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Nuclear atypia scoring (NAS), forms a significant factor in determining individualized treatment plans and also for the prognosis of the disease. Automation of cancer grading using quantitative image-based analysis of histopathological images can circumvent the shortcomings of the prevailing manual grading and can assist the pathologists in cancer diagnosis. However, developing such a robust classifier model require sufficient amount of annotated data, while the labeled histopathological images are scarce and expensive to procure as annotation forms a time-consuming and laborious task. Hence, a semisupervised learning framework combined with the deep neural network based generative adversarial training, that can improve the performance of the classification model with limited annotated data, is proposed in this paper. The proposed NAS-SGAN model consists of discriminator and generator models that are trained in an adversarial manner using both labeled and unlabeled samples. The discriminator model is designed as an unsupervised model stacked over the supervised model sharing the model parameters and learns the data distribution by extracting the discriminative features. The generator model is trained over a stable feature matching objective function following a composite GAN architecture. The novelty of the proposed model is that, we have used a stacked supervised and unsupervised discriminator and a feature matching generator for the NAS-SGAN model and its for the first time the semi-supervised GAN model is explored for the grading of breast cancer. Experimental analysis shows that the proposed model could better discriminate different cancer grades thereby improving the robustness and accuracy of the system, even with limited amount of labeled samples.

Purpose: Toca 511 is a gammaretroviral replicating vector encoding cytosine deaminase that selectively infects tumor cells and converts the antifungal drug 5-fluorocytosine into the antineoplastic drug 5-fluorouracil, which directly kills tumor cells and stimulates antitumor immune responses. As part of clinical monitoring of phase I clinical trials in recurrent high-grade glioma, we have performed extensive molecular analyses of patient specimens to track vector fate.Patients and Methods: Toca 511 and Toca FC (extended-release 5-fluorocytosine) have been administered to 127 high-grade glioma patients across three phase I studies. We measured Toca 511 RNA and DNA levels in available body fluids and tumor samples from patients to assess tumor specificity. We mapped Toca 511 integration sites and sequenced integrated Toca 511 genomes from patient samples with detectable virus. We measured Toca 511 levels in a diverse set of tissue samples from one patient.Results: Integrated Toca 511 is commonly detected in tumor samples and is only transiently detected in blood in a small fraction of patients. There was no believable evidence for clonal expansion of cells with integrated Toca 511 DNA, or preferential retrieval of integration sites near oncogenes. Toca 511 sequence profiles suggest most mutations are caused by APOBEC cytidine deaminases acting during reverse transcription. Tissue samples from a single whole-body autopsy affirm Toca 511 tumor selectivity.Conclusions: Toca 511 and Toca FC treatment was not associated with inappropriate integration sites and clonal expansion. The vector is tumor-selective and persistent in patients who received Toca 511 injections. Clin Cancer Res; 24(19); 4680–93. ©2018 AACR.

Figure S9

Toca 511 qPCR detection results

Tg 511-13-01 (Study 13) dosing table.

Supplementary Figure, Table & Dataset legends

The present research work is based on the formulation and evaluation of topical gel of Ibuprofen where Carbopol 940 is used as the polymer. Gels were prepared by dispersing the polymers in a mixture of water and glycerol with methyl paraben as the preservative and the varying amount of ibuprofen, being kept under magnetic stirring until the homogeneous dispersion was formed. The dispersion was then neutralized and made viscous by the addition of triethanolamine. The Carbopol gels of Ibuprofen were found to be homogenous with good drug loading. The pH of all the gel formulations was found within the neutral pH range which is compatible with skin. And the viscosity of the formulations was found to be feasible for topical drug delivery. The drug content of the three formulations was found in the range of 87.56% to 90.45% which shows efficient drug loading. Results of In vitro drug release study showed that F5 formulation has better diffusion of drug through egg membrane and hence further permeation studies were carried out through rat epidermis. The compatibility study showed that the major peaks in FTIR spectra of the pure drug were found to be intact in their physical mixture. Hence there is no interaction between drug and Carbopol in their physical mixture. Carbopol can be effectively used as the polymer for topical gel preparation. And F5 formulation containing 0.5 % w/w Carbopol 940 may be effectively used as topical transdermal delivery for Ibuprofen. Keywords: Ibuprofen, Transdermal Gel, Drug release, Compatibility study

Breast carcinoma is the most prevalent type of malignancy among women worldwide. Breast cancer grading often termed as Nuclear Atypia Scoring (NAS) forms a significant factor in determining individualized treatment plans and in the prognosis of the disease. For addressing the problem of breast cancer grading, we attempt to model the variations in features between histopathological images of different cancer grades and thereby explore the discriminative information concealed in these variations. In this regard, we aggregate multiple correlated features from the images using the geodesic geometric mean of the region covariances, to obtain the gmRC descriptors. As these gmRC descriptors are symmetric positive definite (SPD) matrices lying on the non-Euclidean Riemannian manifold, the discriminant analysis techniques developed for the Euclidean framework may not be appropriate. Hence, we propose a kernel-based Fisher discriminant analysis on the Riemannian manifold (KFDAR), that exploits the kernel trick for embedding the non-linear Riemannian manifold M into a higher dimensional linear Hilbert space H , which are then reduced to a low-dimensional and more discriminative subspace, where the samples become linearly separable. The kernel approach formulated for the Hilbert space embedding and for the kernel discriminant analysis is based on three Riemannian distance metrics: the log-Euclidean metric and the two symmetrized Bregman divergences – Stein and Jeffrey divergences. The experimental results show that this mapping to a highly discriminative space has succeeded in well-separating the histopathological images belonging to different cancer grades and hence it qualitatively and quantitatively outperforms the existing algorithms for cancer grading.

