201
|
Ang C, O'Reilly EM, Carvajal RD, Capanu M, Gonen M, Doyle L, Ghossein R, Schwartz L, Jacobs G, Ma J, Schwartz GK, Abou-Alfa GK. A Nonrandomized, Phase II Study of Sequential Irinotecan and Flavopiridol in Patients With Advanced Hepatocellular Carcinoma. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:185-189. [PMID: 23293699 PMCID: PMC3533846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/16/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Flavopiridol, a Cdk inhibitor, potentiates irinotecan-induced apoptosis. In a phase I trial of sequential irinotecan and flavopiridol, 2 patients with advanced hepatocellular carcinoma (HCC) had stable disease (SD) for ≥14 months. We thus studied the sequential combination of irinotecan and flavopiridol in patients with HCC. METHODS Patients with advanced HCC naïve to systemic therapy, Child-Pugh ≤B8, and Karnofsky performance score (KPS) ≥70% received 100 mg/m(2) irinotecan followed 7 hours later by flavopiridol 60 mg/m(2) weekly for 4 of 6 weeks. The primary end point was an improvement in progression-free survival at 4 months (PFS-4) from 33% to 54%, using a Simon's two-stage design. Tumors were stained for p53. RESULTS Only 16 patients in the first stage were enrolled: median age, 64 years; median KPS, 80%; Child-Pugh A, 87.5%; and stage III/IV, 25%/75%. The primary end point was not met; PFS-4 was 20%, leading to early termination of the study. Ten patients were evaluable for response: 1 had SD >1 year and 9 had disease progression. Grade 3 fatigue, dehydration, diarrhea, neutropenia with or without fever, lymphopenia, anemia, hyperbilirubinemia, and transaminitis occurred in ≥10% of the patients. Of the 9 patients who progressed, 5 had mutant p53 and 4 had wild-type p53. The patient with stable disease had wild-type p53. CONCLUSION Sequential irinotecan and flavopiridol are ineffective and poorly tolerated in patients with advanced HCC. Despite our limited assessments, it is possible that the presence of wild-type p53 is necessary but not sufficient to predict response in HCC.
Collapse
|
202
|
Epstein AS, O'Reilly EM. Exocrine pancreas cancer and thromboembolic events: a systematic literature review. J Natl Compr Canc Netw 2012; 10:835-46. [PMID: 22773799 DOI: 10.6004/jnccn.2012.0087] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Exocrine pancreas cancer continues to represent a significant therapeutic challenge, with high rates of mortality and morbidity, including from thromboembolic events, which have long been described as a frequent complication of the disease. This article provides a systematic and comprehensive review of the literature to address the clinical and pathologic features recognized in pancreas cancer pertaining to thrombosis, and to discuss ongoing investigations of prophylactic anticoagulation in the hopes of improving disease-related outcomes.
Collapse
|
203
|
Karamurzin Y, Zeng Z, Stadler ZK, Zhang L, Ouansafi I, Al-Ahmadie HA, Sempoux C, Saltz LB, Soslow RA, O'Reilly EM, Paty PB, Coit DG, Shia J, Klimstra DS. Unusual DNA mismatch repair-deficient tumors in Lynch syndrome: a report of new cases and review of the literature. Hum Pathol 2012; 43:1677-87. [PMID: 22516243 DOI: 10.1016/j.humpath.2011.12.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 12/09/2011] [Accepted: 12/14/2011] [Indexed: 12/24/2022]
Abstract
Immunohistochemical detection of DNA mismatch repair proteins and polymerase chain reaction detection of microsatellite instability have enhanced the recognition of mismatch repair-deficient neoplasms in patients with Lynch syndrome and, consequently, led to the identification of tumors that have not been included in the currently known Lynch syndrome tumor spectrum. Here, we report 4 such unusual tumors. Three of the 4, a peritoneal mesothelioma, a pancreatic acinar cell carcinoma, and a pancreatic well-differentiated neuroendocrine tumor, represented tumor types that, to the best of our knowledge, have not been previously reported in Lynch syndrome. The fourth tumor was an adrenocortical carcinoma, which has rarely been reported previously in Lynch syndrome. Three of our 4 patients carried a pathogenic germ-line mutation in a mismatch repair gene. The unusual tumor in each of the 3 patients showed loss of the mismatch repair protein corresponding to the mutation. The fourth patient did not have mutation information but had a history of colonic and endometrial carcinomas; both lacked MSH2 and MSH6 proteins. Interestingly, none of the 4 unusual tumors revealed microsatellite instability on polymerase chain reaction testing, whereas an appendiceal carcinoma from 1 of the study patients who was tested simultaneously did. The recognition of such tumors expands the repertoire of usable test samples for the workup of high-risk families. As yet, however, there are no data to support the inclusion of these tumors into general screening guidelines for detecting Lynch syndrome, nor are there data to warrant surveillance for these tumors in patients with Lynch syndrome.
Collapse
|
204
|
Snyder A, Allen P, Shamseddine A, Haydar A, Eloubeidi M, Faraj W, Khalife M, Temraz S, El-Olayan A, Kelsen DP, El-Merhi F, Naghy M, Saltz LB, Abou-Alfa GK, O'Reilly EM. Neoadjuvant Therapy in Clinical Stage II Pancreatic Adenocarcinoma. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:169-173. [PMID: 23112885 PMCID: PMC3481149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
205
|
O'Reilly EM. Adjuvant therapy for pancreas adenocarcinoma. J Surg Oncol 2012; 107:78-85. [PMID: 22886586 DOI: 10.1002/jso.23230] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/10/2012] [Indexed: 01/04/2023]
Abstract
Adjuvant therapy for pancreas adenocarcinoma in 2012 includes consideration of systemic therapy based on high level evidence and combined chemoradiotherapy based on less robust data. Current major adjuvant questions are examining the role of the addition of a second agent, either cytotoxic or targeted agent, to gemcitabine and whether or not the utilization of combined chemoradiotherapy improves overall survival. Progress to date has been modest and incremental in the adjuvant setting.
Collapse
|
206
|
Epstein AS, Abou-Alfa GK, Shamseddine A, Al-Olayan A, Ang C, Naghy M, Lowery MA, O'Reilly EM. Communication and palliative care in a 64-year-old man with pancreatic adenocarcinoma. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:130-134. [PMID: 23077687 PMCID: PMC3433262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
207
|
Tamraz S, Shamseddine A, Shah M, el-Oubeidi M, Zaatari G, Geara F, Lowery MA, O'Reilly EM, Al-Kutoubi A, Faraj W, Kelsen DP, Abou-Alfa GK. A 72-year-old man with duodenal adenocarcinoma. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:93-96. [PMID: 22888389 PMCID: PMC3415721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
208
|
O'Neill CB, Atoria CL, O'Reilly EM, LaFemina J, Henman MC, Elkin EB. Costs and trends in pancreatic cancer treatment. Cancer 2012; 118:5132-9. [PMID: 22415469 DOI: 10.1002/cncr.27490] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 12/12/2011] [Accepted: 01/24/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population-based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time. METHODS In the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer-free beneficiaries. RESULTS A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer-directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700. CONCLUSIONS Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future.
