Immunotherapy Efficacy in Advanced Hepatocellular Carcinoma in a Diverse and Underserved Population in the United States

Background 

  Incidence of hepatocellular cancer (HCC) in the Bronx is 61% higher than the rest of New York State. Underserved populations are not well represented in clinical trials of immune checkpoint inhibitors (ICI).

Methods

Demographics were tabulated for 194 patients treated with ICI at the Montefiore-Einstein Comprehensive Cancer Center (MECCC) between 2017 and 2022. Categorical variables were analyzed by Chi-squared test, and survival was analyzed using Kaplan-Meier (KM) curves.

Results

MECCC patients were 40.7% Hispanic and 20.6% Black, compared with 3% and 2%, respectively, in the landmark IMbrave 150 study. Median overall survival (mOS) on ICI was 9.0 months, 25.0 months for the 100 (51.5%) favorable-prognosis Child Pugh A (CPA) patients included in HCC clinical trials. Disease control rate (DCR) was 58.5% among 123 evaluable patients per mRECIST 1.1. Baseline liver function, as defined by CP and the Model for End-Stage Liver Disease-Sodium (MELD-Na), correlated with survival (p < 0.001). Hepatitis C Virus (HCV) and alcoholism were over-represented relative to National Cancer Institute (NCI) data (56.2% vs 4.7% and 38.7% vs 8.2%, respectively). HCV treatment correlated with prolonged survival in infected patients (p = 0.0017). AFP decline correlated with response (p = 0.001). Hispanic patients lived longer when clinical variables were controlled for (mOS 52 vs 23 months; p = 0.011).

Conclusion

In an underserved HCC population, ICI yielded a DCR of 58.5% and low rates of severe toxicity. This work highlights ICI efficacy in minority groups, a need for earlier HCC diagnosis and for studies of genetic and environmental factors in Hispanics with HCC.

A phase II study of bevacizumab and temsirolimus in advanced extra-pancreatic neuroendocrine tumors

We assessed the efficacy and safety of combining bevacizumab with temsirolimus in patients with advanced extra-pancreatic neuroendocrine tumors. This NCI-sponsored multicenter, open-label, phase II study (NCT01010126) enrolled patients with advanced, recurrent, or metastatic extra-pancreatic neuroendocrine tumors. All patients were treated with temsirolimus and bevacizumab until disease progression or unacceptable toxicity. Temsirolimus 25 mg was administered i.v. on days 1, 8, 15, and 22 and bevacizumab 10 mg/kg i.v. on days 1 and 15 of a 4-week cycle. Discontinuation of temsirolimus or bevacizumab did not require discontinuation of the other agent. The primary endpoints were objective response rate and 6-month progression-free survival rate. Fifty-nine patients were enrolled in this study, and 54 were evaluated for efficacy and adverse events. While median progression-free survival was 7.1 months, the median duration of treatment with temsirolimus was 3.9 months and that with bevacizumab was 3.5 months. The objective response rate of combination therapy was 2%, and 6-month progression-free survival was 48%. The most frequently reported grade 3-4 adverse events included fatigue (13%), hypertension (13%), and bleeding (13%). Close to 54% of the patients discontinued treatment due to adverse events, refusal of further treatment, or treatment delays. Three deaths occurred in the study, of which two were due to treatment-related bowel perforations. Given the minimal efficacy and increased toxicity seen with the combination of bevacizumab and temsirolimus, we do not recommend the use of this regimen in patients with advanced extra-pancreatic neuroendocrine tumors.

Association of Radiation and Neutrophil to Lymphocyte Ratio with Survival in Hepatocellular Carcinoma Patients with Portal Vein Thrombus

PURPOSE/OBJECTIVE(S)

Hepatocellular carcinoma (HCC) is increasing in incidence worldwide with up to 60% of patients found to have a portal vein tumor thrombus at diagnosis. Recent studies demonstrated that high neutrophil-to-lymphocyte ratio (NLR) is associated with poorer survival in patients with hepatocellular carcinoma. Whether NLR can predict survival after local therapy, such as radiation (RT), is currently unknown. We, therefore, reviewed the patient outcomes with special focus on the type of therapies received.