Breast cancer is found to be the most pervasive type of cancer among women. Computer aided detection and diagnosis of cancer at the initial stages can increase the chances of recovery and thus reduce the mortality rate through timely prognosis and adequate treatment planning. The nuclear atypia scoring or histopathological breast tumor grading remains to be a challenging problem due to the various artifacts and variabilities introduced during slide preparation and also because of the complexity in the structure of the underlying tissue patterns. Inspired by the success of symmetric positive definite (SPD) matrices in many of the challenging tasks in machine learning and computer vision, a sparse coding and dictionary learning on SPD matrices is proposed in this paper for the breast tumor grading. The proposed covariance-based SPD matrices form a Riemannian manifold and are represented as the sparse combination of Riemannian dictionary atoms. Non-linearity of the SPD manifold is tackled by embedding into the reproducing kernel Hilbert space using kernels derived from log-Euclidean metric, Jeffrey and Stein divergences and compared with the non-kernel-based affine invariant Riemannian metric. The novelty of the work lies in exploiting the kernel approach for the Hilbert space embedding of the Riemannian manifold, that can achieve a better discrimination of the breast cancer tissues, following a sparse representation over learned dictionaries and henceforth it outperforms many of the state-of-the-art algorithms in breast cancer grading in terms of quantitative and qualitative analysis.

Author(s): Cloughesy, Timothy F; Landolfi, Joseph; Vogelbaum, Michael A; Ostertag, Derek; Elder, James B; Bloomfield, Stephen; Carter, Bob; Chen, Clark C; Kalkanis, Steven N; Kesari, Santosh; Lai, Albert; Lee, Ian Y; Liau, Linda M; Mikkelsen, Tom; Nghiemphu, Phioanh; Piccioni, David; Accomando, William; Diago, Oscar R; Hogan, Daniel J; Gammon, Dawn; Kasahara, Noriyuki; Kheoh, Thian; Jolly, Douglas J; Gruber, Harry E; Das, Asha; Walbert, Tobias | Abstract: Background:Vocimagene amiretrorepvec (Toca 511) is an investigational gamma-retroviral replicating vector encoding cytosine deaminase that, when used in combination with extended-release 5-fluorocytosine (Toca FC), results preclinically in local production of 5-fluorouracil, depletion of immune-suppressive myeloid cells, and subsequent induction of antitumor immunity. Recurrent high-grade glioma (rHGG) patients have a high unmet need for effective therapies that produce durable responses lasting more than 6 months. In this setting, relapse is nearly universal and most responses are transient. Methods:In this Toca 511 ascending-dose phase I trial (NCT01470794), HGG patients who recurred after standard of care underwent surgical resection and received Toca 511 injected into the resection cavity wall, followed by orally administered cycles of Toca FC. Results:Among 56 patients, durable complete responses were observed. A subgroup was identified based on Toca 511 dose and entry requirements for the follow-up phase III study. In this subgroup, which included both isocitrate dehydrogenase 1 (IDH1) mutant and wild-type tumors, the durable response rate is 21.7%. Median duration of follow-up for responders is 35.7+ months. As of August 25, 2017, all responders remain in response and are alive 33.9+ to 52.2+ months after Toca 511 administration, suggesting a positive association of durable response with overall survival. Conclusions:Multiyear durable responses have been observed in rHGG patients treated with Toca 511 + Toca FC in a phase I trial, and the treatment will be further evaluated in a randomized phase III trial. Among IDH1 mutant patients treated at first recurrence, there may be an enrichment of complete responders.

Breast cancer is the most prevalent invasive type of cancer among women. The mortality rate of the disease can be reduced considerably through timely prognosis and felicitous treatment planning, by utilizing the computer aided detection and diagnosis techniques. With the advent of whole slide image (WSI) scanners for digitizing the histopathological tissue samples, there is a drastic increase in the availability of digital histopathological images. However, these samples are often unlabeled and hence they need labeling to be done through manual annotations by domain experts and experienced pathologists. But this annotation process required for acquiring high quality large labeled training set for nuclear atypia scoring is a tedious, expensive and time consuming job. Active learning techniques have achieved widespread acceptance in reducing this human effort in annotating the data samples. In this paper, we explore the possibilities of active learning on nuclear pleomorphism scoring over a non-Euclidean framework, the Riemannian manifold. Active learning technique adopted for the cancer grading is in the batch-mode framework, that adaptively identifies the apt batch size along with the batch of instances to be queried, following a submodular optimization framework. Samples for annotation are selected considering the diversity and redundancy between the pair of samples, based on the kernelized Riemannian distance measures such as log-Euclidean metrics and the two Bregman divergences - Stein and Jeffrey divergences. Results of the adaptive Batch Mode Active Learning on the Riemannian metric show a superior performance when compared with the state-of-the-art techniques for breast cancer nuclear pleomorphism scoring, as it makes use of the information from the unlabeled samples.

