Utility of a multidisciplinary tumor board in the management of pancreatic and upper gastrointestinal diseases: an observational study

BACKGROUND & OBJECTIVES

Multidisciplinary tumor boards (MDTBs) are frequently employed in cancer centers but their value has been debated. We reviewed the decision-making process and resource utilization of our MDTB to assess its utility in the management of pancreatic and upper gastrointestinal tract conditions.

METHODS

A prospectively-collected database was reviewed over a 12-month period. The primary outcome was change in management plan as a result of case discussion. Secondary outcomes included resources required to hold MDTB, survival, and adherence to treatment guidelines.

RESULTS

Four hundred seventy cases were reviewed. MDTB resulted in a change in the proposed plan of management in 101 of 402 evaluable cases (25.1%). New plans favored obtaining additional diagnostic workup. No recorded variables were associated with a change in plan. For newly-diagnosed cases of pancreatic ductal adenocarcinoma (n = 33), survival time was not impacted by MDTB (p = .154) and adherence to National Comprehensive Cancer Network guidelines was 100%. The estimated cost of physician time per case reviewed was $190.

CONCLUSIONS

Our MDTB influences treatment decisions in a sizeable number of cases with excellent adherence to national guidelines. However, this requires significant time expenditure and may not impact outcomes. Regular assessments of the effectiveness of MDTBs should be undertaken.

Analysis of the effect of adjuvant therapy on overall survival for resected gallbladder adenocarcinoma using the National Cancer Database

360

Background: The effect of adjuvant chemotherapy on survival after resection for gallbladder adenocarcinoma (GBC) is based on limited evidence. Since prospective trials are not generally practical for GBC, we sought to evaluate current best evidence to evaluate the role of adjuvant chemotherapy in multiple clinical scenarios by analyzing data from the U.S. National Cancer Database (NCDB). Methods: Patients who underwent resection for GBC diagnosed between 2004 and 2012 were identified in the NCDB. The effect of adjuvant therapy on overall survival (OS) was assessed using Kaplan-Meier analysis and Cox proportional hazards regression modeling. Results: 10,402 patients met inclusion criteria. Median follow-up was 14 months. Median survival was 16 months. One- and five-year OS were 57% and 23%, respectively. 3,509 patients (34%) received any modality of adjuvant therapy. Receipt of adjuvant therapy improved one-year OS (63% vs 55%, p < 0.01), but median OS was minimally changed (17 vs 15 months, NS). Adjuvant therapy was associated with improved one-year OS in T3 and T4N1 disease (Table 1). Only chemoradiation therapy was associated with improved one-year OS for T2 disease. Adjuvant chemotherapy was associated with worse one-year OS in T1N0 disease. Conclusions: Using data from the US NCDB, adjuvant therapy for resected gallbladder adenocarcinoma is associated with improved one-year overall survival with the exception of T1N0 disease. In the absence of prospective studies in this rare disease, retrospective data can provide insights into successful treatment strategies and guidelines for GBC. [Table: see text]

A phase I/II study combining tosedostat with capecitabine in patients with metastatic pancreatic ductal adenocarcinoma (PDAC)

410

Background: Recent advances in front-line therapy have improved survival in patients with advanced PDAC. A fluorouracil-based regimen is recommended for patients who progress on a gemcitabine-based therapy. Tosedostat is an oral aminopeptidase inhibitor that disrupts the cleavage of amino acids from peptides downstream of proteasomal degradation. It prevents the recycling of free amino acids, leads to intracellular depletion of amino acids, and triggers an amino acid deprivation response that subsequently results in apoptosis. Because PDAC cells frequently upregulate expression of these aminopeptidases, tosedostat offers therapeutic promise, particularly in combination with fluoropyrimidines. Methods: This is a single institution phase I/II trial to evaluate the safety and toxicity of tosedostat plus capecitabine in patients with metastatic PDAC progressed on a gemcitabine-based therapy. The phase I portion is being conducted in a dose de-escalation fashion, with two dose levels of tosedostat (120 mg or 60 mg) p.o. daily on days 1 to 21 with capecitabine 1000 mg/m2 p.o. BID on days 1 to 14 of a 21-day cycle. If more than one out of 6 patients in the tosedostat (120 mg) cohort experience a dose limiting toxicity (DLT), then 6 more will be enrolled to the tosedostat (60 mg) cohort. The primary objective of the phase I portion is to determine the optimal phase II dose. The primary objective of the phase II portion is to determine the progression-free survival at 3 months. Secondary objectives include the overall response rate, overall survival and CA 19-9 response. To avoid futility, interim analysis is planned after 10 evaluable patients enrolled. Results: Up to date, a total of 11 patients have been enrolled in the study, and 10 patients are evaluable. No DLT have been observed. Tosedostat at a dose of 120 mg with capecitabine is extremely well tolerated. Prolonged stable disease has been observed in 4 (40%) patients with a time on treatment of 10 months, 7.5 months, 5.5 months and 4 months, and 3 of the 4 patients remain on the trial. Conclusions: The combination of tosedostat and capecitabine is a well-tolerated regimen with impressive clinical activity in the subset of patients studied thus far. Clinical trial information: NCT02352831.

