Adjuvant treatment of resectable biliary tract cancer with cisplatin plus gemcitabine: A prospective single center phase II study.

BACKGROUND: Biliary tract cancer (BTC) is a dismal disease, even after curative intent surgery. We conducted this prospective, non-randomized phase II study to evaluate the feasibility and efficacy of cisplatin and gemcitabine as adjuvant treatment in patients with resected BTC. METHODS: Patients initially received gemcitabine 1000 mg/m2 alone on days 1, 8 and 15 every 28-days for a total of six cycles (single agent cohort), and after protocol amendment a combination therapy with gemcitabine 1000 mg/m2 and cisplatin 25 mg/m2 on days 1 and 8 was administered every 21 days for a total of eight cycles (combined regimen cohort). Treatment was planned to start within eight weeks after curative intent resection. Adverse events, disease-free survival and overall survival were assessed. RESULTS: Overall 30 patients were enrolled in the study from August 2008 and last patient was enrolled at 2nd December 2014. The follow-up of the patients ended at 31st December 2016. The first 9 patients received single-agent gemcitabine. The interim analysis met the predefined feasibility criteria and, from September 2010 on, the second group of 21 patients received the combination of cisplatin plus gemcitabine. In the single-agent cohort with gemcitabine the median relative dose intensity (RDI) was 100% (IQR 88.3-100). Patients treated with the combination cisplatin-gemcitabine received an overall median RDI of 100% (IQR 50-100) for cisplatin and 100% (IQR 75-100) for gemcitabine respectively. The most significant non-hematological adverse events (grade 3 or 4) were fatigue (20%), infections during neutropenia (10%), and two cases of biliary sepsis (7%). Abnormal liver function was seen in 10% of the patients. One patient died due to infectious complications during treatment with cisplatin and gemcitabine. The median disease-free survival (DFS) was 14.9 months (95% CI 0-33.8) with a corresponding 3-year DFS of 43.1 ± 9.1%. The median overall survival (OS) was 40.6 months (95% CI 18.8-62.3) with a 3-year OS of 55.7 ± 9.2%. No statistically significant differences in survival were seen between the two treatment cohorts. CONCLUSION: Adjuvant chemotherapy with gemcitabine with or without cisplatin was well tolerated and resulted in promising survival of the patients. TRIAL REGISTRATION: The study was retrospectively registered on 25th June 2009 at clinicaltrials.gov ( NCT01073839 ).

Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus.

Selective internal radiation therapy (SIRT) with microspheres labelled with the ß-emitter yttrium-90 (Y-90) enables targeted delivery of radiation to hepatic tumors. SIRT is primarily used to treat inoperable primary or metastatic liver tumors. Eligible patients have usually been exposed to a variety of systemic anticancer therapies, including cytotoxic agents, targeted biologics, immunotherapy and peptide receptor radionuclide therapy (PRRT). All these treatments have potential interactions with SIRT; however, robust evidence on the safety of these potential combinations is lacking. This paper provides current clinical experiences and expert consensus guidelines for the use of SIRT in combination with the anticancer treatment agents likely to be encountered in clinical practice. It was agreed by the expert panel that precautions need to be taken with certain drugs, but that, in general, systemic therapies do not necessarily have to be stopped to perform SIRT. The authors recommend stopping vascular endothelial growth factor inhibitors 4-6 weeks before SIRT, and restart after the patient has recovered from the procedure. It may also be prudent to stop potent radiosensitizers such as gemcitabine therapy 4 weeks before SIRT, and restart treatment at least 2‒4 weeks later. Data from phase III studies combining SIRT with fluorouracil (5FU) or folinic acid/5FU/oxaliplatin (FOLFOX) suggest that hematological toxicity is more common from the combination than it is from chemotherapy without SIRT. There is no evidence to suggest that chemotherapy increases SIRT-specific gastro-intestinal or liver toxicities.

