Usefulness of serum carcinoembryonic antigen (CEA) in evaluating response to chemotherapy in patients with advanced non small-cell lung cancer: a prospective cohort study

Background

High serum carcinoembryonic antigen (CEA) levels are an independent prognostic factor for recurrence and survival in patients with non-small cell lung cancer (NSCLC). Its role as a predictive marker of treatment response has not been widely characterized.

Methods

180 patients with advanced NSCLC (stage IIIB or Stage IV), who had an elevated CEA serum level (>10 ng/ml) at baseline and who had no more than one previous chemotherapy regimen, were included. CEA levels were measured after two treatment cycles of platinum based chemotherapy (93%) or a tyrosine kinase inhibitor (7%). We assessed the change in serum CEA levels and the association with response measured by RECIST criteria.

Results

After two chemotherapy cycles, the patients who achieved an objective response (OR, 28.3%) had a reduction of CEA levels of 55.6% (95% CI 64.3-46.8) compared to its basal level, with an area under the ROC curve (AURC) of 0.945 (95% CI 0.91-0.99), and a sensitivity and specificity of 90.2 and 89.9%, respectively, for a CEA reduction of ≥14%. Patients that achieved a decrease in CEA levels ≥14% presented an overall response in 78% of cases, stable disease in 20.3% and progression in 1.7%, while patients that did not attain a reduction ≥14% had an overall response of 4.1%, stable disease of 63.6% and progression of 32.2% (p < 0.001). Patients with stable (49.4%) and progressive disease (22.2%) had an increase of CEA levels of 9.4% (95% CI 1.5-17.3) and 87.5% (95% CI 60.9-114) from baseline, respectively (p < 0.001). The AURC for progressive disease was 0.911 (95% CI 0.86-0.961), with sensitivity and specificity of 85 and 15%, respectively, for a CEA increase of ≥18%. PFS was longer in patients with a ≥14% reduction in CEA (8.7 vs. 5.1 months, p < 0.001). Reduction of CEA was not predictive of OS.

Conclusions

A CEA level reduction is a sensitive and specific marker of OR, as well as a sensitive indicator for progression to chemotherapy in patients with advanced NSCLC who had an elevated CEA at baseline and had received no more than one chemotherapy regimen. A 14% decrease in CEA levels is associated with a longer PFS.

Association of clinical and nutritional factors with treatment related toxicity of “fixed standard dose” of afatinib in patients with advanced NSCLC

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Background: Afatinib, an irreversible tyrosine kinase inhibitor of ErbB-family, has shown clinical benefits and prolonged progression free survival in EGFR mutated patients. Adverse effects related to afatinib such as diarrhea, stomatitis and rash can negatively impact on QoL and survival by interrupting treatment. Dose of TKI´s of EGFR are fixed regardless of weight or body surface (BS), which could affect the severity of treatment related toxicity. Methods: We prospectively studied patients with advanced NSCLC treated with afatinib in order to determine if malnutrition and clinical factors are associated to higher incidence of severe toxicity. Prior treatments with afatinib 40mg, 78 patients were assessed. Nutritional status was assessed by Subjective Global Assessment (SGA), and toxicity was obtained during 2 cycles by CTCAE 4.0, severe toxicity is defined as grades 3 and 4. Results: Mean age was 59.2 years, 71.8% were women, 89.7% had adenocarcinoma, 76.9% had a good performance status (ECOG 0-1), and median weight and BS were 59.9kg and 1.58m2. Sixty percent of patients had some grade of malnutrition (SGA B+C). Factors associated to severe diarrhea, mucositis and other gastrointestinal toxicity are shown in Table 1, no factors were found to be associated with the development of severe rash. Conclusions: The performance status, malnutrition and body surface are independent factors related to severe gastrointestinal toxicity to Afatinib. This study suggests that for the initial dose selection of TKI´s of the EGFR these factors should be considered in order to reduce the risk of severe toxicity.

[National consensus of diagnosis and treatment of non-small cell lung cancer]

Mexican specialists in oncology, oncologic surgery, thoracic surgery, pneumology, pathology, molecular biology, anesthesiology, algology, psychology, nutrition, and rehabilitation (all of them experts in lung cancer treatment) in order to develop the National Consensus on Lung Cancer. The consensus has been developed as an answer to the need of updated Mexican guidelines for the optimal treatment of the disease, as well as to the requirements that such guidelines be established by multidisciplinary panel, depicting the current attention given to cancer lung cases in Mexico. Thus, this paper analyses the epidemiological review, screening, diagnosis, staging, pathology, translational medicine, and the suitable therapies for early, locally advanced, and metastatic disease in the first, second, and third lines of management, as well as rehabilitation and palliative measures.

Impact of obesity and overweight in the prognosis of women diagnosed with non metastatic breast cancer in a Mexican cohort

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Background: Mexico positions right up at the top with U.S. in worldwide rankings of the most obese countries. In addition, breast cancer (BrCa) is the main type of cancer among women in this country. Studies have shown inconsistent results regarding obesity as a prognostic factor for worse outcome. Methods: Our aim is to identify if overweight and obesity confer poor prognosis in non-metastasic BrCa patients (pts). We identified 1799 Hispanic women with newly diagnosed BrCa who attended the National Cancer Institute in Mexico from 2004-2008 and compared clinical and pathological features and overall survival (OS) between pts with a body mass index (BMI) > or ≤ than 25. Results: The median age at diagnosis was 51 years. A BMI>25 was found in 71% of pts. Postmenopausal women comprised 52%, and had a greater proportion of cases with a BMI>25 than premenopausal pts (75% vs. 67%, p<0.0001). Pts with BMI>25 presented with more advanced TNM stages and nodal involvement than their counterparts (73% vs. 67%, p=0.005 and 76% vs. 71%, p=0.017; respectively). Overall prevalence of hormone-receptor (HR), triple-negative (TN) and HER2 positive disease was 62%, 23%, and 27%, respectively. Differences according to receptor status between pre and postmenopausal pts and BMI are shown in table. There was no difference in disease-free survival and OS according to overweight and obesity in the overall population, but when menopausal status was considered, premenopausal pts with BMI>25 had a worse OS compared to pts with BMI<25 (HR 1.6, p=0.037). This difference was not seen in the postmenopausal group. Conclusions: Obesity may influence BrCa outcomes via several hormonal and inflammatory mechanisms. In this study, overweight and obesity confer a poor prognosis in premenopausal patients, possibly related to excess estrogen availability and higher prevalence of TN BrCa. Therefore, overweight and obesity deserve additional attention to assess possible causal relationships that potentially could be modified to improve outcomes in premenopausal patients. [Table: see text]

Gene-expression profile of primary non-small cell lung cancer associated with brain metastasis: A prospective study

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Background: Brain metastases (BM) occur in 30-50% of non-small cell lung cancer (NSCLC) patients and confer worse prognosis and quality of life. Better selection of in-risk patients through an accurate biomarker could improve the benefit of prophylactic therapies. The aim of this prospective study was to determine a gene-expression profile (GEP) of primary tumor (PT) associated with BM in patients with advanced NSCLC. Methods: From January 2009 to June 2011, patients with stage IV of NSCLC were evaluated. PT core biopsy was performed prior to any treatment and snap-frozen. Samples with tumor cellularity > 70% and RNA integrity number > 8 were chosen for RNA isolation. A cDNA microarray platform representing 33,297 genes was used to obtain GEPs. All patients received standard chemotherapy. BM were confirmed by magnetic resonance imaging. Non- and supervised hierarchical clustering methods were employed to identify GEPs. Results: A total of 29 patients were enrolled, 79.4% (23/29) were adenocarcinomas, and 20.6% have other histology. BM were present in 15 (51.7%) patients, 14 at diagnosis and 1 was developed at 5 months of follow-up. Clinical characteristics were similar for patients with and without BM. At non- and supervised analyses, 35 genes up and down regulated were evidenced in BM group. From these, 11 transcripts with proteomic functions previously associated with metastasis processes were identified. Conclusions: Our work provides valuable biological information for development of predictive biomarkers for metastatic brain tumors from primary NSCLC. External validation of our gene-expression signature in a different set of patients is warranted. [Table: see text]

