Operative outcomes using bevacizumab, docetaxel, and cisplatin as induction therapy in patients with operable lung cancer

7559

Background: Induction chemotherapy in patients with operable non-small cell lung cancer (NSCLC) is better tolerated than adjuvant chemotherapy. Bevacizumab improves survival in patients with advanced NSCLC; however its impact as an induction agent in patients undergoing lung resection is unknown. Here, we evaluated surgical outcomes in patients undergoing resection for NSCLC after induction therapy with bevacizumab (Bev), docetaxel (D) and cisplatin (C). Methods: Patients with stage IB-IIIA NSCLC, who could undergo resection with curative intent, were eligible for this phase II trial. None had squamous histology, large central tumors, or recent hemoptysis. All patients received up to 4 cycles of D 75 mg/m2 and C 75 mg/m2 and also received 3 cycles of Bev 15 mg/kg, followed by surgery. Two age and stage matched controls who received induction chemotherapy were selected per study patient. Fisher's exact tests compared pathologic stage, gender, and smoking history. Conditional logistic regression explored the association between clinical variables and outcomes in study versus control patients. Results: 30 patients received Bev-DC. Gender, smoking history, operative time, blood loss, and overall 30-day morbidity was similar between study and control patients. The 30 patients who received Bev-DC preoperatively had 12 complications vs 23 in the 60 controls. In the Bev-DC group there were 7 grade 3/4 complications (abscess (1), empyema (1), bronchopleural fistula (2), sigmoid volvulus (1), anastomotic dehiscence (1), GI bleed (1)) as compared to 2 in the control group (p=0.004). There were no deaths in the Bev-DC group and 2 among the controls. After controlling for age, gender and stage, patients in the study group had a trend towards increase incidence of overall complications (OR=3.89 (95%CI: 0.61–24.77) p=0.151). Conclusions: Although rates of 30-day morbidity were comparable, patients receiving Bev-DC induction had a higher incidence of grade 3/4 complications. There was no 30-day mortality among the patients receiving Bev-DC. Based on this interim analysis, patients receiving Bev-DC in the preoperative setting merit close monitoring.

[Table: see text]

Impact on disease-free survival of adjuvant erlotinib or gefitinib in patients with resected lung adenocarcinomas that harbor epidermal growth factor receptor (EGFR) mutations

7523

Background: Patients with stage IV adenocarcinoma whose tumors harbor EGFR mutations have high rates of response (∼ 75%) and prolonged progression free survival after EGFR tyrosine kinase inhibitor (TKI) treatment. Adjuvant cisplatin-based chemotherapy improves disease free survival (DFS) and overall survival (OS) in patients with resected stages IB-IIIA NSCLC. To see if adjuvant treatment with EGFR TKI (gefitinib or erlotinib) improves DFS in patients with EGFR mutation NSCLC, we conducted a retrospective review of patients with resected lung adenocarcinoma harboring EGFR mutations, some of whom received EGFR TKIs postoperatively. Methods: With Institutional Review Board approval, clinical information was obtained on all patients with stage I-III lung adenocarcinoma harboring EGFR exon 19 or 21 mutations that underwent resection at MSKCC between May 2002 and August 2008. Age, gender, type of surgery, histology, EGFR mutation status (exon 19 deletions and exon 21 L858R), stage, perioperative therapy and survival were recorded. Kaplan-Meier analysis and Cox regression analysis were performed. Results: We studied 150 patients (112 women, 38 men) with completely resected stage I-III lung adenocarcinoma whose resection specimens contained EGFR activating mutations in exon 19 or 21. Median age was 69. Forty two patients (28%) received cytotoxic chemotherapy. Forty eight (32%) received either erlotinib (n=26) or gefitinib (n=22) postoperatively. The median time on TKI was 16 months. The median DFS was 43 months in the group that received a TKI vs. 31 months for those that did not. After controlling for stage, individuals who received adjuvant gefitinib or erlotinib had a better DFS (HR=0.38, 95%CI: 0.16–0.90) than the non-TKI group (p=0.03). The median overall survival has not been reached. Conclusions: These data indicate that the adjuvant use of either gefitinib or erlotinib improves DFS in patients with completely resected stage I -III lung adenocarcinomas with mutations in EGFR exons 19 and 21. These data justify a randomized trial in similar patients.

