Clinical implementation of pre-treatment DPYD genotyping in capecitabine-treated metastatic breast cancer patients

Purpose Metastatic breast cancer (mBC) patients with DPYD genetic variants linked to loss of dihydropyrimidine dehydrogenase (DPD) activity are at risk of severe capecitabine-associated toxicities. However, prospective DPYD genotyping has not yet been implemented in routine clinical practice. Following a previous internal review in which two patients underwent lengthy hospitalisations whilst receiving capecitabine, and were subsequently found to be DPD deficient, we initiated routine DPYD genotyping prior to starting capecitabine. This study evaluates the clinical application of routine DPYD screening at a large cancer centre in London. Methods We reviewed medical records for consecutive patients with mBC who underwent DPYD genotyping before commencing capecitabine between December 2014 and December 2017. Patients were tested for four DPYD variants associated with reduced DPD activity. Results Sixty-six patients underwent DPYD testing. Five (8.4%) patients were found to carry DPYD genetic polymorphisms associated with reduced DPD activity; of these, two received dose-reduced capecitabine. Of the 61 patients with DPYD wild-type, 14 (23%) experienced grade 3 toxicities which involved palmar–plantar erythrodysesthesia (65%), and gastrointestinal toxicities (35%); no patient was hospitalised due to toxicity. Conclusions Prospective DPYD genotyping can be successfully implemented in routine clinical practice and can reduce the risk of severe fluoropyrimidine toxicities

Randomised trial of proton vs. carbon ion radiation therapy in patients with chordoma of the skull base, clinical phase III study HIT-1-Study

<p>Abstract</p> <p>Background</p> <p>Chordomas of the skull base are relative rare lesions of the bones. Surgical resection is the primary treatment standard, though complete resection is nearly impossible due to close proximity to critical and hence also dose limiting organs for radiation therapy. Level of recurrence after surgery alone is comparatively high, so adjuvant radiation therapy is very important for the improvement of local control rates. Proton therapy is the gold standard in the treatment of skull base chordomas. However, high-LET beams such as carbon ions theoretically offer biologic advantages by enhanced biologic effectiveness in slow-growing tumors.</p> <p>Methods/design</p> <p>This clinical study is a prospective randomised phase III trial. The trial will be carried out at Heidelberger Ionenstrahl-Therapie centre (HIT) and is a monocentric study.</p> <p>Patients with skull base chordoma will be randomised to either proton or carbon ion radiation therapy. As a standard, patients will undergo non-invasive, rigid immobilization and target volume delineation will be carried out based on CT and MRI data. The biologically isoeffective target dose to the PTV in carbon ion treatment (accelerated dose) will be 63 Gy E ± 5% and 72 Gy E ± 5% (standard dose) in proton therapy respectively. Local-progression free survival (LPFS) will be analysed as primary end point. Toxicity and overall survival are the secondary end points. Additional examined parameters are patterns of recurrence, prognostic factors and plan quality analysis.</p> <p>Discussion</p> <p>Up until now it was impossible to compare two different particle therapies, i.e. protons and carbon ions directly at the same facility.</p> <p>The aim of this study is to find out, whether the biological advantages of carbon ion therapy can also be clinically confirmed and translated into the better local control rates in the treatment of skull base chordomas.</p> <p>Trial registration</p> <p>ClinicalTrials.gov identifier: NCT01182779</p

Non-randomized therapy trial to determine the safety and efficacy of heavy ion radiotherapy in patients with non-resectable osteosarcoma

<p>Abstract</p> <p>Background</p> <p>Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. For effective treatment, local control of the tumor is absolutely critical, because the chances of long term survival are <10% and might effectively approach zero if a complete surgical resection of the tumor is not possible. Up to date there is no curative treatment protocol for patients with non-resectable osteosarcomas, who are excluded from current osteosarcoma trials, e.g. <it>EURAMOS1</it>. Local photon radiotherapy has previously been used in small series and in an uncontrolled, highly individualized fashion, which, however, documented that high dose radiotherapy can, in principle, be used to achieve local control. Generally the radiation dose that is necessary for a curative approach can hardly be achieved with conventional photon radiotherapy in patients with non-resectable tumors that are usually located near radiosensitive critical organs such as the brain, the spine or the pelvis. In these cases particle Radiotherapy (proton therapy (PT)/heavy ion therapy (HIT) may offer a promising new alternative. Moreover, compared with photons, heavy ion beams provide a higher physical selectivity because of their finite depth coverage in tissue. They achieve a higher relative biological effectiveness. Phase I/II dose escalation studies of HIT in adults with non-resectable bone and soft tissue sarcomas have already shown favorable results.</p> <p>Methods/Design</p> <p>This is a monocenter, single-arm study for patients ≥ 6 years of age with non-resectable osteosarcoma. Desired target dose is 60-66 Cobalt Gray Equivalent (Gy E) with 45 Gy PT (proton therapy) and a carbon ion boost of 15-21 GyE. Weekly fractionation of 5-6 × 3 Gy E is used. PT/HIT will be administered exclusively at the Ion Radiotherapy Center in Heidelberg. Furthermore, FDG-PET imaging characteristics of non-resectable osteosarcoma before and after PT/HIT will be investigated prospectively. Systemic disease before and after PT/HIT is targeted by standard chemotherapy protocols and is not part of this trial.</p> <p>Discussion</p> <p>The primary objectives of this trial are the determination of feasibility and toxicity of HIT. Secondary objectives are tumor response, disease free survival and overall survival. The aim is to improve outcome for patients with non-resectable osteosarcoma.</p> <p>Trail Registration</p> <p>Registration number (ClinicalTrials.gov): NCT01005043</p