Collapse
|
209
|
Ang C, Janjigian YY, Shamseddine A, Tawil A, Lowery MA, Intlekofer A, Faraj W, Al-Olayan A, Tang L, O'Reilly EM, Geara F, Al-Kutoubi A, Kelsen DP, Abou-Alfa GK. A case of advanced gastric cancer. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:59-63. [PMID: 22690259 PMCID: PMC3369598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
210
|
Lowery M, Klimstra D, Hedvat C, Jarnagin W, Chi D, O'Reilly EM. A case of synchronous pancreatic ductal adenocarcinoma and ovarian mucinous cystic neoplasm: use of kras mutation molecular phenotyping to demonstrate independent primary origin. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:67-70. [PMID: 22690261 PMCID: PMC3369596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
211
|
Volandes AE, Levin TT, Slovin S, Carvajal RD, O'Reilly EM, Keohan ML, Theodoulou M, Dickler M, Gerecitano JF, Morris M, Epstein AS, Naka-Blackstone A, Walker-Corkery ES, Chang Y, Noy A. Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study. Cancer 2012; 118:4331-8. [PMID: 22252775 DOI: 10.1002/cncr.27423] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND The authors tested whether an educational video on the goals of care in advanced cancer (life-prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation. METHODS A survey of 80 patients with advanced cancer was conducted before and after they viewed an educational video. The outcomes of interest included changes in goals of care preference and knowledge and consistency of preferences with code status. RESULTS Before viewing the video, 10 patients (13%) preferred life-prolonging care, 24 patients (30%) preferred basic care, 29 patients (36%) preferred comfort care, and 17 patients (21%) were unsure. Preferences did not change after the video, when 9 patients (11%) chose life-prolonging care, 28 patients (35%) chose basic care, 29 patients (36%) chose comfort care, and, 14 patients (18%) were unsure (P = .28). Compared with baseline, after the video presentation, more patients did not want cardiopulmonary resuscitation (CPR) (71% vs 62%; P = .03) or ventilation (80% vs 67%; P = .008). Knowledge about goals of care and likelihood of resuscitation increased after the video (P < .001). Of the patients who did not want CPR or ventilation after the video augmentation, only 4 patients (5%) had a documented do-not-resuscitate order in their medical record (kappa statistic, -0.01; 95% confidence interval, -0.06 to 0.04). Acceptability of the video was high. CONCLUSIONS Patients with advanced cancer did not change care preferences after viewing the video, but fewer wanted CPR or ventilation. Documented code status was inconsistent with patient preferences. Patients were more knowledgeable after the video, reported that the video was acceptable, and said they would recommend it to others. The current results indicated that this type of video may enable patients to visualize "goals of care," enriching patient understanding of worsening health states and better informing decision making.
Collapse
|
212
|
Mukherji D, Faraj W, Khalife M, Shamseddine A, El Majzoub N, Zaatari G, Shah M, Abou-Alfa GK, O'Reilly EM. A 71-year-old man with a large cystic pancreatic mass. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:29-31. [PMID: 22574234 PMCID: PMC3348712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
213
|
Lowery MA, O'Reilly EM. Genomics and pharmacogenomics of pancreatic adenocarcinoma. THE PHARMACOGENOMICS JOURNAL 2011; 12:1-9. [PMID: 22186617 DOI: 10.1038/tpj.2011.52] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The last decade has brought significant advances in the development of molecularly targeted therapies for treatment of a variety of human malignancies. In contrast to other solid tumors, however, the impact of novel therapeutic strategies on clinical outcomes in patients with pancreas adenocarcinoma (PAC) has been limited to date. Gemcitabine was established as a standard of care for treatment of advanced PAC in 1997 based on an observed improvement in clinical benefit as adjudicated principally by pain scores and analgesic consumption, and demonstration of an overall survival (OS) benefit in a randomized comparison with 5-fluorouracil (5-FU). Since then, multiple agents targeting oncogenic signaling pathways and mediators of angiogenesis have failed to improve outcomes in phase III clinical trials when compared with gemcitabine monotherapy. An exception to this is the anti-epidermal growth factor receptor therapy erlotinib, which yielded a survival benefit in patients with advanced disease in combination with gemcitabine compared with gemcitabine alone, although this was a marginal incremental improvement for which the clinical significant has been heavily debated. More recently, the most significant therapeutic advance in PAC has come from the combination of several cytotoxic agents; infusional 5-FU, irinotecan and oxaliplatin. This combination chemotherapy regimen, known as FOLFIRINOX, improved survival in patients with an excellent functional status and stage IV disease by 4.3 months compared with gemcitabine alone. This improvement in survival did come at the cost expectedly of a significant increase in toxicities, including gastrointestinal and hematologic particularly. Other gemcitabine-based combination chemotherapy regimens including gemcitabine and platinum analogs and gemcitabine and capecitabine have consistently shown an increased response rate but no OS benefit in individual trials; albeit pooled and meta-analyses have indicated a survival benefit in good performance status patient for both these cytotoxic combinations. Accordingly, the 5-year survival for patients with PAC remains <5%, with an annual disease-specific mortality which approaches the incidence. The challenge remains therefore, to develop more effective systemic therapies against this challenging malignancy. Recent progress toward understanding the genetic events in the development of PAC, in combination with advances in the field of pharmacogenomics offer hope that we may build on achievements to-date to develop more effective therapeutic strategies for PAC in years to come.
Collapse
|
214
|
Lowery MA, O'Reilly EM. New approaches to the treatment of pancreatic cancer: from tumor-directed therapy to immunotherapy. BioDrugs 2011; 25:207-16. [PMID: 21815696 DOI: 10.2165/11592470-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The development of novel therapeutic strategies for pancreatic adenocarcinoma (PAC) has traditionally been considered particularly challenging for clinical and laboratory investigators due to its aggressive underlying biology and inherent resistance to currently available therapies. More recently, however, advances have been made in the identification of promising therapeutic targets for intervention, along with several key insights into the complex sequence of genetic alterations involved in the evolution of PAC from premalignant precursor lesion to malignant cells with metastatic potential. FOLFIRINOX (5-fluorouracil/leucovorin/irinotecan/oxaliplatin) has recently been identified as a combination cytotoxic therapy associated with a significant survival benefit over single-agent gemcitabine in good performance status patients with advanced disease; it is hoped that a similar benefit will be seen in planned trials of FOLFIRINOX as perioperative therapy. The success of immune therapy with the anti-cytotoxic T-lymphocyte antigen-4 antibody ipilimumab in advanced melanoma has spurred interest in the development of vaccines and immune therapies for other solid tumors. Certainly, the concept of harnessing the power of the immune system for cancer treatment is an attractive concept to patients and clinicians alike. Herein we discuss recent advances in the development of novel therapeutic approaches to PAC, focusing in particular on recent developments in immune and vaccine therapy.
Collapse
|
215
|
Lowery MA, O'Reilly EM. Pancreatic cancer: the role of molecular markers in diagnosis and management. CLINICAL ADVANCES IN HEMATOLOGY & ONCOLOGY : H&O 2011; 9:900-908. [PMID: 22252658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Despite an annual incidence of just 40,000 new cases per year, pancreatic adenocarcinoma (PAC) remains the fourth most common cause of cancer-related mortality in the United States, a fact indicative of the considerable diagnostic and therapeutic challenges posed by this malignancy. The availability of increasingly sophisticated molecular techniques over the last decade has intensified the search for biomarkers not only to predict outcome and response to therapy in established pancreatic malignancy but also to identify premalignant pancreatic lesions in at-risk individuals. A wealth of information regarding the complex sequence of genetic abnormalities in PAC has been gained from recent in-depth molecular analyses, and lately the role of epigenetic alterations in the development and maintenance of pancreatic carcinogenesis has been more clearly described. In addition, advances in serum proteomic methods and the collection of circulating tumor cells offer hope for the development of noninvasive techniques for biomarker discovery. At present, we are awaiting the development and validation of robust biomarkers suitable for clinical application in this disease. Herein, we discuss the current status of molecular markers in the diagnosis and management of PAC and review potential clinical applications thereof.