[Table: see text]

Phase II study of bevacizumab (B) plus cisplatin (C) plus intensity-modulated radiation therapy (IMRT) for locoregionally advanced head and neck squamous cell cancer (HNSCC): Preliminary results

6013

Background: For patients with locoregionally advanced HNSCC, concurrent high-dose cisplatin + radiation therapy is a historical standard of care. HNSCC tumors expressing high levels of VEGF have been associated with worse prognosis, and bevacizumab may sensitize tumors to cisplatin and radiation. Methods: Percutaneous gastrostomy (PEG) tube was placed pre-treatment for all patients. Planned treatment consisted of definitive IMRT (total, 70 Gy) with concurrent C (50 mg/m2 days 1, 2, 22, 23, 43, 44) and B (15 mg/kg days 1, 15, and 43). The initial version of the protocol called for an additional 6 months of maintenance B, but this was discontinued in an amendment after a G4 pulmonary hemorrhage event in subject 1 during maintenance treatment. 1o endpoint was 2-year PFS. Results: 42 previously untreated patients (34 M, 8 F), median age 55 (27–75), with stage III/IV, M0 HNSCC (oropharynx 39, larynx 3) enrolled. HPV status by ISH: 16 pos, 14 neg, 12 unknown). All patients have completed treatment. CTCAE v3.0 toxicities (% patients) have included: functional mucositis G3 (76 %); nausea G3 (24%); vomiting G3 (17%); neutropenia G3 (31%), G4 (10%); hemoglobin G3 (17%); hyponatremia G3 (14%). Median weight loss during treatment was 8.9 kg (2.1–26 kg). There were two deaths within 90 days of last treatment: 1 aspiration pneumonia, 1 sudden death. Median follow up is approximately 9 months (range, <3 to 24 months). Locoregional control rate is 100%. Three patients have developed distant metastasis. Estimated one-year PFS is 83% (± 10%) and estimated 1 year OS is 88% (± 6%). At a median of 8 months after completion of radiation therapy, PSS-HN scores were 100 for eating, speech, and diet in respectively 88%, 76%, and 53% of surveyed patients (n = 17). Conclusions: The addition of B to C + IMRT did not appear to increase toxicity to unacceptable levels, and preliminary efficacy results are encouraging.

[Table: see text]

Phase I study of everolimus (E; RAD001) + low-dose weekly cisplatin (C) for patients with advanced solid tumors: Preliminary results

e14527

Background: Preclinical studies demonstrate synergistic anti-tumor activity with the combination of E + C. Methods: Patients received E per oral for days 1–21 of a 28 day cycle. E was dose escalated though 4 planned dose levels (DLs): 2.5 mg/day, 5 mg/day, 7.5 mg/day, and 10 mg/day. Cisplatin dose was fixed at 20 mg/m2 intravenously on days 1, 8, 15. A standard 3 + 3 dose escalation scheme was used. Blood samples for pharmacokinetics were collected on Day 1 and Day 8 of Cycle 1. Response was assessed by RECIST after 2 cycles. Results: 24 patients enrolled: 13 M, 11F; median age 62 (32–77); median number of prior cytotoxic chemotherapy regimens 1 (0–3; 75% with prior RT). At DL1, 3 patients were inevaluable (1 withdrawal of consent prior to treatment, 1 disease progression during cycle 1, 1 recurrent diverticulitis during cycle 1) and were replaced. DL 1 was expanded after a patient with melanoma metastatic to liver had sudden death of unclear cause, and the protocol was amended to exclude patients with hepatic dysfunction. At DL2, one patient experienced grade 3 small bowel obstruction of uncertain etiology, and the dose level was expanded to 6 evaluable patients without additional DLT. No DLTs occurred at DL3. No DLTs have occurred to date among 6 patients enrolled at DL 4. Adverse events per cycle (total n = 63 cycles; 20 patients evaluable for toxicity) include: lymphopenia G3 (19%), AST G3 (3.2%), alkaline phosphatase G3 (3.2%), ALT G3 (1.6%), hyponatremia (1.6%). Median cycles per patient, 2 (range <1 to 10+). Minor response seen in pulmonary carcinoid (n = 1); prolonged SD ≥ 6 cycles seen in pulmonary carcinoid (n=2), basal cell carcinoma (n=1), and esthesioneuroblastoma (n=1). Conclusions: Pending safety analysis at the final planned dose level, the phase II recommended dose is E 10 mg/day (days 1 - 21) + C 20 mg/m2 (days 1, 8, and 15) on a 28-day cycle.