MATERIALS/METHODS

This study is a retrospective review of HCC patients with portal vein thrombus from a single institution diagnosed between 2010 and 2022. Follow up time was defined as time from diagnosis to death or last follow up visit. Cox regression models were used to analyze overall survival (OS) rates.

RESULTS

One-hundred and forty-five patients met inclusion criteria. Median follow-up time was 4 months [interquartile range (IQR): 1.7 - 13 months]. Median NLR at diagnosis was 3.5 (IQR: 2.2-4.9). Forty patients received RT as part of their therapy. Higher NLR was associated with shorter survival (HR 1.10, 95% CI 1.04 - 1.17, p = 0.002). Treatment with RT improved OS (HR 0.55, 95% CI 0.35 - 0.86, p = 0.009). After controlling for NLR at diagnosis, the addition of radiation still provides survival benefit (HR 0.55, 95% CI 0.35 - 0.86, p = 0.01). In patients who received immunotherapy as the first systemic agent, RT improved OS (HR 0.47, 95% CI 0.22 - 1.01, p = 0.05). This improvement held even when controlling for NLR. In patients who received tyrosine kinase inhibitor (TKI) as first systemic agent, RT did not improve OS. However, when controlling for NLR in patients receiving TKI, RT did improve OS (HR 0.45, 95% CI 0.2 - 1.0, p = 0.05).

CONCLUSION

This retrospective, hypothesis-generating analysis suggests that NLR at diagnosis could predict OS benefit of RT addition in certain patients. These results could be due to the effect of radiation on the immune system; however, further studies are needed.

Hepatocellular Carcinoma in HIV-Infected Patients: Clinical Presentation and Outcomes in a Racially Diverse Urban Population

PURPOSE

As life expectancy for HIV patients improve, hepatocellular carcinoma (HCC) has become a non-AIDS defining illness with a high impact on morbidity and mortality of HIV-infected individuals. We sought to compare outcomes in HIV- versus non-HIV-infected patients treated for HCC at a multiethnic academic medical health system.

METHODS

A retrospective chart review of patients diagnosed with HCC from 1/1/2005 to 12/31/2016 was performed. Differences in characteristics among HIV and non-HIV subjects were assessed. Associations between HIV status, viral load, CD4 count, and overall survival (OS) were also assessed.

RESULTS

We identified 915 subjects (842 non-HIV and 73 with HIV). HIV-infected subjects were younger, predominantly male non-Hispanic Blacks, and more likely to have HBV and HCV co-infection, and alcohol use at diagnosis compared to non-HIV counterparts. Stage, MELD score, Child-Pugh, and ECOG performance status were similar. HIV-positive patients received systemic therapy at significantly higher rates and liver transplantation for HCC at significantly lower rates than those without HIV. The actuarial 3- and 5-year overall survival (OS) for all patients was 48.3% and 39.4%. For HIV-infected subjects, 3- and 5-year OS was significantly worse at 36.8% and 28.3% compared to 49.3% and 40.4%, respectively, for non-HIV subjects (log rank p = 0.033).

CONCLUSIONS

HIV-infected HCC patients have lower survival rates compared to those without HIV. Despite younger age and similar stage, MELD, and ECOG at diagnosis, HIV portends worse outcomes in patients with HCC.

