplification (SDA) mediated in the same cells by chemical carcinogens. SDA and MC formation had the same inducers and were essentially transient phenomena whose occurrence and disappearance were simultaneous. The banding properties of MC and the respective time courses of induction of chromosome aberrations and MC formation/disappearance indicated that MC were not chromosome or chromatid breaks but rather acentric double minute-like chromosomes. Double minute chromosomes (DM) have been shown to contain amplified genes. They specifically occur in established cell lines and in vivo tumor cells. Therefore, the reported correlations between SDA and MC formation and the homologies between MC and DM in CO60 cells further support the existence of specific relationships between mutagenesis, gene amplification, in vivo selective pressures and tumor cytogenetics.