[Table: see text]

Modulation of 11beta-hydroxysteroid dehydrogenase expression by bombesin: a possible mechanism for glucocorticoid resistance in androgen independent prostate cancer

Treatment with glucocorticoids is one of a limited number of options for androgen independent prostate cancer. Neuroendocrine differentiation has been shown to contribute to androgen-independent prostate cancer progression. To study the potential link between neuroendocrine differentiation and the glucocorticoid action, we investigated the effects of the product of neuroendocrine differentiation--bombesin on glucocorticoid metabolizing enzymes--11beta-hydroxysteroid dehydrogenases in PC-3 cells. Our Western analysis, RT-PCR, and activity assays demonstrate that while 18-hour exposure to bombesin reduces 11beta-hydroxy-steroid dehydrogenases-1 profiles (activities 25% less, protein level 29% lower, mRNA levels 45% lower), contrarily it increases 11beta-hydroxysteroid dehydrogenases-2 profiles (activities 34%, protein levels 100%, mRNA levels 120%). Blockade bombesin action with bombesin receptor antagonists and the enzyme degrading bombesin prevented these changes, suggesting the observed modulations were bombesin receptor-specific. In addition, bombesin increased the amounts of interleukin-8 and mRNA of vascular endothelial growth factor receptor 2, which were lowered in the presence of cortisol, suggesting that neuropeptide blockade may extend the benefits of glucocorticoids in treating androgen-independent prostate cancer.

The DIURNAL project: DIURNAL and circadian expression profiling, model-based pattern matching, and promoter analysis

The DIURNAL project ( http://diurnal.cgrb.oregonstate.edu/ ) provides a graphical interface for mining and viewing diurnal and circadian microarray data for Arabidopsis thaliana, poplar, and rice. The database is searchable and provides access to several user-friendly Web-based data-mining tools with easy-to-understand output. The associated tools include HAYSTACK ( http://haystack.cgrb.oregonstate.edu/ ) and ELEMENT ( http://element.cgrb.oregonstate.edu/ ). HAYSTACK is a model-based pattern-matching algorithm for identifying genes that are coexpressed and potentially coregulated. HAYSTACK can be used to analyze virtually any large-scale microarray data set and provides an alternative method for clustering microarray data from any experimental system by grouping together genes whose expression patterns match the same or similar user-defined patterns. ELEMENT is a Web-based program for identifying potential cis-regulatory elements in the promoters of coregulated genes in Arabidopsis, poplar, and rice. Together, DIURNAL, HAYSTACK, and ELEMENT can be used to facilitate cross-species comparisons among the plant species supported and to accelerate functional genomics efforts in the laboratory.