Steroid Responsive Mononeuritis Multiplex in the Cronkhite-Canada Syndrome

The Cronkhite-Canada syndrome (CCS) is a rare disorder of unknown origin characterized by generalized gastrointestinal polyposis, alopecia, hyperpigmentation, and onychodystrophy. We report a case of CCS with concomitant presentation of mononeuritis multiplex. The electrophysiological findings and steroid responsiveness suggests presence of an autoimmune mechanism.

Constitutive IRAK4 Activation Underlies Poor Prognosis and Chemoresistance in Pancreatic Ductal Adenocarcinoma

Purpose: Aberrant activation of the NF-κB transcription factors underlies the aggressive behavior and poor outcome of pancreatic ductal adenocarcinoma (PDAC). However, clinically effective and safe NF-κB inhibitors are not yet available. Because NF-κB transcription factors can be activated by the interleukin-1 receptor-associated kinases (IRAKs) downstream of the Toll-like receptors (TLRs), but has not been explored in PDAC, we sought to investigate the role of IRAKs in the pathobiology of PDAC.Experimental Design: We examined the phosphorylation status of IRAK4 (p-IRAK4), the master regulator of TLR signaling, in PDAC cell lines, in surgical samples and commercial tissue microarray. We then performed functional studies using small-molecule IRAK1/4 inhibitor, RNA-interference, and CRISPR/Cas9n techniques to delineate the role of IRAK4 in NF-κB activity, chemoresistance, cytokine production, and growth of PDAC cells in vitro and in vivoResults: p-IRAK4 staining was detectable in the majority of PDAC lines and about 60% of human PDAC samples. The presence of p-IRAK4 strongly correlated with phospho-NF-κB/p65 staining in PDAC samples and is predictive of postoperative relapse and poor overall survival. Inhibition of IRAK4 potently reduced NF-κB activity, anchorage-independent growth, chemoresistance, and secretion of proinflammatory cytokines from PDAC cells. Both pharmacologic suppression and genetic ablation of IRAK4 greatly abolished PDAC growth in mice and augmented the therapeutic effect of gemcitabine by promoting apoptosis, reducing tumor cell proliferation and tumor fibrosis.Conclusions: Our data established IRAK4 as a novel therapeutic target for PDAC treatment. Development of potent IRAK4 inhibitors is needed for clinical testing. Clin Cancer Res; 23(7); 1748-59. ©2016 AACR.

Abstract 181: Constitutive IRAK1/4 kinase activation contributes to NF-kB activity and chemoresistance in pancreatic cancer

Constitutive activation of the NF-κb transcription factor is a major molecular mechanism that contributes to the aggressive behavior and treatment resistance of pancreatic cancer. Understanding the molecular mechanisms that activate NF-κB will provide novel therapeutic opportunities to improve the dismal outcome of pancreatic cancer patients. In the present study, we showed that the Interleukin-1 Receptor-Associated Kinases 1 and 4 (IRAK1 and IRAK4) are constitutively activated in a majority of pancreatic cancer cell lines and patients samples, and are major drivers of NF-κB activity. Notably, we found that constitutive phosphorylation of IRAK4 is associated with poor patient prognosis. Suppression of IRAK1 and IRAK4 with small molecule inhibitor or RNA-interference in pancreatic cancer cells significantly reduces NF-κB activity, three-dimensional growth, invasiveness, production of inflammatory, and augment their sensitivity to chemotherapeutic agents in vitro. Notably, we showed that the NF-κB activity of pancreatic cancer cell with IRAK4 ablated using CRISPR technology can be restored with wild-type, but not kinase-dead IRAK4 mutant, supporting development of IRAK4 inhibitor as a novel therapeutic agent in pancreatic cancer. Silencing of IRAK1 or IRAK4, and more potently both, significantly abrogated the tumorigenic potential of human and murine pancreatic cancer cells as xenograft in mice. Lastly, we showed that IRAK1/4 inhibitor augments the therapeutic effect of gemcitabine in tumor-bearing mice by suppressing proliferation and increasing apoptosis of neoplastic cells, and reducing stromal fibrosis. Together, our data established IRAK4 kinase inhibitors as a promising novel class of targeted agent in pancreatic cancer.

Citation Format: Daoxiang Zhang, Lin Li, Hongmei Jiang, Jinsheng Yu, Brett Knolhoff, Richard Head, Albert C. Lockhart, David G. DeNardo, Andrea Wang-Gillam, Marianna B. Ruzinova, Kian-Huat Lim. Constitutive IRAK1/4 kinase activation contributes to NF-kB activity and chemoresistance in pancreatic cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 181.