Reovirus exerts potent oncolytic effects in head and neck cancer cell lines that are independent of signalling in the EGFR pathway

Background: reovirus exploits aberrant signalling downstream of Ras to mediate tumor-specific oncolysis. Since ~90% squamous cell carcinomas of the head and neck (SCCHN) over-express EGFR and SCCHN cell lines are sensitive to oncolytic reovirus, we conducted a detailed analysis of the effects of reovirus in 15 head and neck cancer cell lines. Both pre- and post-entry events were studied in an attempt to define biomarkers predictive of sensitivity/resistance to reovirus. In particular, we analysed the role of EGFR/Ras signalling in determining virus-mediated cytotoxicity in SCCHN. Methods: to test whether EGFR pathway activity was predictive of increased sensitivity to reovirus, correlative analyses between reoviral IC50 by MTT assay and EGFR levels by western blot and FACS were conducted. Inhibition or stimulation of EGFR signalling were analysed for their effect on reoviral oncolysis by MTT assay, and viral growth by TCID50 assay. We next analysed the effects of inhibiting signalling downstream of Ras, by specific inhibitors of p38MAPK, PI3-K or MEK, on reoviral killing examined by MTT assay. The role of PKR in reoviral killing was also determined by blockade of PKR using 2-aminopurine and assaying for cell survival by MTT assay. The apoptotic response of SCCHN to reovirus was examined by western blot analysis of caspase 3 cleavage. Results: correlative analyses between reoviral sensitivity and EGFR levels revealed no association. Intermediate sub-viral and core particles showed the same infectivity/cytotoxicity as intact reovirus. Therefore, sensitivity was not determined by cell entry. In 4 cell lines, oncolysis and viral growth were both unaffected by inhibition or stimulation of EGFR signalling. Inhibition of signalling downstream of Ras did not abrogate reoviral oncolysis and, in addition, modulation of PKR using 2-aminopurine did not alter reovirus sensitivity in resistant cell lines. Caspase 3 cleavage was not detected in infected cells and oncolysis was observed in pan-caspase inhibited cells. Conclusions: in summary, reovirus is potently oncolytic in a broad panel of SCCHN cell lines. Attempts to define sensitivity/resistance by analysis of the EGFR/Ras/MAPK pathway have failed to provide a clear predictive biomarker of response. Further analysis of material from in vitro and clinical studies is ongoing in an attempt to shed further light on this issue

Custom CGH array profiling of copy number variations (CNVs) on chromosome 6p21.32 (HLA locus) in patients with venous malformations associated with multiple sclerosis

<p>Abstract</p> <p>Background</p> <p>Multiple sclerosis (MS) is a complex disorder thought to result from an interaction between environmental and genetic predisposing factors which have not yet been characterised, although it is known to be associated with the HLA region on 6p21.32. Recently, a picture of chronic cerebrospinal venous insufficiency (CCSVI), consequent to stenosing venous malformation of the main extra-cranial outflow routes (VM), has been described in patients affected with MS, introducing an additional phenotype with possible pathogenic significance.</p> <p>Methods</p> <p>In order to explore the presence of copy number variations (CNVs) within the HLA locus, a custom CGH array was designed to cover 7 Mb of the HLA locus region (6,899,999 bp; chr6:29,900,001-36,800,000). Genomic DNA of the 15 patients with CCSVI/VM and MS was hybridised in duplicate.</p> <p>Results</p> <p>In total, 322 CNVs, of which 225 were extragenic and 97 intragenic, were identified in 15 patients. 234 known polymorphic CNVs were detected, the majority of these being situated in non-coding or extragenic regions. The overall number of CNVs (both extra- and intragenic) showed a robust and significant correlation with the number of stenosing VMs (Spearman: r = 0.6590, p = 0.0104; linear regression analysis r = 0.6577, p = 0.0106).</p> <p>The region we analysed contains 211 known genes. By using pathway analysis focused on angiogenesis and venous development, MS, and immunity, we tentatively highlight several genes as possible susceptibility factor candidates involved in this peculiar phenotype.</p> <p>Conclusions</p> <p>The CNVs contained in the HLA locus region in patients with the novel phenotype of CCSVI/VM and MS were mapped in detail, demonstrating a significant correlation between the number of known CNVs found in the HLA region and the number of CCSVI-VMs identified in patients. Pathway analysis revealed common routes of interaction of several of the genes involved in angiogenesis and immunity contained within this region. Despite the small sample size in this pilot study, it does suggest that the number of multiple polymorphic CNVs in the HLA locus deserves further study, owing to their possible involvement in susceptibility to this novel MS/VM plus phenotype, and perhaps even other types of the disease.</p