Author(s): Zadeh, G; Walbert, T; Perry, J; Zhu, J; Salacz, M; Bota, D; Kim, L; Iwamoto, F; Petrecca, K; Sully, S; Montellano, T; Kheoh, T; Das, A; Cloughesy, TF | Abstract: Toca 511 (vocimagene amiretrorepvec) is an investigational, conditionally lytic, retroviral replicating vector (RRV). RRVs selectively infect cancer cells due to innate and adaptive immune response defects in cancers that allow virus replication, and the requirement for cell division for virus integration into the genome. Toca 511 spreads through tumors, stably delivering an optimized yeast cytosine deaminase gene that converts the prodrug Toca FC (investigational, extended-release 5-FC) into 5-FU within the tumor microenvironment. 5-FU kills infected dividing cancer cells and surrounding tumor, myeloid derived suppressor cells, and tumor associated macrophages, resulting in long-term tumor immunity in preclinical models. Data from a Phase 1 resection trial showed six durable CRs and extended mOS compared to historical controls. The FDA granted Breakthrough Therapy Designation for Toca 511 a Toca FC in the treatment of patients with rHGG. Toca 5 is an international, randomized, open-label Phase 3 trial (NCT02414165) of Toca 511 a Toca FC versus SOC in patients undergoing resection for first or second recurrence of rHGG. Patients will be stratified by IDH1 status, KPS, and geographic region. Primary endpoint is OS, and secondary endpoints are durable response rate, durable clinical benefit rate, duration of durable response, and 12-month survival rate. Key inclusion criteria are histologically proven GBM or AA, tumor size ≥1cm and ≤5cm, and KPS ≥70. Immune monitoring and molecular profiling will be performed. Approximately 380 patients will be randomized. An IDMC is commissioned to review the safety and efficacy data which includes 2 interim analyses. Enrollment is ongoing.

Purpose: Toca 511 is a gammaretroviral replicating vector encoding cytosine deaminase that selectively infects tumor cells and converts the antifungal drug 5-fluorocytosine into the antineoplastic drug 5-fluorouracil, which directly kills tumor cells and stimulates antitumor immune responses. As part of clinical monitoring of phase I clinical trials in recurrent high-grade glioma, we have performed extensive molecular analyses of patient specimens to track vector fate. Patients and Methods: Toca 511 and Toca FC (extended-release 5-fluorocytosine) have been administered to 127 high-grade glioma patients across three phase I studies. We measured Toca 511 RNA and DNA levels in available body fluids and tumor samples from patients to assess tumor specificity. We mapped Toca 511 integration sites and sequenced integrated Toca 511 genomes from patient samples with detectable virus. We measured Toca 511 levels in a diverse set of tissue samples from one patient. Results: Integrated Toca 511 is commonly detected in tumor samples and is only transiently detected in blood in a small fraction of patients. There was no believable evidence for clonal expansion of cells with integrated Toca 511 DNA, or preferential retrieval of integration sites near oncogenes. Toca 511 sequence profiles suggest most mutations are caused by APOBEC cytidine deaminases acting during reverse transcription. Tissue samples from a single whole-body autopsy affirm Toca 511 tumor selectivity. Conclusions: Toca 511 and Toca FC treatment was not associated with inappropriate integration sites and clonal expansion. The vector is tumor-selective and persistent in patients who received Toca 511 injections. Clin Cancer Res; 24(19); 4680–93. ©2018 AACR.

A dose-escalation clinical study (NCT01470794) using a retroviral replicating vector (RRV), Toca 511 (vocimagene amiretrorepvec), in combination with oral Toca FC (extended-release 5-fluorocytosine, 5-FC) is ongoing to evaluate safety, mechanism of action, and preliminary efficacy of this investigational therapy in patients with recurrent HGG. Toca 511 encodes a yeast-derived, codon-optimized, heat-stabilized cytosine deaminase that converts 5-FC to the anti-cancer drug 5-FU in infected tumors. This virus replicates selectively in malignant tissue and may have broad application in cancer therapies. When Toca FC is administered, cytosine deaminase is designed to convert 5-FC to 5-FU resulting in cancer cell death. In preclinical tumor models, as infected cancer cells are killed, diffusible 5-FU also kills susceptible cells, including myeloid derived suppressor cells that contribute to immune-suppression in the tumor microenvironment. This action by Toca 511 and Toca FC in animal models generates durable anti-tumor immune responses that can be transferred to naïve, untreated animals. In the clinical study presented here, Toca 511 is injected into resection cavity walls at time of resection followed by multiple courses of oral Toca FC. Multi-year durable and ongoing objective responses are observed, including four complete responses and two partial responses. We plan to report temporal changes in peripheral immune cells between responding and non-responding patients, including baseline differences in peripheral blood cell populations as well as temporal shifts in leukocyte subsets, T-cell receptor clonality, and serum cytokine levels. Sustained markers of proliferation and immune activation are observed in patients with response or stable disease compared to those that progressed. Immunohistochemistry analysis of resident T-cells in patient tumors taken at time of resection show fewer T-cells in responding and stable disease patients before treatment compared to those that did not respond. Data are consistent with the induction of anti-tumor immune response after Toca 511 and Toca FC administration.

Toca 511 (vocimagene amiretrorepvec) is an investigational retroviral replicating vector that selectively infects dividing cancer cells, integrates into the genome and replicates due to immune defects in tumors. Toca 511 spreads through tumors and stably delivers the gene encoding an optimized yeast cytosine deaminase that converts the prodrug Toca FC (an investigational, extended-release formulation of 5-fluorocytosine) into 5-fluorouracil. 5-fluorouracil kills infected cancer cells and surrounding cancer cells, myeloid derived suppressor cells and tumor associated macrophages, thus enabling immune activity against the tumor. In this phase 1 trial (NCT01470794), ascending doses of Toca 511 were injected into the resection bed of patients with rHGG, followed by multiple courses of oral Toca FC. Additional cohorts included combination of the investigational therapy with bevacizumab or lomustine. Objective responses (ORs) are observed in patients with IDH1 wildtype and mutant tumors, including 3 complete responses (CRs) and 2 partial responses with the investigational therapy, and 1 CR with the investigational therapy and bevacizumab. The IDH1-mutant patients treated at 1st recurrence all had CRs and the fact that a CR in rHGG is rare suggests that the investigational treatment may be playing a role. ORs are observed 6–19 months after Toca 511 injection, consistent with an immunologic mechanism. Median time to initial response is 9.2 months; median duration of response (mDoR) is 25.2 months. Excluding combination cohorts, mDoR is 26.7 months. All responders are alive 21.2+ to 42.6+ months, suggesting a correlation of durable responses (ORs lasting > 24 weeks) with overall survival. In a 24-patient subgroup who received the recommended Ph2 Toca 511 dose, a durable response rate of 20.8% was observed. Across the Phase 1 program, the safety profile remains favorable. Updated clinical benefit, safety, immune activity, and molecular profiles will be reported.

