Tarek Assi

Dilemma of first line regimens in metastatic pancreatic adenocarcinoma

Pancreatic cancer is one of the deadliest cancers, ranking fourth among cancer-related deaths. Despite all the major molecular advances and treatment breakthroughs, mainly targeted therapies, the cornerstone treatment of metastatic pancreatic cancer (mPC) remains cytotoxic chemotherapy. In 2016, more than 40 years after the introduction of gemcitabine in the management of mPC, the best choice for first-line treatment has not yet been fully elucidated. Two main strategies have been adopted to enhance treatment efficacy. The first strategy is based on combining non-cross resistant drugs, while the second option includes the development of newer generations of chemotherapy. More recently, two new regimens, FOLFIRINOX and gemcitabine/nab-paclitaxel (GNP), have both been shown to improve overall survival in comparison with gemcitabine alone, at the cost of increased toxicity. Therefore, the best choice for first line therapy is a matter of debate. For some authors, FOLFIRINOX should be the first choice in patients with an Eastern Cooperative Oncology Group score (0-1) given its lower hazard ratio. However, others do not share this opinion. In this paper, we review the main comparison points between FOLFIRINOX and GNP. We analyze the two pivotal trials to determine the similarities and differences in study design. In addition, we compare the toxicity profile of the two regimens as well as the impact on quality of life. Finally, we present studies revealing real life experiences and review the advantages and disadvantages of possible second-line therapies including their cost effectiveness.

Advances in urothelial bladder cancer immunotherapy, dawn of a new age of treatment

Urothelial bladder cancer displays a high number of somatic mutations that render these tumors more responsive to immunotherapy. Several immunotherapeutic agents were examined in patients with advanced stage urothelial bladder cancer and recently atezolizumab - an (PDL-1) immune checkpoint inhibitor antibody - was approved for the treatment of patients with metastatic disease progressing after platinum combination therapy. Despite the great success, there are still some unanswered questions and ongoing trials that are in progress to define the role of combination therapy and sequencing strategies. The objective of our manuscript is to summarize the most recent data on immunotherapy in advanced urothelial cancer. Current challenges and future perspectives of immunotherapy as a monotherapy or in combination strategies will also be analyzed.

PDL-1/PD1 inhibitors: antibody or antinobody?

Department of Urology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon Department of Medical Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon *Author for correspondence: Tel.: +009611615300; elie.rassy@hotmail.com

Efficacy of a Silicon Based Continuous Scalp Cooling System with Thermostat on Chemotherapy Induced Alopecia

Introduction: Alopecia although reversible, is one of the most distressing side effects of chemotherapy. Preventive measures mainly focus on scalp cooling with variable and unpredictable efficacy reported in the literature. The objective of this work is to test the tolerance and effectiveness of a new silicon based cooling technique in preventing chemotherapy induced alopecia (CIA) after each of six cycles of chemotherapy. Method: This is a one center prospective descriptive study. Included patients were females receiving Taxanes and/or Adriamycin based regimens at the oncology department of Hotel-Dieu de France University Hospital. Cooling was done using the Orbis-Paxman scalp cooling system. Hair loss severity was evaluated using the World Health Organization (WHO) grading system. Failure or success of cooling was defined on the basis of wig or head cover use. Independent factors like age, type of hair, type and dose of chemotherapy, total and post infusion cooling time hemoglobin and creatinine at each course. Results: 81 patients were included. Success ranged between 84.8% and 96% for the repeated cycles. No association was found with the independent factors, except for the dose of chemotherapy in the first course with higher doses of Adriamycin (99 mg v/s 77 mg, p value 0.037) as well as taxanes (140 mg v/s 122 mg, p value 0.035) in patients experiencing failure. Conclusion: Scalp cooling has proved to be a successful and well tolerated prevention method for CIA in breast cancer patients treated by Taxanes and Adriamycin.

Distribution of Testicular Tumors in Lebanon: A Single Institution Overview

BACKGROUND Testicular tumors constitute a rare type of cancer affecting adolescents and young adults with recent reports confirming an increase in incidence worldwide. The purpose of this study was to estimate the epidemiological characteristics and histological subtypes of testicular tumors in the Lebanese population according to the WHO classification of testicular and paratesticular tumors. MATERIALS AND METHODS In this single institutional retrospective study, all patients diagnosed with a testicular tumor in Hotel-Dieu de France Hospital University in Beirut between 1992 and 2014 were enrolled. The age, subtype based on the 2004 WHO classification and body side of tumor were analyzed. RESULTS A total of two hundred and forty-four (244) patients diagnosed with a testicular tumor in our institution were included in the study. Two hundred and one patients (82.4% of all testicular tumors) had germ cell tumors (TGCT). Among TGCT, 50% were seminomatous tumors, 48% non-seminomatous tumors (NST) and 2% were spermatocytic seminomas. The NST were further divided into mixed germ cell tumors (63.9%), embryonic carcinomas (18.6%), teratomas (15.4%) and yolk sac tumors (2.1%). The mean age for testicular tumors was 32 years. The mean age for germ cell tumors was 31 years and further subtypes such as seminomatous tumors had a mean age of 34 years, 28 years in non-seminomatous tumors and 56 years in spermatocytic seminoma. Patients with right testicular tumor were the predominant group with 55% of patients. Three patients (1.2%) presented with bilateral tumors. CONCLUSIONS The distribution of different subgroups and the mean age for testicular tumors proved comparable to most countries of the world except for some Asian countries. Germ cell tumors are the most common subtype of testicular tumors with seminomatous tumors being slightly more prevalent than non-seminomatous tumors in Lebanese patients.