Collapse
|
216
|
Epstein AS, O'Reilly EM. Targeting thrombosis in exocrine pancreas cancer: a continued need for improved therapies. Expert Rev Anticancer Ther 2011; 11:1783-5. [PMID: 22117145 DOI: 10.1586/era.11.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
217
|
Ang C, O'Reilly EM, Abou-Alfa GK. MicroRNA, hypoxic stress and hepatocellular carcinoma: future directions. J Gastroenterol Hepatol 2011; 26:1586-8. [PMID: 22011295 DOI: 10.1111/j.1440-1746.2011.06903.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
|
218
|
Lowery MA, Klimstra DS, Shia J, Yu KH, Allen PJ, Brennan MF, O'Reilly EM. Acinar cell carcinoma of the pancreas: new genetic and treatment insights into a rare malignancy. Oncologist 2011; 16:1714-20. [PMID: 22042785 DOI: 10.1634/theoncologist.2011-0231] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acinar cell carcinoma (ACC) of the pancreas is a rare neoplasm, accounting for 1% of all pancreatic neoplasms. There remains a lack of data regarding the use of systemic therapy in this disease. We present a series of 40 consecutive cases of ACC of the pancreas treated at Memorial Sloan-Kettering Cancer Center, with an emphasis on evaluation of activity of new therapeutic agents. METHODS Patients reviewed at our institution from January 2000 through January 2011 were identified from an institutional database with prior institutional review board approval. Pathology was confirmed in all cases as ACC or a closely related entity. RESULTS Forty patients were identified; 29 were male (73%). The median age at diagnosis was 65 years (range, 16-87 years). The median overall survival (OS) time for patients with localized, resectable disease was 56.9 months and the OS time for patients with metastatic ACC (n = 18) was 19.6 months. Six patients with metastatic or recurrent ACC had a partial response to chemotherapy and five patients had stable disease for ≥6 months on systemic chemotherapy. Clinical observation was made of a patient with ACC and hereditary nonpolyposis colorectal cancer and a patient with ACC and a BRCA1 germline mutation. CONCLUSIONS ACC is moderately chemoresponsive to agents that have activity in pancreatic adenocarcinoma and colorectal carcinoma. A potential association between germline mutations in DNA mismatch repair genes and ACC warrants further evaluation.
Collapse
|
219
|
Epstein AS, Soff GA, Capanu M, Crosbie C, Shah MA, Kelsen DP, Denton B, Gardos S, O'Reilly EM. Analysis of incidence and clinical outcomes in patients with thromboembolic events and invasive exocrine pancreatic cancer. Cancer 2011; 118:3053-61. [PMID: 21989534 DOI: 10.1002/cncr.26600] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/16/2011] [Accepted: 06/23/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic adenocarcinoma is among the most common malignancies associated with thromboembolic events (TEs); however, reported incidence figures vary significantly and contain small patient cohorts. Pancreatic cancer-specific thrombosis studies examining the correlation between clinical variables, including thrombosis timing and the impact of thrombosis on survival, have not been reported. METHODS Survival analyses were performed relating to the development and timing of a TE in 1915 patients administered chemotherapy at Memorial Sloan-Kettering Cancer Center with invasive exocrine pancreatic cancer from January 1, 2000 to December 31, 2009. TE timing, relative to clinical parameters including laboratory data, erythropoietin-stimulating agent use, and body mass index (BMI), were also analyzed. RESULTS A thrombosis was identified in 690 (36%) patients. After adjusting for patients with pancreatic surgery and thrombosis (n = 127), developing a TE significantly increased the risk of death (hazard ratio [HR], 2.6; 95% confidence interval [CI], 2.3-2.8; P < .01). Patients with an early TE (within 1.5 months from pancreatic cancer diagnosis) had a significantly higher risk of death (HR, 2.1; 95% CI, 1.7-2.5; P < .01) compared with patients with late TE or no TE. Erythropoietin-stimulating agent use and an elevated international normalized ratio were associated with significantly shorter time to thrombosis. Low BMI was associated with significantly longer time to thrombosis. CONCLUSIONS TEs are common in exocrine pancreatic cancer, with coagulopathy, erythropoietin-stimulating agent use, and underweight BMI influencing thrombosis timing. TEs, particularly early ones, confer a significantly worse prognosis, suggesting a biological significance, underscoring the relevance of ongoing prophylaxis trials, and raising the question of whether early TEs should be considered a stratification factor for clinical trials.
Collapse
|
220
|
Lowery MA, Kelsen DP, Stadler ZK, Yu KH, Janjigian YY, Ludwig E, D'Adamo DR, Salo-Mullen E, Robson ME, Allen PJ, Kurtz RC, O'Reilly EM. An emerging entity: pancreatic adenocarcinoma associated with a known BRCA mutation: clinical descriptors, treatment implications, and future directions. Oncologist 2011; 16:1397-402. [PMID: 21934105 DOI: 10.1634/theoncologist.2011-0185] [Citation(s) in RCA: 195] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND BRCA1 and BRCA2 germline mutations are associated with an elevated risk for pancreas adenocarcinoma (PAC). Other BRCA-associated cancers have been shown to have greater sensitivity to platinum and poly(ADP-ribose) polymerase (PARP) inhibitors with better clinical outcomes than in sporadic cases; however, outcomes in BRCA-associated PAC have not been reported. METHODS Patients with a known BRCA1 or BRCA2 mutation and a diagnosis of PAC were identified from the Gastrointestinal Oncology Service, Familial Pancreas Cancer Registry, and Clinical Genetics Service at Memorial Sloan-Kettering Cancer Center. RESULTS Fifteen patients, five male, with a BRCA1 (n = 4) or BRCA2 (n = 11) mutation and PAC and one patient with a BRCA1 mutation and acinar cell carcinoma of the pancreas were identified. Seven female patients (70%) had a prior history of breast cancer. Four patients received a PARP inhibitor alone or in combination with chemotherapy; three demonstrated an initial radiographic partial response by Response Evaluation Criteria in Solid Tumors whereas one patient had stable disease for 6 months. Six patients received platinum-based chemotherapy first line for metastatic disease; five of those patients had a radiographic partial response. CONCLUSION BRCA mutation-associated PAC represents an underidentified, but clinically important, subgroup of patients. This is of particular relevance given the ongoing development of therapeutic agents targeting DNA repair, which may potentially offer a significant benefit to a genetically selected population. We anticipate that further study and understanding of the clinical and biologic features of BRCA-mutant PAC will aid in the identification of tissue biomarkers indicating defective tumor DNA repair pathways in sporadic PAC.
Collapse
|
221
|
Ang C, Abu-Alfa AK, Abdullah K, Lowery M, Sibai H, El Farran H, Tamraz S, Al Olayan A, Shamseddine A, Naghy M, Faraj W, O'Reilly EM, Abou-Alfa GK. Hepatocellular carcinoma following renal transplantation. GASTROINTESTINAL CANCER RESEARCH : GCR 2011; 4:180-183. [PMID: 22295131 PMCID: PMC3269137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
222
|
O'Reilly EM. Adjuvant therapy for pancreas adenocarcinoma: where are we going? Expert Rev Anticancer Ther 2011; 11:173-7. [PMID: 21342036 DOI: 10.1586/era.10.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Evaluation of: Neoptolemos JP, Stocken DD, Bassi C et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs. gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 304(10), 1073-1081 (2010). Over the last decade, adjuvant therapy in the treatment of resected pancreas adenocarcinoma has had its value established. Such treatment incrementally increases 5-year survivorship and delays time to tumor recurrence. The backbone of adjuvant therapy is the single-agent gemcitabine, based primarily on results from the Charité Onkologie Clinical (CONKO)-001 study. Based on the combined results of the European Study Group for Pancreas Cancer (ESPAC)-1 and ESPAC-3 trials, Neoptolemos and colleagues have established both bolus 5-fluorouracil and leucovorin and gemcitabine as standard options for resected pancreatic cancer. Gemcitabine remains the main standard therapy based on its ease of administration and a more favorable toxicity profile; however, there is now a clearly validated alternate option of 5-fluororuacil and leucovorin based on the results of ESPAC-3. Moving forward, the integration of novel cytotoxic and targeted agents into adjuvant therapy, along with refining the role of neoadjuvant therapy for patients with resectable pancreas cancer, will hopefully accrue a more substantial improvement in outcome for patients with resected pancreas adenocarcinoma.