Purpose To expedite drug development, we propose a two-step decision-making process that utilizes interim efficacy results from a comparative phase 2 trial to determine whether to accelerate subsequent phase 3 preparations, and final analysis to ultimately determine whether to conduct phase 3 testing. Methods The operational characteristics of this process were evaluated by modeling simulated data of oncology trials and retrospectively analyzing data from historical comparative phase 2 trials. Progression-free survival (PFS) was used as the primary endpoint; the estimated PFS hazard ratios (HRs) of ≤ 0.60 at interim and of ≤ 0.65 at final analysis favoring the experimental arm were defined as positive results. The conditional probability of achieving a target PFS HR at final analysis, based on observed interim results, was also estimated by imputing post-interim data with and without the proportional hazard assumption. Results Simulations of phase 2 trials showed that estimated interim PFS HRs correlated with estimated final PFS HRs, with reasonably low false-positive rates for supporting phase 3 “go” decisions at interim. Using observed historical data, decisions based on interim PFS analyses also matched final phase 3 “go” and “no-go” decisions with a false-positive rate of 16.7% (2 of 12 trials) and a false-negative rate of 9.4% (3 of 32 trials). Analytical modeling accurately predicted final PFS HRs from observed interim data when accounting for appropriate underlying assumptions. Conclusions The results support the usefulness of a two-step decision-making process that utilizes interim phase 2 results to reduce the interval between phase 2 completion and phase 3 initiation.

Background The aim of this study was to determine correlations between progression-free survival (PFS) and the objective response rate (ORR) with overall survival (OS) in glioblastoma and to evaluate their potential use as surrogates for OS. Method Published glioblastoma trials reporting OS and ORR and/or PFS with sufficient detail were included in correlative analyses using weighted linear regression. Results Of 274 published unique glioblastoma trials, 91 were included. PFS and OS hazard ratios were strongly correlated; R2 = 0.92 (95% confidence interval [CI], 0.71–0.99). Linear regression determined that a 10% PFS risk reduction would yield an 8.1% ± 0.8% OS risk reduction. R2 between median PFS and median OS was 0.70 (95% CI, 0.59–0.79), with a higher value in trials using Response Assessment in Neuro-Oncology (RANO; R2 = 0.96, n = 8) versus Macdonald criteria (R2 = 0.70; n = 83). No significant differences were demonstrated between temozolomide- and bevacizumab-containing regimens (P = .10) or between trials using RANO and Macdonald criteria (P = .49). The regression line slope between median PFS and OS was significantly higher in newly diagnosed versus recurrent disease (0.58 vs 0.35, P = .04). R2 for 6-month PFS with 1-year OS and median OS were 0.60 (95% CI, 0.37–0.77) and 0.64 (95% CI, 0.42–0.77), respectively. Objective response rate and OS were poorly correlated (R2 = 0.22). Conclusion In glioblastoma, PFS and OS are strongly correlated, indicating that PFS may be an appropriate surrogate for OS. Compared with OS, PFS offers earlier assessment and higher statistical power at the time of analysis.

Toca 511 (vocimagene amiretrorepvec) is an investigational nonlytic, retroviral replicating vector (RRV) that delivers a yeast cytosine deaminase, which converts subsequently administered courses of the investigational prodrug Toca FC (extended-release 5-fluorocytosine) into the antimetabolite 5-fluorouracil. Forty-five subjects with recurrent or progressive high-grade glioma were treated. The end points of this phase 1, open-label, ascending dose, multicenter trial included safety, efficacy, and molecular profiling; survival was compared to a matching subgroup from an external control. Overall survival for recurrent high-grade glioma was 13.6 months (95% confidence interval, 10.8 to 20.0) and was statistically improved relative to an external control (hazard ratio, 0.45; P = 0.003). Tumor samples from subjects surviving more than 52 weeks after Toca 511 delivery disproportionately displayed a survival-related mRNA expression signature, identifying a potential molecular signature that may correlate with treatment-related survival rather than being prognostic. Toca 511 and Toca FC show excellent tolerability, with RRV persisting in the tumor and RRV control systemically. The favorable assessment of Toca 511 and Toca FC supports confirmation in a randomized phase 2/3 trial (NCT02414165).

Despite treatment with the current standard-of-care therapies, patients with newly diagnosed glioblastoma multiforme (GBM) exhibit dismal prognoses. Bevacizumab has demonstrated activity in patients with recurrent GBM and phase 2 trials indicate that the combination of bevacizumab with standard-of-care therapy is feasible and active for patients with newly diagnosed GBM. Bevacizumab has been granted US approval for use as single-agent therapy for patients with progressive GBM following prior therapy, although it has not received approval for use in patients with GBM in Europe. Phase 3 studies have been initiated in patients with newly diagnosed GBM and are currently recruiting patients. We describe the protocol for the AVAglio phase 3 registration trial, which is designed to evaluate the efficacy and safety of combining bevacizumab with standard-of-care therapy in patients with newly diagnosed GBM.