Rare occurrence of metastasis from lung cancer to the anus: case report and review of the literature.

BACKGROUND: Anal metastases from lung cancer are infrequent, and there are only 10 published cases. Life expectancy is no longer than 1 year after diagnosis because of the typically advanced stage of disease. Treatment, which is typically inefficient, is administered with the intent to cure or avoid local complications. CASE PRESENTATION: We report a case of a patient with non-small cell lung cancer presenting with perianal metastasis mimicking an abscess. CONCLUSIONS: Because perianal masses may be misdiagnosed, patients with lung and other cancers should be evaluated for metastatic disease.

Bevacizumab, Pemetrexed, and Cisplatin, or Bevacizumab and Erlotinib for Patients With Advanced Non-Small-Cell Lung Cancer Stratified by Epidermal Growth Factor Receptor Mutation: Phase II Trial SAKK19/09.

OBJECTIVE: The goal was to demonstrate that tailored therapy, according to tumor histology and epidermal growth factor receptor (EGFR) mutation status, and the introduction of novel drug combinations in the treatment of advanced non-small-cell lung cancer are promising for further investigation. METHODS: We conducted a multicenter phase II trial with mandatory EGFR testing and 2 strata. Patients with EGFR wild type received 4 cycles of bevacizumab, pemetrexed, and cisplatin, followed by maintenance with bevacizumab and pemetrexed until progression. Patients with EGFR mutations received bevacizumab and erlotinib until progression. Patients had computed tomography scans every 6 weeks and repeat biopsy at progression. The primary end point was progression-free survival (PFS) ≥ 35% at 6 months in stratum EGFR wild type; 77 patients were required to reach a power of 90% with an alpha of 5%. Secondary end points were median PFS, overall survival, best overall response rate (ORR), and tolerability. Further biomarkers and biopsy at progression were also evaluated. RESULTS: A total of 77 evaluable patients with EGFR wild type received an average of 9 cycles (range, 1-25). PFS at 6 months was 45.5%, median PFS was 6.9 months, overall survival was 12.1 months, and ORR was 62%. Kirsten rat sarcoma oncogene mutations and circulating vascular endothelial growth factor negatively correlated with survival, but thymidylate synthase expression did not. A total of 20 patients with EGFR mutations received an average of 16 cycles. PFS at 6 months was 70%, median PFS was 14 months, and ORR was 70%. Biopsy at progression was safe and successful in 71% of the cases. CONCLUSIONS: Both combination therapies were promising for further studies. Biopsy at progression was feasible and will be part of future SAKK studies to investigate molecular mechanisms of resistance.

Targeting mutated K-ras in pancreatic adenocarcinoma using an adjuvant vaccine.

PURPOSE: Codon 12 mutations of K-ras are frequent in pancreatic adenocarcinoma, and represent potential tumor-specific neoantigens. The objective of this study was to assess the safety and efficacy of immunizing patients with resected pancreatic cancer with a vaccine targeted against their tumor-specific K-ras mutation. METHODS: Patients with resected pancreatic cancer, with K-ras mutations at codon 12, were vaccinated once monthly for 3 months with a 21-mer peptide vaccine containing the corresponding K-ras mutation of the patient's tumor. About 200 µg of peptide vaccine was injected intradermally on day 7 of a 10-day course of intradermal granulocyte macrophage colony-stimulating factor. Toxicity was assessed by National Cancer Institute Common Toxicity Criteria v2.0. Immune responses were evaluated by delayed-type hypersensitivity (DTH) tests and the enzyme-linked immunosorbent spot assays. RESULTS: Of 62 screened patients, 24 were vaccinated. There were no grade 3-5 vaccine-specific toxicities. The only National Cancer Institute grade 1 and 2 toxicity was erythema at the injection site (94%). Nine patients (25%) were evaluable for immunologic responses. One patient (11%) had a detectable immune response specific to the patient's K-ras mutation, as assessed by DTH. Three patients (13%) displayed a DTH response that was not specific. Median recurrence free survival time was 8.6 months (95% confidence interval, 2.96-19.2) and median overall survival time was 20.3 months (95% confidence interval, 11.6-45.3). CONCLUSIONS: K-ras vaccination for patients with resectable pancreatic adenocarcinoma proved to be safe and tolerable with however no elicitable immunogenicity and unproven efficacy. Future development of adjuvant vaccine therapies should use more immunogenic vaccines.