Collapse
|
223
|
Roberts AS, Campa MJ, Gottlin EB, Jiang C, Owzar K, Kindler HL, Venook AP, Goldberg RM, O'Reilly EM, Patz EF. Identification of potential prognostic biomarkers in patients with untreated, advanced pancreatic cancer from a phase 3 trial (Cancer and Leukemia Group B 80303). Cancer 2011; 118:571-8. [PMID: 21713765 DOI: 10.1002/cncr.26270] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 04/05/2011] [Accepted: 04/13/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with advanced stage adenocarcinoma of the pancreas have a poor prognosis. The identification of prognostic and/or predictive biomarkers may help stratify patients so that therapy can be individualized. METHODS Serum samples from patients enrolled in the Cancer and Leukemia Group B 80303 phase 3 trial, "Randomized Study of Gemcitabine With Versus Without Bevacizumab in Patients With Locally Advanced or Metastatic Adenocarcinoma of the Pancreas" were used to discover novel biomarkers. For the discovery phase, 40 sera were selected based on length of survival and type of therapy, and subjected to liquid chromatography coupled to tandem mass spectrometry analysis (LC-MS-MS). The top features (proteins) were then further selected for validation by enzyme-linked immunosorbent assay (ELISA). RESULTS Quantification by nano-LC-MS-MS resulted in 1452 peptides mapping to 156 proteins across all 40 samples, 92 of which had 2 or more peptides. After curation of the data, the authors selected 1 putative prognostic protein, alpha 1-antichymotrypsin (AACT), and 2 putative predictive proteins, histidine-rich glycoprotein (HRG) and complement factor H (CFH), for validation by ELISA. AACT was found to be negatively correlated with overall survival (τ = -0.30 [-0.38, -0.22]; P < .00001). There was no evidence for interaction with bevacizumab and HRG, but there was some evidence for a weak positive correlation of HRG with overall survival (τ = 0.11 [0.03, 0.19]; P < .01). CFH was found to be neither a predictive nor a prognostic factor for overall survival. CONCLUSIONS AACT may be a useful prognostic marker in patients with advanced stage pancreatic carcinoma, although additional validation studies are needed.
Collapse
|
224
|
O'Reilly EM, Niedzwiecki D, Hall M, Hollis D, Bekaii-Saab T, Pluard T, Douglas K, Abou-Alfa GK, Kindler HL, Schilsky RL, Goldberg RM. A Cancer and Leukemia Group B phase II study of sunitinib malate in patients with previously treated metastatic pancreatic adenocarcinoma (CALGB 80603). Oncologist 2010; 15:1310-9. [PMID: 21148613 PMCID: PMC3227926 DOI: 10.1634/theoncologist.2010-0152] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 10/08/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Cancer and Leukemia Group B (CALGB) conducted a phase II study evaluating sunitinib in patients with progressive metastatic pancreas adenocarcinoma following prior gemcitabine-based therapy (trial CALGB 80603; ClinicalTrials.gov identifier, NCT00397787). The primary endpoint was to determine the disease control rate (DCR) as measured by the Response Evaluation Criteria in Solid Tumors (complete response, partial response [PR], and stable disease) at 6 weeks. PATIENTS AND METHODS Patients aged ≥18 years with an Eastern Cooperative Oncology Group (ECOG) performance status score of 0-2 and with progressive pancreas adenocarcinoma following treatment with gemcitabine were eligible. Sunitinib was dosed at 50 mg orally days 1-28, every 42 days (1 cycle). The statistical plan called for a three-stage design. A DCR ≥15% was considered worthy of further study. RESULTS In total, 77 patients were enrolled. Forty-two (54.6%) enrollees were male. The median age was 65 years. The ECOG performance status score distribution was: 0, 39%; 1, 50%; 2, 11%. The DCR was 21.6%; one patient (1.4%) had a PR and 15 patients (20.3%) had stable disease as their best response. The progression-free survival time was 1.31 months (95% confidence interval [CI] 1.25-1.38 months) and overall survival time was 3.68 months (95% CI, 3.06-4.24 months). CONCLUSIONS The study met its primary endpoint; however sunitinib had minimal activity and moderate toxicity in a population of gemcitabine-refractory pancreas adenocarcinoma patients. For future studies, limiting enrollment to patients with an ECOG performance status score of 0-1 is recommended.
Collapse
|
225
|
Lowery MA, O'Reilly EM. Pancreatic adenocarcinoma: new approaches to a challenging malignancy. ONCOLOGY (WILLISTON PARK, N.Y.) 2010; 24:1339-1342. [PMID: 21294480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
|
226
|
|
227
|
Picozzi VJ, Abrams RA, Decker PA, Traverso W, O'Reilly EM, Greeno E, Martin RC, Wilfong LS, Rothenberg ML, Posner MC, Pisters PWT. Multicenter phase II trial of adjuvant therapy for resected pancreatic cancer using cisplatin, 5-fluorouracil, and interferon-alfa-2b-based chemoradiation: ACOSOG Trial Z05031. Ann Oncol 2010; 22:348-54. [PMID: 20670978 DOI: 10.1093/annonc/mdq384] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The American College of Surgeons Oncology Group sought to confirm the efficacy of a novel interferon-based chemoradiation regimen in a multicenter phase II trial. PATIENTS AND METHODS Patients with resected (R0/R1) adenocarcinoma of the pancreatic head were treated with adjuvant interferon-alfa-2b (3 million units s.c. on days 1, 3, and 5 of each week for 5.5 weeks), cisplatin (30 mg/m(2) i.v. weekly for 6 weeks), and continuous infusion 5-fluorouracil (5-FU; 175 mg·m(2)/day for 38 days) concurrently with external-beam radiation (50.4 Gy). Chemoradiation was followed by two 6-week courses of continuous infusion 5-FU (200 mg·m(2)/day). The primary study end point was 18-month overall survival from protocol enrollment (OS18); an OS18 ≥65% was considered a positive study outcome. RESULTS Eighty-nine patients were enrolled. Eighty-four patients were assessable for toxicity. The all-cause grade ≥3 toxicity rate was 95% (80 patients) during therapy. No long-term toxicity or toxicity-related deaths were noted. At 36-month median follow-up, the OS18 was 69% [95% confidence interval (CI) 60% to 80%]; the median disease-free survival and overall survival were 14.1 months (95% CI 11.0-20.1 months) and 25.4 months (95% CI 23.4-34.1 months), respectively. CONCLUSIONS Notwithstanding promising multi-institutional efficacy results, further development of this regimen will require additional modifications to mitigate toxic effects.
