Role of Predictive Value of the Modified Glasgow Prognostic Score for Later-line Chemotherapy in Patients With Metastatic Colorectal Cancer

BACKGROUND

Assessment of patient factors is essential for selecting later-line chemotherapy in patients with metastatic colorectal cancer (mCRC). The efficacy, prognosis, and safety of each treatment regimen according to nutritional and inflammatory status still remain to be elucidated.

PATIENTS AND METHODS

A total of 550 patients with mCRC who were registered in the REGOTAS study (Regorafenib versus TAS-102 as Salvage-line in patients with colorectal cancer refractory to standard chemotherapies: a multicenter observational study, UMIN 000020416) and treated with trifluridine/tipiracil (TFTD) or regorafenib as a later-line therapy were retrospectively stratified according to the modified Glasgow Prognostic Score (mGPS), which divided patients into mGPS 0 to 2 by serum albumin and C-reactive protein, and compared.

RESULTS

The median overall survival (OS) of patients with mGPS 0, 1, and 2 was 10.0 months (95% confidence interval [CI], 9.2-11.6 months), 6.5 months (95% CI, 5.3-7.1 months), and 3.9 months (95% CI, 3.3-4.9 months), respectively. The median progression-free survival (PFS) with mGPS 0, 1, and 2 was 2.5 months (95% CI, 2.1-3.0 months), 2.0 months (95% CI, 1.9-2.3 months), and 1.7 months (95% CI, 1.4-1.9 months), respectively. There were significant differences by mGPS in both OS and PFS (all P < .001). No significant differences in OS and PFS were observed between the patient groups treated with TFTD and regorafenib in each mGPS group. In patients aged ≥ 65 years with mGPS 2, the OS and PFS were worse with regorafenib than with TFTD (OS: hazard ratio, 1.45; 95% CI, 0.93-2.25; P = .097; PFS: hazard ratio, 1.57, 95% CI, 1.01-2.44; P = .047), but there were no consistent trends observed as mGPS increased. The frequency of grade 3 and more adverse events was generally similar in each mGPS group. The multivariate analyses showed that mGPS was the strongest predictive factor for OS.

CONCLUSIONS

The mGPS before later-line chemotherapy is strongly correlated with survival in patients with mCRC.

Abstract 2651: A mesenchymal-associated transcriptomic signature has a prognostic and predictive potential in stage II and III colorectal cancer patients

Purpose: Clinical decision making for adjuvant chemotherapy, which includes selection of appropriate patients and optimal treatment regimen, remains the most pressing challenge in the management of stage II and III colorectal cancer (CRC) patients. In this study, we attempted to address this issue by developing a clinically actionable mesenchymal-associated transcriptomic signature (MATS) that can accurately predict prognosis and identify CRC patients who could realistically benefit from adjuvant chemotherapy.

Experimental Design: To develop a mesenchymal-associated transcriptomic signature, we first performed gene expression profiling in 152 laser capture microdissected CRC tissues, followed by validation of this signature in 1365 CRC patients from various publicly available cohorts (GSE41258, GSE39582, GSE33113, GSE17536 and TCGA). Subsequently, this signature was trained (N=142) and validated (N=286) in two independent clinical cohorts of stage II and III CRC patients, in which Cox's regression analysis was performed to evaluate the recurrence predictive power of this signature. Furthermore, we investigated the clinical significance of MATS in its ability to identify patients who can benefit from fluoropyrimidine-based adjuvant chemotherapy.

Results: Through a comprehensive genome-wide expression analysis, we have identified an eight-gene mesenchymal-associated transcriptomic signature that can significantly predict recurrence-free survival (RFS) and identify a mesenchymal CRC subtype with high accuracy. To evaluate its translational potential, we further trained and validated this signature in two independent CRC cohorts consisting of 428 stage II and III CRC patients. Interestingly, MATS successfully stratified patients into low- and high-risk groups with 5-year RFS rates ranging from 87% and 54% in the training cohort [HR: 4.11 (CI: 2.72-15.43)] and 82% and 56% in the validation cohort [HR: 2.66 (CI: 1.66-3.98)], respectively. While the 48 patients with MATS low-risk stage III CRC showed a substantial improvement in survival, the 77 patients with MATS high-risk stage III CRC did not benefit from the fluoropyrimidine-based adjuvant chemotherapy. Furthermore, in multivariate analysis, MATS was significantly associated with RFS along with T-stage and lymphovascular invasion in both training as well as validation cohorts with HRs of 3.80 (CI: 1.85-7.82, p=0.0003) and 2.09 (CI: 1.28-3.42, p=0.003), respectively.