Malignant portal vein tumor thrombosis (PVTT) in patients with hepatocellular (HCC) carcinoma: Insights from a Western single-institutional cohort

552

Background: Macrovascular tumor invasion in the portal vein system is associated with poor survival and response to therapy. The Japanese portal vein invasion (Vp) classification is based on anatomical location of the thrombus and has been reported to predict prognosis in Asian cohorts of patients. Systemic treatment (ST) options have been increasing over the last decade, coupled with a refinement of radiation (RT) delivery and surgical techniques. Modern literature about HCC and PVTT is scarce in the West. Aim of this study was to characterize outcomes of PVTT patients stratified by Vp categories and by treatment strategies in a Western cohort of HCC patients. Methods: A total of 837 patients with HCC, treated at our tertiary referral center between 2010 and 2022, were retrospectively reviewed. 136 (16.3%) patients with PVTT at the time of diagnosis were identified. PVTT was diagnosed by contrast-enhanced computed tomography or magnetic resonance imaging. The extent of portal tumor-in-vein burden was characterized according to the Liver Cancer Study Group of Japan classification. Treatment modalities were delineated. Median OS was calculated for each group. Cox proportional hazard was used to compare OS between groups. Results: Etiology of liver disease was chronic hepatitis B in 18 (13%) patients, chronic hepatitis C in 79 (57%), alcohol in 53 (39%) and NASH in 10 (7%). Our group comprised 8 Vp1, 16 Vp2, 53 Vp3 and 59 Vp4 patients. 42% were in class Child-Pugh A, 42% B and 16% C. 14 (10%) patients underwent surgical resection of their tumor, 31 (23%) received radiation therapy, 90 (68%) were treated with systemic therapy, while 27 (23%) only received best supportive care (BSC). Median OS was 7.2 months in all comers; 16.0, 3.6, and 1.9 months when stratified by Child-Pugh class A, B, C respectively. Patients lived longer when they had more limited PVTT extent (Table). There was a trend towards worse OS in patients with Vp4 tumors compared to more peripheral thrombi (median OS 4.7 vs 12.8 mo, p=0.055). Patients treated with both ST and RT had a better OS than those treated with either alone (median OS 17.7 vs 5.7 mo, p=0.022). Median OS by treatment type is shown in Table. Conclusions: This retrospective study confirms an association between the extent of PVTT and OS in a Western HCC cohort. Patients with adequate hepatic reserve may benefit from more aggressive multi-modality treatment approaches. OS by PVTT extent and treatment modality.[Table: see text]

Induction Chemotherapy With FOLFIRINOX Followed by Chemoradiation With Gemcitabine in Patients With Borderline-Resectable Pancreatic Ductal Adenocarcinoma

Introduction

Perioperative therapy is standard for patients with borderline-resectable pancreatic ductal adenocarcinoma (BR-PDAC); however, an optimal neoadjuvant regimen is lacking. We assessed the efficacy of FOLFIRINOX chemotherapy followed by gemcitabine-based chemoradiation as preoperative therapy.

Methods

Patients received 4 cycles of FOLFIRINOX, followed by 6-weekly gemcitabine with concomitant intensity-modulated radiation. The primary endpoint was the R0 resection rate. Secondary outcomes included resection rate, overall-response, overall survival (OS), progression-free survival (PFS), and tolerability. The trial was terminated early due to slow accrual. A Simon’s optimal two-stage phase II trial single arm design was used. The primary hypothesis of treatment efficacy was tested using a multistage group sequential inference procedure. The secondary failure time analysis endpoints were assessed using the Kaplan-Meier procedure and the Cox regression model.

Results

A total of 22 patients enrolled in the study, 18 (81.8%) completed neoadjuvant treatment. The bias corrected R0 rate was 55.6% (90% CI: 33.3, 68.3; P value = .16) among patients that received at least 1 cycle of FOLFIRINOX and was 80% among patients that underwent surgery. The median OS was 35.1 months. The median PFS among patients that underwent surgery was 34 months.

