Evidence suggests that metastatic colorectal carcinoma (mCRC) has a high level of intratumor heterogeneity. We carried out a quantitative assessment of tumor heterogeneity for KRAS, NRAS, BRAF and ...PIK3CA mutations, in order to assess potential clinical implications.
Tumor samples (n = 182) from the CAPRI-GOIM trial of first-line cetuximab + FOLFIRI in KRAS exon-2 wild-type mCRC patients were assessed by next-generation sequencing that allows quantitative assessment of mutant genes. Mutant allelic frequency was normalized for the neoplastic cell content and, assuming that somatic mutations usually affect one allele, the Heterogeneity Score (HS) was calculated by multiplying by 2 the frequency of mutant alleles in neoplastic cells. Therefore, HS virtually corresponds to the fraction of neoplastic cells carrying a specific mutation.
The KRAS HS ranged between 12 and 260 with mean value of 87.1 and median value of 84.4, suggesting that in most CRC, the majority of neoplastic cells carry mutant KRAS. Similar findings were observed for NRAS (HS range 35.5–146.7; mean 102.8; median 117.1). In contrast, in BRAF (HS range 17.1–120; mean 54.8; median 54.3) and PIK3CA (HS range 14.3–120; mean 59.5; median 47.3) mutant cases, only a fraction of neoplastic cells seem to carry the mutant allele. The response rate was 70% in KRAS mutant patients with an HS <33 (low KRAS; n = 10) and 45.7% in KRAS HS >33 patients (high KRAS; n = 35); median progression-free survival were 7.97 and 8.37 months, respectively. Low-KRAS tumors had a higher frequency of additional mutations in PIK3CA when compared with high-KRAS (6/10 versus 8/35).
KRAS and NRAS mutations are usually present in the majority of neoplastic cells, whereas BRAF and PIK3CA mutations often affect a limited fraction of transformed cells. Resistance to cetuximab in low-KRAS patients might be driven by the complex mutational profile rather than KRAS mutation load.
Cetuximab plus chemotherapy is a first-line treatment option in metastatic KRAS and NRAS wild-type colorectal cancer (CRC) patients. No data are currently available on continuing anti-epidermal ...growth factor receptor (EGFR) therapy beyond progression.
We did this open-label, 1:1 randomized phase II trial at 25 hospitals in Italy to evaluate the efficacy of cetuximab plus 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX) as second-line treatment of KRAS exon 2 wild-type metastatic CRC patients treated in first line with 5-fluorouracil, folinic acid and irinotecan (FOLFIRI) plus cetuximab. Patients received FOLFOX plus cetuximab (arm A) or FOLFOX (arm B). Primary end point was progression-free survival (PFS). Tumour tissues were assessed by next-generation sequencing (NGS). This report is the final analysis.
Between 1 February 2010 and 28 September 2014, 153 patients were randomized (74 in arm A and 79 in arm B). Median PFS was 6.4 95% confidence interval (CI) 4.7–8.0 versus 4.5 months (95% CI 3.3–5.7); hazard ratio (HR), 0.81; 95% CI 0.58–1.12; P = 0.19, respectively. NGS was performed in 117/153 (76.5%) cases; 66/117 patients (34 in arm A and 32 in arm B) had KRAS, NRAS, BRAF and PIK3CA wild-type tumours. For these patients, PFS was longer in the FOLFOX plus cetuximab arm median 6.9 (95% CI 5.5–8.2) versus 5.3 months (95% CI 3.7–6.9); HR, 0.56 (95% CI 0.33–0.94); P = 0.025. There was a trend in better overall survival: median 23.7 (95% CI 19.4–28.0) versus 19.8 months (95% CI 14.9–24.7); HR, 0.57 (95% CI 0.32–1.02); P = 0.056.
Continuing cetuximab treatment in combination with chemotherapy is of potential therapeutic efficacy in molecularly selected patients and should be validated in randomized phase III trials.
