East Beirut, Lebanon

DOSAGE Study: Upfront Dose-Reduced Chemotherapy in Older Patients with Metastatic Colorectal Cancer

Treating older adults with chemotherapy remains a challenge, as they are strongly underrepresented in clinical trials and no robust guidelines for treating older patients exist. Moreover, older adults are at increased risk of chemotherapy-related toxicity, resulting in decreased quality of life (QoL), increased hospital admissions and high health care costs. Therefore, the aim of the DOSAGE study is to demonstrate that upfront dose-reduced chemotherapy in patients with metastasized colorectal cancer is non-inferior to full-dose treatment with regard to progression-free survival (PFS). Treatment plans (monotherapy or doublet chemotherapy) will be based on expected risk of treatment toxicity for the individual patient (according to the Geriatric 8 (G8) questionnaire). The investigators expect that this treatment strategy will lead to less grade ≥3 toxicity, less early treatment continuation and hospitalizations and a better QoL and physical functioning. The DOSAGE study is a phase III, open-label, non-inferiority, randomized controlled clinical trial in patients aged ≥70 years with metastasized colorectal cancer eligible for palliative chemotherapy. All participating patients will undergo geriatric screening by the G8 questionnaire and will be classified as "low risk of toxicity" (G8-score of 15 or higher) or "high risk of toxicity" (G8-score of 14 or lower or judged as "high toxicity risk" by their treating oncologist). Patients classified as low risk will be randomized between a fluoropyrimidine and oxaliplatin in either full-dose, or with an upfront dose-reduction of 25%. Patients classified as high risk will be randomized between fluoropyrimidine monotherapy in either full-dose or upfront dose-reduction. Addition of targeted treatment (bevacizumab or epidermal growth factor receptor (EGFR) inhibition) is allowed. Patients with a moderate renal impairment (GFR 30- 50 mL/min) will be treated with 25% reduced starting dose of capecitabine when randomized for full dose treatment and treated with 40% reduced starting dose when randomized for upfront dose reduction. Primary outcome is PFS. Secondary endpoints include grade ≥3 toxicity, QoL, physical functioning, overall survival, number of treatment cycles, dose reductions, hospital admissions, cumulative received dosage and cost-effectiveness. Given a non-inferiority margin of 8 weeks, 587 patients will be included (293/292 patients per arm).

SGM-101 Tumor Targeted Fluorescence Endoscopy in Rectal Polyps With Suspected T1 Adenocarcinoma or High Grade Dysplasia

Selection of patients with early rectal cancer, T1 rectal cancer (T1RC) or high-grade dysplasia (HGD), for local resection is based on endoscopic imaging, endorectal ultrasound and/or MRI. However, all these imaging modalities have their limitations in the accurate detection of small areas of cancer in large rectal polyps. Fluorescent guided endoscopy may offer the opportunity to aid in detecting these small cancerous areas in colorectal polyps. Detection of T1RC or HGD in large rectal polyps is essential to select patients for the appropriate (endoscopic) resection technique. Completely benign polyps, solely containing low-grade dysplasia (LGD), could be resected by piecemeal endoscopic mucosal resection (pEMR), a fast technique on which almost all endoscopists are trained. However, for rectal polyps with T1RC or HGD, curative resection must be achieved by en-bloc resection techniques such as endoscopic submucosal dissection (ESD) or endoscopic intermuscular dissection (EID). These techniques are more complex and expensive and only a small number of endoscopists are trained on these techniques. pEMR of lesions with HGD or T1RC must be avoided because they may result in irradical resections (R1) or in inconclusive histological margin assessment since the polyp is not resected en-bloc. Often, this leads to unnecessary additional abdominal surgical resections. Furthermore reported sensitivities for optical diagnosis of T1RC in a polyp are low, varying from 20.8% to 77.8%. Because of the limited accuracy of optical diagnosis, the current Dutch guideline suggest that rectal polyps >3cm should be resected in an en-bloc manner, although it has been demonstrated that only 10.2% of rectal polyps >3cm contain a malignant component. Similarly, in recent studies it was shown that 10-15% of entirely benign polyps were removed by abdominal surgery rather than endoscopically. This has major implications for the patient since surgical resection is associated with considerable morbidity. Therefore, there is a need of a technique that provide the endoscopist with real-time information about specific molecular features of the tumor to differentiate between benign polyps with LGD amenable for pEMR and those that contain HGD or T1RC that require en-bloc resection. Tumor targeted fluorescence-guided surgery (FGS) has emerged as a technique with the potential to enable real-time lesion visualization based on specific molecular features rather than on morphology. Recently it was shown that carcinoembryonic antigen (CEA) is overexpressed in approximately 75% of T1RC/HGD. Additionally, expression in LGD was (nearly) absent in 66% of low-grade dysplastic tissue and in 98% of normal rectum tissue, making it a suitable marker for distinguishing T1RC and HGD from LGD and normal tissue. CEA can be targeted by SGM-101, an anti-CEA antibody attached to a fluorophore which has been studied in several clinical studies for patients with colorectal cancer undergoing surgery. The investigators hypothesize that the use of SGM-101 during endoscopy aids the endoscopist in discriminating benign polyps with solely LGD from polyps containing T1RC/HGD.