Randomized trial effect of an oral nutritional supplement with eicosapentaenoic acid on nutritional and inflammatory parameters, response and toxicity to chemotherapy, quality of life, and survival in treatment-naive patients with advanced non-small lung cancer

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Background: Nutritional interventions have shown increased of energy intake but the effect of improvement in health related quality of life (HRQL) in non small cell lung cancer (NSCLC) patients is controversial. Eicosapentaenoic acid has been proposed to have anti-inflammatory, anticachectic and possibly could have antitumoral effects. Methods: Patients with advanced NSCLC naive to treatment were included and randomly assigned to receive diet and oral nutritional supplement enriched with EPA or only isocaloric diet. All patients received paclitaxel and cisplatin-carboplatin treatment. Weight, body composition measured with bioelectrical impedance analysis, dietary ingestion, inflammatory parameters and HRQL were assessed at baseline and after 1st and 2nd cycle. Response to chemotherapy and survival were evaluated. Results: Ninety-two patients were analyzed, (46 EPA, 46 control group). No basal differences between groups were found. Experimental group present significantly increased albumin levels, energy, proteins, lipids and carbohydrate intake, and reduced serum CPR, TNF-α and Neutrophyls/Lymphocytes index. Patients in experimental group presented minor prevalence of weight loss and increased 1.6 kg of lean body mass (LBM) compared with controls. In HRQL, experimental group presented an improvement in global and physical scale and anorexia, and regarding toxicity, fatigue and neuropathy diminished. There was no difference in response rate, progression free survival and overall survival between groups. Conclusions: EPA enriched supplementation provided a therapeutic advantage by increasing LBM and nutrients intake, improving HRQL, and reduce several toxicity parameters in NSCLC patients under chemotherapy. The study was registered with ClinicalTrials.gov, number NCT01048970.

Outcomes in Latin American NSCLC patients harboring wild-type or activating mutations of EGFR (CLICaP Registry)

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Background: Previous exploratory analysis of EGFR status in tumor samples from five LATAM countries suggested that frequency of mutations lies between that of Asian and Caucasian populations and therefore support the genetic heterogeneity of NSCLC around the world. Methods: We analyzed the EGFR sequence of tumor samples from advanced stage NSCLC patients previously participated in the CLICaP registry. We compared the outcomes (overall and progression free survival) of 175 patients (from Argentina, Colombia and México) with an activating EGFR mutation with 414 subjects without this condition. Results: Mutations were more frequent in women (57,1%), in patients who had never smoked (67,4%), and in those with adenocarcinomas (89,4%) (P<0,002 for all comparisons). The mutations were deletions in exon 19 (58,3%) and L858R (36%). Median progression-free survival and overall survival for 175 patients who received tyrosine-kinase inhibitors (TKIs) were 13-mo (95%CI 11,2-14,8) months and 36-mo (95%CI 25,4-46,5), respectively. TKIs produced higher response rates (used as first or second line therapy) in the EGFR mutation-positive patients (70,8% vs. 29,2%; P<0,001), as well as improved PFS (13,0 vs. 3,0; P<0,001). OS is significantly different between treatment groups (36 vs. 14; P<0,001). Conclusions: The analysis of a large comparative registry of Latin-American EGFR mutated and wild type patients confirms the results of individual clinical trials previously published.

Phase II trial: Concurrent chemotherapy and radiotherapy with nitroglycerin in locally advanced non-small cell lung cancer patients

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Background: The treatment of choice for locally advanced non small cell lung cancer (NSCLC) is concurrent chemoradiation (CRT). However, efforts to improve treatment results include targeted therapy and the use of radiosensitizers. Nitroglycerin (NTG), a nitric oxide (NO) donor agent, reduces expression of Hypoxia-Induced Factor, which is associated to both chemo and radio resistance. Methods: This is phase II trial in patients with locally advanced NSCLC treated with chemotherapy (CT) based on cisplatin and vinorelbin with NTG concurrent with radiation therapy. A 25 mg NTG patch was administered to the patients during the first 5 days of each induction treatment cycle and during chemo-radiotherapy. Blood samples of VEGF were taken before any treatment and after two cycles of CT. The protocol is registered with ClinicalTrials.gov, number NCT00886405. Results: 35 patients were enrolled in this trial. Median Follow up was 16.6 months (SD ±13.6). Mean age was of 59.9 years (±10.8), 68.6% of the patients were smokers. ECOG status was 0 in 22.9%, 1 in 65.7% and 2 in 11.5%, respectively. Histopathology was adenocarcinoma in 68.6%, epidermoid in 17.1% and undifferentiated in 14.3%. Stage distribution was: IIIa, 57.6% and IIIb, 42.5%. All patients completed CRT treatment and four underwent surgical treatment. Toxicity profile related to NTG was grade 1 and 2 headache in 17.1%. Grade 3 and 4 toxicities were esophagitis (17.1%), neutropenia (62.9%), and nausea (5.7%). Sixty-four per cent of patients achieved partial response after CT and 75.8% after CRT. PFS was 11.8 months (95%, IC 7.8-15.6) and OS was 42.9 months (95%IC 31.3-52.1). After two cycles of CT, plasma VEGF levels were significantly lower (Median 132±79 vs. 53±78 pg/ml, p<0.001). No differences on PFS and OS were found between patients with a reduction ≥ 93 pg/ml (median of differences between VEGFR before and after chemotherapy). Conclusions: The addition of NTG to induction CT, and concurrent CRT on locally advanced NSCLC patients seems to increase the response rate, PFS and OS with an acceptable toxicity profile. A prospective trial is warranted to confirm these findings.

Prospective study on the association of depression and anxiety on quality of life, treatment adherence and prognosis in patients with advanced non small cell lung cancer

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Background: Symptoms of depression and anxiety are common in patients with lung cancer and could produce impact on health-related quality of life (HRQL) and survival. The aim of the present study is to evaluate the association of depression and anxiety on HRQL, treatment adherence and prognosis in patients with non-small cell lung cancer (NSCLC). Methods: This is a prospective study of consecutive patients with stages IIIB-IV NSCLC. Depression and anxiety were measured with the Hospital Anxiety and Depression Scale (HADS) and the International Psychiatric Interview (MINI), and HRQL with the EORTC QLQ-C30 and QLQ-LC13 questionnaires.All instruments were applied before treatment; at three and six months. Lack of adherence to treatment was considered in patients who stopped attending consultation. Overall survival (OS) was calculated with the Kaplan-Meier and Cox methods. Results: Eighty-two patients were included, mean age 58.9 years. Depression and anxiety were found in 32.9 and 34.1% - respectively - at the initial evaluation. Factors associated with depression were: female gender (p=0.034) and poor performance status (p=0.048). Depression showed association to HRQL; particularly Global health status/QoL and functional scales (i.e: Physical, Role, Emotional, cognitive and Social); Anxiety also showed association to HRQL; particularly Global health status/QoL and functional scales (all p≤0.05).Patients with depression presented a median OS of 6.8 months (95% CI 2.4-11.1) whilst non-depressed patients: 14 (10.3-17.6). Anxiety was not associated to OS. By multivariate analysis, depression has a hazard ratio of 1.9 (95% CI 1.03-3.7, p=0.042). Forty-four percent of the patients with depression had poor treatment adherence versus 14% of the non-depressed (p<0.05). Conclusions: One third of patients with advanced NSCLC presented depression and anxiety. Both were associated to decreased HRQL functional scales of QLQ-C30 and treatment adherence. Depression was independently associated to poor prognosis.

Abstract B3: Relevance of genotyping non-small-cell lung cancer patients on response to platinum-basedchemotherapy and tyrosine kinase inhibitors

Background: Subdividing non-small cell lung cancer (NSCLC) based on molecular alterations such as EGFR, KRAS and ALK genes is important for selecting treatment involving EGFR and EML4-ALK tyrosine kinase inhibitors (TKI). However, little information is available comparing patients' response and progression-free survival in the presence or absence of EGFR, KRAS mutations or the EML4-ALK fusion gene when being treated with chemotherapy.

