Complete longitudinal analyses of the randomized, placebo-controlled, phase III trial of sunitinib in patients with gastrointestinal stromal tumor following imatinib failure.

PURPOSE: To analyze final long-term survival and clinical outcomes from the randomized phase III study of sunitinib in gastrointestinal stromal tumor patients after imatinib failure; to assess correlative angiogenesis biomarkers with patient outcomes. EXPERIMENTAL DESIGN: Blinded sunitinib or placebo was given daily on a 4-week-on/2-week-off treatment schedule. Placebo-assigned patients could cross over to sunitinib at disease progression/study unblinding. Overall survival (OS) was analyzed using conventional statistical methods and the rank-preserving structural failure time (RPSFT) method to explore cross-over impact. Circulating levels of angiogenesis biomarkers were analyzed. RESULTS: In total, 243 patients were randomized to receive sunitinib and 118 to placebo, 103 of whom crossed over to open-label sunitinib. Conventional statistical analysis showed that OS converged in the sunitinib and placebo arms (median 72.7 vs. 64.9 weeks; HR, 0.876; P = 0.306) as expected, given the cross-over design. RPSFT analysis estimated median OS for placebo of 39.0 weeks (HR, 0.505, 95% CI, 0.262-1.134; P = 0.306). No new safety concerns emerged with extended sunitinib treatment. No consistent associations were found between the pharmacodynamics of angiogenesis-related plasma proteins during sunitinib treatment and clinical outcome. CONCLUSIONS: The cross-over design provided evidence of sunitinib clinical benefit based on prolonged time to tumor progression during the double-blind phase of this trial. As expected, following cross-over, there was no statistical difference in OS. RPSFT analysis modeled the absence of cross-over, estimating a substantial sunitinib OS benefit relative to placebo. Long-term sunitinib treatment was tolerated without new adverse events.

Correlations between imatinib pharmacokinetics, pharmacodynamics, adherence, and clinical response in advanced metastatic gastrointestinal stromal tumor (GIST): An emerging role for drug blood level testing?

Imatinib is the standard of care for patients with advanced metastatic gastrointestinal stromal tumors (GIST), and is also approved for adjuvant treatment in patients at substantial risk of relapse. Studies have shown that maximizing benefit from imatinib depends on long-term administration at recommended doses. Pharmacokinetic (PK) and pharmacodynamic factors, adherence, and drug-drug interactions can affect exposure to imatinib and impact clinical outcomes. This article reviews the relevance of these factors to imatinib's clinical activity and response in the context of what has been demonstrated in chronic myelogenous leukemia (CML), and in light of new data correlating imatinib exposure to response in patients with GIST. Because of the wide inter-patient variability in drug exposure with imatinib in both CML and GIST, blood level testing (BLT) may play a role in investigating instances of suboptimal response, unusually severe toxicities, drug-drug interactions, and suspected non-adherence. Published clinical data in CML and in GIST were considered, including data from a PK substudy of the B2222 trial correlating imatinib blood levels with clinical responses in patients with GIST. Imatinib trough plasma levels <1100ng/mL were associated with lower rates of objective response and faster development of progressive disease in patients with GIST. These findings have been supported by other analyses correlating free imatinib (unbound) levels with response. These results suggest a future application for imatinib BLT in predicting and optimizing therapeutic response. Nevertheless, early estimates of threshold imatinib blood levels must be confirmed prospectively in future studies and elaborated for different patient subgroups.

Immunonutrition in gastrointestinal surgery.

Background: Patients undergoing major gastrointestinal surgery are at increased risk of developing complications. The use of immunonutrition (IN) in such patients is not widespread because the available data are heterogeneous, and some show contradictory results with regard to complications, mortality and length of hospital stay. Methods: Randomized controlled trials (RCTs) published between January 1985 and September 2009 that assessed the clinical impact of perioperative enteral IN in major gastrointestinal elective surgery were included in a meta-analysis. Results: Twenty-one RCTs enrolling a total of 2730 patients were included in the meta-analysis. Twelve were considered as high-quality studies. The included studies showed significant heterogeneity with respect to patients, control groups, timing and duration of IN, which limited group analysis. IN significantly reduced overall complications when used before surgery (odds ratio (OR) 0.48, 95 per cent confidence interval (c.i.) 0.34 to 0.69), both before and after operation (OR 0.39, 0.28 to 0.54) or after surgery (OR 0.46, 0.25 to 0.84). For these three timings of IN administration, ORs of postoperative infection were 0.36 (0.24 to 0.56), 0.41 (0.28 to 0.58) and 0.53 (0.40 to 0.71) respectively. Use of IN led to a shorter hospital stay: mean difference -2.12 (95 per cent c.i. -2.97 to -1.26) days. Beneficial effects of IN were confirmed when low-quality trials were excluded. Perioperative IN had no influence on mortality (OR 0.90, 0.46 to 1.76). Conclusion: Perioperative enteral IN decreases morbidity and hospital stay but not mortality after major gastrointestinal surgery; its routine use can be recommended.

Future development of gastrointestinal cancer incidence and mortality rates in Switzerland: a tumour registry- and population-based projection up to 2030.