Treatment with antiepidermal growth factor receptor (anti-EGFR) monoclonal antibodies has been restricted to metastatic colorectal cancer (mCRC) patients with RAS wild-type tumors. Next-generation ...sequencing (NGS) allows the assessment in a single analysis of a large number of gene alterations and might provide important predictive and prognostic information.
In the CAPRI-GOIM trial, 340 KRAS exon 2 wild-type mCRC patients received first-line FOLFIRI plus cetuximab. Tumor samples (182/340, 53.5%) were assessed by NGS to search for mutations in 22 genes involved in colon cancer.
Objective responses in the NGS cohort were observed in 104/182 patients overall response rate (ORR) 57.1%; 95% confidence interval (95% CI) 52% to 66.4% with a median progression-free survival (mPFS) of 9.8 (95% CI 8.7–11.5) months. NGS analysis was successfully completed in all 182 samples. One or more gene mutations (up to five) were detected in 124/182 (68.1%) tumors within 14/22 genes for a total of 206 mutations. KRAS exon 2 mutations were identified in 29/182 (15.9%) samples, defined as wild type by local laboratory assessment. Frequently mutated genes were: TP53 (39.6%), KRAS exons 3/4 (8.8%), NRAS exons 2/3 (7.1%), PIK3CA exons 9/20 (13.2%), BRAF (8.2%). FOLFIRI plus cetuximab treatment determined ORR of 62.0% (95% CI 55.5% to 74.6%) with mPFS of 11.1 (95% CI 9.2–12.8) months in patients with KRAS and NRAS wild-type tumors. Conversely, ORR was 46.6% (95% CI 39.9–57.5%) with mPFS of 8.9 (95% CI 7.4–9.6) months in patients with KRAS or NRAS mutations. Similarly, the subgroup of patients carrying KRAS, NRAS, BRAF, or PIK3CA mutations showed a worse outcome, although this might be due to a prognostic effect.
This study demonstrates that NGS analysis in mCRC is feasible, reveals high level of intra and intertumor heterogeneity, and identifies patients that might benefit of FOLFIRI plus cetuximab treatment.
Liquid biopsy is an alternative to tissue for RAS testing in metastatic colorectal carcinoma (mCRC) patients. Little information is available on the predictive role of liquid biopsy RAS testing in ...patients treated with first-line anti-EGFR monoclonal antibody-based therapy.
In the CAPRI-GOIM trial, 340 KRAS exon-2 wild-type mCRC patients received first-line cetuximab plus FOLFIRI. Tumor samples were retrospectively assessed by next generation sequencing (NGS). Baseline plasma samples were analyzed for KRAS and NRAS mutations using beads, emulsion, amplification, and magnetics digital PCR (BEAMing). Discordant cases were solved by droplet digital PCR (ddPCR) or deep-sequencing.
A subgroup of 92 patients with available both NGS data on tumor samples and baseline plasma samples were included in this study. Both NGS analysis of tumor tissue and plasma testing with BEAMing identified RAS mutations in 33/92 patients (35.9%). However, 10 cases were RAS tissue mutant and plasma wild-type, and additional 10 cases were tissue wild-type and plasma mutant, resulting in a concordance rate of 78.3%. Analysis of plasma samples with ddPCR detected RAS mutations in 2/10 tissue mutant, plasma wild-type patients. In contrast, in all tissue wild-type and plasma mutant cases, ddPCR or deep-sequencing analysis of tumor tissue confirmed the presence of RAS mutations at allelic frequencies ranging between 0.15% and 1.15%. The median progression-free survival of RAS mutant and wild-type patients according to tissue (7.9 versus 12.6 months; P = 0.004) and liquid biopsy testing (7.8 versus 13.8 moths; P < 0.001) were comparable. Similar findings were observed for the median overall survival of RAS mutant and wild-type patients based on tissue (22.1 versus 35.8 months; P = 0.016) and plasma (19.9 versus 35.8 months; P = 0.013) analysis.
This study indicates that RAS testing of liquid biopsy results in a similar outcome when compared with tissue testing in mCRC patients receiving first-line anti-EGFR monoclonal antibodies.