A case of lenalidomide-induced hypersensitivity pneumonitis.

BACKGROUND: Lenalidomide is a new immunomodulatory drug, FDA-approved for the treatment of the 5q-myelodysplastic syndrome and refractory or relapsed multiple myeloma (MM). Regarding the treatment of MM, there have been published cases of acute pulmonary toxicity for the proteasome inhibitor bortezomib and the immunomodulatory drug thalidomide; only 1 case of lenalidomide-induced pulmonary toxicity has been described in the literature. CASE REPORT: In our manuscript, we describe the clinical course and diagnostic workup of a 66-year-old male patient with MM on lenalidomide with signs of acute pulmonary toxicity. The diagnostic workup resulted in the diagnosis of drug-induced interstitial hypersensitivity pneumonitis. CONCLUSIONS: Given the frequently reported pulmonary infectious complications in patients treated with lenalidomide and a possibly underreported rate of interstitial pneumonitis, we advocate a more aggressive pulmonary workup for patients with pulmonary symptoms.

Norovirus outbreak in a district general hospital--new strain identified.

INTRODUCTION: Media reports about Norovirus outbreaks, especially in hospitals and nursing homes, have accumulated in the past years. The reasons for this increasing problem are manifold: resistance against common disinfectants, a high level of contagion (a dose of less than 100 particles may be infective); variability of the virus-genome documented by polymerase chain reaction-studies, as well as further factors concerning modern life-style. The following study describes and analyses a Norovirus outbreak in the SRO-Hospital Langenthal from November 25, 2003, to December 31, 2003. PATIENTS AND METHODS: The case definition included sudden vomiting and diarrhoea, abdominal cramps, fever below 38.5 degrees C and recovery after 48 hours. Stool cultures were taken and tested for bacteria (Campylobacter jejuni, salmonella and shigella species) and rotaviruses. Stool and vomit specimens were then tested using Real Time Polymerase Chain Reaction (RT-PCR) for noroviruses using different primer sets. Epidemiological data were gained such as transmission modus from person-to-person or food-borne. RESULTS: A total of 77 persons were affected by the viral disease. Two incidence-peaks of gastroenteritis were noted. The first peak happened in the geriatric ward and the second in the geographically distinct department of internal medicine. The existence of a new norovirus strain of genogroup II/4 has been confirmed by the CDC Enteric Viruses Branch in Atlanta, GA. The measures to be taken are pointed out. CONCLUSIONS: A norovirus gastroenteritis outbreak of such intensity and extent as described had not thus far occurred in the hospital's history. The strains newly found by sequencing are associated with genogroup II/4. This genogroup caused a striking increase of gastroenteritis outbreaks in Europe in the year 2002 including atypical spring and summer peaks. This new variant is supposed to be more virulent and environmentally more stable than previous strains [21]. Preventive measures that are in agreement with the published guidelines were taken before the viral pathogen was identified by RT-PCR. The obvious emerging problem of norovirus infections in our society and the economic data analysing the costs caused by lost bed days and staff absence make epidemiological investigation of outbreaks and application of molecular tests more important. They are the basis for determining transmission routes and characterising the different strains in order to improve preventive strategies.

Peroxisome proliferator-activated receptors (PPARs) and associated transcription factors in colon cancer: reduced expression of PPARgamma-coactivator 1 (PGC-1).