Conclusions: Our novel MATS could robustly identify RFS, and this classifier was superior to various clinicopathologic risk factors used in the clinic for risk stratification in CRC patients. In addition, MATS could also predict which stage III CRC patients might benefit from fluoropyrimidine-based adjuvant chemotherapy, which is a significant step forward in the clinical management of these patients.

Citation Format: Takatoshi Matsuyama, Raju Kandimalla, Xuan Wang, Toshiaki Ishikawa, Naoki Takahashi, Yasuhide Yamada, Masamichi Yasuno, Yusuke Kinugasa, Hiroyuki Uetake, Ajay Goel. A mesenchymal-associated transcriptomic signature has a prognostic and predictive potential in stage II and III colorectal cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2651.

Differential Cross Section and Photon-Beam Asymmetry for the γ[over →]p → π^{-}Δ^{++}(1232) Reaction at Forward π^{-} Angles for E_{γ}=1.5-2.95 GeV

Differential cross sections and photon-beam asymmetries for the γ[over →]p→π^{-}Δ^{++}(1232) reaction have been measured for 0.7<cosθ_{π}^{c.m.}<1 and E_{γ}=1.5-2.95  GeV at SPring-8/LEPS. The first-ever high statistics cross-section data are obtained in this kinematical region, and the asymmetry data for 1.5<E_{γ}(GeV)<2.8 are obtained for the first time. This reaction has a unique feature for studying the production mechanisms of a pure uu[over ¯] quark pair in the final state from the proton. Although there is no distinct peak structure in the cross sections, a non-negligible excess over the theoretical predictions is observed at E_{γ}=1.5-1.8  GeV. The asymmetries are found to be negative in most of the present kinematical regions, suggesting the dominance of π exchange in the t channel. The negative asymmetries at forward meson production angles are different from the asymmetries previously measured for the photoproduction reactions producing a dd[over ¯] or an ss[over ¯] quark pair in the final state. Advanced theoretical models introducing nucleon resonances and additional unnatural-parity exchanges are needed to reproduce the present data.

CCAT1 and CCAT2 long noncoding RNAs, located within the 8q.24.21 'gene desert', serve as important prognostic biomarkers in colorectal cancer

Background

8q24.21 is a frequently amplified genomic region in colorectal cancer (CRC). This region is often referred to as a 'gene desert' due to lack of any important protein-coding genes, highlighting the potential role of noncoding RNAs, including long noncoding RNAs (lncRNAs) located around the proto-oncogene MYC. In this study, we have firstly evaluated the clinical significance of altered expression of lncRNAs mapped to this genomic locus in CRC.

Patients and methods

A total of 300 tissues, including 280 CRC and 20 adjacent normal mucosa specimens were evaluated for the expression of 12 lncRNAs using qRT-PCR assays. We analyzed the associations between lncRNA expression and various clinicopathological features, as well as with recurrence free survival (RFS) and overall survival (OS) in two independent cohorts.

Results

The expression of CCAT1, CCAT1-L, CCAT2, PVT1, and CASC19 were elevated in cancer tissues (P = 0.039, <0.001, 0.018, <0.001, 0.002, respectively). Among these, high expression of CCAT1 and CCAT2 was significantly associated with poor RFS (P = 0.049 and 0.022, respectively) and OS (P = 0.028 and 0.015, respectively). These results were validated in an independent patient cohort, in which combined expression of CCAT1 and CCAT2 expression was significantly associated with a poor RFS (HR:2.60, 95% confidence interval [CI]: 1.04-6.06, P = 0.042) and a poor OS (HR:8.38, 95%CI: 2.68-37.0, P < 0.001). We established a RFS prediction model which revealed that combined expression of CCAT1, CCAT2, and carcinoembryonic antigen was a significant determinant for efficiently predicting RFS in stage II (P = 0.034) and stage III (P = 0.001) CRC patients.