Conclusion

An R0 resection rate of 55.6% is favorable. Neoadjuvant FOLFIRINOX followed by concomitant Gemcitabine with radiation was well-tolerated. NCT01897454

Genetic profile and survival outcomes in a modern cohort of patients with biliary tract cancers (BTC): Single center experience in New York City

e16157

Background: BTCs are the second most common primary hepatobiliary malignancy with rising incidence and mortality worldwide. Individual characterization of BTCs at a genomic level is critical to tailor management strategies. Currently available data stem from studies in predominantly White populations. We conducted a retrospective study to determine the demographic, clinical and survival profiles of patients with BTCs seen in our center, who had been tested for genomic alterations. Methods: We identified 69 patients with BTCs diagnosed between 2015-2022 who had tissue-based genomic results available. Chi-square test was used to compare frequency distributions. Univariate analysis with cox regression model and multivariate cox proportional hazards test were conducted. Kaplan-Meier curves were used to assess overall survival (OS). Results: Median age at diagnosis was 67 years and median follow-up time was 15.5 months. Racial and ethnic minority populations were highly represented with 41% Hispanic, 29% Black and 17% White patients. ECOG performance status (PS) ranged between 0-2 at diagnosis. Most patients (40%) had stage IV BTC, with intrahepatic cholangiocarcinoma (CCA) being most prevalent (48%). On univariate modeling, variables associated with a shorter OS were age (HR 1.03, 95% CI 1.00-1.07, p = 0.05) and ECOG PS of 2 (HR 7.03, 95% CI 1.49-33.3, p = 0.014). In a multivariate model, ECOG PS 2 was independently associated with a shorter OS. The most common mutations (N, %) found on NGS were TP53 (28, 41%), KRAS (13, 19%), ARID1A (11, 16%), PIK3CA (9, 13%), ERBB2 (5, 7%) and FGFR2 (5, 7%). Median tumor mutation burden (TMB) was 4 Mut/Mb, with 18.9% having hypermutated (≥10 Mut/Mb) BTCs. Potentially actionable targets were found in 40 (58%) patients, 5.8% of which received targeted therapies with a median OS of 27 months (median OS of entire cohort was 22.8 months). KRAS mutation was significantly less common in intrahepatic CCA compared to the other BTC subtypes (p = 0.016). Race or ethnicity were not found to have a significant association with mutation frequency (Table). TP53 and ARID1A mutations were associated with a trend towards reduced OS in univariable analysis, with HR = 1.46 (p = 0.29) and HR = 1.64 (p = 0.28) respectively. Conclusions: Extensive genomic diversity was observed among BTC patients in our center which serves a large minority population. Studies with larger sample size are required to expand our understanding of the genomic spectrum in BTCs, its therapeutic and survival implications. [Table: see text]

The Neutrophil-to-Lymphocyte Ratio is a Prognostic Biomarker in An Ethnically Diverse Patient Population with Advanced Pancreatic Cancer

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) is associated with decreased overall survival in patients with pancreatic adenocarcinoma (PAC) in studies including few minority patients. We investigated the association between NLR and survival in patients with advanced PAC in an ethnically diverse population.

METHODS

We retrospectively evaluated 226 patients with advanced PAC treated at Montefiore Medical Center between 2006 and 2015. Adjusted Cox proportion hazard regression models were utilized to derive effect estimates for survival duration.

RESULTS

Patients with a NLR ≤ 5 (126 patients, median age 66 years) were more likely to be non-Hispanic Black (30.8% vs. 20%), while patients with a NLR > 5 (70 patients, median age 66 years) were more likely to be non-Hispanic White (21.4% vs. 12.2%) or Hispanic (44.3% vs. 34%). A NLR > 5 compared with a NLR ≤ 5 was significantly associated with a worse overall survival when adjusted for a priori and exploratory variables from the univariate analysis (median survival 7.4 vs. 12 months, HR 1.650, 95% CI 1.139, 2.390).

CONCLUSIONS

In an ethnically diverse population, elevated NLR is an independent marker of poor prognosis and a potentially valuable factor in driving therapeutic decisions and defining prognosis for patients in the locally advanced or metastatic for PAC setting, meriting investigation in prospective clinical trials.