Peroxisome proliferator-activated receptors (PPARs) alpha,beta/delta and gamma are fatty acid sensitive transcription factors that have been implicated in colorectal cancer. To better understand their role, we studied the expression levels of all PPAR-isoforms and transcriptional partners such as the retinoid X receptor alpha (RXRalpha) and PPARgamma-coactivator-1 (PGC-1) by means of real-time PCR in 17 patients with colon cancer. While a heterogeneous pattern was observed for the expression level of the PPAR-isoforms alpha,beta/delta and gamma, the coactivator PGC-1 was significantly decreased in 15 of 17 tumors. Taken together our data suggest that the transcriptional activity of PPARgamma may not only be decreased by mutation but also by downregulation of the coactivator PGC-1 of PPARgamma.

Endurance training in humans leads to fiber type-specific increases in levels of peroxisome proliferator-activated receptor-gamma coactivator-1 and peroxisome proliferator-activated receptor-alpha in skeletal muscle.

The peroxisome proliferator-activated receptor (PPAR)-gamma coactivator-1 (PGC-1) can induce mitochondria biogenesis and has been implicated in the development of oxidative type I muscle fibers. The PPAR isoforms alpha, beta/delta, and gamma control the transcription of genes involved in fatty acid and glucose metabolism. As endurance training increases skeletal muscle mitochondria and type I fiber content and fatty acid oxidative capacity, our aim was to determine whether these increases could be mediated by possible effects on PGC-1 or PPAR-alpha, -beta/delta, and -gamma. Seven healthy men performed 6 weeks of endurance training and the expression levels of PGC-1 and PPAR-alpha, -beta/delta, and -gamma mRNA as well as the fiber type distribution of the PGC-1 and PPAR-alpha proteins were measured in biopsies from their vastus lateralis muscle. PGC-1 and PPAR-alpha mRNA expression increased by 2.7- and 2.2-fold (P < 0.01), respectively, after endurance training. PGC-1 expression was 2.2- and 6-fold greater in the type IIa than in the type I and IIx fibers, respectively. It increased by 2.8-fold in the type IIa fibers and by 1.5-fold in both the type I and IIx fibers after endurance training (P < 0.015). PPAR-alpha was 1.9-fold greater in type I than in the II fibers and increased by 3.0-fold and 1.5-fold in these respective fibers after endurance training (P < 0.001). The increases in PGC-1 and PPAR-alpha levels reported in this study may play an important role in the changes in muscle mitochondria content, oxidative phenotype, and sensitivity to insulin known to be induced by endurance training.

Expression of galectin-3 in normal and malignant thyroid tissue by quantitative PCR and immunohistochemistry.

Galectin-3 has been extensively studied as an immunohistochemical marker of thyroid malignancy, and a high diagnostic accuracy has been reported even for difficult pathological diagnoses, such as minimal invasive follicular carcinoma. We consequently hypothesized that the quantitative analysis of galectin-3 mRNA rather than the more observer-dependent immunohistological determination might enhance the diagnostic workup of ambiguous thyroid lesions. In the present study, we set out to validate this approach by analyzing concomitantly the expression and production of galectin-3 in benign and malignant thyroid tumors by means of quantitative PCR and immunohistochemistry. Twenty-eight benign and 31 malignant thyroid samples were quantified by real-time PCR for the mRNA levels of galectin-3 and thyroglobulin. Galectin-3 protein expression was examined by immunohistochemistry in 13 benign and 14 malignant thyroid samples. There was a significant increase in galectin-3 at both the mRNA (12/20) and protein levels in papillary cancer (8/8), although the mRNA values overlapped partly with benign lesions. Surprisingly, only a focal and discrete galectin-3 immunoreactivity was seen in follicular cancer (1/5); no augmentation of the mRNA was found. The expression of the thyroid-specific gene thyroglobulin was highly variable in benign and malignant thyroid tissue. These results suggest that the quantitative measurement of galactin-3 mRNA is unlikely to be clinically useful and underscore the need for searching for novel markers for thyroid malignancies.