Intradermal Ipilimumab and Nivolumab in High Risk Stage II Melanoma

Deep Phenotyping of Cutaneous Lupus Erythematosus

Cutaneous lupus erythematosus (CLE) is a rare but burdensome autoimmune disease that includes various subtypes including acute cutaneous LE (ACLE), subacute cutaneous LE (SCLE), intermittent cutaneous LE (ICLE) i.e., lupus tumidus (LET) and chronic cutaneous LE (CCLE). These subtypes differ in lesion morphology and histopathology, however disease stratification is often a challenge. Knowledge on mechanisms involved in the pathogenesis and pathophysiology of CLE is growing, however much remains unknown. The current concept regarding the onset of the disease comprises a genetic background predisposing to CLE triggered by factors such as UV light, what leads to cellular stress and eventually to the release of DNA components in keratinocytes (Fetter et al., 2022). Activation of both Toll-like receptor (TLR)-dependent and TLR-independent inflammatory signalling cascades leads to increased expression of several cytokines, in particular type I interferon (IFN). Type I interferon mediates increased expression of proinflammatory chemokines via the JAK-STAT pathway, leading to recruitment of immune cells, release of cytokines and a chronic reactivation of innate immune pathways. Findings on the pathogenesis of the disease have led to the development of several targeted therapies that are currently being investigated in clinical trials. However, blockage of one important pathway might not suffice for decreasing disease activity given the limited efficacy of selective IFN antibodies in clinical trials (Kalunian et al., 2016), (Khamashta et al., 2016) (Werth et al., 2017). Only few biomarkers for CLE have been validated and widely incorporated into clinical practice (Zhu et al., 2021). Type I interferon-inducible proteins can be potentially used to assess disease severity of SCLE and CDLE (Braunstein et al., 2013). Furthermore, low complement in CLE patients may be related to poor prognosis and increased risk of developing systemic disease (Vera et al., 2010) (Vera et al., 2010). Therefore, the objectives of the current study are to evaluate disease-related characteristics in CLE patients and to evaluate the variability between patients using a deep phenotyping approach, and to investigate the immune response of CLE patients following an ex vivo and in vivo imiquimod skin challenge. The study consists of an observational (part A) and interventional (part B) part in CLE patients and healthy volunteers.- With this approach the investigators aim to characterize objectively measured disease characteristics and detect novel biomarkers for CLE(-subtypes). This study is part of the Next Generation Immuno Dermatology consortium SKINERGY trials.