Collapse
|
228
|
Philip PA, Benedetti J, Corless CL, Wong R, O'Reilly EM, Flynn PJ, Rowland KM, Atkins JN, Mirtsching BC, Rivkin SE, Khorana AA, Goldman B, Fenoglio-Preiser CM, Abbruzzese JL, Blanke CD. Phase III study comparing gemcitabine plus cetuximab versus gemcitabine in patients with advanced pancreatic adenocarcinoma: Southwest Oncology Group-directed intergroup trial S0205. J Clin Oncol 2010; 28:3605-10. [PMID: 20606093 DOI: 10.1200/jco.2009.25.7550] [Citation(s) in RCA: 478] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Patients with advanced pancreas cancer present with disease that is poorly responsive to conventional therapies. Preclinical and early clinical evidence has supported targeting the epidermal growth factor receptor (EGFR) signaling pathway in patients with pancreas cancer. This trial was conducted to evaluate the contribution of an EGFR-targeted agent to standard gemcitabine therapy. Cetuximab is a monoclonal antibody against the ligand-binding domain of the receptor. PATIENTS AND METHODS Patients with unresectable locally advanced or metastatic pancreatic adenocarcinoma were randomly assigned to receive gemcitabine alone or gemcitabine plus cetuximab. The primary end point was overall survival. Secondary end points included progression-free survival, time to treatment failure, objective response, and toxicity. RESULTS A total of 745 eligible patients were accrued. No significant difference was seen between the two arms of the study with respect to the median survival time (6.3 months for the gemcitabine plus cetuximab arm v 5.9 months for the gemcitabine alone arm; hazard ratio = 1.06; 95% CI, 0.91 to 1.23; P = .23, one-sided). Objective responses and progression-free survival were similar in both arms of the study. Although time to treatment failure was longer in patients on gemcitabine plus cetuximab (P = .006), the difference in length of treatment was only 2 weeks longer in the combination arm. Among patients who were studied for tumoral EGFR expression, 90% were positive, with no treatment benefit detected in this patient subset. CONCLUSION In patients with advanced pancreas cancer, the anti-EGFR monoclonal antibody cetuximab did not improve the outcome compared with patients treated with gemcitabine alone. Alternate targets other than EGFR should be evaluated for new drug development.
Collapse
|
229
|
Moinpour CM, Vaught NL, Goldman B, Redman MW, Philip PA, Millwood B, Lippman SM, Seay TE, Flynn PJ, O'Reilly EM, Rowland KM, Wong RP, Benedetti J, Blanke CD. Pain and emotional well-being outcomes in Southwest Oncology Group-directed intergroup trial S0205: a phase III study comparing gemcitabine plus cetuximab versus gemcitabine as first-line therapy in patients with advanced pancreas cancer. J Clin Oncol 2010; 28:3611-6. [PMID: 20606094 DOI: 10.1200/jco.2009.25.8285] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE S0205 was a randomized clinical trial that compared the therapeutic impact of gemcitabine versus gemcitabine plus cetuximab. Study results for patient-reported health-related quality of life (HRQL) outcomes are reported. PATIENTS AND METHODS Patients completed the Brief Pain Inventory and a measure of emotional well-being (each measured on a 0 to 10 scale) at baseline and at weeks 5, 9, 13, and 17 postrandom assignment. Worst pain status was classified as palliated (worst pain scores < 5 maintained for 2 consecutive cycles) or not palliated (remaining patients) and tested with a chi(2) test. Change in emotional well-being and worst pain (exploratory analysis) were assessed over 17 weeks using generalized estimating equations with inverse probability of censoring weights. RESULTS Seven hundred twenty of 766 enrolled patients contributed baseline HRQL data. The two treatment arms did not differ statistically in the percentage of patients with successful worst pain palliation. Longitudinal analyses showed significantly improved emotional well-being for patients on both arms by weeks 13 and 17 (P < .01 and P < .001). An exploratory longitudinal analysis of worst pain showed significant decreases at all time points for both arms (P < .01 and P < .001). Significant treatment arm differences for either worst pain or emotional well-being were not observed at any of the assessment times. CONCLUSION We observed palliated pain and improved well-being for patients on this trial. However, these improvements were similar in both treatment arms, suggesting that the addition of cetuximab did not contribute to improvement in these HRQL outcomes.
Collapse
|
230
|
Nagula S, Jarnagin WR, O'Reilly EM, Schattner MA. Capsule-induced small-bowel obstruction during video capsule endoscopy in a patient with carcinomatosis. Dig Dis Sci 2010; 55:1778-80. [PMID: 19657736 DOI: 10.1007/s10620-009-0904-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 06/29/2009] [Indexed: 12/22/2022]
|
231
|
Huitzil-Melendez FD, Capanu M, O'Reilly EM, Duffy A, Gansukh B, Saltz LL, Abou-Alfa GK. Advanced hepatocellular carcinoma: which staging systems best predict prognosis? J Clin Oncol 2010; 28:2889-95. [PMID: 20458042 DOI: 10.1200/jco.2009.25.9895] [Citation(s) in RCA: 252] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The purpose of cancer staging systems is to accurately predict patient prognosis. The outcome of advanced hepatocellular carcinoma (HCC) depends on both the cancer stage and the extent of liver dysfunction. Many staging systems that include both aspects have been developed. It remains unknown, however, which of these systems is optimal for predicting patient survival. PATIENTS AND METHODS Patients with advanced HCC treated over a 5-year period at Memorial Sloan-Kettering Cancer Center were identified from an electronic medical record database. Patients with sufficient data for utilization in all staging systems were included. TNM sixth edition, Okuda, Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP), Chinese University Prognostic Index (CUPI), Japan Integrated Staging (JIS), and Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire (GETCH) systems were ranked on the basis of their accuracy at predicting survival by using concordance index (c-index). Other independent prognostic variables were also identified. RESULTS Overall, 187 eligible patients were identified and were staged by using the seven staging systems. CLIP, CUPI, and GETCH were the three top-ranking staging systems. BCLC and TNM sixth edition lacked any meaningful prognostic discrimination. Performance status, AST, abdominal pain, and esophageal varices improved the discriminatory ability of CLIP. CONCLUSION In our selected patient population, CLIP, CUPI, and GETCH were the most informative staging systems in predicting survival in patients with advanced HCC. Prospective validation is required to determine if they can be accurately used to stratify patients in clinical trials and to direct the appropriate need for systemic therapy versus best supportive care. BCLC and TNM sixth edition were not helpful in predicting survival outcome, and their use is not supported by our data.
Collapse
|
232
|
Lowery M, O'Reilly EM. Targeted therapies for pancreatic adenocarcinoma. MINERVA CHIR 2009; 64:501-519. [PMID: 19859040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The majority of patients diagnosed with adenocarcinoma of the pancreas have advanced disease at presentation, with only 20% surviving beyond one year. Even among the 10% to 15% of patients who present with localized disease, only 20% will be alive 5 years post surgical resection. Systemic therapy for pancreatic adenocarcinoma to date has failed to provide more than a very modest survival benefit for patients with advanced disease. However, the past decade has seen significant advances in the understanding of the molecular pathogenesis of pancreatic cancer, culminating in the sequencing of the pancreatic cancer genome. New generations of therapeutic agents targeting key oncogenic cellular signaling pathways are currently under evaluation in advanced pancreatic adenocarcinoma. Although thus far only erlotinib has been shown to improve survival when compared to gemcitabine monotherapy, the authors anticipate that further developments in biomarker analysis and pharmacogenomics, along with the identification of new drugs will help maximize the benefit of novel therapeutics by directing effective use in the future. Herein the authors review the evidence to date for the use of novel cytotoxic and molecularly targeted agents in pancreatic adenocarcinoma, and discuss key areas for future therapeutic development.