Factors associated with long-term survival in patients with early-onset and standard-onset colorectal cancer

141

Background: Differences in incidence, clinical features, and survival between early-onset (EO) and standard-onset (SO) colorectal cancer (CRC) are well-established. Factors associated with longer survival have not been reported. We aim to determine clinical and treatment factors associated with longer survival in patients (pts) with metastatic EO and SO CRC. Methods: Pts with metastatic CRC diagnosed between 2010-2019 at two NYC hospitals were identified by tumor registry and classified as EO (diagnosis at < 50 years) or SO (diagnosis at ≥ 50 years). Median overall survival (OS) was calculated for each group using Kaplan Meier curves. Long-term survival was defined as OS > 2 years (EO-CTC median OS). Data was collected by chart review and compared between short vs long-term survivors in EO and SO CRC pts independently. Stata v15 was used for statistical analysis. Results: Of 646 pts, 144 (22.3%) had EO and 502 (77.7%) had SO. High grade tumors were more likely in EO (33.3% vs 24%, OR: 1.59, p = 0.04) than SO; whereas no differences were seen in gender, sidedness, KRAS mutation or chemotherapy. Biologics were used more frequently in EO than SO (OR = 1.7; p = 0.008]. Median OS was 2.1 and 1.9 years in EO and SO. There were 53 (36.8%) and 175 (35.1%) long-term survivors in EO and SO groups. In pts with SO, metastasectomy, irinotecan-based chemotherapy and use of biologics were significantly associated with long-term survival, whereas metastasectomy was the only associated factor in pts with EO. Conclusions: Metastatectomy was the only factor associated with longer survival in both EO and SO groups. Other clinical/pathological and treatment-related factors associated with long-term survival among SO-CRC were not associated with long-term survival among EO-CRC patients. [Table: see text]

Racial ethnic disparities in clinical/pathological features, treatment, and survival among patients with early-onset colorectal cancer

21

Background: Globally, the incidence of early-onset colorectal cancer has risen. Racial disparities in colorectal cancer (CRC) are well-described, however data in EO by race/ethnicity is lacking. We aim to compare the presenting features, treatment, and survival features of patients with metastatic early-onset CRC (EO). Methods: Patients with metastatic CRC diagnosed between 2010-2019 at two NYC hospitals were identified by tumor registry (n = 646). Clinical/pathological features, treatment and survival data was collected by chart review and compared between Non-Hispanic Whites (NHW), Non-Hispanic Blacks (NHB) and Hispanics (H) using Chi-square or Fisher’s exact test. Kaplan Meier curves were plotted to compare overall survival (OS) among groups. Stata v15 was used for statistical analysis. Results: Of 646 CRC patients, 126 (21.5%) were NHW, NHB or H diagnosed with EO with a frequency ranging from 16.6% in NHW to 26.1% in H. Non statistically significant lower frequencies of male gender, low/moderate grade, left-sided tumors,and higher frequency of KRAS mutations were seen in NHB (Table). Metastectomy was performed in 20 patients (13.9%) and did not differ between groups. There was no difference in the use of chemotherapy or biologics in general (Table), but NHW were more likely to get cetuximab than NHB (OR:4.5, p = 0.02) and H (OR:4.7, p = 0.02).There were no differences in median OS (1.8 vs. 2.2 vs. 2 years, p = 0.9)or 1-year OS (72% vs 72.3% vs 70.8%) in NHW, NHB and H, respectively. A lower 5-year OS was seen in NBH (14.5%) and Hispanics (24.4%) compared to NHW (44%). Conclusions: EO-CRC is more frequently seen in minority racial/ethnic groups. Despite no differences in the use of chemotherapy or biologic treatment in general, NHB have a lower 5-year survival rate compared to NHW and H. [Table: see text]

Association of Addition of Ablative Therapy Following Transarterial Chemoembolization With Survival Rates in Patients With Hepatocellular Carcinoma

IMPORTANCE

Hepatocellular carcinoma (HCC) is a heterogeneous disease with many available treatment modalities. Transarterial chemoembolization (TACE) is a valuable treatment modality for HCC lesions. This article seeks to evaluate the utility of additional ablative therapy in the management of patients with HCC who received an initial TACE procedure.