QUESTIONS UNDER STUDY: Since tumour burden consumes substantial healthcare resources, precise cancer incidence estimations are pivotal to define future needs of national healthcare. This study aimed to estimate incidence and mortality rates of oesophageal, gastric, pancreatic, hepatic and colorectal cancers up to 2030 in Switzerland. METHODS: Swiss Statistics provides national incidences and mortality rates of various cancers, and models of future developments of the Swiss population. Cancer incidences and mortality rates from 1985 to 2009 were analysed to estimate trends and to predict incidence and mortality rates up to 2029. Linear regressions and Joinpoint analyses were performed to estimate the future trends of incidences and mortality rates. RESULTS: Crude incidences of oesophageal, pancreas, liver and colorectal cancers have steadily increased since 1985, and will continue to increase. Gastric cancer incidence and mortality rates reveal an ongoing decrease. Pancreatic and liver cancer crude mortality rates will keep increasing, whereas colorectal cancer mortality on the contrary will fall. Mortality from oesophageal cancer will plateau or minimally increase. If we consider European population-standardised incidence rates, oesophageal, pancreatic and colorectal cancer incidences are steady. Gastric cancers are diminishing and liver cancers will follow an increasing trend. Standardised mortality rates show a diminution for all but liver cancer. CONCLUSIONS: The oncological burden of gastrointestinal cancer will significantly increase in Switzerland during the next two decades. The crude mortality rates globally show an ongoing increase except for gastric and colorectal cancers. Enlarged healthcare resources to take care of these complex patient groups properly will be needed.

Characterizing the impact of multiple potential enemies (predators and parasites) on the behaviour of ranid tadpoles

In order to fully understand an organism's behaviours the interactions between multiple enemies or selective pressures need to be considered, as these interactions are usually far more complex than the simple addition of their effects in isolation. In this thesis, I consider the impact of multiple enemies (fish predators and parasites) on the behaviour of three larval anurans (Lithobates sylvaticus, L. clamitans and L. catesbeianus). I also determine whether species that differ in life-histories and habitat preferences possess different antipredator mechanisms and how this affects species responses to multiple enemies. I show that the three Ranid larvae respond differently to the trade-off imposed by the presence of both fish predators and trematode parasites within the environment. The two more permanent pond breeders (L. clamitans and L. catesbeianus) increased activity when in the combined presence of predators and parasites. In contrast, the temporary pond breeder (L. sylvaticus) decreased activity in the combined presence of predator and parasites, in the same manner as they responded to fish alone. Further, the presence of fish along with parasites increased the susceptibility of both L. sylvaticus and L. clamitans to trematode infection, whereas parasite infection in L. catesbeianus was unaffected by the presence of fish. A second experiment to assess palatability of the three anuran species to fish, revealed a range of palatabilities, with L. catesbeianus being least palatable, L. clamitans being somewhat unpalatable, and L. sylvaticus being highly palatable. This result helps to explain the species differences in tthe observed behaviour to the combined presence of fish and parasites. In conclusion, the results from this study highlight the importance of considering multiple selective pressures faced by organisms and how this shapes their behaviour.

Análisis farmacogenético y funcional del gen Timidilato sintasa en cáncer gastrointestinal

Tesis (Maestría en Ciencias con Orientación Terminal en Biología Molecular e Ingeniería Genética) U.A.N.L., 2007.

Elements de zoologie medicale, contenant la description des animauxutiles a la medecine et des especes nuisibles a l'homme venimeuses ou parasites

UANL

Studies on Copepod Parasites on Elasmobranchs of Kerala Coast

The present study of the parasitic copepods gives the taxonomic description of thirty one species of parasites collected from various elasmobranch fishes of Kerala coast. Copepods parasitic on fishes include three sub orders, viz. poecilostomatoida, cyclopoida and siphonostomatoida. Parasitic copepods of elasmobranch fishes for the present study were collected from different fish landing centres of Kerala and by undertaking regular fishing trips. The collected parasites are identified to the species level and described. It is found that out of thirty one species, fifteen are new to science. They belong to the genera viz. Nothobomolochus Vervoot, 1962, Caligus Muller, 1785, Alebion, Kroyer, 1863, Gloipotes Steenstrup and Lutken, 1861, Pandarus Leach,1819, Perissopus Steenstrup and Lutken, 1861, Echthrogaleus Steenstrup and Lutken, 1861 and Kroyeria van Beneden, 1853. Fifteen new host records were reported. Two genera viz. Echthrogaleus and Entepherus were reported for first time from Indian waters. A new genus called Penicillus was erected. The general observations made during this study revealed certain interesting aspects of host-parasite relationship, host specificity, site specificity, adaptive modifications and geographical distribution.

Studies on The Copepod Fish Parasites of Kerala Coast

The present study of the parasitic copepods gives an account of the taxonomic description of seventy seven species of parasites collected from the food fishes of the Kerala coast. Out of the seventy seven species described, fourteen are new to science, two new records for the Indian waters and ten new host records. The males of Parapetalus longipinnatus Rangnekar and Lerna~thropus indicus Pillai were collected and described for the first time. The parasites described belong to the suborders Cyclopoida, Caligoida and Lernaeopodoida. The available description of many species of this locality is reviewed and supplemented with the help of the present detailed study. The general observations made during this study reveale certain interesting aspects of the host parasite relationship, host specificity, adaptive modification and geographical distribution. A brief discussion of these observations made is also presented.