Methods: NSCLC patients were treated with chemotherapy and/or TKIs. Tests were performed for EGFR and KRAS gene mutation as well as EML4-ALK fusion genes. Progression-free survival and overall survival association with type of treatment and mutational status was analyzed.

Results: The factors associated with a response to chemotherapy were the presence of EGFR and KRAS mutation (p = 0.006 and p = 0.028, respectively). Factors associated with TKI response were adenocarcinoma (HR 2.7: 1.6–4.6 95%CI; p&lt;0.001), EGFR mutation (HR 0.5: 0.3–0.8 95%CI; p = 0.009) and wild-type KRAS (HR 1.7: 1.1–2.8 95%CI; p = 0.013). Mean progression-free survival in the chemotherapy group was 5.3 months (4.8–5.7 95%CI).

Conclusion: EGFR and KRAS mutation status appeared to subdivide NSCLC patients into TKI and chemotherapy response groups.

Simple robust autotuning rules for 2-DoF PI controllers

This paper addresses the problem of providing simple tuning rules for a Two-Degree-of-Freedom (2-DoF) PI controller (PI(2)) with robustness considerations. The introduction of robustness as a matter of primary concern is by now well established among the control community. Among the different ways of introducing a robustness constraint into the design stage, the purpose of this paper is to use the maximum sensitivity value as the design parameter. In order to deal with the well known performance/robustness tradeoff, an analysis is conducted first that allows the determination of the lowest closed-loop time constant that guarantees a desired robustness. From that point, an analytical design is conducted for the assignment of the load-disturbance dynamics followed by the tuning of the set-point weight factor in order to match, as much as possible, the set-point-to-output dynamics according to a first-order-plus-dead-time dynamics. Simple tuning rules are generated by considering specific values for the maximum sensitivity value. These tuning rules, provide all the controller parameters parameterized in terms of the open-loop normalized dead-time allowing the user to select a high/medium/low robust closed-loop control system. The proposed autotuning expressions are therefore compared with other well known tuning rules also conceived by using the same robustness measure, showing that the proposed approach is able to guarantee the same robustness level and improve the system time performance.

Long-term survival in patients with non-small cell lung cancer and synchronous brain metastasis treated with whole-brain radiotherapy and thoracic chemoradiation

BACKGROUND

Brain metastases occur in 30-50% of Non-small cell lung cancer (NSCLC) patients and confer a worse prognosis and quality of life. These patients are usually treated with Whole-brain radiotherapy (WBRT) followed by systemic therapy. Few studies have evaluated the role of chemoradiotherapy to the primary tumor after WBRT as definitive treatment in the management of these patients.

METHODS

We reviewed the outcome of 30 patients with primary NSCLC and brain metastasis at diagnosis without evidence of other metastatic sites. Patients were treated with WBRT and after induction chemotherapy with paclitaxel and cisplatin for two cycles. In the absence of progression, concurrent chemoradiotherapy for the primary tumor with weekly paclitaxel and carboplatin was indicated, with a total effective dose of 60 Gy. If disease progression was ruled out, four chemotherapy cycles followed.

RESULTS

Median Progression-free survival (PFS) and Overall survival (OS) were 8.43 ± 1.5 and 31.8 ± 15.8 months, respectively. PFS was 39.5% at 1 year and 24.7% at 2 years. The 1- and 2-year OS rates were 71.1 and 60.2%, respectively. Three-year OS was significantly superior for patients with N0-N1 stage disease vs. N2-N3 (60 vs. 24%, respectively; Response rate [RR], 0.03; p= 0.038).

CONCLUSIONS

Patients with NSCLC and brain metastasis might benefit from treatment with WBRT and concurrent thoracic chemoradiotherapy. The subgroup of N0-N1 patients appears to achieve the greatest benefit. The result of this study warrants a prospective trial to confirm the benefit of this treatment.

Adjuvant immunotherapy of C6 glioma in rats with pertussis toxin

PURPOSE

In spite of the recent advances in surgery and antitumor drugs, the brain tumors, like glioblastoma, have shown a poor prognosis. The aim of this study was to determine the effect of pertussis toxin (PTx) as immunomodulatory molecule on glial tumors induced by C6 glioma cells.

METHODS

Given the pleiotropic effect of PTx on the immune system, we analyzed the effect of PTx on CD4+/CD25+/FoxP3+ (Treg) cells like as immunotherapeutic adjuvant. Thirty rats with a glial tumor of 1.5 cm in diameter were separated in two groups: the first group was treated with PTx and the second group was non-treated (controls). Tumoral volume was measured weekly; tumor, blood and spleen were taken for analysis of subpopulations of T cells, apoptotic index and cytokine contents, in both groups.

RESULTS

We observed a significant decrease in tumor volume in the PTx group; this was associated with a decreased in the number of Treg cells, in both spleen and tumor. The percentage of apoptotic cells was increased as compared with that of controls. The production of proinflammatory cytokines was increased in mRNA for IL-6 as well as a small increase in the mRNA expression of perforin and granzime in tumors from rats treated with PTx. No changes were found in the mRNA expression of MCP-1 and MIP-1α.

CONCLUSION

These results suggest that PTx could be an immunotherapeutic adjuvant in the integral therapy against glial tumors.

Randomized phase III trial of paclitaxel/carboplatin with or without PF-3512676 (Toll-like receptor 9 agonist) as first-line treatment for advanced non-small-cell lung cancer

PURPOSE

This phase III study examined efficacy of the synthetic Toll-like receptor 9-activating oligodeoxynucleotide PF-3512676 in combination with standard paclitaxel/carboplatin chemotherapy in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemotherapy-naive patients with stage IIIB or IV NSCLC were randomly assigned (1:1) to receive up to six courses of paclitaxel/carboplatin (intravenous paclitaxel 200 mg/m(2) and carboplatin at area under the [concentration-time] curve 6 on day 1 of a 3-week cycle) alone (control arm) or in combination with 0.2 mg/kg subcutaneous PF-3512676 on days 8 and 15 (investigational arm). Primary end point was overall survival (OS).

RESULTS

Baseline demographics were similar across arms (N = 828). Most patients (88%) had stage IV disease. Median OS and median progression-free survival (PFS) were similar (OS: investigational arm, 10.0 months v control arm, 9.8 months; P = .56; PFS: investigational arm, 4.8 months v control arm, 4.7 months; P = .79). Most commonly reported PF-3512676-related adverse events (AEs) were mild-to-moderate local injection site reactions, pyrexia, and flu-like symptoms. In the investigational arm, grades 3 to 4 AEs, including neutropenia, thrombocytopenia, and anemia, were more frequent, and more patients had one or more sepsis-related AEs versus controls (17 v 3). At first interim analysis, the Data Safety Monitoring Committee recommended study discontinuation because of lack of incremental efficacy and more sepsis-related serious AEs in the PF-3512676 arm. Administration of PF-3512676, but not chemotherapy, was halted.

CONCLUSION

Addition of PF-3512676 to paclitaxel/carboplatin did not improve OS or PFS versus paclitaxel/carboplatin alone for first-line treatment of patients with advanced NSCLC but did increase toxicity. This regimen cannot be recommended for treating patients with advanced NSCLC.

Second order inverse response process identification from transient step response

Simple algorithms for identification of inverse response models from step response are difficult to obtain because analytically the solution of a system of coupled nonlinear equations is required. In this article we propose a simple identification procedure for second order inverse response processes, based on the plant step response. The algorithm provides the model parameters in a sequential way, thus avoiding the solution of a nonlinear equation system. Moreover the algorithm is flexible because it can be suited to user requirements, thus modifying the algorithm performance. Finally error bounds on the identified parameters are provided which are useful if the model is used for control design purposes.