By promoting awareness at several levels in collaboration with Italian organizations like the Circolo Italiano and the General Consulate of Italy in São Paulo as well as local partners (USP ...university and SP Municipality), this project seeks to value the local identity of a significant place for Brazil in terms of culture and distinctiveness. The collaboration's results included the dissemination of historical research and the digital documentation of buildings (carried out through the Scan-to-BIM process), which were intended to be pivotal events in the site's cultural rehabilitation. In order to prevent significant portions of a nation's history from being forgotten by the populace, historical recollections were thus encouraged. The purpose of this contribution is to use digital technologies to highlight the history of the most important area for the Brazil's Independence, which is situated in São Paulo on the banks of the Ipiranga stream, in the location where Dom Pedro I would have declared Brazil's independence from the United Kingdom of Portugal, Brazil, and the Algarves on September 7, 1822.The primary tasks established by the project's partners were the dissemination activities. They attempted to value the cultural characteristics of the location, dealing with both the preservation of memories and long-term preservation of the monuments while always staying within the bounds of reliable science. The information gathered was subsequently put together in an online platform (in Portuguese language) that could explain the major outcomes and next steps to a larger audience (local population).
Choosing the correct target behavior to teach is fundamental for parents, teachers, therapists and other professionals working with people with autism and other intellectual disabilities. While early ...intensive behavioral intervention (EIBI) for young children diagnosed with autism can produce large gains in social, cognitive, and language development, choosing the appropriate curriculum for adolescents and adults warrants some further reflections. Starting from puberty and adolescence, the focus of teaching should move from what the student is missing with respect to typically development peers to what the student needs to become an effective adult, with the final outcome of “making a life”. Applied Behavior Analysis is effective in teaching functional skills, adaptive skills, daily living skills, safety skills, sexuality, physical exercise, self-advocacy and other often overlooked skills that can contribute to the improvement of the quality of life of people with or without disabilities. Research suggests that working on functional skills provided through a meaningful curriculum leads to a more independent life. During this presentation the contribution ABA can offer in developing a meaningful curriculum for adolescents will be reviewed. Particular focus will be placed on using Behavior Skills Training (BST) and other environmental manipulations to teach safety skills to adolescents and young adults with autism spectrum disorders. Examples of safety skills include abduction prevention, seeking help if lost, inappropriate physical contact and information disclosure. The use of technology in teaching safety skills to students with a poor repertoire of verbal behavior will be discussed.
Выбор правильного целевого поведения для обучения является основополагающим для родителей, учителей, терапевтов и других специалистов, работающих с людьми с аутизмом и с другими людьми, имеющими интеллектуальные нарушения. В то время как у маленьких детей с диагнозом «аутизм» раннее интенсивное поведенческое вмешательство может привести к большим достижениям в социальном, когнитивном и языковом развитии, выбор соответствующей учебной программы для подростков и взрослых требует несколько более глубокого подхода. Начиная с периода половой зрелости и подросткового возраста, фокус обучения должен сместиться с того, чего не хватает обучающемуся в развитии по сравнению с типичными сверстниками, на то, что обучающемуся нужно, чтобы стать успешно функционирующим взрослым человеком и, в конечном итоге, «сделать свою жизнь». Прикладной поведенческий анализ эффективен в обучении функциональным, адаптивным навыкам, навыкам повседневной жизни, безопасности, сексуальности, физическим упражнениям, самозащите и другим часто упускаемым навыкам, которые могут способствовать улучшению качества жизни людей с ограниченными возможностями или без них. Исследования показывают, что работа над функциональными навыками в рамках полноценной программы обучения приводит к достижению большей степени независимости обучающегося в жизни. В статье будет рассмотрена возможность использования ABA при разработке полноценной программы обучения подростков. Особое внимание будет уделено отработке поведенческих навыков (BST) и другим способам манипуляции средовыми факторами для обучения навыкам безопасности подростков и молодых людей с аутизмом. Примеры навыков безопасности включают предотвращение похищения, обращение за помощью, когда обучающийся потерялся, в случае неприемлемого физического контакта и раскрытия информации. Будет обсуждаться использование технологий в обучении навыкам безопасности обучающихся с недостаточным репертуаром вербального поведения.