Collapse
|
233
|
Duffy A, Capanu M, Allen P, Kurtz R, Olson SH, Ludwig E, Klimstra DS, O'Reilly EM. Pancreatic adenocarcinoma in a young patient population--12-year experience at Memorial Sloan Kettering Cancer Center. J Surg Oncol 2009; 100:8-12. [PMID: 19384918 DOI: 10.1002/jso.21292] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a dearth of data in a younger population of patients with pancreatic ductal adenocarcinoma (PAC) regarding epidemiology, genetics, prognosis, and outcome. This report examines a large cohort of patients with PAC <or=45 years of age evaluated at MSKCC over a 12-year period. METHODS A retrospective analysis of patients referred to MSKCC with PAC identified from the institutional tumor registry, who were <or=45 years on the date of the diagnostic biopsy, between January 1995 and February 2008, was performed. Information reviewed included demographics, clinical and pathological staging, surgical management, therapy, date of relapse, death or last follow-up. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS One hundred thirty-six cases of PAC, age <or=45 years at diagnosis, were identified. Seventy-four (54%) females, 62 (46%) males. Age range: 24-45; 4, 38, and 94 patients in age groups 20-29, 30-39, 40-45 years, respectively. Fifty (37%) had a smoking history. Fourteen (10.3%) had a positive family history of PAC. Thirty-five (25.7%) underwent a curative resection for localized disease. Twenty-eight (20.1%) presented with locally advanced, inoperable disease. Sixty-eight (50%) presented as AJCC Stage IV. Twenty-three (37%) of those resected underwent adjuvant chemoradiation. Thirteen received adjuvant gemcitabine. The median overall survival for the entire cohort was 12.3 months (95% CI 10.2-14.0 months). The median overall survival for the patients with locally resectable disease was 41.8 months (95% CI 20.3-47 months). The median overall survival for the patients who presented with locally advanced, unresectable disease was 15.3 months (95% CI 12-19.3 months). The median overall survival for those who presented with metastatic disease was 7.2 months (95% CI 5.2-9.5 months). CONCLUSIONS This is the largest reported cohort of young patients with PAC <or=45 years of age. The data suggest that patients with stages I-II disease may have an improved prognosis, however the prognosis for stages III-IV patients appears to be similar to the typical (older) patient population with PAC.
Collapse
|
234
|
Huitzil-Melendez FD, O'Reilly EM, Duffy A, Abou-Alfa GK. Indications for neoadjuvant, adjuvant, and palliative chemotherapy in the treatment of biliary tract cancers. Surg Oncol Clin N Am 2009; 18:361-79, x. [PMID: 19306817 DOI: 10.1016/j.soc.2008.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Advanced biliary tract carcinomas represent a group of aggressive diseases that still carries a poor prognosis. Chemotherapy has been shown to provide disease control and may also prolong survival. An established role for systemic therapy in the adjuvant setting is still lacking. This article reviews the available evidence to support indications of systemic chemotherapy in the palliative setting and discuss the attempts to study it in the perioperative settings.
Collapse
|
235
|
Murugesan SR, King CR, Osborn R, Fairweather WR, O'Reilly EM, Thornton MO, Wei LL. Combination of human tumor necrosis factor-alpha (hTNF-alpha) gene delivery with gemcitabine is effective in models of pancreatic cancer. Cancer Gene Ther 2009; 16:841-7. [PMID: 19444305 DOI: 10.1038/cgt.2009.32] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pancreatic adenocarcinoma is an aggressive and highly lethal malignancy. Currently, gemcitabine is commonly used in patients with pancreatic cancer. However, the life expectancy of pancreatic cancer patients remains poor. We explored the possibility of increased anti-tumor activity by combining human tumor necrosis factor-alpha (hTNF-alpha) with current front-line therapy. Human TNF-alpha displays potent anti-tumor activity, but its use is limited by the toxicity of systemic administration. We developed a gene delivery approach using intratumoral injections of an adenoviral vector expressing hTNF-alpha, AdEgr.TNF.11D (TNFerade), to increase local concentrations of hTNF-alpha within the tumor, thereby maximizing local anti-tumor activity and yet minimizing the systemic toxicities. An ongoing phase III clinical trial is testing the efficacy of AdEgr.TNF.11D-injected intratumorally and combining with chemotherapy in locally advanced pancreatic cancer. In this study, we show that treatment with AdEgr.TNF.11D and gemcitabine results in a high level of hTNF-alpha expression in human pancreatic cancer cell lines. The combined treatment was well tolerated, highly active and produced marked delays in the growth of human pancreatic xenograft tumors relative to either agent alone. Our results strongly suggest that combination of AdEgr.TNF.11D and gemcitabine may be a potentially useful therapeutic approach for the improved treatment of pancreatic cancer.
Collapse
|
236
|
Abrams RA, Lowy AM, O'Reilly EM, Wolff RA, Picozzi VJ, Pisters PWT. Combined modality treatment of resectable and borderline resectable pancreas cancer: expert consensus statement. Ann Surg Oncol 2009; 16:1751-6. [PMID: 19390900 DOI: 10.1245/s10434-009-0413-9] [Citation(s) in RCA: 201] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 12/30/2008] [Accepted: 12/31/2008] [Indexed: 12/14/2022]
|
237
|
O'Reilly EM. Pancreatic adenocarcinoma: new strategies for success. GASTROINTESTINAL CANCER RESEARCH : GCR 2009; 3:S11-S15. [PMID: 19461915 PMCID: PMC2684727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Pancreatic adenocarcinoma ranks as the most challenging of human malignancies, with overall 5-year survivorship being measured in a couple of percent. Major progress has occurred regarding the molecular underpinnings and pathogenesis of pancreatic adenocarcinoma, definition of the epidemiology and genetics of this disease, identification of individuals at risk, and in 2008, the preliminary description of the pancreatic genome. However, clinical developments over the past decade have been modest and incremental at most. The core drug and the backbone of treatment in all settings of pancreatic adenocarcinoma- adjuvant, locally advanced, and metastatic-remains gemcitabine. The past decade of research focused initially on combining cytotoxic therapies with gemcitabine, and more recently, on combining newer "targeted agents." Some success has been observed by combining the platinum analogs and the fluoropyrimidines with gemcitabine in the advanced pancreatic cancer setting. Three- and four-drug combinations have also been assessed, but the data are limited and the major trade-off becomes a toxicity-benefit equation. In relative terms, more limited incremental gains have been observed by combining erlotinib with gemcitabine, while other randomized phase III trials of targeted agents combined with gemcitabine have essentially shown no benefit. Several of the newer generation anti-vascular agents (VEGF-trap, axitinib) are being evaluated in ongoing phase III trials. In the short-term, expectations for advances in pancreatic adenocarcinoma therapy are reserved, with most progress likely to be made in therapy refinement and patient selection. However, it is reasonable to surmise that major progress will evolve as the molecular biology of pancreatic adenocarcinoma continues to be unraveled, as the infrastructure for translational research is strengthened with new preclinical models, and with recognition of the prerequisite requirement for intensive cross-disciplinary collaboration.
Collapse
|
238
|
Ku GY, O'Reilly EM, Saltz LB, Schrag D, Maki RG, Kelsen DP, Ilson DH. Phase I study of weekly cisplatin, bolus fluorouracil and escalating doses of irinotecan in advanced solid tumors. Cancer Invest 2009; 27:402-6. [PMID: 19219674 DOI: 10.1080/07357900802406327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE We performed a phase I study of 5-fluorouracil (5-FU), cisplatin and irinotecan. METHODS Twenty-nine patients received cisplatin 25 mg/m(2) and bolus 5-FU 425 mg/m(2), along with irinotecan at 40, 50, and 65 mg/m(2) weekly for 4 out of 6 weeks. RESULTS The maximum tolerated dose (MTD) for untreated patients was irinotecan 65 mg/m(2) while the MTD for previously treated patients was irinotecan 40 mg/m(2). Neutropenia and diarrhea were the major dose-limiting toxicities. Antitumor activity was noted in gastric, esophageal and pancreatic cancers. CONCLUSION Because of the toxicity profile, combinations with continuous infusion 5-FU or capecitabine should be explored.