High efficiency of alphaviral gene transfer in combination with 5-fluorouracil in a mouse mammary tumor model

Copyright: Copyright 2014 Elsevier B.V., All rights reserved.Background: The combination of virotherapy and chemotherapy may enable efficient tumor regression that would be unachievable using either therapy alone. In this study, we investigated the efficiency of transgene delivery and the cytotoxic effects of alphaviral vector in combination with 5-fluorouracil (5-FU) in a mouse mammary tumor model (4 T1).Methods: Replication-deficient Semliki Forest virus (SFV) vectors carrying genes encoding fluorescent proteins were used to infect 4 T1 cell cultures treated with different doses of 5-FU. The efficiency of infection was monitored via fluorescence microscopy and quantified by fluorometry. The cytotoxicity of the combined treatment with 5-FU and alphaviral vector was measured using an MTT-based cell viability assay. In vivo experiments were performed in a subcutaneous 4 T1 mouse mammary tumor model with different 5-FU doses and an SFV vector encoding firefly luciferase.Results: Infection of 4 T1 cells with SFV prior to 5-FU treatment did not produce a synergistic anti-proliferative effect. An alternative treatment strategy, in which 5-FU was used prior to virus infection, strongly inhibited SFV expression. Nevertheless, in vivo experiments showed a significant enhancement in SFV-driven transgene (luciferase) expression upon intratumoral and intraperitoneal vector administration in 4 T1 tumor-bearing mice pretreated with 5-FU: here, we observed a positive correlation between 5-FU dose and the level of luciferase expression.Conclusions: Although 5-FU inhibited SFV-mediated transgene expression in 4 T1 cells in vitro, application of the drug in a mouse model revealed a significant enhancement of intratumoral transgene synthesis compared with 5-FU untreated mice. These results may have implications for efficient transgene delivery and the development of potent cancer treatment strategies using alphaviral vectors and 5-FU.publishersversionPeer reviewe

Επίπεδα ορού λεπτίνης και κυτταροκινών (κυτοκινών) σε ασθνείς με μη μικροκυτταρικό καρκίνο του πνεύμονα (ΜΜΚΠ), συσχέτιση με κλινικές και παθολογοανατομικές παραμέτρους