Development of effective therapies for recurrent glioblastoma multiforme (GBM) and reliable, timely evaluation of their benefit are needed. Understanding the relationship between objective response (OR) and survival is important for determining whether OR can provide an early signal of treatment activity in clinical trials. We performed a landmark analysis to evaluate the association between OR and survival at 9, 18, and 26 weeks for 167 patients with recurrent GBM who participated in BRAIN, a phase II trial that evaluated efficacy of bevacizumab alone or in combination with irinotecan, using the Cox regression models adjusted for age, baseline Karnofsky performance score, first vs second relapse, and treatment arm. Hazard ratios (HRs) and P-values for survival between responders and nonresponders were calculated. Additional analyses were performed to test robustness, validity, fit, and accuracy of the models. The relationships between progression-free survival (PFS) and survival and between OR and PFS were also explored. There were 55 responders and 112 nonresponders across the 2 treatment arms in BRAIN. OR status at 9, 18, and 26 weeks was a statistically significant predictor of survival (HR ≤ 0.52, P < .01). PFS was also a statistically significant predictor of survival at each landmark (HR ≤ 0.25, P < .0001). The association between OR and PFS was not statistically significant, likely due to inadequate statistical power for the analysis. Clarifying the relationship of OR and survival is important for determining whether OR can be a reliable predictor of the benefit of a therapeutic agent in patients with recurrent GBM.

Toca 511 (vocimagene amiretrorepvec) is an investigational retroviral replicating vector that selectively infects dividing cancer cells, integrates into the genome and replicates due to immune defects in tumors. Toca 511 spreads through tumors and stably delivers the gene encoding an optimized yeast cytosine deaminase that converts the prodrug Toca FC (investigational, extended-release of 5-fluorocytosine) into 5-fluorouracil. In preclinical models, 5-fluorouracil kills infected dividing cancer cells, myeloid derived suppressor cells and tumor associated macrophages, enabling immune activation against the tumor. In this dose ascending Ph1 trial (NCT01470794), Toca 511 was injected into the resection cavity wall of patients with rHGG, followed by courses of oral Toca FC. Additional cohorts included combination with bevacizumab or lomustine. Across the Ph1 program, the safety profile remains favorable. Objective responses (ORs) were assessed by IRR using MRI scans prior to Toca FC treatment as baseline. ORs occurred 6-19 months after Toca 511 administration, suggesting an immunologic mechanism. The ORs were observed in 4 patients with IDH1-wildtype and 2 patients with IDH1-mutant tumors, including 5 complete responses (CRs) with the investigational therapy alone, and 1 CR in combination with bevacizumab. The median duration of response (mDoR) was 35.1+ months. As of AUG2017, all responders were CR and remain alive. In a 23-patient subgroup who received high doses of Toca 511 and met Ph3 trial criteria, mOS was 14.4 months, 3-year survival rate was 26.1%, and mDoR was 35.7+ months with a durable response rate of 21.7%. Data suggest a positive association of durable response with OS.

In Asian populations, meningiomas account for up to 35% of all central nervous system tumours, a significantly higher incidence than in Caucasian populations. While several studies have examined p53 both at the level of the gene and the protein in both benign and malignant meningiomas, its role remains controversial, particularly with regard to the discrepancy between p53 over-expression and gene mutation. We examined 19 benign meningiomas, all of which were known to over-express p53, and eight malignant meningiomas, of which three were known to over-express p53, for mutations in the p53 gene using polymerase chain reaction amplification and direct sequencing of exons 4 to 9, inclusive. Only one single mutation was detected in a benign meningioma, confirming that p53 over-expression in meningiomas is commonly found in the absence of gene mutations, and that despite the significantly higher incidence of meningiomas in some Asian populations, this is not associated with a significantly higher rate of p53 mutations.

BACKGROUND. The authors previously sought to identify novel markers of glioma invasion and recurrence. Their research demonstrated that brain gliomas overexpressed a subset of vascular basement components, laminins, that contained the alpha4 chain. One of these laminins, laminin-8, was found to be present in highly invasive and malignant glioblastoma multiforme (GBM) (Grade 4 astrocytoma); its expression was associated with a decreased time to tumor recurrence, and it was found in vitro to promote invasion of GBM cell lines. METHODS. in the current study, the authors studied glial tumors of different grades in an attempt to correlate laminin-8 expression with tumor recurrence and patient survival. Immunohistochemistry and Western blot analysis were used to detect laminin isoforms of interest. RESULTS. Using immunohistochemistry and Western blot analysis, the authors confirmed high levels of laminin-8 expression in approximately 75% of the GBM cases examined and in their adjacent tissues, whereas astrocytomas of lower grades expressed for the most part a different isoform, laminin-9, which also was found in low amounts in normal brain tissue and benign meningiomas. Overexpression of laminin-8 in GBM was found to be associated with a statistically significant shorter time to tumor recurrence (P < 0.0002) and a decreased patient survival time (P < 0.015). CONCLUSIONS. The data suggest that laminin-8, which may facilitate tumor invasion, contributes to tumor regrowth after therapy. Laminin-8 may be used as a predictor of tumor recurrence and patient survival and as a potential molecular target for glioma therapy.

Survivin is a recently characterised inhibitor of apoptosis protein that has been implicated in the pathogenesis of several types of solid organ cancer. This study sought to describe the expression of survivin in a cohort of 90 benign meningiomas, together with the pattern of expression of other genes involved in the apoptotic process, namely bax and bcl2. Survivin expression was noted in 94% (85/90) of samples and was not correlated with the expression of either bax or bcl2 or with clinicopathological factors.