Methylenetetrahydrofolate reductase polymorphism (677 C>T) predicts long time to progression in metastatic colon cancer treated with 5-fluorouracil and folinic acid

BACKGROUND AND AIMS

Fluoropyrimidine-based chemotherapy is the most common treatment for unresectable metastatic colorectal cancer (m-CRC). Therapy with 5-FU/folinic acid (FA) continues to be a standard treatment in developing countries. Pharmacogenomics allows the tailoring of cancer therapy to the patient. The polymorphism 677C>T of the methylenetetrahydrofolate reductase (MTHFR) gene seems to influence the effectiveness of treatment with 5-FU. We undertook this study to evaluate the frequency of MTHFR 677C>T polymorphism and its relationship to the time to progression (TTP) and overall survival (OS) in m-CRC treated with 5-FU/FA.

METHODS

The MTHFR 677C>T polymorphism was determined using PCR and allele-specific digestion. The clinical variables, TTP and OS, were analyzed in each case and compared between wild-type and variant polymorphic groups.

RESULTS

Among 34 patients (12 males and 22 females), we detected eight wild-type homozygous patients (CC; 24%), nine variant homozygous (TT; 26%), and 17 heterozygous (CT; 50%) individuals. The median TTP in patients with the MTHFR 677 CC, CT, and TT genotypes was 3.43, 4.77, and 4.80 months, respectively (p = 0.047, log rank). A longer TTP was observed in patients with polymorphic variant (CT and TT) compared with the wild-type homozygous patients (4.80 vs. 3.43 months; p = 0.031, log rank).

CONCLUSIONS

In this study, the frequency of the MTHFR 677C>T polymorphism is 50% among m-CRC Mexican patients. The results of this study appear to show that the presence of the MTHFR 677C>T polymorphism is associated with longer TTP and OS in m-CRC treated with 5-FU/FA.

Randomized Phase II Trial of All-Trans-Retinoic Acid With Chemotherapy Based on Paclitaxel and Cisplatin As First-Line Treatment in Patients With Advanced Non–Small-Cell Lung Cancer

Purpose

This randomized phase II trial evaluated whether the combination of cisplatin and paclitaxel (PC) plus all-trans retinoic acid (ATRA) increases response rate (RR) and progression-free survival (PFS) in patients with advanced non–small-cell lung cancer (NSCLC) with an acceptable toxicity profile and its association with the expression of retinoic acid receptor beta 2 (RAR-β2) as a response biomarker.

Patients and Methods

Patients with stages IIIB with pleural effusion and IV NSCLC were included to receive PC, and randomly assigned to receive ATRA 20 mg/m2/d (RA/PC) or placebo (P/PC) 1 week before treatment until two cycles were completed. RAR-β2 expression was analyzed in tumor and adjacent lung tissue.

Results

One hundred seven patients were included, 55 in the P/PC group and 52 in the RA/PC group. RR for RA/PC was 55.8% (95% CI, 46.6% to 64.9%) and for P/PC, 25.4% (95% CI, 21.3 to 29.5%; P = .001). The RA/PC group had a longer median PFS (8.9 v 6.0 months; P = .008). Multivariate analysis of PFS showed significant differences for the RA/PC group (hazard ratio, 0.62; 95% CI, 0.4 to 0.95). No significant differences in toxicity grade 3/4 were found between groups, except for hypertriglyceridemia (10% v 0%) in RA/PC (P = .05). Immunohistochemistry and reverse-transcriptase polymerase chain reaction assays showed expression of RAR-β2 in normal tissues of all tumor samples, but only 10% of samples in the tumor tissue.

Conclusion

Adding ATRA to chemotherapy could increase RR and PFS in patients with advanced NSCLC with an acceptable toxicity profile. A phase III clinical trial is warranted to confirm these findings.

Influence of taste disorders on dietary behaviors in cancer patients under chemotherapy

Objectives

To determine the relationship between energy and nutrient consumption with chemosensory changes in cancer patients under chemotherapy.

Methods

We carried out a cross-sectional study, enrolling 60 subjects. Cases were defined as patients with cancer diagnosis after their second chemotherapy cycle (n = 30), and controls were subjects without cancer (n = 30). Subjective changes of taste during treatment were assessed. Food consumption habits were obtained with a food frequency questionnaire validated for Mexican population. Five different concentrations of three basic flavors --sweet (sucrose), bitter (urea), and a novel basic taste, umami (sodium glutamate)-- were used to measure detection thresholds and recognition thresholds (RT). We determine differences between energy and nutrient consumption in cases and controls and their association with taste DT and RT.

Results

No demographic differences were found between groups. Cases showed higher sweet DT (6.4 vs. 4.4 μmol/ml; p = 0.03) and a higher bitter RT (100 vs. 95 μmol/ml; p = 0.04) than controls. Cases with sweet DT above the median showed significant lower daily energy (2,043 vs.1,586 kcal; p = 0.02), proteins (81.4 vs. 54 g/day; p = 0.01), carbohydrates (246 vs.192 g/day; p = 0.05), and zinc consumption (19 vs.11 mg/day; p = 0.01) compared to cases without sweet DT alteration. Cases with sweet DT and RT above median were associated with lower completion of energy requirements and consequent weight loss. There was no association between flavors DT or RT and nutrient ingestion in the control group.

Conclusion

Changes of sweet DT and bitter RT in cancer patients under chemotherapy treatment were associated with lower energy and nutrient ingestion. Taste detection and recognition thresholds disorders could be important factors in malnutrition development on patients with cancer under chemotherapy treatment.

Association of nutritional status and serum albumin levels with development of toxicity in patients with advanced non-small cell lung cancer treated with paclitaxel-cisplatin chemotherapy: a prospective study

Background

A frequent manifestation of advanced NSCLC is malnutrition, even though there are many studies which relate it with a poor survival, its relation with toxicity has not yet been consistently reported. The aim of this study was to associate malnutrition and albumin serum levels with the occurrence of chemotherapy-induced toxicity in cisplatin plus paclitaxel chemotherapy-treated NSCLC.

Methods

We prospectively evaluated 100 stage IV NSCLC patients treated with paclitaxel (175 mg/m²) and cisplatin (80 mg/m²). Malnutrition was assessed using SGA prior treatment. Neutrophil Lymphocyte Ratio (NLR) and the Platelet Lymphocyte Ratio (PLR) were used to determine the presence of systemic inflammatory response (SIR) and were related to the development of toxicity. Toxicity was graded according to NCI CTCAE version 3.0 after two chemotherapy cycles.

Results

Median age was 58 ± 10 years, 51% of patients were malnourished, 50% had albumin ≤3.0 mg/mL. NLR ≥ 5 was associated with basal hypoalbuminemia (mean ranks, 55.7 vs. 39 p = 0.006), ECOG = 2 (47.2 vs. 55.4 p = 0.026) and PLR ≥ 150 were significantly related with a basal body mass index ≤20 (56.6 vs. 43.5; p = 0.02) and hypoalbuminemia (58.9 vs. 41.3; p = 0.02). Main toxicities observed after 2 cycles of chemotherapy were alopecia (84%), nausea (49%), neuropathy (46%), anemia (33%), lymphopenia (31%), and leukopenia (30%). Patients malnourished and with hypoalbuminemia developed more chemotherapy-induced toxicity overall when compared with those without malnutrition (31 vs 22; p = 0.02) and normal albumin (mean ranks, 62 vs 43; p = 0.002), respectively. Hypoalbuminemia was associated with anemia (56 vs 47; p = 0.05), fatigue (58 vs 46; p = 0.01), and appetite loss (57.1 vs 46.7; p = 0.004) compared with normal albumin. PLR ≥ 150 was related with the development of toxicity grade III/IV (59.27 vs. 47.03 p = 0.008) and anemia (37.9 vs 53.8 p = 0.004).

Conclusion

SIR parameters were associated with malnutrition, weight loss and hypoalbuminemia. Chemotherapy-induced toxicity in NSCLC patients treated with paclitaxel and cisplatin was associated with malnutrition and hypoalbuminemia. Early nutritional assessment and support might confer beneficial effects.