Background: Adipose tissue secretes adipokines with proinflammatory and anti-inflammatory properties. The role of adipose tissue in generalized inflammatory state of advanced Non-Small Cell Lung Cancer (NSCLC) patients as well as in cachexia often present in these patients has not fully explored. The aim of this study was to detect the role of leptin, adiponectin, resistin and ghrelin in both systemic inflammation and cachexia of advanced NSCLC patients. The possible use of these cytokines as diagnostic and prognostic markers was evaluated. Methods: Fasting serum levels of leptin, adiponectin and resistin were determined in 101 advanced NSCLC patients (76 without weight loss and 25 with weight loss) and 51 healthy volunteers. Adipokine serum levels were determined at diagnosis, at the end of first-line chemotherapy and at the time of disease progression for those who responded to treatment. Ghrelin serum levels were also measured in NSCLC patients before receiving any therapy and 60 healthy control volunteers. For cytokines measurements commercially available ELISA were used. Epidemiological, anthropometrical and laboratory data were assessed for patients as well as for healthy volunteers. Results: Serum resistin (P=0.023) and ghrelin (P<0.001) levels were significantly increased in NSCLC patients after adjustment for age, sex and BMI. Serum leptin and adiponectin levels presented no differences. Multivariate analysis showed that these adipokines and ghrelin at diagnosis could not be used as predictive factors for overall survival or time to progression. Increased resistin and ghrelin levels at diagnosis were associated with weight loss. Conclusions: Despite no direct involvement of leptin and adiponectin, resistin as a proinflammatory cytokine and ghrelin as a body weight regulator may be actively involved in the NSCLC cachexia syndrome and systemic inflammation.Εισαγωγή: Ο λιπώδης ιστός παράγει λιποκίνες με προφλεγμονώδεις και αντιφλεγμονώδεις ιδιότητες. Ο ρόλος του λιπώδους ιστού στη γενικευμένη φλεγμονή που συνοδεύει τον προχωρημένο μη μικροκυτταρικό καρκίνο του πνεύμονα (ΜΜΚΠ) αλλά και στην καχεξία που συχνά παρατηρείται σε ασθενείς με προχωρημένη νόσο δεν έχει πλήρως διευκρινιστεί. Σκοπός της μελέτης αυτής είναι να διερευνηθεί ο ρόλος της λεπτίνης, αντιπονεκτίνης, ρεσιστίνης και γκρελίνης στη γενικευμένη φλεγμονώδη αντίδραση και καχεξία που συνοδεύουν τον ΜΜΚΠ. Επιπλέον, η πιθανότητα να χρησιμοποιηθούν οι κυτταροκίνες (κυτοκίνες) αυτές ως διαγνωστικοί ή προγνωστικοί δείκτες εξετάστηκε. Μέθοδοι: Τα επίπεδα νηστείας ορού της λεπτίνης, αντιπονεκτίνης και ρεσιστίνης μετρήθηκαν σε 101 ασθενείς με προχωρημένο ΜΜΚΠ (76 ασθενείς χωρίς απώλεια βάρους και 25 με απώλεια βάρους κατά τη διάγνωση) και 51 υγιείς εθελοντές (μάρτυρες). Τα επίπεδα των λιποκινών μετρήθηκαν κατά τη διάγνωση, στο τέλος της πρώτης γραμμής χημειοθεραπείας και στην υποτροπή σε όσους ασθενείς αρχικά είχαν ανταποκριθεί στη θεραπεία. Τα επίπεδα νηστείας ορού της γκρελίνης μετρήθηκαν στους ίδιους ασθενείς και συνεκρίθησαν με τα επίπεδα νηστείας ορού γκρελίνης σε 60 υγιείς μάρτυρες. Όλες οι μετρήσεις των κυτοκινών έγιναν χρησιμοποιώντας kit Elisa του εμπορίου. Επιδημιολογικά και ανθρωπομετρικά δεδομένα κατεγράφησαν λεπτομερώς όπως και παρακλινικά δεδομένα τόσο για τους ασθενείς όσο και για τους μάρτυρες. Αποτελέσματα: Τα επίπεδα ορού της ρεσιστίνης (Ρ=0.023) και της γκρελίνης (Ρ<0.001) ήταν στατιστικά σημαντικά υψηλότερα στους ασθενείς με ΜΜΚΠ συγκριτικά με τους υγιείς μάρτυρες μετά από διόρθωση για το φύλο, την ηλικία και το ΔΣΒ (Δείκτη Σωματικού Βάρους). Τα επίπεδα ορού λεπτίνης και αντιπονεκτίνης δεν παρουσίασαν καμία διαφορά. Η πολυπαραγοντική ανάλυση έδειξε ότι οι λιποκίνες και η γκρελίνη δεν μπορούν να χρησιμοποιηθούν ως προγνωστικοί δείκτες για το συνολικό διάστημα επιβίωσης ή για το διάστημα ελεύθερο προόδου νόσου. Αυξημένα επίπεδα ρεσιστίνης και γκρελίνης κατά τη διάγνωση συσχετίστηκαν με απώλεια βάρους. Συμπεράσματα: Η ρεσιστίνη ως προφλεγμονώδης παράγοντας και η γκρελίνη ως ρυθμιστής του βάρους σώματος, αντίθετα από τη λεπτίνη και την αντιπονεκτίνη, φαίνεται να συμμετέχουν ενεργά στην καχεξία και στη γενικευμένη φλεγμονή που συνοδεύει τον προχωρημένο ΜΜΚΠ

The clinical significance of molecular markers to bladder cancer

Stage and grade of transitional cell carcinoma are currently the most useful tools for taking therapeutic decisions and evaluating the prognosis of bladder cancer patients. However, as there are remarkable differences in biological behavior and “biological potential” of tumors classified in the same stage, it is very difficult to predict which superficial tumors will recur and which tumors will give distant metastases. During the last two decades, the better understanding of the molecular mechanisms involved in carcinogenesis and tumor progression has provided a large number of molecular markers of bladder cancer, with a potential diagnostic and prognostic value. This article reviews comprehensively the molecular role and evaluates the clinical significance and the perspectives of these molecular markers. We concluded that, although at the moment there is not a single marker able to predict with accuracy the biological potential of bladder cancer, the most promising markers, at this point, are deletions of chromosome 9, and the tumor suppressor gene p53. Clinical studies are in progress for the assessment of other biological molecules with prognostic potential, such as the E-cadherin, the protein p120, and the telomerase