Purpose. Studies in several tumour types have suggested that the inappropriate expression of the novel inhibitor of apoptosis protein survivin may play a key role in tumourigenesis. This study presents the first immunohistochemical examination of survivin expression in glioblastomas. Method. The cohort consisted of 39 ethnic Chinese patients diagnosed with primary glioblastoma multiforme. Samples were archival paraffin-embedded blocks. Concomitant with examination for survivin expression, samples were also examined for over-expression of the p53 protein as well as for evidence of apoptotic cells via the terminal deoxynucleotide transferease (TdT) mediated nick end labelling (TUNEL) technique. Results. Results showed that survivin was expressed in nearly 80% (31/39) of samples. Over-expression of moderate or high levels of survivin was correlated with the absence of apoptotic cells (P=0.03). Expression of survivin and p53 was found to be significantly related (P=0.037), and 70% (27/39) of tumours showed co-ordinate expression of p53 and survivin. Conclusion. Given that p53 over-expression in primary glioblastomas is predominantly detected in the absence of mutations of the gene, and that both survivin and p53 are regulated at the level of the protein by the same ubiquitin-proteosome degradation pathway, these results suggest that primary glioblastomas may occur as a result of a failure of appropriate protein degradation regulation.

Objective: To develop a transdermal patch of Indomethacin using patchouli oil as a natural enhancer to increase transdermal permeation of the drug from the matrix system across rat epidermis.Materials and Methods: The chemical characterization of patchouli oil was done by gas chromatography-mass spectrometry. Transdermal patches of indomethacin were formulated after studying the drug-excipient compatibility studies by differential scanning calorimetry and Fourier transform infrared spectroscopy (FTIR). The transdermal patches were evaluated for various physiochemical properties. In-vitro transdermal permeation was carried using modified Keshary-Chein diffusion cell across rat epidermis. FTIR studies of rat epidermis were done to understand the mechanism of the permeation enhancing effect of the oil from the matrix patch.Result: The results of physiochemical parameters of the transdermal patch were found satisfactory. The transdermal flux obtained of the different concentration of patchouli oil tend to increase with increasing concentration of the oil and the maximum transdermal flux of 61.92 ± 0.89 μg/cm2/hr was obtained with formulation F7 (containing 1% w/v of patchouli oil) which is similar to the flux of the formulation F2 containing standard enhancer dimethyl sulphoxide. The skin irritation test did not show any edema and the FTIR data of rat epidermis indicated that patchouli oil enhances transdermal permeation of indomethacin by partial extraction of lipids in the stratum corneum.Conclusion: Thus, the results showed a potential enhancing effect of patchouli oil on the transdermal permeation of the model drug indomethacin and may be used as natural permeation enhancer in transdermal drug delivery systems.

In Singapore astrocytic tumours occur in only 25% of patients with primary brain tumours compared to 40–60% in other series. Glioblastoma multiforme arises either de novo as a primary glioblastomas associated with epidermal growth factor receptor (EGFR) and mdm2 over-expression or as a secondary glioblastomas, through malignant progression from low-grade astrocytomas, associated with p53 mutations and PDGFR-α over-expression. Using immunohistochemical methods and DNA sequencing, we studied our population of glioblastomas for over-expression of EGFR, mdm2, p53, and PDGFR-α as well directly for mutations of the p53 gene. While levels of over-expression of EGFR and mdm2 were consistent with levels expected for primary glioblastomas, levels of p53 and PDGFR-α were consistent with levels documented for secondary glioblastomas. Notably 96% of the samples over-expressed p53 as detected with monoclonal antibody pAb 240. Of the 39 samples available for DNA sequencing 18% (7/39) had p53 mutations, including three mutations previously undocumented in glioblastomas. These results provide strong evidence that glioblastomas in Asian patients do not conform to currently accepted models of glioblastoma development, and that clinically defined glioblastomas in these patients show genetic changes consistent with both ‘primary’ and 'secondary’ glioblastomas.

The transdermal drug delivery route is evolving as a potential route due to its advantages of bypassing the hepatic first pass metabolism, decreased side effects and gastrointestinal effects, improve patience compliance as it is a pain-free self-administration for patients, etc. The major setback appearing in this route is the difficulty of the drugs to penetrate through the skin as the stratum corneum (outermost layer of the skin) forms a protective barrier for the underlying tissues from the outer environment. A transdermally delivered drug can only show its action when it can cross the transdermal barrier to reach the systemic circulation and for helping on doing that the penetration enhancer are the agents which increase the permeability of the skin which on return maintains the drug level in the blood. Permeation enhancers can be of a chemical type, natural type, and physical type. The present review describes the natural permeation enhancers can be which be employed for transdermal permeation of drugs.

e13504 Background: Toca 511 (vocimagene amiretrorepvec) is an investigational, conditionally lytic, retroviral replicating vector (RRV). RRVs selectively infect cancer cells due to cell division requirements for virus integration into the genome and defects in innate and adaptive immune responses found in cancers that support virus replication. Toca 511 spreads through cancer cells and stably delivers the gene for an optimized yeast cytosine deaminase that converts the prodrug Toca FC (an investigational, extended-release formulation of 5-fluorocytosine) into 5-fluorouracil (5-FU). 5-FU kills infected cancer cells that are dividing, diffuses and kills surrounding cancer cells as well as myeloid derived suppressor cells and tumor associated macrophages, thus reestablishing immunity to tumor. Methods: In this phase 1 trial (NCT01470794), ascending doses of Toca 511 were injected into the resection bed of patients with recurrent high grade glioma undergoing resection, followed by oral administration of courses of Toca FC 5-7 weeks after Toca 511 injection. Additional cohorts included combination of Toca 511 & Toca FC with bevacizumab or lomustine. Results: Objective responses (ORs) are observed in IDH1 wildtype (wt) and mutant (mt) phenotypes, including 3 complete responses (CRs) (2 IDH1 mt and 1 IDH1 wt) and 2 partial responses (2 IDH1 wt) for patients treated with Toca 511 & Toca FC, and 1 CR (1 IDH1 mt) for a patient treated with Toca 511 & Toca FC and bevacizumab. ORs are observed 6-19 months after Toca 511 injection and are consistent with an immunologic mechanism. Median time to initial response is 9.2 months; median duration of response (mDOR) is 25.2 months. Excluding the combination cohorts, mDOR is 26.7 months. All responders are alive 21.2+ to 42.6+ months, suggesting a correlation of OR and OS. An additional radiologic CR is observed in 1 IDH1 mt patient at 1st recurrence who received intravenous Toca 511 plus injection into the resection bed. All 4 IDH1 mt patients treated at 1st recurrence had CRs. Conclusions: There may be an association between ORs and IDH1 mutation with Toca 511 & Toca FC treatment. Updated clinical benefit, molecular profiles and tumor mutational load are reported. Clinical trial information: NCT01470794.