The Therapeutic use of human albumin in cancer patients’ management

Human albumin (HA) has been widely used in clinical practice due to its unique physiological characteristics and pharmacokinetics. However, with the absence of clear institutional recommendations, its uncontrolled prescription remains largely controversial. An extensive review on the albumin chemistry, pharmacology, physiology and pathology was performed, and data on commercially available HA, its cost, medical usage and the related available guidelines, particularly in oncology patients were gathered. Studies assessing the appropriate use and safety of HA in cancer patients are lacking. A retrospective survey of the appropriateness of HA infusions according to the SIMTI guidelines (2009) was performed in our department. Among 53 patients who received HA infusions, only 5.7% of the indications were appropriate for HA administration. Occasionally appropriate and inappropriate indications were considered in 10% and 84.3% of the prescriptions respectively with a relatively high cost. The adoption of strict guidelines may substantially reduce the inappropriate use and the subsequent healthcare costs.

Diffuse edema suggestive of cytokine release syndrome in a metastatic lung carcinoma patient treated with pembrolizumab

Immune checkpoint inhibitors (ICIs) are actually being indicated more commonly in the management of chemoresistant cancer patients in view of their favorable toxicity profile in comparison to cytotoxic chemotherapy. In this paper, we report, to our knowledge, the first case suggestive of cytokine release syndrome secondary to pembrolizumab in a patient with metastatic lung squamous cell carcinoma. In view of the quick approvals of ICI and the absence of sufficient knowledge of the corresponding toxicity profile, the occurrence of any clinical or biological sign or symptom in patients receiving ICI requires further investigation.

The optimal treatment of metastatic hormone-naive prostate cancer: abiraterone acetate or docetaxel?

AIM To determine whether abiraterone acetate or docetaxel should be regarded as the current standard of care for metastatic hormone-naive prostate cancer (mHNPC). METHODS & MATERIALS A network meta-analysis (NMA) using the frequentist approach and generalized pairwise modeling was computed. RESULTS The results of this NMA favored abiraterone acetate over docetaxel-based regimens (hazard ratio: 0.79; 95% CI: 0.64-0.99) in patients with mHNPC. The results also suggest a reconsideration of the role of prednisone in view of the absence of a survival benefit (hazard ratio: 0.98; 95% CI: 0.59-1.65) with its use. CONCLUSION Despite the paucity of direct comparative evidence, the results of this NMA favor the use of abiraterone acetate in the first-line treatment of mHNPC.

Could the combination of Nab-paclitaxel plus gemcitabine salvage metastatic pancreatic adenocarcinoma after folfirinox failure? A single institutional retrospective analysis

Sex Male 10 (83.3%) Female 2 (16.7%) Age (years), median (range) 61 (52—74) Comorbidities, median (range) 1.5 (1—4) Smoking 8 (66.7%) Diabetes mellitus 6 (50%) High blood pressure 5 (41.7%) Hyperlipidemia 2 (16.7%) Pancreatic tumor location Head 8 (66.7%) Body 3 (25%) Tail 1 (8.3%) Metastatic sites, median (range) 1.5 (1—3) Liver — (exclusive) 11 (91.7%) — 5 (41.7%) Peritoneum 2 (16.7%) Adrenal gland 1 (8.3%) First-line chemotherapy Folfirinox 12 (100%) Number of cycles, median (range) 9 (2—36)

Viral-induced Hemorrhagic Cystitis After Allogeneic Hematopoietic Stem Cell Transplant

Micro‐Abstract The potential risk factors for viral‐induced hemorrhagic cystitis in allogeneic HSCT are not well elaborated. We conducted a retrospective analysis including 64 patients who underwent allogeneic HSCT at Jules Bordet Institute. Hemorrhagic cystitis correlated to BK virus and adenovirus infection. Preventive measures for BK virus and adenovirus infections in patients undergoing allogeneic HSCT are required. Introduction: Hemorrhagic cystitis (HC) is a well‐recognized problem that is regularly observed after hematopoietic stem cell transplantation (HSCT). The published data does not report on the potential risk factors for the viral‐induced HC that might require prophylactic treatments. Patients and Methods: We conducted a retrospective analysis of all adult patients who underwent allogeneic HSCT at Jules Bordet Institute between 1992 and 2013. Our institutional protocol consists in monitoring the patient for signs and symptoms of HC on a daily basis during the initial admission for HSCT, then once weekly after discharge until 2 months thereafter. Results: HC was found in 64 patients, of whom 56 (87.5%) had viral‐induced HC. The median time between HSCT and HC was 39.5 days (range, 1‐2766 days); the median time between detection of a viral infection and HC was 32 days (range, 0‐2752 days). In multivariate analysis, HC is correlated to the infection with the BK virus (hazard ratio, 6.0; 95% confidence interval, 5.03‐6.90; P = .0001) and the adenovirus (hazard ratio, 4.93; 95% confidence interval, 4.06‐5.80; P = .0003). The 5‐year overall survival of patients with HC was 36%. The 5‐year survival rates were not statistically different between patients with or without HC (25% vs. 39%; P = .20). Conclusion: The presence of the identified risk factors should prompt closer follow‐up with screening tests and preventive measures for BK virus and adenovirus infections in patients undergoing HSCT.