Collapse
|
239
|
Duffy A, Capanu M, Abou-Alfa GK, Huitzil D, Jarnagin W, Fong Y, D'Angelica M, Dematteo RP, Blumgart LH, O'Reilly EM. Gallbladder cancer (GBC): 10-year experience at Memorial Sloan-Kettering Cancer Centre (MSKCC). J Surg Oncol 2009; 98:485-9. [PMID: 18802958 DOI: 10.1002/jso.21141] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of gallbladder cancer (GBC) in the US is 1.2/100,000. This report examines the patterns of presentation, adjuvant treatment and survival of a large cohort of patients with GBC evaluated at MSKCC over a 10-year period. METHODS A retrospective analysis of patients referred to MSKCC with a diagnosis of GBC between January 1995 and December 2005 was performed. Patients were identified from the MSKCC cancer registry. Information extracted included, demographics, clinical and pathological stage, surgical management, pathology, adjuvant and palliative therapy, date of relapse, death or last follow-up. Date of diagnosis was defined as date of surgery or biopsy. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS Four hundred thirty-five GBC cases were identified: 285 (65.5%) females,150 (34.5%) males. Median age 67 years (range 28-100). Pathology: 88% adenocarcinoma, 4% squamous, 3% neuroendocrine, 2% sarcoma. 36.6% presented as AJCC Stage IV. 47% were discovered incidentally at laparoscopic cholecystectomy. One hundred thirty-six of these were re-explored, of whom 100 (73.5%) had residual disease. Of those who underwent curative resections (N = 123), 8 (6.5%) received adjuvant chemotherapy, 8 (6.5%) chemoradiation alone and 8 (6.5%) both chemoradiation and systemic chemotherapy. Median overall survival for the cohort was 10.3 months (95% CI 8.8-11.8) with a median follow up of 26.6 months. The median survival for those presenting with stage Ia-III disease was 12.9 months (95% CI 11.7-15.8 months) and 5.8 months (95% CI 4.5-6.7) for those presenting with stage IV disease. Median survival was 15.7 months (95% CI 12.4-18.4) for those discovered incidentally at laparoscopic cholecystectomy. For those who underwent re-exploration, median survival was 14.6 months (95% CI 12.6-18.3) if residual disease was present, and 72 months (95% CI 34 to infinity) if no evidence of disease. The median survival for those who received adjuvant therapy was 23.4 months (95% CI 15.7-47). CONCLUSIONS GBC is commonly diagnosed incidentally (47%). Re-exploration reveals a high incidence of residual disease (74%). Median survival is better for patients who have no evidence of disease on re-exploration (72 months) compared to those with residual disease detected (P < 0.0001). Overall prognosis is poor. Although we did not observe a survival benefit for those who received adjuvant therapy, the study did not have sufficient power to address this question. In addition, the number of patients who received adjuvant therapy was small with marked heterogeneity in clinical and therapeutic details, precluding any definitive conclusions being drawn. Prospective randomized trials of adjuvant therapy are needed in this disease.
Collapse
|
240
|
Carvajal RD, Tse A, Shah MA, Lefkowitz RA, Gonen M, Gilman-Rosen L, Kortmansky J, Kelsen DP, Schwartz GK, O'Reilly EM. A phase II study of flavopiridol (Alvocidib) in combination with docetaxel in refractory, metastatic pancreatic cancer. Pancreatology 2009; 9:404-9. [PMID: 19451750 PMCID: PMC4053191 DOI: 10.1159/000187135] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 12/04/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Pancreatic adenocarcinoma (PC) harbors frequent alterations in p16, resulting in cell cycle dysregulation. A phase I study of docetaxel and flavopiridol, a pan-cyclin-dependent kinase inhibitor, demonstrated encouraging clinical activity in PC. This phase II study was designed to further define the efficacy and toxicity of this regimen in patients with previously treated PC. METHODS Patients with gemcitabine-refractory, metastatic PC were treated with docetaxel 35 mg/m(2) followed by flavopiridol 80 mg/m(2) on days 1, 8, and 15 of a 28-day cycle. Tumor measurements were performed every two cycles. A Simon two-stage design was used to evaluate the primary endpoint of response. RESULTS Ten patients were enrolled, and 9 were evaluable for response. No objective responses were observed; however, 3 patients (33%) achieved transient stable disease, with one of these patients achieving a 20% reduction in tumor size. Median survival was 4.2 months, with no patients alive at the time of analysis. Adverse events were significant, with 7 patients (78%) requiring >or=1 dose reduction for transaminitis (11%), grade 4 neutropenia (33%), grade 3 fatigue (44%), and grade 3 diarrhea (22%). CONCLUSIONS The combination of flavopiridol and docetaxel has minimal activity and significant toxicity in this patient population. These results reflect the challenges of treating patients with PC in a second-line setting where the risk/benefit equation is tightly balanced.
Collapse
|
241
|
Duffy A, Shia J, Klimstra D, Temple L, O'Reilly EM. Collision Tumor of the Large Bowel in the Context of Advanced Pregnancy and Ulcerative Colitis. Clin Colorectal Cancer 2008; 7:402-5. [DOI: 10.3816/ccc.2008.n.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
242
|
Duffy A, O'Reilly EM. What is the optimal treatment of localized pancreatic adenocarcinoma? ONCOLOGY (WILLISTON PARK, N.Y.) 2008; 22:1283-1298. [PMID: 18980025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The term localized disease as it applies to pancreatic adenocarcinoma encompasses distinct entities associated with varied prognoses and therapeutic recommendations. These include three disease categories: (1) disease that is localized and resectable, (2) localized disease that is borderline resectable, and (3) unequivocally unresectable pancreatic adenocarcinoma, all representing a continuum. The incorporation of systemic chemotherapy into the management of pancreatic adenocarcinoma at all stages has become standard of care, and the basis for this is discussed with reference to the major clinical trial landmarks. The role of radiation therapy (in association with concomitant chemotherapy) in the management of localized pancreatic adenocarcinoma, however, has become less clear and represents an area of management confusion in this disease. Going forward, with the expectation of new and improved systemic agents, locoregional tumor control and, hence, chemoradiotherapy are anticipated to have a greater role and impact.