IMC based feedforward controller framework for disturbance attenuation on uncertain systems

This paper presents a generalization of the Internal Model Control (IMC) approach to feedforward control action generation. As is well known, one of the distinctive features of the IMC formulation is the possibility to distinguish between the nominal and uncertain situations. However the consideration of the presence of uncertainty for the feedforward part of the controller is not as simple as that for the feedback one. In this sense, what is proposed in this paper provides a more systematic way of addressing a robust feedforward design. In addition, being one of the major drawbacks of the Internal Model Control to have to deal with stable systems, the generalization presented here allows for unstable plants as well as unstable disturbance models.

Serum human chorionic gonadotropin is associated with angiogenesis in germ cell testicular tumors

Background

Germ cell testicular tumors have survival rate that diminishes with high tumor marker levels, such as human chorionic gonadotropin (hCG). hCG may regulate vascular neoformation through vascular endothelial growth factor (VEGF). Our purpose was to determine the relationship between hCG serum levels, angiogenesis, and VEGF expression in germ cell testicular tumors.

Methods

We conducted a retrospective study of 101 patients. Serum levels of hCG, alpha-fetoprotein (AFP), and lactate dehydrogenase were measured prior to surgery. Vascular density (VD) and VEGF tissue expression were determined by immunohistochemistry and underwent double-blind analysis.

Results

Histologically, 46% were seminomas and 54%, non-seminomas. Median follow-up was 43 ± 27 months. Relapse was present in 7.5% and mortality in 11.5%. Factors associated with high VD included non-seminoma type (p = 0.016), AFP ≥ 14.7 ng/mL (p = 0.0001), and hCG ≥ 25 mIU/mL (p = 0.0001). In multivariate analysis, the only significant VD-associated factor was hCG level (p = 0.04). When hCG levels were stratified, concentrations ≥ 25 mIU/mL were related with increased neovascularization (p < 0.0001). VEGF expression was not associated with VD or hCG serum levels.

Conclusion

This is the first study that relates increased serum hCG levels with vascularization in testicular germ cell tumors. Hence, its expression might play a role in tumor angiogenesis, independent of VEGF expression, and may explain its association with poor prognosis. hCG might represent a molecular target for therapy.

Concurrent chemo-radiotherapy following neoadjuvant chemotherapy in locally advanced breast cancer

BACKGROUND

Despite broad advances in multimodal treatment of locally advanced breast cancer (LABC), 30 to 40% of patients develop loco-regional relapse. The aim of this study was to analyze in a retrospective manner the effectiveness of concurrent chemo-radiotherapy (CCRTh) after neoadjuvant chemotherapy (NCT) in patients with LABC.

METHODS

One hundred twelve patients with LABC (stage IIB-IIIB) were treated with NCT (5-fluorouracil 500 mg/m2, doxorubicin 50 mg/m2, and cyclophosphamide 500 mg/m2 (FAC), or doxorubicin 50 mg/m2 and cyclophosphamide 500 mg/m2 (AC) IV in four 21-day courses) followed by CCRTh (60 Gy breast irradiation and weekly mitomycin 5 mg/m2, 5-fluorouracil 500 mg/m2, and dexamethasone 16 mg, or cisplatin 30 mg/m2, gemcitabine 100 mg/m2 and dexamethasone 16 mg), and 6-8 weeks later, surgery and two additional courses of FAC, AC, or paclitaxel 90 mg/m2 weekly for 12 weeks, and in case of estrogen-receptor positive patients, hormonal therapy.

RESULTS

Stages IIB, IIIA and -B were 21.4, 42.9, and 35.7%, respectively. Pathological complete response (pCR) in the breast was 42% (95% CI, 33.2-50.5%) and, 29.5% (95% CI, 21.4-37.5%) if including both the breast and the axillary nodes. Multivariate analysis showed that the main determinant of pCR was negative estrogen-receptor status (HR=3.8; 95% CI, 1.5-9; p=0.016). The 5-year disease-free survival (DFS) was 76.9% (95% CI, 68.2-84.7%). No relationship between pCR and DFS was found. Multivariate analysis demonstrated that the main DFS determinant was clinical stage (IIB and IIIA vs. IIIB, HR=3.1; 95% CI, 1.02-9.74; p=0.04). Only one patient had local recurrence. Five-year overall survival was 84.2% (95% CI, 75-93.2%). The toxicity profile was acceptable.

CONCLUSION

This non-conventional multimodal treatment has good loco-regional control for LABC. Randomized clinical trials of preoperative CCRTh following chemotherapy, in patients with LABC are warranted.

Paclitaxel and cisplatin versus paclitaxel and cisplatin plus all-trans retinoic acid for the prevention of chemotherapy-induced neuropathy: A randomized phase II trial

e14506

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse event, similar to that of diabetes where there is reduction of the expression and transport of Neural Growth Factor (NGF). Retinoic acid regulates genes related to cellular proliferation and NGF expression. We conducted this clinical trial to determine the effect of all-trans retinoic acid (ATRA) on the development of CIPN with paclitaxel and cisplatin in patients with advanced non-small cell lung cancer (NSCLC). Methods: Ninety five patients with advanced NSCLC were included to receive chemotherapy based on paclitaxel 175 mg/m2 and cisplatin 80 mg/m2 every 3 weeks for a maximum of 6 cycles. The patients were randomized to receive ATRA 20 mg/day or placebo 1 week before treatment until after completing 2 cycles. Prior to chemotherapy and after 2 cycles of treatment neurophysiology tests, clinical exam and serum NGF levels (34 patients) were performed. Results: There were no differences in general characteristics of the patients between groups. NGF serum levels were lower in the placebo group 4.89 pg/ml baseline and 4.6 pg/ml 2C (p = 0.007) versus ATRA 4.8 pg/ml and 4.7 pg/ml (p=0.107). The electrophysiological studies showed a greater degree of motor axonal damage in the right (p=0.003) and left (p=0.013) tibial nerves in the placebo group after 2C. In the ATRA group there were no significant differences baseline and after chemotherapy. Conclusions: ATRA might have a neuroprotective effect in patients with NSCLC treated with paclitaxel and cisplatin. A phase III trial is needed to confirm these findings.

No significant financial relationships to disclose.

Liposomal doxorubicin and cisplatin as first-line chemotherapy in unresectable malignant pleural mesothelioma: A phase II study

e13507

Background: Malignant pleural mesothelioma (MPM) is a poor prognosis neoplasm. Its worldwide incidence is rising but until recently chemotherapy has not been shown to be effective in its treatment. The combination of cisplatin and pemetrexed is the approved “standard” treatment in unresectable MPM. Liposomal doxorubicin (LD) consists of pegylated phospholipid- vesicles that encapsulate doxorubicin conferring minimal capture from the reticulo-endothelial system resulting in a greater serum half- life, an enhanced liposome deposition in the tumor and a lower degree of toxicity. We evaluated the combination of LD and Cisplatin (Cis) in chemonaive patients with unresectable MPM. Methods: From September 2006 to October 2008, consecutive patients with stage III / IV MPM were included to receive LD 40 mg/m2 and Cis 60 mg/m2 every 21 days for a maximum of 4 cycles. Imaging studies were performed prior and after 2 cycles to assess response. Gamma camera images (GCI) of Tc-99m-labeled LD were acquired to evaluate LD accumulation in measurable tumor tissue. Patients gave written informed consent. Results: Twenty seven patients were included, 81.5% were stage III and 18.5% were IV. According to EORTC prognostic factors, 33.3% and 66.7% had poor and good prognosis, respectively. Median age was 59.2 years (33–80). Median follow-up was of 5.2 ± 0.8 months. Median survival has not been reached. The 2-year overall survival was 52.5% ± 14.2. Median time to progression was 5.0 ± 1.1 months (CI 95%, 2.7–7.3). Overall response was 45.5%, stable disease 36.4% and progression of 18.2%. GCI showed good accumulation and retention (60%) of the labeled LD in tumor tissue at 4 h after the initial injection. There were no toxic deaths. Conclusions: Cis+LD is a highly active regimen in MPM with comparable results to the most active regimens so far reported. A phase III trial is warranted to confirm these findings.

No significant financial relationships to disclose.