Conclusions

Several lncRNAs located in 8q24.21 locus are highly over-expressed in CRC. High expression of CCAT1 and CCAT2 significantly associates with poor RFS and OS. The expression of these two lncRNAs independently, or in combination, serves as important prognostic biomarkers in CRC.

Genome-wide Discovery and Identification of a Novel miRNA Signature for Recurrence Prediction in Stage II and III Colorectal Cancer

Purpose: The current tumor-node-metastasis (TNM) staging system is inadequate at identifying patients with high-risk colorectal cancer. Using a systematic and comprehensive biomarker discovery and validation approach, we aimed to identify an miRNA recurrence classifier (MRC) that can improve upon the current TNM staging as well as is superior to currently offered molecular assays.Experimental Design: Three independent genome-wide miRNA expression profiling datasets were used for biomarker discovery (N = 158) and in silico validation (N = 109 and N = 40) to identify an miRNA signature for predicting tumor recurrence in patients with colorectal cancer. Subsequently, this signature was analytically trained and validated in retrospectively collected independent patient cohorts of fresh-frozen (N = 127, cohort 1) and formalin-fixed paraffin-embedded (FFPE; N = 165, cohort 2 and N = 139, cohort 3) specimens.Results: We identified an 8-miRNA signature that significantly predicted recurrence-free interval (RFI) in the discovery (P = 0.002) and two independent publicly available datasets (P = 0.00006 and P = 0.002). The RT-PCR-based validation in independent clinical cohorts revealed that MRC-derived high-risk patients succumb to significantly poor RFI in patients with stage II and III colorectal cancer [cohort 1: hazard ratio (HR), 3.44 (1.56-7.45), P = 0.001; cohort 2: HR, 6.15 (3.33-11.35), P = 0.001; and cohort 3: HR, 4.23 (2.26-7.92), P = 0.0003]. In multivariate analyses, MRC emerged as an independent predictor of tumor recurrence and achieved superior predictive accuracy over the currently available molecular assays. The RT-PCR-based MRC risk score = (-0.1218 × miR-744) + (-3.7142 × miR-429) + (-2.2051 × miR-362) + (3.0564 × miR-200b) + (2.4997 × miR-191) + (-0.0065 × miR-30c2) + (2.2224 × miR-30b) + (-1.1162 × miR-33a).Conclusions: This novel MRC is superior to currently used clinicopathologic features, as well as National Comprehensive Cancer Network (NCCN) criteria, and works regardless of adjuvant chemotherapy status in identifying patients with high-risk stage II and III colorectal cancer. This can be readily deployed in clinical practice with FFPE specimens for decision-making pending further model testing and validation. Clin Cancer Res; 24(16); 3867-77. ©2018 AACRSee related commentary by Rodriguez et al., p. 3787.

Abstract P5-03-05: Sphingosine-1-phosphate produced by sphingosine kinase 1 and exported via ABCC1 shortens survival of mice and humans with breast cancer

Background: Sphingosine-1-phosphate (S1P), a bioactive sphingolipid mediator that is generated by sphingosine kinase 1 (SphK1) when it is phosphorylated (pSphK1) inside cells, has been implicated in regulation of many process important for breast cancer progression. Previously we have shown that S1P is exported out of human breast cancer cells by ATP-binding cassette (ABC) transporter ABCC1, but not by ABCB1, both known multidrug resistance proteins that efflux chemotherapeutic agents. However, the pathological consequences of these events to breast cancer progression and metastasis have not been elucidated. Here, we report that high expression of ABCC1, but not ABCB1, is associated with poor prognosis in breast cancer patients via exporting S1P.