Collapse
|
243
|
Duffy A, Shia J, Huitzil-Melendez FD, Fong Y, O'Reilly EM. Pathologic Complete Response to Neoadjuvant FOLFOX in Combination with Bevacizumab in Unresectable Metastatic Colorectal Carcinoma. Clin Colorectal Cancer 2008; 7:140-3. [DOI: 10.3816/ccc.2008.n.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
244
|
Goldberg RM, Marshall JL, Ajani JA, Philip PA, O'Reilly EM, Venook AP. Section IV: Significance of Recent Study Results and Future Research Directions in Gastrointestinal Oncology. GASTROINTESTINAL CANCER RESEARCH : GCR 2007; 1:S13-S16. [PMID: 19330058 PMCID: PMC2659796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
|
245
|
Hochster HS, O'Reilly EM, Ajani JA, Venook AP. Section III: Treatment of Advanced Gastrointestinal Cancers. GASTROINTESTINAL CANCER RESEARCH : GCR 2007; 1:S8-S12. [PMID: 19330060 PMCID: PMC2659794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
|
246
|
Duffy A, Kortmansky J, Schwartz GK, Capanu M, Puleio S, Minsky B, Saltz L, Kelsen DP, O'Reilly EM. A phase I study of erlotinib in combination with gemcitabine and radiation in locally advanced, non-operable pancreatic adenocarcinoma. Ann Oncol 2007; 19:86-91. [PMID: 17878176 DOI: 10.1093/annonc/mdm441] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine the maximum tolerated dose (MTD) of erlotinib when administered concurrently with twice weekly gemcitabine and radiation therapy (RT) for locally advanced pancreatic cancer, assess the safety and toxicity profile of this combination and secondarily evaluate response, time to tumor progression and overall survival. METHODS Patients with untreated locally advanced pancreas cancer were treated with daily erlotinib in combination with gemcitabine 40 mg/m(2)/30 min twice weekly and RT delivered at 180 cGy/day in 28 fractions over 5.5 weeks for a total of 5040 cGy. Erlotinib was dose escalated in successive cohorts (100 mg, 125 mg). When the MTD was determined, the cohort was expanded to better define toxicity and preliminarily efficacy. All patients were surgically staged. After chemoradiation, patients received maintenance weekly gemcitabine 1000 mg/m(2) on days 1 and 8 of a 21 day cycle and daily erlotinib for four cycles. RESULTS Three patients were treated at dose level 1 (erlotinib 100 mg) without limiting toxicity. Two of six patients at dose level 2 (erlotinib 125 mg) had dose-limiting toxicities, neutropenia and thrombocytopenia, causing dose delay and elevated liver enzymes. The MTD for erlotinib in combination with twice weekly gemcitabine-based chemoradiation was 100 mg/day. Eleven additional patients were treated at dose level 1. All twenty patients were assessable for toxicity. Seventeen patients were assessable for response. The partial response rate was 35% and 53% had stable disease. The median survival for all patients was 18.7 months. CONCLUSION In combination with fixed dose gemcitabine at 40 mg/m(2) twice weekly and radiation at 180 cGy/day, the MTD of erlotinib was found to be 100 mg/day. This is a relatively well tolerated, biologically active combination in a poor prognostic cancer.
Collapse
|
247
|
Abstract
Pancreatic adenocarcinoma is a highly lethal disease with anecdotal long-term survivorship when the disease is inoperable at presentation. A new era in the treatment of advanced pancreatic cancer commenced a decade ago with the advent of gemcitabine as a standard of care. While many large phase III trials have been conducted in the last 10 years, it has proved a difficult challenge to advance beyond the modest bar set by gemcitabine. For the most part, gemcitabine-combination cytotoxic studies have been negative where the principal end point has been overall survival with only a few noted exceptions; however, for vigorous individuals with bulky or symptomatic disease, a gemcitabine-based fluoropyrimidine or platinum combination is considered a standard of care and these data are reviewed in detail. In this new era of targeted therapy, the addition of erlotinib to gemcitabine has provided an alternate standard option to single-agent gemcitabine or gemcitabine-based cytotoxic combinations, a topic which will be discussed in a separate chapter. Other phase III studies of gemcitabine and bevacizumab and gemcitabine and cetuximab, respectively, which were both preliminarily reported as negative, have provided an indirect endorsement for the relative value of cytotoxic therapy in advanced pancreatic cancer. This underscores the major therapeutic hurdles that we have to surmount in this most challenging of human malignancies.
Collapse
|
248
|
Abou-Alfa GK, Letourneau R, Harker G, Modiano M, Hurwitz H, Tchekmedyian NS, Feit K, Ackerman J, De Jager RL, Eckhardt SG, O'Reilly EM. Randomized phase III study of exatecan and gemcitabine compared with gemcitabine alone in untreated advanced pancreatic cancer. J Clin Oncol 2006; 24:4441-7. [PMID: 16983112 DOI: 10.1200/jco.2006.07.0201] [Citation(s) in RCA: 218] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Exatecan mesylate is a hexacyclic, water-soluble, topoisomerase-1 inhibitor. Exatecan has single-agent and combination activity with gemcitabine in advanced pancreatic cancer. A multicenter, randomized, phase III trial comparing exatecan plus gemcitabine versus gemcitabine alone in advanced pancreatic cancer was conducted. PATIENTS AND METHODS Eligibility criteria included Karnofsky performance status > or = 60%, locally advanced or metastatic pancreatic adenocarcinoma, and no prior chemotherapy. Radiation alone for locally advanced disease was permitted. Patients were randomly assigned on a 1:1 basis. For the exatecan plus gemcitabine arm, exatecan 2.0 mg/m2 and gemcitabine 1,000 mg/m2 were administered on days 1 and 8, every 3 weeks. Gemcitabine alone was dosed at 1,000 mg/m2 up to 7 weeks in the first cycle, then once a week for the first 3 weeks of a 4-week cycle. Tumor assessment was performed every 6 weeks. The primary end point was overall survival. An intent-to-treat analysis was used. RESULTS From August 2001 to January 2003, 349 patients were randomly assigned, 175 to exatecan plus gemcitabine and 174 to gemcitabine alone. Twenty-four patients (6.9%) were not treated. The median survival time was 6.7 months for exatecan plus gemcitabine and 6.2 months for gemcitabine alone (P = .52). One complete response (CR; < 1%) and 11 partial responses (PRs; 6.3%) were observed in the exatecan plus gemcitabine treatment group, and one CR (< 1%) and eight PRs (4.6%) were observed in the gemcitabine-alone group. Grade 3 and 4 toxicities were higher for the exatecan plus gemcitabine arm versus the gemcitabine alone arm; neutropenia (30% v 15%) and thrombocytopenia (15% v 4%). CONCLUSION Exatecan plus gemcitabine was not superior to gemcitabine alone with respect to overall survival in the first-line treatment of advanced pancreatic cancer.
Collapse
|
249
|
Abou-Alfa GK, Rowinsky EK, Patt YZ, Schwartz GK, Kelsen DP, Sharma S, Siegel E, Becerra CR, Eckhardt SG, Feit K, De Jager R, O'Reilly EM. A Phase II Study of Intravenous Exatecan Administered Daily for 5 Days, Every 3 Weeks to Patients With Biliary Tract Cancers. Am J Clin Oncol 2005; 28:334-9. [PMID: 16062073 DOI: 10.1097/01.coc.0000158829.63542.2c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE Exatecan is a hexacyclic topoisomerase-1 inhibitor that has broad in vitro and in vivo activity. A multicenter phase II study to determine the antitumor activity of exatecan was conducted in patients with advanced cholangiocarcinoma and gallbladder carcinoma. METHODS Patients with 0 to 1 prior chemotherapy regimens, adequate major organ function, and metastatic disease were eligible. Exatecan was administered at a dose of 0.5 mg/m2 IV over 30 minutes daily on days 1 through 5 every 21 days. The primary end point was overall response rate: complete response and partial response (PR). A Simon optimal 2-stage design was employed. Response was assessed every 6 weeks. RESULTS Forty-two patients were enrolled. Two of 41 evaluated patients (4.9%) had a PR, 4 patients (9.8%) had a minor response, and 12 had stable disease. Twenty patients (51.2%) had progressive disease. The major toxicity was grade 3/4 neutropenia. The median overall survival was 7 months. The 6-month survival rate was 56.1% and the 12-month survival rate was 31.7%. CONCLUSION Exatecan has minimal activity in advanced biliary tree cancers. Toxicity was predictable and manageable.
Collapse
|
250
|
Deming DA, Stella AL, Holen KD, Ku G, O'Reilly EM. A dramatic response to long-acting octreotide in metastatic hepatocellular carcinoma. CLINICAL ADVANCES IN HEMATOLOGY & ONCOLOGY : H&O 2005; 3:468-72; discussion 472-4. [PMID: 16167024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
|