Circulating tumor cells (CTC): Assessment of treatment efficacy in metastatic breast cancer (MBC)

10535

Background: Preliminary data in MBC suggest that ≥5 CTC/7.5 mL blood is associated with worse progression free survival (PFS) and overall survival (OS), and that the persistence of ≥5 CTC/7.5 mL blood after the initiation of therapy predicts for treatment failure (NEJM 2004. 351:781.). We are conducting a prospective clinical research study to validate the prognostic and predictive significance of this serum biomarker in MBC. Methods: Serial CTC levels are obtained in patients starting a new systemic treatment regimen for progressive, radiographically measurable MBC. 10 mL samples of peripheral blood are collected before the start of treatment and then at 3–4 week intervals. All subjects are followed prospectively for PFS and OS, and they are offered the opportunity to continue CTC testing upon disease progression. CTC enumeration is performed on a 7.5 mL blood volume using the CellSearch technology (Veridex, LLC; Warren, NJ). Epithelial cells are immunomagnetically separated and fluorescently labeled, and nucleated (DAPI+) cells with the EpCAM+, cytokeratin 8/18/19+, and CD45- phenotype are counted as CTC. Clinical outcomes are based on radiographic studies and physical examination in accordance with RECIST criteria. Results: 46 of 100 subjects have been accrued, and 33 have completed at least one radiographic staging evaluation with a median follow up of 7 mos (range 2–18 mos). Treatment for the 33 evaluable patients includes chemotherapy (27%), endocrine therapy (46%), and combination therapy with a biologic agent (27%). At baseline, 85% (28/33) had at least 1 CTC/7.5 mL (range 1–78), and 27% (9/33) had ≥5 CTC/7.5 mL. Median PFS was 2.57 months and 6.77 months for subjects with ≥5 vs <5 CTC/7.5 mL at baseline, respectively (p=0.02). Conclusions: The current data validate the observation that baseline CTC levels correlate with PFS in patients with MBC and measurable disease. Patient accrual and data analysis are ongoing to confirm that persistent CTC levels ≥5/7.5 mL correlate with a lack of treatment efficacy and therefore are a reliable surrogate marker of disease responsiveness and PFS.

[Table: see text]

A phase I trial of RX-0201 (AKT anti-sense) in patients with an advanced cancer

3564

Background: Akt-1, a proto-oncogene, plays a vital role in cancer progression by stimulating proliferation and inhibiting apoptosis of cancer cells. RX-0201, a 20-mer oligonucleotide with sequence complementary to Akt-1 mRNA, is designed to inhibit the expression of Akt-1 within cancer cells in cancer patients (pts). Non-clinical studies conducted on RX-0201 demonstrated that RX-0201 bears significant in vitro and in vivo anti-cancer activities with favorable safety. Purposes: The aims of the current phase I trial were to determine the maximum tolerated dose (MTD) and to establish pharmacokinetic (PK) and safety profiles of RX-0201 in pts with an advanced cancer. Methods: RX-0201 was administered to pts with an advanced cancer by up to 2 cycles of continuous infusion; each cycle of infusion lasted for 14 days which was followed by a 7-day rest. Rapid dose escalation had been used until at least a grade (G) 2 toxicity was observed, and then a traditional dose escalation followed. Entry criteria included Karnofsky Performance Status score =70, advanced cancer, tumor accessible for paired biopsy, and signed informed consent. 17 pts were enrolled and treated at a dose level ranging from 6 to 315 mg/m2/d on D1–14, repeated q 21 d. Results: G 3 fatigue was observed in two pts at the 315 mg/m2/d dose; three pts dosed at 250 mg/m2/d were not noted with any G 3 toxicity, which make this dose (250 mg/m2/d) the recommended phase II trial dose. No other significant, compound-related, adverse events were observed in those 17 pts participated. Pts PK profiles of RX-0201 and AKT-1 immunohistochemistry results on pts’ tumor biopsy samples will also be presented. Conclusion: MTD of RX-0201 is 315 mg/m2/d in pts with an advanced cancer when the compound is administered in the current continuous infusion regimen.

No significant financial relationships to disclose.