Radiation pneumonitis in patients with locally advanced non-small cell lung cancer treated with concurrent radiotherapy and gemcitabine after induction with gemcitabine and carboplatin

e18504

Background: The combination of chemotherapy (CT) and thoracic radiation (RT) is the standard treatment for locally advanced non-small cell lung cancer (NSCLC). The most favorable CT regime, timing of full-dose CT and the best way to combine CT with RT to maximize systemic and radiosensitizing effects remain to be determined. The aim of this study was to assess the efficacy, safety and tolerability of gemcitabine concurrent with RT after induction CT (gemcitabine + carboplatin) in locally advanced NSCLC. Methods: Patients with histologically proven NSCLC IIIA and IIIB received carboplatin (AUC of 2.5) and gemcitabine (800 mg/m2) on day 1 and 8, every 21 days (two cycles), followed by conventional fractioned RT (60Gy) with concomitant weekly gemcitabine 200 mg/m2 and by consolidation CT. Survival was analyzed with Kaplan-Meier. Results: Median follow-up was of 11.9 months, 11 patients (57.9%) had stage IIIB disease. Patient inclusion was discontinued due to high grade 3/4 radiation pneumonitis events (5/19 patients, 26.3%). One treatment-related death from radiation pneumonitis occurred. The most common hematological side effects grade 3/4 were anemia and neutropenia 3/19 (15.8%) each and thrombocytopenia 4/19 (21.1%) during induction CT. Partial response was observed in 11 patients (57.9%) following induction. After concurrent chemo-radiotherapy, overall response was 68.4%. Four patients underwent surgical resection. Median progression-free survival was 12 ± 1 months (95% CI, 9.8 -14.1). Overall survival was of 21 ± 3.5 months (95% CI, 14–27.9). Conclusions: Concurrent RT with gemcitabine after induction CT with gemcitabine and carboplatin showed a high response rate. However, it is associated with excessive pulmonary toxicity. Adjustments in gemcitabine dosage during RT or changes in RT planning could reduce toxicity.

No significant financial relationships to disclose.

Angiogenesis and expression of estrogen and progesterone receptors as predictive factors of recurrence in meningiomas: A long-term prospective study

e13013

Background: Meningioma is a bening tumor, with a high rate of recurrence after surgery (80%); the most important relapse predictive factor is the extent of surgical resection; other potentially predictive factors have been studied with poor results. Angiogenesis has an important role in growth and spread of neoplasic cells; previous studies have shown a high incidence of cyclin E (CE), estrogen, and progesterone receptors (ER, PR) in meningiomas. The aim of this prospective study was to evaluate the prognostic significance of clinical-pathological factors (CPF), vascular density index (VDI), cell proliferation index (CPI), CE, ER, and PR tissue expression in meningioma recurrence of patients submitted to surgical resection. Methods: From January 1995 to December 2000, we enrolled 42 patients with histopathological diagnosis of meningioma and treated only with surgical resection. Tumor VDI, CPI, CE, ER, and PR tissue expression were evaluated by immunohistochemistry in patients with or without recurrence. CPF, VDI, CPI, and expression of CE, ER, and PR were associated with recurrence. Results: Complete surgical resection was achieved in 32.5% of patients. Minimal follow-up was 6 years. Recurrence of meningioma was found in 17 patients (40%). Mean time of recurrence was 32 + 8 months. Tissue expression was positive for CE, ER, and PR in 90.9%, 27.6%, and in 64% of patients, respectively. VDI was >8 (40X in 10 fields) in 52.6% of patients and CPI was >600 (40X in 10 fields) in 54.2% of patients. Significant recurrence-associated factors were extent of resection (RR = 2.4, 95% CI 1.7–2.9, p = 0.03) and VDI >8 (RR = 1.7, 95% CI 1.003–2.9, p = 0.001). CPI, CE, ER, and PR expressions were not statistically significant (p = 0.83, p = 0.16, p = 0.46, and p = 0.74, respectively). Conclusions: Patients with partially resected meningioma and high VDI have an increased recurrence risk and could benefit of additional therapeutic measures.

No significant financial relationships to disclose.

Brain metastasis development and poor survival associated with carcinoembryonic antigen (CEA) level in advanced non-small cell lung cancer: a prospective analysis

Background

Central nervous system is a common site of metastasis in NSCLC and confers worse prognosis and quality of life. The aim of this prospective study was to evaluate the prognostic significance of clinical-pathological factors (CPF), serum CEA levels, and EGFR and HER2 tissue-expression in brain metastasis (BM) and overall survival (OS) in patients with advanced NSCLC.

Methods

In a prospective manner, we studied 293 patients with NSCLC in IIIB-IV clinical stage. They received standard chemotherapy. CEA was measured prior to treatment; EGFR and HER2 were evaluated by immunohistochemistry. BM development was confirmed by MRI in symptomatic patients.

Results

BM developed in 27, and 32% of patients at 1 and 2 years of diagnosis with adenocarcinoma (RR 5.2; 95% CI, 1.002–29; p = 0.05) and CEA ≥ 40 ng/mL (RR 11.4; 95% CI, 1.7–74; p < 0.01) as independent associated factors. EGFR and HER2 were not statistically significant. Masculine gender (RR 1.4; 95% CI, 1.002–1.9; p = 0.048), poor performance status (RR 1.8; 95% CI, 1.5–2.3; p = 0.002), advanced clinical stage (RR 1.44; 95% CI, 1.02–2; p = 0.04), CEA ≥ 40 ng/mL (RR 1.5; 95% CI, 1.09–2.2; p = 0.014) and EGFR expression (RR 1.6; 95% CI, 1.4–1.9; p = 0.012) were independent associated factors to worse OS.

Conclusion

High CEA serum level is a risk factor for BM development and is associated with poor prognosis in patients with advanced NSCLC. Surface expression of CEA in tumor cells could be the physiopathological mechanism for invasion to CNS.

Importance of the preoperative evaluation of multifocal and multicentric breast cancer with magnetic resonance imaging in women with dense parenchyma

BACKGROUND

The presence and detection of multifocal and multicentric disease significantly increases the risk of recurrence and changes the best therapeutic approach in patients with breast cancer. Mammography has low sensitivity to detect multiple malignant foci in patients with dense breast parenchyma. We prospectively evaluated Magnetic Resonance Imaging (MRI) as part of preoperative assessment.

MATERIAL AND METHODS

Women with clinical and radiological suspicion of breast cancer and dense breast parenchyma (> 75% dense tissue) were included. All patients underwent mammography, ultrasonogram and MRI prior to surgery. Surgical specimens were used for the detection of multifocal and multicentric disease. Patients who required neoadjuvant chemotherapy or radiotherapy were excluded.

RESULTS

Nineteen patients were evaluated. Histological diagnosis was confirmed in 14 patients, multifocal and multicentric disease was found in five and two patients, respectively. Sensitivity and accuracy to detect multiple malignant foci were 42 and 64%, respectively, for mammography plus ultrasound and 100 and 92% for MRI (p<0.05).

CONCLUSIONS

MRI is more sensible and has a better accuracy than mammography plus ultrasound to detect both multicentric and multifocal breast cancer in women with dense breast parenchyma. MRI can improve preoperative assessment of breast cancer in this group of patients.

Expression of AT1 and AT2 angiotensin receptors in astrocytomas is associated with poor prognosis

Astrocytomas develop intense vascular proliferation, essential for tumour growth and invasiveness. Angiotensin II (ANGII) was initially described as a vasoconstrictor; recent studies have shown its participation in cellular proliferation, vascularisation, and apoptosis. We conducted a prospective study to evaluate the expression of ANGII receptors – AT1 and AT2 – and their relationship with prognosis. We studied 133 tumours from patients with diagnosis of astrocytoma who underwent surgery from 1997 to 2002. AT1 and AT2 were expressed in 52 and 44% of the tumours, respectively, when determined by both reverse transcriptase–polymerase chain reaction and immunohistochemistry. Ten per cent of low-grade astrocytomas were positive for AT1, whereas grade III and IV astrocytomas were positive in 67% (P<0.001). AT2 receptors were positive in 17% of low-grade astrocytomas and in 53% of high-grade astrocytomas (P=0.01). AT1-positive tumours showed higher cellular proliferation and vascular density. Patients with AT1-positive tumours had a lower survival rate than those with AT1-negative (P<0.001). No association to survival was found for AT2 in the multivariate analysis. Expression of AT1 and AT2 is associated with high grade of malignancy, increased cellular proliferation, and angiogenesis, and is thus related to poor prognosis. These findings suggest that ANGII receptors might be potential therapeutic targets for high-grade astrocytomas.