Background: This analysis evaluated the incidence of and risk factors for bevacizumab-related proteinuria and assessed for any associated clinical sequelae, including renal function changes. Methods: Patient-level adverse event and laboratory data from a pooled safety database were used to characterize alterations in urine protein excretion following interventional therapy ± bevacizumab in 17 randomized trials across multiple tumor types. Severity of renal function change was assessed using changes in serum creatinine concentration from baseline values. Potential predictors of proteinuria and the association between proteinuria and other adverse events were also investigated. Results: Among 14,548 patients, the incidence of any-grade proteinuria was 8.2% (733/8,917) and 4.6% (257/5,631) in the bevacizumab and control groups, respectively; rates of grade ≥3 proteinuria were 1.4 and 0.2%. Post-baseline proteinuria grade and bevacizumab were associated with increased rates of renal dysfunction. Patients developing proteinuria had an increased rate of any-grade infection but not thromboembolic events. History of diabetes was the only examined risk factor that appeared to have a significant association with proteinuria development. Conclusions: This analysis confirmed a significant increase in the development of proteinuria during bevacizumab treatment. We also observed an increased rate of renal dysfunction associated with bevacizumab treatment and among subjects with proteinuria, although the dysfunction was generally mild. The development of proteinuria was also associated with a modest increase in risk of infection.

We sought to determine the relative incidence of meningiomas compared to other central nervous system tumours in an Asian surgical series, as well as the demographic and biological characteristics of these meningiomas. A review of 655 consecutive cases of central nervous system tumours from 583 patients representing the last five years admissions to one hospital in Singapore was undertaken. A total of 33 malignant/atypical tumours from 19 patients and 196 benign meningiomas from 187 patients were identified. Twenty malignant/atypical and 20 benign tumours were selected at random and subjected to histochemical and immunohistochemical analysis using antibodies directed against p53, bax and 3′-DNA hydroxy groups (TUNEL). Meningiomas comprised some 35.2% of all central nervous system tumours with malignant/atypical meningiomas representing 9.2% of meningiomas. Histochemically, necrosis was the predominant finding. However, peri-necrotic areas displayed p53 positivity in 10% of cases and bax positivity in 25% of cases. Apoptotic cells were detected in the peri-necrotic areas in 90% of benign and 75% of malignant/atypical meningiomas. Meningiomas represent the predominant form of central nervous system tumour in the Singaporean population, and aberration of p53 expression is not associated with tumour formation or progression. There was a slight but non-significant reduction in apoptosis in the progression from benign to malignant meningioma, suggesting that in contrast to many other tumour types disruption of cellular apoptosis is not a predominant driving force in Asian meningioma tumourigenesis.

A novel Hendra-like paramyxovirus named Nipah virus (NiV) was the cause of an outbreak among workers from one abattoir who had contact with pigs. Two patients had only respiratory symptoms, while 9 patients had encephalitis, 7 of whom are described in this report. Neurological involvement was diverse and multifocal, including aseptic meningitis, diffuse encephalitis, and focal brainstem involvement. Cerebellar signs were relatively common. Magnetic resonance imaging scans of the brain showed scattered lesions. IgM antibodies against Hendra virus (HeV) were present in the serum of all patients. Two patients recovered completely. Five had residual deficits 8 weeks later.

The therapy of paraneoplastic neurologic syndromes remains unclear and warrants a systematic review of the literature. Reports in English and foreign language literature were abstracted. Data were sorted by the primary paraneoplastic neurologic syndrome, the primary malignancy, and the methods of treatment. Neurologic improvement follows surgical, chemotherapeutic, and radiation treatments. Adjuvant immunosuppressive therapy with steroids, plasmapheresis, or immunoglobulin may help stabilize the progression of neurologic symptoms. Syndromes characterized by inflammation or neurotransmitter production without neuronal loss are most responsive to therapy. While treatment of the underlying cancer with appropriate surgery, chemotherapy, and radiation is recommended, the paraneoplastic syndrome should probably be managed with immunosuppressive therapy.