Neutral endopeptidase inhibits prostate cancer tumorigenesis by reducing FGF-2-mediated angiogenesis

Neutral endopeptidase (NEP) is a cell surface peptidase that catalytically inactivates a variety of physiologically active peptides including basic fibroblast growth factor (FGF-2). We investigated the effect of using lentivirus to overexpress NEP in NEP-deficient DU145 prostate cancer cells. Third-generation lentiviral vectors encoding wild-type NEP (L-NEP), catalytically inactive mutant NEP (L-NEPmu), and green fluorescent protein (L-GFP) were stably introduced into DU145 cells. FGF-2 levels in cell culture supernatants decreased by 80% in L-NEP-infected DU145 cells compared to cells infected with L-NEPmu or L-GFP (P<0.05) while levels of other angiogenic factors were not altered. In vitro tubulogenesis of human vascular endothelial cells induced by conditioned media from DU145 cells infected with L-NEP was significantly reduced compared with that from DU145 cells infected with L-GFP (P<0.05). Tumor xenografts from L-NEP-infected DU145 cells were significantly smaller compared to control cell xenografts and vascularity within these tumors was decreased (P<0.05). Our data suggest that stable expression of NEP in DU145 cells inhibits prostate cancer tumorigenicity by inhibiting angiogenesis, with a probable mechanism being proteolytic inactivation of FGF-2.

The role of double-balloon enteroscopy in diagnosis and management of incomplete small-bowel obstruction

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) is a newly developed endoscopic technique for investigating various small-bowel diseases. The aim of this study was to evaluate the diagnostic yield and therapeutic impact of DBE in patients with incomplete small-bowel obstruction (SBO).

PATIENTS AND METHODS

This study is a prospective analysis of 45 consecutive patients specifically referred to our hospital between December 2004 and January 2006 for investigation of incomplete SBO that had been confirmed by both clinical symptoms and imaging tests. Patients with a high suspicion of postoperative adhesion were excluded and DBE was performed in stable patients. The final management was guided by the results of DBE and radiographic studies. Demographic, clinical, procedural, and outcome data were collected for analysis.

RESULTS

A total of 30 DBEs were performed in 29 patients (11 women, 18 men; mean age 52.0 +/- 13.5 years). DBE identified causes of incomplete SBO in 27 patients (93.1%) and allowed histopathologic evaluation in 17 patients (58.6%). The more common abnormalities detected were small-bowel tumors (48.3%) and strictures caused by Crohn's disease (24.1%). In detecting small-bowel abnormalities, DBE showed a sensitivity of 96.4%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 50%. DBE influenced the therapeutic strategy in 41.4% of patients by adding more information regarding appropriate treatment. Follow-up data were obtained for 26 patients (89.7%), for a mean 9.4 months (range 4-18 months). Of the 26 patients with follow-up, 21 (72.4%) had no further SBO.

CONCLUSIONS

Double-balloon enteroscopy is a feasible diagnostic tool for detecting the causes of incomplete SBO in patients without a history of abdominal surgery and also influences therapy in patients without a definite cause detected by conventional radiography.

Advantages and challenges of using census and multiplier methods to estimate the number of female sex workers in a Chinese city

Using census and multiplier methods to estimate the size of the population of female sex workers (FSWs) in a small city in western China, this study compared the advantages and challenges of the two methods. It was estimated that there were about 1,500 FSWs within the urban area using the census method, which was significantly lower than that estimated by the multiplier method (2,500). Each method has advantages and limitations, and could be applied to different situations. The census method is less time and resource consuming in smaller regions and has a tendency to underestimate, and therefore, the result can be viewed as a low limit. It is useful in a local setting, for example, when estimations are needed for planning HIV/AIDS prevention programmes in a single city. Using existing information or resources, multiplier method could be used to produce estimates for a large geographic area or at a national level.