Materials and methods: Microarray based gene expression data of 2509 patients associated with their survival were obtained from METABRIC database. Single gene survival analysis based on expressin of SphK1, and dual ABCC1 or ABCB1 and SphK1 survival analyses were perfomerd. For protein analyses, tissues were obrained from 275 patients with stage 1-3 breast cancers treated in Yokohama City University Medical Center in Japan between 2006 and 2008. The expression of pSphK1 was analyzed by immunohistochemistry and investigate the relationship with clinicopathological findings. For in vitro and in vivo experiments, breast cancer cell lines were transfected by ABCB1, ABCC1 or vector transiently or stably. BALB/c nu/nu mice and BALB/c mice were used for in vivo experiments. S1P was measured by LC-ESI-MS/MS.

Results: SphK1 expression significantly associate with worse overall survival (median survival of 124 months with high SphK1 expression compared to 163 months for patients with low SphK1 expression, p=0.0014). Although patients with high ABCC1 expression had only a slightly worse overall survival of 150 months, those with high levels of both SphK1 and ABCC1 had much worse prognosis with median overall survival of 114 months (p &lt; 0.0068). Such association was not observed with ABCB1 expression. The frequency of strong pSphK1 protein expression was higher in HER2 enrhiched or TNBC than in Luminal. pSphK1 was more prevalent and increased in a larger tumors and in tumors from patients with lymph node metastases. Patients with breast cancers that express both pSphK1 and ABCC1 proteins have significantly shorter disease free survival. Overexpression of ABCC1, but not ABCB1, in human MCF7 and murine 4T1 cells enhanced S1P secretion, proliferation and migration of breast cancer cells. Implantation of breast cancer cells overexpressing ABCC1, but not ABCB1, into the mammary pad markedly enhanced tumor growth, angiogenesis and lymphangiogenesis with concomitant increases in lymph node and lung metastases as well as shorter survival of mice. Interestingly, S1P exported via ABCC1 from breast cancer cells upregulated transcription of SphK1 and its own formation.

Conclusions: Our findings suggest that production and export of S1P via ABCC1, but not ABCB1, is associated with worse overall and disease free survival of breast cancer patients and that S1P axis play a role in aggressive biology of breast cancer progression and metastasis.

Citation Format: Yamada A, Nagahashi M, Aoyagi T, Huang W-C, Lima S, Miyazaki H, Narui K, Ishikawa T, Endo I, Waters MR, Milstien S, Spiegel S, Takabe K. Sphingosine-1-phosphate produced by sphingosine kinase 1 and exported via ABCC1 shortens survival of mice and humans with breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-03-05.

Abstract P6-15-05: Randomized controlled trial of neoadjuvant eribulin mesylate versus paclitaxel in women with operable breast cancer (JONIE-3 study)

Background:

Although treatment of eribulin mesylate (E) improved overall survival in metastatic breast cancer (BC) patients, little is known about the efficacy in early BC. The hypothesis of this study is that sequential administration of E followed by FEC would have less toxic, particularly peripheral neuropathy, and also have similar effect compared to paclitaxel (P) followed by FEC as primary systemic therapy (PST) for woman with operable BC.

Methods:

This is a phase II multicenter open label study (UMIN000012817). Patients (pts) were randomly assigned to either E (1.4mg/m2, d1 and d8, q21 days, 4 cycles) + FEC (fluorouracil 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2) or P (80mg/m2, weekly, 12 cycles) + FEC as PST. HER2+ patients were allowed to receive trastuzumab. Stratification factors were ER, HER2, and menopausal status. Primary endpoint was the incidence of peripheral sensory and motor neuropathy (PSN and PMN) with Grade 1 or higher according to CTCAE ver.4.0. Secondary endpoints were pathological complete response (pCR) rates (ypT0/is/ypN0), clinical response rates (CR+PR), and adverse events. Safety was assessed in all pts who received at least one dose of the study drug.