Alexander et al1 recently introduced a different interpretation involving our paper,2 in which we systematically evaluated glioblastoma clinical trials published from 1991 to the present and demonstrated that progression-free survival (PFS) may be an appropriate surrogate endpoint for overall survival (OS). Although the authors did not raise any methodological and clinical questions directly to us, we wish to comment on the authors' interpretation of our results and provide our insights. Since the introduction of temozolomide 10 years ago,3 there has been little success in developing an effective drug against glioblastoma. The prognosis remains poor, with median OS of approximately 15 months4 and 8 months2 for newly diagnosed and recurrent disease, respectively. To date, the increasing number of clinical trials and drug candidates has not expedited the progress but has instead created new challenges such as competing for the highly limited glioblastoma patient resource (fewer than 20 000 new cases diagnosed in the United States each year5). Therefore, it is critical that glioblastoma clinical trials become more efficient. One way of achieving this goal is to explore surrogate endpoints for OS. To contribute to this field, we conducted our analysis. Our data and analysis led to 2 major findings supporting our surrogacy conclusion: (i) a strong correlation between PFS and OS hazard ratio (HR) estimates in non–bevacizumab-containing comparative studies and (ii) a significant lead time that could be gained by using PFS instead of OS as endpoint. One of the minor findings we observed was that a moderate-to-good correlation exists between point estimates of median PFS and OS within groups. Although this was not intended to contribute to the surrogacy question, it still adds value to overall understanding of the relationship between these endpoints. We respectfully disagree with Alexander et al statement that “the strong correlation between PFS and OS reported by Han et al provides evidence that postprogression heterogeneity is limited (as in EORTC 26981/NCIC CE.3), thereby refuting one of the strongest arguments to use PFS.” First, the correlation between median PFS and OS demonstrated in our paper is only moderate to good (R2 = 0.7) and, more importantly, to our knowledge there has been no comprehensive study supporting the assumption that “for glioblastoma, strong correlation between PFS and OS can therefore be at least partially explained by the short SPP (survival post-progression)”. On the contrary, several studies (eg, Tang et al 2007 JCO6) have shown coexistence of long SPP and a moderate-to-good correlation between PFS and OS, the same as shown in our paper. Second, we have demonstrated a very significant lead time (a concept similar to SPP) that is close to half of the median OS (see above) of glioblastoma patients: 7.4 months and 4.2 months in newly diagnosed and recurrent cases, respectively, in Figure 5 in our paper. Finally, Figure 5 in our paper also illustrated the large postprogression heterogeneity of patients included in our analysis. The lead time ranged from 1.4 to 18 months in newly diagnosed patients and from 1.8 to 8.1 months in recurrent patients. The framework introduced by Broglio et al7 is certainly very useful, but it also needs to be kept in mind that the framework was mainly based on simulations, while clinical data come with much more variation and complexity. As extensively discussed in our paper, the applicability of the linear relationship between the HR of OS and PFS to anti-VEGF agents (ie, agents targeting VEGF or VEGFR) may require further validation because none of the trials in our HR correlation analysis contained an anti-VEGF agent such as bevacizumab (an anti-VEGF antibody) or cediranib (a VEGFR tyrosine kinase inhibitor). Therefore, discussion of AVAglio, RTOG-0825, and therapeutics affecting the ability to assess progression, as well as the use of them as examples (eg, in paragraphs 3, 5 and 7 in Alexander et al1) may be outside the scope, although we agree that it is important to standardize the definition and criteria for PFS in glioblastoma. We also cannot fully agree with Alexander et al comment that “In non-adaptive trials, OS data is ultimately collected without the need to make decisions in the intervening few months. Small lead-time gains using PFS are outweighed by the uncertainty of the relationship with OS.” As discussed at the beginning of this manuscript, the decade-long unmet medical need of this oncology indication and the challenges faced by the pharmaceutical industry put an emphasis on early decision-making. Given the significant lead time demonstrated in our paper, it is possible that making correct decisions in the intervening few months could benefit a significant portion of glioblastoma patients. Furthermore, early efficacy evaluation and early decision-making in early phases of drug development are critical for the viability and sustainability of the current drug development model of the pharmaceutical industry. The implication of our analysis was not to replace OS with PFS. Instead, our analysis suggested that PFS may be an appropriate surrogate marker for early efficacy evaluation and decision-making, especially in early phases of drug development. As is true for any endpoint, PFS possesses both advantages and disadvantages. Use of PFS as a surrogate marker for OS may lead to opportunities for early efficacy evaluation and clinical trials that are more efficient and less confounded by subsequent therapies. At the same time, the use of PFS, especially in glioblastoma, demands continuous efforts in the advancement of imaging technologies and the standardization of progression criteria. Reward and risk will always coexist in any field, and further evaluation weighing the reward and risk of using PFS is always warranted. Conflict of interest statement. Kelong Han is an employee of Genentech and holds stock in F. Hoffmann–La Roche. Melanie Ren was an employee of Genentech at the time the manuscript was written. Wolfgang Wick has acted as a consultant for F. Hoffmann–La Roche, Eli Lilly (uncompensated), and MSD and has received research support from Apogenix, Boehringer Ingelheim, Eli Lilly, and MSD. Lauren Abrey is an employee of F. Hoffmann–La Roche and holds stock in F. Hoffmann–La Roche. Asha Das is an employee of Genentech and holds stock in F. Hoffmann–La Roche. Jin Jin is an employee of Genentech and holds stock in F. Hoffmann–La Roche and Eli Lilly. David A. Reardon has received remuneration (other than research funding, honoraria, and consultancy fees) from F. Hoffmann–La Roche/Genentech and Merck & Co.

✓In this report the authors describe the clinical features of a rare neonatal anaplastic astrocytoma in the setting of in vitro fertilization (IVF). The infant had been conceived using IVF and was born full term to a 29-year-old prima gravida mother. At birth, the baby boy was irritable and demonstrated poor feeding. Cranial ultrasonography and magnetic resonance imaging revealed an echogenic mass in the left hemisphere with midline shift and hydrocephalus. Gross-total resection of an anaplastic astrocytoma was followed by chemotherapy with temozolomide and vincristine. Previous cases of neonatal brain tumors occurring in the setting of assisted reproduction are reviewed. A possible association between IVF and congenital neuroepithelial tumors is highlighted.

Intracranial metastases are the single most costly neurologic ailment. This article provides the clinician with detailed statements of the patterns of their appearance and tumors of origin. Most common causative cancers are of lung, breast, or melanoma origin. Aggressive therapies carry with them the risk of nervous system dissemination of rare tumors, remote complications of these cancers and the morbidity of therapy.