Targeting tumour-associated macrophages with CCR2 inhibition in combination with FOLFIRINOX in patients with borderline resectable and locally advanced pancreatic cancer: a single-centre, open-label, dose-finding, non-randomised, phase 1b trial

BACKGROUND

In pancreatic ductal adenocarcinoma, the CCL2-CCR2 chemokine axis is used to recruit tumour-associated macrophages for construction of an immunosuppressive tumour microenvironment. This pathway has prognostic implications in pancreatic cancer, and blockade of CCR2 restores anti-tumour immunity in preclinical models. We aimed to establish the safety, tolerability, and recommended phase 2 oral dose of the CCR2 inhibitor PF-04136309 in combination with FOLFIRINOX chemotherapy (oxaliplatin and irinotecan plus leucovorin and fluorouracil).

METHODS

We did this open-label, dose-finding, non-randomised, phase 1b study at one centre in the USA. We enrolled treatment-naive patients aged 18 years or older with borderline resectable or locally advanced biopsy-proven pancreatic ductal adenocarcinoma, an Eastern Cooperative Oncology Group performance status of 1 or less, measurable disease as defined by Response Evaluation Criteria in Solid Tumors version 1.1, and normal end-organ function. Patients were allocated to receive either FOLFIRINOX alone (oxaliplatin 85 mg/m(2), irinotecan 180 mg/m(2), leucovorin 400 mg/m(2), and bolus fluorouracil 400 mg/m(2), followed by 2400 mg/m(2) 46-h continuous infusion), administered every 2 weeks for a total of six treatment cycles, or in combination with oral PF-04136309, administered at a starting dose of 500 mg twice daily in a standard 3 + 3 dose de-escalation design. Both FOLFIRINOX and PF-04136309 were simultaneously initiated with a total treatment duration of 12 weeks. The primary endpoints were the safety, tolerability, and recommended phase 2 dose of PF-04136309 plus FOLFIRINOX, with an expansion phase planned at the recommended dose. We analysed the primary outcome by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01413022.

RESULTS

Between April 19, 2012, and Nov 12, 2014, we treated 47 patients with FOLFIRINOX alone (n=8) or with FOLFIRINOX plus PF-04136309 (n=39). One patient had a dose-limiting toxic effect in the dose de-escalation group receiving FOLFIRINOX plus PF-04136309 at 500 mg twice daily (n=6); this dose was established as the recommended phase 2 dose. We pooled patients in the expansion-phase group (n=33) with those in the dose de-escalation group that received PF-04136309 at the recommended phase 2 dose for assessment of treatment-related toxicity. Six (75%) of the eight patients receiving FOLFIRINOX alone were assessed for treatment toxicity, after exclusion of two (25%) patients due to insurance coverage issues. The median duration of follow-up for treatment toxicity was 72·0 days (IQR 49·5-89·0) in the FOLFIRINOX alone group and 77·0 days (70·0-90·5) in the FOLFIRINOX plus PF-04136309 group. No treatment-related deaths occurred. Two (5%) patients in the FOLFIRINOX plus PF-04136309 group stopped treatment earlier than planned due to treatment-related toxic effects. Grade 3 or higher adverse events reported in at least 10% of the patients receiving PF-04136309 included neutropenia (n=27), febrile neutropenia (n=7), lymphopenia (n=4), diarrhoea (n=6), and hypokalaemia (n=7). Grade 3 or higher adverse events reported in at least 10% of patients receiving FOLFIRINOX alone were neutropenia (n=6), febrile neutropenia (n=1), anaemia (n=2), lymphopenia (n=1), diarrhoea (n=2), hypoalbuminaemia (n=1), and hypokalaemia (n=3). Therapy was terminated because of treatment-related toxicity in one (17%) of the six patients receiving FOLFIRINOX alone. 16 (49%) of 33 patients receiving FOLFIRINOX plus PF-04136309 who had undergone repeat imaging achieved an objective tumour response, with local tumour control achieved in 32 (97%) patients. In the FOLFIRINOX alone group, none of the five patients with repeat imaging achieved an objective response, although four (80%) of those patients achieved stable disease.

INTERPRETATION

CCR2-targeted therapy with PF-04136309 in combination with FOLFIRINOX is safe and tolerable.

FUNDING

Washington University-Pfizer Biomedical Collaborative.

Prevalence of smoking and its associated factors with smoking among elderly smokers in Malaysia: findings from a nationwide population-based study

BACKGROUND

The determination of smoking prevalence and its associated factors among the elderly could provide evidence-based findings to guide the planning and implementation of policy in order to will help in reducing the morbidity and mortality of smoking-related diseases, thus increase their quality of life. This paper describes the rate of smoking and identifies the factor(s) associated with smoking among the elderly in Malaysia.

METHODS

A representative sample of 2674 respondents was obtained via a two-stage sampling method in proportion to population size. Face-to-face interviews were conducted using a set of standardized validated questionnaire. Data was weighted by taking into consideration the complex sampling design and non-response rate prior to data analysis. Univariable and multivariable logistic regression were used to determine the factor/s associated with smoking.