A Phase 1/2 Study to Assess the Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of BMN 351 in Participants with Duchenne Muscular Dystrophy

This is Phase 1/2, open-label, multi-center study consisting of 2 parts to evaluate the safety and tolerability of BMN 351 at escalating doses in participants with Duchenne Muscular Dystrophy (DMD) with genetic mutations amenable to exon 51 skipping. Participants will be assigned to one of three groups called cohorts (Cohort 1, 2 or 3). Cohort 1 participants are further divided into Cohort 1A and Cohort 1B. In Cohort 1A, 3 participants will receive increasing doses once every 2 weeks with a visit to assess safety measures collected the week after dosing prior to escalating doses of BMN 351. In part 2, the participants in cohort 1A will transition to once weekly dosing. The participants in Cohort 1B, 2, and 3 will initiate low, medium, and high doses of BMN 351 and continue once weekly dosing at that same dose. The study will enroll approximately 18 participants.

Stage II-IIIa Urothelial Cancer Randomizing Pre-operative Nivolumab With or Without Relatlimab

This is a phase 2 study in which ninety adult patients with cT2-4aN0 or cT1-4aN1urothelial bladder cancer will be included. Included patients will be treated with two cycles of checkpoint inhibition with nivolumab or two cycles of nivolumab+relatlimab every 28 days. Response of this induction therapy will be evaluated by cystoscopy, mpMRI and a CT scan. The primary endpoint is efficacy, defined as pathological complete response (pCR) defined as pT0N0 or pTisN0 at cystectomy. Secondary end-points consist of feasibility analysis, defined as percentage of patients completing cystectomy within 12 weeks of start of treatment. Other key secondary end points are drug safety and overall and event-free survival. Events consist of death by any cause; disease recurrence inside or outside the urinary tract and switching to other treatments. The first evaluation after completion of both treatment cycles will be after six months. Further follow-up visits will take place at 12 and 24 months after completion of the treatment. During these visits, focused physical examination, cystoscopy and a CT chest-abdomen will be performed, combined with registration of treatment-related adverse events and a questionnaire for evaluating QoL, bladder function and long-term effects of immunotherapy on QoL.

Adjuvant Tebentafusp in High Risk Ocular Melanoma

International Cardiac Amyloidosis Registry

Rationale: Patients with cardiac amyloidosis are in general underdiagnosed and undertreated. AL amyloidosis is a disease with a very poor prognosis if left untreated. For ATTR amyloidosis, recently, specific treatment has become available for patients fulfilling certain criteria with good results in clinical trials. The rationale behind this prospective registry is to collect real-world data on diagnostic process, management, progression of disease and outcome of patients with cardiac AL and ATTR amyloidosis who are treated following local standards and to obtain (echocardiographic) predictors of prognosis in these patients. Objective: The objective of the study is to evaluate the diagnostic process from onset symptoms to diagnosis, the outcome in a real-world cohort of amyloidosis patients and to find predictors (both clinical and echocardiographic) of outcome Study design: Prospective long-term observational study Study population: All patients >18 years old, prospectively diagnosed with cardiac AL or ATTR amyloidosis Intervention (if applicable): n/a Main study parameters/endpoints: The main study endpoints are death, heart failure hospitalization and cardiovascular events Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Patients who participate in the registry will undergo structured follow up according to the clinical care pathway for amyloidosis patients based on the recommendations in the most recent Position Statement from the European Society of Cardiology [1]. There will be no additional visits planned, therefore no additional burden is associated with participation in the registry. Patients agree that their anonymized data is shared with other centers within the amyloidosis consortium.

Implementation of Home Monitoring in Patients with Pulmonary Fibrosis

Patients will be randomly assigned to receive either hospital-based care or a home monitoring program integrated into hospital-based care. Hospital-based care involves outpatient clinic visits every three months including lung function testing. Home monitoring involves weekly measurements of both physiological- and patient reported outcomes (PROs) in a mobile health care application with half of the outpatient clinic visits alternately being replaced by remote video consultations. The home monitoring program includes home spirometry, pulse-oximetry, PROs, video consultations, a medication coach, and an infotheque showing disease-specific information. Questionnaires will be filled out by both study groups at set time points. The total study duration for individual patients will be 12 months.