A method for on-line monitoring of the joint penetration depth is reported, based on the spectroscopic analysis of the optical emission collected from laser-metal interaction zone. This technique has ...been applied to quite diverse welding procedures (c.w. CO2 laser, cw fiber laser and pulsed Nd: YAG laser) of stainless steel plates. Although the acquired spectra reveal different characteristics according to the employed laser source, a discrete contribution of several iron lines can be highlighted in both types of investigated welding processes. Starting from the measurement of the intensities of those lines it is possible to calculate the plasma electron temperature, which was found to decrease as far as the laser power is enhanced together with the penetration depth, in static as well as dynamic conditions. Such a behavior does not correspond to a real decrease of the plasma plume temperature but has to be ascribed to the position of the optical collimator collecting light only from the top of the keyhole. Indeed, for deeper penetrations the hottest core of the plume moves down into the vaporized capillary so that the plasma temperature measured on top of the keyhole appears lower at higher incident powers. The electron temperature signal could be useful for the development of a feedback loop system of the laser power to control the weld penetration depth.
Following the learner’s motivation is fundamental when teaching new skills to people with autism. Novel verbal behavior, play skills and functional skills are easily acquired by the learner when they ...directly benefit him.But sooner or later the variety of teaching opportunities available to the teacher may be hindered by restricted interests and limited motivation for social consequences. The severity of this barrier varies across the learner’s profile and features, but the challenge has to be faced at some point. Behavior analysis can help, by providing powerful strategies with which to overcome these barriers and expand teaching opportunities. Analysis of the Transitive Conditioned Establishing Operations (CEO-T) describes how, when access to a terminal reinforcer is blocked or denied, the environment operates to condition new stimuli as reinforcers 16; 12. To date, several studies have demonstrated the effectiveness of strategies derived from the analysis of the CEO-T in teaching verbal and nonverbal behavior 6; 2. The variety of target behavior taught suggests that teaching opportunities based on this analysis are countless, but despite its power in explaining behavior and inspiring teaching strategies, the concept of CEO-T has been overlooked in the teaching of skills other than manding. The defining features of the CEO-T will be discussed and a list of teaching ideas will be provided in order to stimulate a broader use of the analysis of CEO-T in clinical practice.
При обучении новым навыкам людей с аутизмом мотивация обучаемых имеет большое значение. Ученик легко усваивает новое вербальное поведение, игровые и функциональные навыки в случаях, когда они приносят ему непосредственную пользу. Но рано или поздно ограниченные интересы и слабая социальная мотивация ребенка воспрепятствуют разнообразию педагогических возможностей. Серьезность такого ограничения зависит от профиля и характерных особенностей ученика, но в какой-то момент с этой проблемой все же придется столкнуться. Здесь может оказаться полезным анализ поведения для обеспечения мощных стратегий по преодолению этих препятствий и расширению возможностей обучения. В анализе транзитивно-условных формирующих действий (CEO-T) описаны способы и время перекрытия, или запрета доступа, к конечному стимулу, функционирования среды для определения новых стимулов в качестве мотивационных факторов. На сегодняшний день в рамках нескольких исследований доказана эффективность стратегий, основанных на анализе CEO-T, для обучения вербальному и невербальному поведению. Разнообразие исследуемого целевого поведения предполагает бесконечность возможностей для обучения, основанных на данном анализе, но несмотря на способность толкования поведения и вдохновляющие стратегии обучения, концепцией CEO-T пренебрегают при обучении навыкам, помимо навыка выражать просьбы. В статье обсуждаются определяющие качества CEO-T и будут представлены примеры методических приемов обучения для поощрения более широкого применения анализа CEO-T в клинической практике.
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