RESULTS

The prevalence of non-smokers, ex-smokers and current smokers among Malaysians aged 60 years and above were 36.3 % (95 % CI = 32.7-39.8), 24.4 % (95 % CI = 21.2-27.5) and 11.9 % (95 % CI = 9.5-14.3), respectively. Current smokers were significantly more prevalent in men (28.1 %) than in women (2.9 %), but the prevalence declined with advancing age, higher educational attainment, and among respondents with known diabetes, hypertension and hypercholesterolemia. Multivariable analysis revealed that males (aOR, 18.6, 95 % CI 10.9-31.9) and other Bumiputras (aOR 2.58, 95 % CI 1.29-5.15) were more likely to smoke. in addition, elderly with lower educational attainment (aOR, 1.70, 95 % CI 1.24-7.41) and those without/unknown hypertension also reported higher likelihood to be current smokers (aOR 1.98, 95 % CI 1.35-2.83). However, there were no significant associations between respondents with no/unknown diabetes or hypercholesterolemia with smoking.

CONCLUSIONS

In short, smoking is common among elderly men in Malaysia. Therefore, intervention programs should integrate the present findings to reduce the smoking rate and increase the smoking cessation rate among the elderly in Malaysia and subsequently to reduce the burden of smoking-related disease.

Impact of comorbidities using Adult Comorbidity Evaluation-27 (ACE-27) score on survival in stage II colon cancer: Age, TNM staging, and pathological high risk-disease

659

Background: Impact of comorbidities is identified in stage III colon cancer patients (CCPs) receiving adjuvant chemotherapy (Wildes et al, PMID 21113435) but is not well defined in predicting overall survival (OS) in stage II CCPs undergoing either adjuvant treatment or observation depending upon high-risk disease. The goal of this study was to identify impact of comorbidities on OS in this potentially curable disease using ACE-27 score, which uses 27 different patient comorbid conditions has been developed and validated by Piccirrillo et al at Barnes Jewish Hospital (BJH) (PMID: 24933715). Methods: We identified stage II CCPs treated at BJH, Siteman cancer center from January 1, 1996 to October 31st, 2013 from BJH oncology data cancer registry. The primary outcome was OS, defined as the time from date of surgery to death from any cause, censored at the time of last follow-up. Patient comorbidities at diagnosis were recorded using ACE-27 score, assigning a comorbidity score of none, mild, moderate and severe to the patients. Survival analysis was done using Cox proportional hazard modelling using STATA/SE 11.2 software. Pathological high risk features such as T4 lesions, < 12 LN, perineural, lymphovascular invasion, positive margins & perforation/obstruction were identified. Results: Out of 579 stage II CCPs, 48% male and 51% were females. High risk features were identified in 45% of patients. ACE-27 comorbidity score of none (n = 146), mild (n = 229), moderate (n = 132) and severe (n = 72) was calculated. 497 patients had T3N0M0 and 82 had T4N0M0 staging. Cox regression hazard model using histological prognostic factors, age at surgery, sex, race, prior cancer history and TNM staging showed that ACE-27 score of moderate and severe were independent predictors of OS with a hazard ratio of 1.6 (95% CI 1.0-2.4), P = 0.036 and 2.5 (95% CI 1.5-4.0), P = 0.00 respectively. Conclusions: Highest commodity burden using ACE-27 comorbidity score was associated with poor OS in stage II CCPs and was independent of other prognostic risk factors including high-risk features. Treatment related mortality will be calculated in patients with high risk disease.

A phase I/II study combining tosedostat with capecitabine in patients with metastatic pancreatic adenocarcinoma

TPS471

Background: Metastatic pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis. Recent advances with fluorouracil in combination with oxaliplatin and irinotecan (FOLFIRINOX) and nab-paclitaxel combined with gemcitabine (AG) have improved survival in patients with PDAC. A fluorouracil-based regimen is recommended for patients who progress after a gemcitabine-based regimen. Tosedostat is an oral aminopeptidase inhibitor shown to have anti-proliferative effects in malignancies. Aminopeptidase inhibitors disrupt the cleavage of amino acids from peptides downstream of proteasomal degradation, preventing the recycling of amino acids needed for new protein synthesis. This leads to intracellular depletion of amino acids, resulting in a cellular stress response known as the amino acid deprivation response, which leads to apoptosis. Because pancreatic cancer cells frequently upregulate expression of these aminopeptidases, aminopeptidases inhibitors hold therapeutic promise. Methods: This is a single institution phase I/II open-label trial to evaluate the safety and tolerability of tosedostat plus capecitabine in patients with metastatic PDAC that have progressed after a gemcitabine-based regimen. The phase I part will be conducted in a dose de-escalation fashion, with two planned dose levels of tosedostat (120mg or 60mg) p.o. daily on days 1 to 21 with capecitabine 1000 mg/m2 p.o. BID on days 1 to 14 of a 21-day cycle. If more than one patient in the tosedostat (120 mg) cohort experiences a dose limiting toxicity (DLT), then 6 more patient will be enrolled to the tosedostat (60 mg) cohort. A total of 36 patients will be enrolled in the phase II portion. Primary objective of the phase I portion is to determine the maximum tolerated dose and DLTs of tosedostat and capecitabine combination therapy. Primary objective of the phase II portion is to determine the progression-free survival at 3 months. Secondary objectives are to determine the overall response rate, time-to-progression, overall survival and CA 19-9 response. Exploratory objectives are to explore the predictive molecular biomarkers for treatment response and to explore the prognostic biomarkers. Clinical trial: NCT02352831. Clinical trial information: NCT02352831.