Results:

Between 12/2013 to 3/2016, 121 pts were randomly assigned equally to E + FEC and P + FEC. Excluding 5 pts from the primary assessment, 116 pts (58 in each group) were included in the full analysis set. The characteristics of the pts were similar in the two arms. At the end of E or P administration, the incidences of PSN were 55.4% and 92.9% in E and P arm, respectively (p&lt;0.001). The incidences of PMN were 25.9% and 44.9% in E and P arm, respectively (p=0.049). At the end of E or P + FEC, PSN accounts for 38.9% in E arm and 85.2% in P arm (p&lt;0.001), and PMN accounts for 20.7% in E arm and 32.8% in P arm (p=0.201). The pCR rates in E and P arm were 20.7% and 29.8% (p=0.092). The clinical response rates in E and P arm were 82.2% and 91.0% (p=0.108). No statistical significant difference was found in efficacy of PST between E and P.

Conclusion:

This randomized phase II study revealed that eribulin had favorable peripheral neuropathy profile with modest efficacy in the neoadjuvant setting, compared with paclitaxel.

Citation Format: Miura D, Hasegawa Y, Ishikawa T, Tachibana A, Horiguchi J, Hayashi M, Miyashita M, Kubota T, Narui K, Suzuki M, Akazawa K, Kohno N. Randomized controlled trial of neoadjuvant eribulin mesylate versus paclitaxel in women with operable breast cancer (JONIE-3 study) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-15-05.

Abstract P6-07-03: Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival

Background: Cancer stem cells (CSC) are good sources of tumor initiation, heterogeneity, progression, and metastasis because of their unique characteristics. Several potential markers for CSCs have been suggested for breast cancer, including CD44+/CD24−/low, aldehyde dehydrogenase 1 (ALDH1), and epithelial cell adhesion molecule/epithelial-specific antigen. We previously reported that ALDH1 gene expression is related to aggressive phenotypes and poor prognosis in breast cancers. In this study, we conducted differential analysis of mRNA expression in ALDH1-positive breast cancer to identify genes associated with CSC. Next, we performed basic and clinical studies of one gene.

Methods: Messenger RNA was isolated from ALDH1-positive cells and ALDH1-negative cells in 5 ALDH1-positive breast cancers. Microarray analysis revealed that several genes were significantly associated with the ALDH1 gene. Among them, we examined a long non-coding RNA of H19 in this study. We evaluated the effect of H19 on CSCs using RNA interference and a sphere formation assay using two cell lines, HCC1937 and iCSCL10A cells. We also investigated H19 expression in 192 surgical specimens by in situ hybridization and analyzed the relationship between H19 expression and clinic pathological findings in breast cancer patients.

Results: Through in vitro experiments, we confirmed that suppression of H19 reduced sphere formation in both HCC1937 and iCSCL10A cells. Among surgical specimens, 48 samples (25%) expressed H19. We verified thatH19 positivity was significantly higher in ALDH1-positive cases than in ALDH1-negative cases (68% vs 9.7%, p &lt; 0.001). H19 was significantly highly expressed in triple-negative breast cancer (TNBC) (46%) compared with other subtypes: luminal (33%), luminal-HER2 (6%), and HER2-enriched subtype (15%). H19-positive patients showed significantly worse prognosis (5-year disease-free survival 75.8% vs 91.5%, p = 0.001 and 5-year overall survival 88.7% vs 97.7%, p = 0.002). The effect of H19 expression on prognosis was the most significant in TNBC compared to in other subtypes (5-year disease-free survival 63.6% vs 88.9%, p = 0.038).

Conclusions: H19 is clearly associated with CSCs and correlated with poor prognosis in breast cancer patients, particularly TNBC. Our future studies will investigate the role of H19 in maintaining the nature of CSCs and protein-coding genes associated with H19.

Citation Format: Shima H, Kida K, Yamada A, Sugae S, Narui K, Miyagi Y, Ryo A, Ichikawa Y, Ishikawa T, Endo I. Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-07-03.

“Mobile Nurse” Platform for Ubiquitous Medicine

Objectives : We introduce “Mobile Nurse" (MN) - an emerging platform for the practice of ubiquitous medicine.

Methods : By implementing in a dynamic setting of daily life the patient care traditionally provided by the clinical nurses on duty, MN aims at integral data collection and shortening the response time to the patient. MN is also capable of intelligent interaction with the patient and is able to learn from the patient's behavior and disease sign evaluation for improved personalized treatment.