A phase II study of epigenetic therapy with hydralazine and magnesium valproate to overcome chemotherapy resistance in refractory solid tumors

BACKGROUND

Epigenetic aberrations lead to chemotherapy resistance; hence, their reversal by inhibitors of DNA methylation and histone deacetylases may overcome it.

PATIENTS AND METHODS

Phase II, single-arm study of hydralazine and magnesium valproate added to the same schedule of chemotherapy on which patients were progressing. Schedules comprised cisplatin, carboplatin, paclitaxel, vinorelbine, gemcitabine, pemetrexed, topotecan, doxorubicin, cyclophosphamide, and anastrozole. Patients received hydralazine at 182 mg for rapid, or 83 mg for slow, acetylators, and magnesium valproate at 40 mg/kg, beginning a week before chemotherapy. Response, toxicity, DNA methylation, histone deacetylase activity, plasma valproic acid, and hydralazine levels were evaluated.

RESULTS

Seventeen patients were evaluable for toxicity and 15 for response. Primary sites included cervix (3), breast (3), lung (1), testis (1), and ovarian (7) carcinomas. A clinical benefit was observed in 12 (80%) patients: four PR, and eight SD. The most significant toxicity was hematologic. Reduction in global DNA methylation, histone deacetylase activity, and promoter demethylation were observed.

CONCLUSIONS

The clinical benefit noted with the epigenetic agents hydralazine and valproate in this selected patient population progressing to chemotherapy' and re-challenged with the same chemotherapy schedule after initiating hydralazine and valproate' lends support to the epigenetic-driven tumor-cell chemoresistance hypothesis (ClinicalTrials.gov Identifier: NCT00404508).

Predictors of mortality and adverse outcome in elderly high-risk patients undergoing percutaneous coronary intervention

OBJECTIVES

We sought to identify predictors of in-hospital and long-term (> 1 year) mortality and major adverse cardiac events (MACE) in elderly patients referred for percutaneous coronary intervention (PCI).

METHODS

Seventy-three patients (> or = 80 years) were included. Clinical and interventional characteristics were collected retrospectively. Primary end points were in-hospital and long-term mortality, and a composite of non-fatal myocardial infarction, target vessel revascularization, urgent coronary artery bypass graft surgery, and death (MACE).

RESULTS

Eighty-three percent of the patients had acute coronary syndromes, 43% three-vessel disease, and 42% heart failure. In-hospital mortality and MACE were 16.4% and 19%, respectively. Long-term mortality and MACE were 11.3% and 16.4%, respectively. Univariate characteristics associated with in-hospital mortality and MACE were: Killip Class III-IV, heart failure, cardiogenic shock, TIMI 0-2 flow prior and after intervention, diabetes mellitus, contrast nephropathy, and presence of A-V block or atrial fibrillation (AF). Long term predictors for mortality were the presence of heart failure, cardiogenic shock, diabetes mellitus, TIMI flow 0-2 before and after intervention, and A-V block or AF.

CONCLUSION

The identification of the factors previously mentioned may help to predict complications in elderly patients.

Erlotinib in non-small cell lung cancer (NSCLC): Interim safety analysis of the TRUST study

7645

Background: In patients (pts) with relapsed NSCLC, erlotinib 150 mg/d significantly prolonged survival, delayed symptom progression, and improved quality of life versus placebo (Shepherd et al, N Engl J Med 2005;353:123–32). TRUST is an open label, non- randomized trial initiated to provide erlotinib access to pts with advanced NSCLC. Methods: Eligible pts had stage IIIb/IV NSCLC, and had failed or were unsuitable for chemotherapy. Erlotinib (150 mg/d p.o.) was given until disease progression or unacceptable toxicity. Pts were monitored monthly. Results: In November 2006, data were available for 5,015 pts (ITT population) from 51 countries. Median age was 63y (range 19–95). Pt characteristics (%) were: male/female 62/38; Caucasian/Oriental/other 76/19/5; non-smoker/ex- or current-smoker 28/71 (no data 1); ECOG PS 0/1/2/3 21/53/20/6; adenocarcinoma/squamous cell/other 53/25/21; stage IIIb/IV 22/78; erlotinib 1st/2nd/3rd-line/other 14/48/37/1. Safety data were available for 4,423 pts, 55% of whom had at least one adverse event (AE). Only 5% had one or more erlotinib- related serious AEs, the most common being gastrointestinal (GI) disorders (86 pts; 63 grade [gr] 3/4). 6% of pts discontinued treatment due to erlotinib-related AEs: GI disorders in 96 pts (54 gr 3/4), skin disorders in 92 (50 gr 3/4). Unexpected erlotinib-related AEs occurred in 10% of pts (4% gr 1, 3% gr 2, 3% gr 3/4). As expected, rash was observed in 70% of pts, with the majority (84%) being of gr 1/2. 80% pts received >4 weeks of erlotinib. Among 4,405 pts, only 14% had dose reductions, mainly due to rash (83%) and diarrhea (21%). Similar safety results were seen for 2nd-line pts only. Efficacy for all and 2nd-line pts will be presented. Conclusions: These results, achieved through routine clinical use of erlotinib in unselected pts with advanced NSCLC, confirm the favorable tolerability profile seen with erlotinib in selected patients in the clinical trial setting.

[Table: see text]

Concurrent chemoradiotherapy (CRT) following neoadjuvant chemotherapy (NACT) in locally advanced breast cancer (LABC)

11063

Background: Despite broad advances in the treatment of LABC, 30 to 40% of patients responding to NACT develop locoregional relapse. We performed a retrospective analysis of the experience obtained so far in patients with LABC who were treated with CRT after NACT in terms of pathologic complete response (pCR), relapse-free survival (RFS) and overall survival (OS) at our institution. Methods: One hundred and twelve patients with LABC (Stage IIB-IIIB) were treated between January 2000 and December 2003 with NACT with 5FU 500mg/m2, doxorubicin 50 mg/m2 and cyclophosphamide 500mg/m2 (FAC) or doxorubicin 50 mg/m2 and cyclophosphamide 500mg/m2 (AC) administered i.v. in four 21-day cycles. CRT with 60 Gy whole-breast irradiation and concurrent weekly mitomycin 5mg, 5FU 500mg and dexamethasone 16 mg or cisplatin 30 mg, gemcitabine 100 mg and dexamethasone 16 mg. Subsequently they underwent surgery and 6 to 8 weeks later received 2 additional courses of FAC, AC or paclitaxel 90mg weekly for 12 weeks and in estrogen receptor (ER) positive patients hormone therapy. Results: Median tumor size 5 cm; stages IIB, IIIA and IIIB were 21.4%, 42.9% and 35.7% respectively. pCR was 42% (CI 95% 33.2 - 50.5) in breast and 29.5% (CI 95% 21.4 - 37.5) in breast and axillary lymph nodes. Multivariate analysis showed the main determinant of pCR was negative ER (P 0.016). Median RFS has not been reached. The 5 year RFS is 76.9% (CI 95% 68.2 - 84.7). No relationship between pCR and RFS was found. Multivariate analysis showed the main determinant of RFS was the clinical stage (p=0.03). Only one patient had local recurrence. The 5 year OS is 84.2% (CI 95% 75 - 93.2). Toxicity during CRT: grade 1–2 neutropenia 32.2%, grade 1–2 anemia 5.2%, grade 3 radioepithelitis 22.4% Conclusions: This modality has good locoregional control for locally advanced breast cancer with an acceptable toxicity profile. Futher investigation of concurrent chemoradiotherapy should be explored in LABC.