Prospective phase I study of nab-paclitaxel plus gemcitabine with concurrent MR-guided IMRT in patients with locally advanced or borderline resectable pancreatic cancer

TPS480

Background: Radiotherapy (RT) for locally advanced and borderline resectable pancreatic cancer (LABPC) is controversial as potential local control benefits are often obscured by high rates of distant progression. However, local failure remains a significant cause of morbidity among patients without distant progression after initial chemotherapy, although toxicity concerns may limit delivery of optimal systemic therapy concurrent with RT. Given known systemic efficacy and radiosensitization effects of nab-paclitaxel (A) with gemcitabine (G), we initiated a phase I study of nab-paclitaxel with gemcitabine (AG) and concurrent intensity modulated radiation therapy with magnetic resonance guidance (MR-IMRT) for LABPC. Methods: A planned 24 patients with LABPC will be enrolled to a phase I dose escalation trial using the Time-to-Event Continual Reassessment Method (TITE-CRM) design. Following one lead-in cycle of GA, MR-IMRT is administered daily with concurrent weekly GA for a total of 25 fractions in 5 weeks. The initial dose levels for RT and AG, respectively, are: 40 Gy MR-IMRT, 75 mg/m2 A and 600mg/m2 G. The maximum possible dose level is 60 Gy MR-IMRT, 100mg/m2 A and 1000mg/m2 G. To reduce toxicity risk, MR-IMRT volumes include the primary tumor only, with cine-MR used for intra-fraction tumor tracking in place of fiducial markers. The primary endpoint is determination of the maximum tolerated dose level, with secondary endpoints including rate of conversion to resectable disease, progression- free survival, overall survival, and patient reported quality of life. Clinical trial information: NCT02283372.

Utility of a multidisciplinary tumor board in the management of pancreatic diseases

319

Background: Multidisciplinary Tumor Boards (MTBs) are a requirement for comprehensive cancer centers and are routinely used to coordinate multidisciplinary care in oncology. Despite their widespread use, the impact of MTBs is not well characterized. We studied the outcomes of all patients presented at our pancreas MTB, with the goal of evaluating our current practices and resource utilization. Methods: Data were prospectively collected for all patients presented at a weekly pancreas-specific MTB over the 12-month period at a single-institution NCI-designated cancer center. The conference is attended by surgical, medical, and radiation oncologists, interventional gastroenterologists, pathologists, and radiologists (diagnostic and interventional). Retrospective chart review was performed at the end of the 12-month period under an IRB-approved protocol. Results: A total of 470 patient presentations were made over a 12-month period. Average age at time of presentation was 61.5 years (range 17 – 89) with 51% males. 61.7% of cases were presented by surgical oncologists and 26% by medical oncologists. 174 cases were the result of new diagnoses or referrals. 78 patients were presented more than once (average of 2.3 times). Pancreatic adenocarcinoma was the most common diagnosis (37%), followed by uncharacterized pancreatic mass (16%), and pancreatic cyst (7%). The treatment plan proposed by the presenting clinician was known or could be evaluated prior to conference in 402 cases. Presentation of a case at MTB changed the plan of management 25% (n = 100) of the time, including MTB recommendation against a planned resection in 46 cases. When the initial plan changed as a result of MTB discussion, the most common new plan was to obtain further diagnostic testing such as biopsy and/or endoscopy (n = 24). Conclusions: MTBs are required and resource-intensive but offer the opportunity to discuss a wide array of pathologies and influence management decisions in a sizable proportion of cases. Additional investigations evaluating adherence rates to MTB decisions and to published guidelines (i.e. National Comprehensive Cancer Network) will further enhance the assessment and utility of MTBs.

Eosinophilic gastroenteritis: Clinical profiles and treatment outcomes, a retrospective study of 18 adult patients in a Singapore Tertiary Hospital

BACKGROUND

Eosinophilic gastroenteritis (EG) can mimic symptoms of common gastrointestinal (GI) disorders but responds well to appropriate treatment. Accurate diagnosis is central to effective management. Data on EG in Southeast Asia is lacking. We aim to describe the clinical profiles and treatment outcomes of adult patients with EG in a Singapore Tertiary Hospital.