Lentiviral vector neutral endopeptidase gene transfer suppresses prostate cancer tumor growth

Neprilysin (neutral endopeptidase, NEP) is a cell surface peptidase whose expression is lost in approximately 50% of prostate cancers (PC). NEP normally functions to inactivate peptides such as bombesin and endothelin-1, and potentiates the effects of the PTEN tumor suppressor via a direct protein-protein interaction. NEP loss contributes to PC progression. We investigated the therapeutic efficacy of using a lentiviral vector system to restore NEP expression in PC cells. Third-generation lentiviral vectors encoding wild-type NEP (L-NEP) or green fluorescent protein (L-GFP) were introduced into NEP-deficient 22RV1 PC cells. Cells infected with L-NEP or L-GFP at a multiplicity of infection of 10 demonstrated NEP enzyme activity of 1171.2+/-4.9 and 17.2+/-5.3 pmol/microg/min (P<0.0001), respectively. Cell viability, proliferation and invasion were each significantly inhibited in 22RV1 cells expressing NEP compared with control cells infected with L-GFP (P<0.01). Analysis of known downstream effects of NEP showed NEP-expressing cells exhibiting decreased Akt and focal adhesion kinase phosphorylation and increased PTEN protein expression. Finally, injection of L-NEP into established 22RV1 xenograft tumors significantly inhibited tumor growth (P<0.01). These experiments demonstrate that lentiviral NEP gene transfer is a novel targeted strategy for the treatment of NEP-deficient PC.

Activation of p300 histone acetyltransferase activity and acetylation of the androgen receptor by bombesin in prostate cancer cells

Androgen receptor signaling in prostate cancer cells is augmented by the androgen receptor (AR) coactivator p300, which transactivates and acetylates the AR in the presence of dihydrotestosterone (DHT). As prostate cancer (PC) cells progress to androgen independence, AR signaling remains intact, indicating that other factors stimulate AR activities in the absence of androgen. We previously reported that neuropeptide growth factors could transactivate the AR in the presence of very low concentrations of DHT. Here, we examine the involvement of p300 in neuropeptide activation of AR signaling. Transfection of increasing concentrations of p300 in the presence of bombesin into PC-3 cells resulted in a linear increase in AR transactivation, suggesting that p300 acts as a coactivator in neuropeptide-mediated AR transactivation. P300 is endowed with histone acetyltransferase (HAT) activity. Therefore, we examine the effect of bombesin on p300 HAT activity. At 4 h after the addition of bombesin, p300 HAT activity increased 2.0-fold (P<0.01). Incubation with neutral endopeptidase, which degrades bombesin, or bombesin receptor antagonists blocked bombesin-induced p300 HAT activity. To explore the potential signaling pathways involved in bombesin-induced p300 HAT activity, we examined Src and PKCdelta pathways that mediate bombesin signaling. Inhibitors of Src kinase activity or Src kinase siRNA blocked bombesin-induced p300 HAT activity, whereas PKCdelta inhibitors or PKCdelta siRNA significantly increased bombesin-induced p300 HAT activity suggesting that Src kinase and PKCdelta kinase are involved in the regulation of p300 HAT activity. As AR is acetylated in the presence of 100 nM DHT, we next examined whether bombesin-induced p300 HAT activity would result in enhanced AR acetylation. Bombesin-induced AR acetylation at the same motif KLKK observed in DHT-induced acetylation. Elimination of p300 using p300 siRNA reduced AR acetylation, demonstrating that AR acetylation was mediated by p300. AR acetylation results in AR transactivation and the expression of the AR-regulated gene prostate-specific antigen (PSA). Therefore, we examined bombesin-induced AR transactivation and PSA expression in the presence and absence of p300 siRNA and found inhibition of p300 expression reduced bombesin-induced AR transactivation and PSA expression. Together these results demonstrate that bombesin, via Src and PKCdelta signaling pathways, activates p300 HAT activity which leads to enhanced acetylation of AR resulting in increased expression of AR-regulated genes.