No significant financial relationships to disclose.

Clinical and prognostic significance of serum carcinoembryonic antigen level in patients with IIIB and IV stage lung cancer: A prospective study

18063

Previous studies have shown pre and post-operative serum CEA levels are a prognostic factor in patients with lung cancer (LC). We prospectively investigated the clinical and pathological characteristics, as well as, prognostic significance of patients with IIIB and IV stage LC and the CEA serum elevation. From March of 2005 to January of 2007, 307 patients with IIIB and IV stage were included; several chemotherapy protocols including gemcitabine, vinorelbine or paclitaxel combined with cisplatin, carboplatin, or erlotinib were used. Serum CEA levels were obtained before and after 2 cycles of treatment. Stage was determined by CT and bone scans; 120 patients had brain CT scan at diagnosis due to neurological symptoms. 28.6% of the patients were stage IIIB and 61.4% stage IV and 18% of patients had CNS metastasis at diagnosis. Histology was adenocarcinoma in 69.1% and epidermoid in 30.9%. Mean CEA was 11.3 ng/ml ± 24.5 with median of 6.7 (range 0.2 to 4,578). Patients with CEA levels > 10, 20, 50 and 100 were 43.6, 32.5, 24 and 17.9%; respectively. Associated factors with CEA >20 were age >62 (p=0.02), stage (p=0.05), CNS metastasis (p=0.0001) and histology (p=0.01). However, in the logistic regression analysis the only associated factors were histology (p=0.0001) and CNS metastasis (p=0.0001). Patients with CEA elevation >20 had a hazard ratio of 26.3 (CI 11.2 to 61.6) for the development of brain metastases. Overall survival associated factors were poor status performance (p=0.006), tobacco use (p=0.05), CEA elevation (p=0.0022), CNS metastases (p=0.01), male gender (p=0.08). There were no differences between stage IIIB, IV and CNS metastasis. The associated factors with survival by Cox proportional hazards regression multivariate analysis were poor performance status (p=0.05) and CEA elevation (p=0.008). The independent factors associated with CEA elevation were histology adenocarcinoma and brain metastasis. Patients with CEA >20 without neurological symptoms could benefit from early CT brain scan with stage IIIB and IV. In this group of patients, the 2 most important independent factors for survival were poor performance status and CEA elevation.

No significant financial relationships to disclose.

Clinical and pathologic factors associated with development of hepatocellular carcinoma in patients with hepatitis virus-related cirrhosis: A long-term follow-up study

4646

Background: Hepatocellular carcinoma (HCC) represents >90% of primary liver neoplasms and develops mainly in patients with liver cirrhosis. Risk factor identification for development of HCC in patients with cirrhosis is of great relevance due to its high incidence and poor prognosis when detected at advanced stages. The aim of our study was to identify HCC development-associated risk factors in a cohort of patients with hepatitis virus-related chronic liver disease and cirrhosis. Materials and Methods: Patients with diagnosis of hepatitis virus-related cirrhosis from January 1980 to January 2000 were included. Patients were followed with abdominal US and determination of AFP levels, physical examination, and biochemical tests every 3–6 months. The endpoint in this study was defined as development of HCC. Liver histology was evaluated according to the METAVIR. Results: 282 patients met the inclusion criteria; most (86%) had a serologic diagnosis of hepatitis C virus, and only 14% had hepatitis B virus at the time of diagnosis of cirrhosis, while 56 and 37% were classified as Child A and B, respectively; only 7% as Child C. Histological activity was mild in 59% of patients; moderate and severe in 41%. Mean annual incidence was 1.87%; 22 and 35% of patients developed HCC at 10 and 15 years of follow-up, respectively. Diagnosis of HCC was made by histopathology in 37% and by tumoral lesion-associated AFP elevation confirmed by imaging studies in 63%. In multivariate analysis, 3 variables were associated with HCC: moderate to severe histological activity; platelet count <105 103/mm3, and alpha- fetoprotein >5 ng/mL. We divided patients into two groups according to regression coefficient: low and high-risk; patients assigned to the low-risk group showed 5, 10, and 15-year HCC incidences of 3.4, 6.4, and 6.4%, respectively, in contrast to patients from the high-risk group, who showed incidences of 17.8, 33.5, and 56.8%, respectively. Conclusions: We found three HCC-associated variables: histological activity; platelet count and alpha-fetoprotein levels. Patients considered as high-risk for developing hepatocellular carcinoma must be considered candidates for closer follow-up.

No significant financial relationships to disclose.

Prognostic factors in gallbladder and biliary tract cancer

BACKGROUND

Cancers of the gallbladder and bile ducts are uncommon neoplasms with poor survival. Prognostic factors are not well defined because of the scant number of patients reported through series of cases.

METHODS

We reviewed the medical records of patients with cancer of the bile ducts and gallbladder between the years 1979 and 1998, and analyzed their characteristics according to location (gallbladder, extrahepatic biliary tract, intrahepatic biliary tract, and Klatskin tumors).

RESULTS

One hundred and sixty-eight patients were included; the mean follow-up time was 238 +/- 54 d. The tumor found at more advanced stages was the biliary tract tumor. Overall survival time was 254 +/- 40 d. Location did not influence survival. The factors significantly associated to increased survival were age at diagnosis less than 50 yr (p = 0.0065), surgical treatment (p < 0.001), adjuvant chemotherapy and radiotherapy (p < 0.001 and p = 0.0072, respectively), surgical treatment with curative purpose (p < 0.001), stage of the disease (p < 0.0001), absence of jaundice (p = 0.0425), and absence of weight loss (p = 0.0446). In the multivariate analysis the significant variables were age, surgical treatment, adjuvant chemotherapy, surgery with curative purpose, stage of the disease, and absence of jaundice.

CONCLUSIONS

Cancers of the bile ducts are neoplasms known to have a poor prognosis. Chemotherapy was an independent survival factor despite the context, there is need of future studies to define its role on this disease.

The progressive elevation of alpha fetoprotein for the diagnosis of hepatocellular carcinoma in patients with liver cirrhosis

Background

Hepatocellular carcinoma is the most common cause of primary liver neoplasms and is one of the main causes of death in patients with liver cirrhosis. High Alpha fetoprotein serum levels have been found in 60–70% of patients with Hepatocellular carcinoma; nevertheless, there are other causes that increase this protein. Alpha fetoprotein levels ≥200 and 400 ng/mL in patients with an identifiable liver mass by imaging techniques are diagnostic of hepatocellular carcinoma with high specificity.

Methods

We analysed the sensitivity and specificity of the progressive increase of the levels of alpha fetoprotein for the detection of hepatocellular carcinoma in patients with liver cirrhosis. Seventy-four patients with cirrhosis without hepatocellular carcinoma and 193 with hepatic lesions diagnosed by biopsy and shown by image scans were included. Sensitivity and specificity of transversal determination of alpha fetoprotein ≥ 200 and 400 ng/mL and monthly progressive elevation of alpha fetoprotein were analysed. Areas under the ROC curves were compared. Positive and negative predictive values adjusted to a 5 and 10% prevalence were calculated.

Results

For an elevation of alpha fetoprotein ≥ 200 and 400 ng/mL the specificity is of 100% in both cases, with a sensitivity of 36.3 and 20.2%, respectively. For an alpha fetoprotein elevation rate ≥7 ng/mL/month, sensitivity was of 71.4% and specificity of 100%. The area under the ROC curve of the progressive elevation was significantly greater than that of the transversal determination of alpha fetoprotein. The positive and negative predictive values modified to a 10% prevalence are of: 98.8% and 96.92%, respectively; while for a prevalence of 5% they were of 97.4% and 98.52%, respectively.

Conclusion

The progressive elevation of alpha fetoprotein ≥7 ng/mL/month in patients with liver cirrhosis is useful for the diagnosis of hepatocellular carcinoma in patients that do not reach αFP levels ≥200 ng/mL. Prospective studies are required to confirm this observation.