MATERIALS AND METHODS

This retrospective study involved archival search of patients with GI biopsies that showed eosinophilic infiltration from January 2004 to December 2012. Patients' clinical data from computerised hospital records and clinical notes was reviewed. Diagnostic criteria for EG included presence of GI symptoms with more than 30 eosinophils/high power field on GI biopsies. Patients with secondary causes for eosinophilia were excluded.

RESULTS

Eighteen patients with EG were identified (mean age 52 years; male/female: 11/7). Fifteen patients (83%) had peripheral blood eosinophilia. Seven patients (39%) had atopic conditions. Most common symptoms were diarrhoea and abdominal pain. Small intestine was the most common site involved. Endoscopic finding was non-specific. Ten patients were treated with corticosteroids (nine prednisolone, one budesonide): eight patients (89%) responded clinically to prednisolone but four patients (50%) relapsed following tapering-off of prednisolone and required maintenance dose. One patient each responded to diet elimination and montelukast respectively. Half of the remaining six patients who were treated with proton-pump inhibitors, antispasmodic or antidiarrheal agents still remained symptomatic.

CONCLUSION

Prednisolone is an effective treatment though relapses are common. Small intestine is most commonly involved. EG should be considered in the evaluation of unexplained chronic recurrent GI symptoms.

Advanced pancreatic adenocarcinoma: a review of current treatment strategies and developing therapies

Pancreatic adenocarcinoma is one of the deadliest solid malignancies. A large proportion of patients are diagnosed with locally advanced or metastatic disease at the time of presentation and, unfortunately, this severely limits the number of patients who can undergo surgical resection, which offers the only chance for cure. Recent therapeutic advances for patients with advanced pancreatic cancer have extended overall survival, but prognosis still remains grim. Given that traditional chemotherapy is ineffective in curing advanced pancreatic adenocarcinoma, current research is taking a multidirectional approach in the hopes of developing more effective treatments. This article reviews the major clinical trial data that is the basis for the current chemotherapy regimens used as first- and second-line treatments for advanced pancreatic adenocarcinoma. We also review the current ongoing clinical trials, which include the use of agents targeting the oncogenic network signaling of K-Ras, agents targeting the extracellular matrix, and immune therapies.

FOLFIRINOX as first-line therapy in patients with metastatic gastroesophageal cancers (GEC)

177

Background: Adenocarcinomas of the distal esophagus, gastroesophageal junction and stomach (GEC) remain challenging cancers to treat. Unfortunately, 80-90% of newly diagnosed patients (pts) present with advanced disease where the overall median survival (mOS) is less than 1 year. Discouragingly, various common first-line metastatic regimens have similar overall response rates (ORR) (30-40%; and 47% for HER2+ with trastuzumab). Given results within other GI tumors, FOLFIRINOX was administered to pts with newly diagnosed advanced GEC. Methods: A pooled analysis from two independent ongoing clinical trials was conducted from: 1) the University of Chicago UC (NCT01643499) where pts received modified ‘mFOLFIRINOX’ with irinotecan dosing based on UGT1A1*28 genotyping; and 2) Washington University (WU) (NCT01928290) where pts received standard ‘sFOLFIRINOX’ as previously described, and HER2+ pts also received trastuzumab (sFOLFIRINOX-T). Both studies administered therapy every 14 days. Trastuzumab was administered as 6 mg/kg loading dose then 4 mg/kg every 14 days. mFOLFIRINOX used UGT1A1 genotype *1/*1, *1/*28, and *28/*28 to assign initial irinotecan doses of 180, 135, and 90 mg/m2, respectively. The mFOLFIRINOX 5-FU dose was 2400 mg/m2 over 46 hours (no bolus) with leucovorin 400 mg/m2, and oxaliplatin 85 mg/m2. Outcomes included ORR, tolerability/safety, mPFS, and mOS for both trials. Results: In the pooled analysis, 18 pts with GEC were enrolled to date (11 at WU and 7 at UC), and 16 evaluable for response. ORR was 62.5% (10/16), (HER2- 58% (7/12), HER2+ 75% (3/4)). One HER2+ pt experienced a CR. mPFS was 8 months (range 1.5-18 months), however 10/16 pts have not progressed on first-line therapy to date. There were no unexpected toxicities for any of the regimens. Conclusions: ORR and PFS with first-line FOLFIRINOX were encouraging for metastatic GEC. sFOLFIRINOX was well tolerated in these patients, and sFOLFIRINOX-T was safely administered.mFOLFIRINOX consisting of genotype-directed irinotecan dose reductions and no 5FU bolus may limit toxicity yet retain similar benefit to sFOLFIRINOX. Continued investigation of this regimen is warranted given these encouraging preliminary results. Clinical trial information: 01928290.