Results : In this paper, we outline the most essential concepts around the hardware, software and methodological designs of MN. We provide an example of the implementation, and elaborate on the possible future impact on medical practice and biomedical science research.

Conclusions : The main innovation of MN, setting it apart from current tele-medicine systems, is the ability to integrate the patient's signs and symptoms on site, providing medical professionals with powerfultools to elucidate disease mechanisms, to make proper diagnoses and to prescribe treatment.

Expression of ATF6 as a marker of pre-cancerous atypical change in ulcerative colitis-associated colorectal cancer: a potential role in the management of dysplasia

BACKGROUND

Diagnosis of low-grade dysplasia (LGD) is important in the management of ulcerative colitis (UC), but it is often difficult to distinguish LGD from inflammatory regenerative epithelium. The unfolded protein response (UPR) is activated in inflammatory bowel disease and malignancies. We aimed to identify a UPR-related gene that is involved in the development of non-UC and UC-associated colorectal cancer (CRC), and to investigate whether the target gene is useful for the diagnosis of LGD.

METHODS

Using our microarray gene expression database of 152 CRCs, we identified activating transcription factor 6 (ATF6) as a target gene. Immunohistochemistry (IHC) of ATF6 were analyzed in 137 surgically resected CRCs, 95 endoscopically resected adenomas and pTis cancers, and 136 samples from 51 UC patients (93 colitis without neoplasia, 31 dysplasia, and 12 UC-associated CRC). The diagnostic accuracy of ATF6 and p53 as markers of LGD was assessed.

RESULTS

ATF6 expression was detectable in all CRCs but not in normal colonic mucosa, was elevated with increase in cellular atypia (adenoma with moderate atypia < severe atypia < pTis CRC, p < 0.001), and higher in dysplasia and CRC than in non-neoplastic colitis (p < 0.001). Notably, the difference between colitis and LGD was significant. Compared to p53-IHC, ATF6-IHC had better diagnostic accuracy for distinguishing LGD from background inflammatory mucosa (sensitivity 70.8 vs. 16.7%, specificity 78.5 vs.71.0%, respectively).

CONCLUSIONS

ATF6 was expressed in lesions undergoing pre-cancerous atypical change in both non-UC and UC-associated CRC and may be used to distinguish LGD from inflammatory regenerative epithelium in UC patients.

Dynamic behaviour of the soft palate during nasal positive pressure ventilation under anaesthesia and paralysis: comparison between patients with and without obstructive sleep-disordered breathing

BACKGROUND

Difficult mask ventilation is common and is known to be associated with sleep-disordered breathing (SDB). It is our hypothesis that the incidence of expiratory retropalatal (RP) airway closure (primary outcome) during nasal positive pressure ventilation (PPV) is more frequent in patients with SDB (apnea hypopnea index ≥5 h^-1) than non-SDB subjects.

METHODS

The severity of SDB was assessed before surgery using a portable sleep monitor. In anaesthetized and paralysed patients with (n=11) and without SDB (n=9), we observed the behaviour of the RP airway endoscopically during nasal PPV with the mouth closed and determined the dynamic RP closing pressure, which was defined as the highest airway pressure above which the RP airway closure was reversed. The static RP closing pressure was obtained during cessation of mechanical ventilation in patients with dynamic RP closure during nasal PPV.

RESULTS

The expiratory RP airway closure accompanied by expiratory flow limitation occurred more frequently in SDB patients (9/11, 82%) than in non-SDB subjects (2/9, 22%; exact logistic regression analysis: P=0.022, odds ratio 3.6, 95% confidence interval 1.1-15.4). Receiver operating characteristic curve analyses indicated AHI >10h^-1 and presence of habitual snoring as clinically useful predictors for the occurrence of RP closure during PPV. Dynamic RP closing pressure was greater than the static RP closing pressure by approximately 4-5 cm H₂O.

CONCLUSIONS

Valve-like dynamic RP closure that limits expiratory flow during nasal PPV occurs more frequently in SDB patients.