Phase II trial of levocetirizine with capecitabine and bevacizumab to overcome the resistance of antiangiogenic therapies in refractory metastatic colorectal cancer

763

Background: Despite clinical success of VEGF blockade in mCRC, resistance to anti-angiogenic drugs invariably develops. IL-8 and other cytokines have been implicated in resistance development to anti-angiogenic therapy. Levocetirizine is a third generation antihistamine with anti-inflammatory and IL-8 suppression properties. We conducted a phase II trial combining levocetirizine with capecitabine and bevacizumab to potentially overcome anti-angiogenic therapy resistance in patients with refractory mCRC. Methods: This was a single-center open-label prospective trial in refractory mCRC patients. Treatment consisted of oral capecitabine 850mg/m2 – 7 days on and 7 days off, IV bevacizumab 5 mg/kg every 14 days and oral levocetirizine 5 mg daily in 14 day cycles. The primary end point was PFS and secondary endpoints included ORR and tolerability. An exploratory endpoint included correlation of PFS with cytokine (IL-8 & IL-6) levels. A sample size of 36 evaluable patients could identify a median PFS of 3.4 months at a 0.05 significance level. To document cytokine changes related to levocetirizine treatment, patients were randomized to Arm A where levocetirizine was started 7 days after starting chemotherapy or to Arm B where levocetirizine was started 7 days prior to chemotherapy. For PFS determination both arms were combined for analysis. Cytokine levels were measured at baseline and with each cycle of chemotherapy (up to three cycles). Results: 43 patients were enrolled in the trial to have 36 evaluable patients. Arm A enrolled 20 patients and Arm B enrolled 23 patients. Of the patients evaluable for best response, 19 had SD and 12 had PD. Median PFS of all patients on the study was 3.4 months (ranging 0.9 to 10.6 months). Conclusions: Median PFS in the trial was comparable to and possibly better than other regimens used in the refractory setting (e.g., median PFS of 1.9 months for regorafenib). Cytokine analysis is in progress and these results and correlations with patient outcomes will be presented to assess the impact of cytokine blockade on mCRC treatment. Clinical trial information: NCT01722162.

Phase IB study of FOLFIRINOX plus PF-04136309 in patients with borderline resectable and locally advanced pancreatic adenocarcinoma (PC)

338

Background: PF-04136309 (a novel CCR2 inhibitor) has shown anti-tumor activity in the preclinical setting in PC by depleting inflammatory monocytes and tumor associated macrophages (TAM) that contribute to an immunosuppressive tumor microenvironment. We hypothesized that combining PF-04136309 with FOLFIRINOX may improve clinical outcomes in PC. Methods: This is a phase Ib study with a dose de-escalation schema given the minimal toxicity of PF-04136309. The study includes Arm A (FOLFIRINOX only), Arm B (FOLFIRINOX plus PF-04136309) and an expansion cohort at the rapid phase II dose (RP2D). FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, LV 400 mg/m2, 5FU bolus 400 mg/m2 and 2,400 mg/m2over 46 hours) was administered every two weeks. PF-04136309 at 500 mg twice daily via oral route was the starting dose level for Arm B. Treatment response was assessed after 6 cycles of treatment. Bone marrow biopsy and EUS/FNA at baseline and post 2 cycles were performed to assess the impact of treatment on the prevalence and function of inflammatory monocytes in the blood, bone marrow and tumor. Results: A total of 41 patients have been enrolled in the study to date (6 in Arm A, 8 in Arm B and 27 in the expansion cohort). The mean age of patients was 61.1 (range 45-75 yrs), male/female: 21/20, Caucasian/others: 32/9, borderline/locally advanced: 7/34. PF-04136309 at the starting dose did not result in additional toxicities when combined with FOLFIRINOX and it is the RP2D. Out of 35 patients treated with FOLFIRINOX plus PF-04136309, 6 are still in treatment, 6 are non-evaluable (withdrew consent or had poor tolerance). Of the 23 evaluable patients, 21 (91.3%) completed all 6 cycles; 12 (52.2%) had PR by RECIST and 11 (47.8%) had SD. Curative resections were achieved in 4 out of 5 with borderline resectable and 2 with locally advanced PC. Moreover, blockade of TAM mobilization was demonstrated by FACS and qPCR analysis of baseline and post-treatment FNA biopsies. Conclusions: Combing PF-04136309 with FOLFIRINOX is safe and tolerable. The regimen resulted in impressive treatment response and it further validated CCR2 inhibition in PC. Survival data and more correlative science will be forthcoming. Clinical trial information: 01413022.

Prevalence, awareness, treatment and control of diabetes mellitus among the elderly: The 2011 National Health and Morbidity Survey, Malaysia

Diabetes mellitus is an important cardiovascular risk factor. The objective of this study was to provide population-based estimates on the prevalence, awareness, treatment and control rate of diabetes among the older persons in Malaysia. Analysis of secondary data from a cross-sectional national population-based survey was done, which was conducted in 2011 throughout Malaysia. A total of 2764 respondents (15.5%) were older persons. The overall prevalence of diabetes among older persons was 34.4% in which 65.2% were aware of their diabetes status. Out of those who were aware, 87.5% had been treated. Only 21.8% of those treated had their diabetes controlled. The results of multiple logistic regression showed that the factors associated with higher awareness rates were women, Indians and higher income groups; factors associated with higher treatment rates were urban residents and those who were married and widow/widower/ divorcee. There was a high overall prevalence, awareness and treatment rate of diabetes among older persons in Malaysia but with suboptimal control rate.

Duplication of the vermiform appendix in an adult patient

Duplication of the appendix is extremely rare. A 69-year-old woman was admitted with a 2-day history of right lower quadrant abdominal pain. Physical examination was consistent with acute appendicitis. Ultrasonography and colonoscopy gave a clinical impression of an inflammatory appendiceal mucocoele. Operative findings were an enlarged and inflamed appendix with distal cystic changes. Laparoscopic wedge resection of the caecum was performed. A tubular structure with a true lumen was found in the appendix. Haematoxylin and eosin staining and trichrome staining showed both structures had a true mucosa and a muscular layer. The duplication in this case does not belong to any of the previously described types of duplication.

The prevalence of physical activity and its associated factors among Malaysian adults: findings from the National Health and Morbidity Survey 2011

OBJECTIVES

Despite the health-enhancing benefits of physical activity, a large segment of the Malaysian population does not engage in regular physical activity at the recommended level. This study aimed to determine physical activity patterns and the associated sociodemographic correlates of physical activity.

STUDY DESIGN

Data on physical activity were obtained from the National Health and Morbidity Survey (NHMS) 2011, a nationally representative, population-based cross-sectional study. A two-stage stratified sampling method was used to select a representative sample of Malaysian adults aged 16 years and above.

METHODS

A total of 19,145 adults aged 16 years and above were recruited, and face-to-face interviews were conducted using the International Physical Activity Questionnaire (IPAQ), short version. The correlates for physical activity were identified using multivariate analysis.

RESULTS

In this study, 64.3% (95%CI: 63.1-65.5) of Malaysian adults aged 16 and above were physically active, but overall physical activity levels decreased with advancing age. Men, rural residents, 'other' ethnic groups, and married women were more likely to demonstrate higher levels of physical activity.

CONCLUSION

Approximately 65% of Malaysian adults were physically active. However, it is recommended that health promotions for active lifestyles should be targeted to the least active segments, which constitute more than a quarter of the Malaysian population.

Abstract 4543: High-throughput combination screening identifies novel drug-drug pairings for a Bruton's tyrosine kinase inhibitor against the ABC subtype of diffuse large B-cell lymphomas

The vast majority of cancer treatments currently administered to patients consist of combinations of more than one drug via routine infusions that adhere to specific dosing schedules. It is thought that this multi-arm and time dependent approach will kill not only the tumor cells within the primary site, but also any metastatic lesions, and importantly, any circulating tumor cells (CTCs) which may still exist in the blood. Combination therapies have also been developed as a means to reduce general cytotoxic side effects and prevent resistance and recurrence. Our labs have recently developed a high throughput screening platform to test compounds in pair-wise combinations to rapidly and systematically identify additive, synergistic and antagonistic drug combinations. This HTS capability can easily generate hundreds of dose response matrices in a single study and can increase significantly when applied to multiple cell lines. We are using this combination screening platform with in vitro models from both established cell lines and primary patient material, and we expect it will serve as a very valuable tool and a starting point when designing clinical trials after these combinations show promise within in vivo models. In a proof of concept study, we tested combinations of compounds that effectively kill 2 established lines of the ABC sub-type of diffuse large B-cell lymphoma (DLBCL); TMD8 and HBL1. We will present the infrastructure and methods that we have developed to implement the combination screens, visualize data from the combination dose response comparisons and numerically compare combinations in terms of their response matrices. We will also describe how this approach allows us to investigate putative polypharmacological effects that play a role in compound combination responses. Finally, we will show the results of a combination screen with TMD8 and HBL1 cells, including the identification of a novel drug-drug combination for the BTK inhibitor ibrutinib (PCI-32765) which is of both basic and translational interest for the treatment of DLBCL.

Citation Format: Lesley A. Mathews, Rajarshi Guha, Paul Shinn, Ryan M. Young, Kian-Huat Lim, Jonathan Keller, Dongbo Liu, Adam Yasgar, Crystal McKnight, Matthew B. Boxer, Damien Y. Duveau, Jian-kang Jiang, Sam Michael, Bryan T. Mott, Paresma R. Patel, William Leister, David J. Maloney, Christopher A. LeClair, Ganesha Rai, Ajit Jadhav, Brian D. Peyser, Christopher P. Austin, Scott Martin, Anton Simeonov, Marc Ferrer, Louis Staudt, Craig J. Thomas. High-throughput combination screening identifies novel drug-drug pairings for a Bruton's tyrosine kinase inhibitor against the ABC subtype of diffuse large B-cell lymphomas. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4543. doi:10.1158/1538-7445.AM2013-4543