OBJECTIVE

To compare the overall survival (OS) and freedom from local progression (FFLP) outcomes after TACE alone with TACE that is followed by an ablative treatment regimen using stereotactic body radiation therapy, radiofrequency ablation, or microwave ablation for patients with HCC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 289 adults at a single urban medical center examined survival outcomes for patients with nonmetastatic, unresectable HCC who received ablative therapies following TACE or TACE alone from January 2010 through December 2018. The Lee, Wei, Amato common baseline hazard model was applied for within-patient correlation with robust variance and Cox regression analysis was used to assess the association between treatment group (TACE vs TACE and ablative therapy) and failure time events (FFLP per individual lesion and OS per patient), respectively. In both analyses, the treatment indication was modeled as a time-varying covariate. Landmark analysis was used as a further sensitivity test for bias by treatment indication.

EXPOSURES

TACE alone vs TACE followed by ablative therapy.

MAIN OUTCOMES AND MEASURES

Freedom from local progression and overall survival. Hypotheses were generated before data collection.

RESULTS

Of the 289 patients identified, 176 (60.9%) received TACE only and 113 (39.1%) received TACE plus ablative therapy. Ablative therapy included 45 patients receiving stereotactic body radiation therapy, 39 receiving microwave ablation, 20 receiving radiofrequency ablation, and 9 receiving a combination of these following TACE. With a median (interquartile range) follow-up of 17.4 (9.5-29.5) months, 242 of 512 (47.3%) lesions progressed, 211 in the group with TACE alone and 31 in the group with TACE plus ablative therapy (P < .001). Over 3 years, FFLP was 28.1% for TACE alone vs 67.4% for TACE with ablative therapy (P < .001). The 1-year and 3-year OS was 87.5% and 47.1% for patients with lesions treated with TACE alone vs 98.7% and 85.3% for patients where any lesion received TACE plus ablative therapy, respectively (P = .01), and this benefit remained robust on landmark analyses at 6 and 12 months. The addition of ablative therapy was independently associated with OS on multivariable analysis for all patients (hazard ratio, 0.26; 95% CI, 0.13-0.49; P < .001) and for patients with Barcelona clinic liver cancer stage B or C disease (hazard ratio, 0.31; 95% CI, 0.14-0.69; P = .004).

CONCLUSIONS AND RELEVANCE

Adding ablative therapy following TACE improved FFLP and OS among patients with hepatocellular carcinoma. This study aims to guide the treatment paradigm for HCC patients until results from randomized clinical trials become available.

A phase II trial of preoperative FOLFIRINOX followed by gemcitabine-based chemoradiotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma (BR PDAC)

4638

Background: Preoperative (preop) therapy is widely accepted as the standard of care for patients (pt) with BR PDAC with limited evidence for a specific regimen. This study aimed to assess the efficacy of FOLFIRINOX (FOL) chemotherapy followed by gemcitabine-based chemo-radiotherapy (RT) as preop therapy in pt with BR-PDAC. Methods: This single arm Simon two stage phase II trial in pt with BR PDAC was conducted in two phases. The first phase included 4 cycles of FOL, and the second included weekly gemcitabine (1000 mg/m2) for 6 cycles with concomitant intensity-modulated RT (50.4 Gy in 28 fractions)(Gem/RT).The primary aim was to compare R0 resection rate (H0: ≤40% vs Ha≥60%) using one-sample one-sided Z test. Secondary outcomes, including overall survival (OS) and progression-free survival (PFS) were assessed using Kaplan-Meier method. Results: Of 22 enrolled pt, 18 (81.8%) completed preoperative treatment. Median age at diagnosis was 63.4 years and 12 (54.5%) were female. There were 10 (45.5%) Hispanics, 4 (18.2%) non-Hispanic black, and 8 (36.4%) non-Hispanic white. Tumor location was predominantly head/neck (21, 95.5%), 15 (68.1%) had T2/3, and 9 (40.9%) had N2 (clinical) disease. Fourteen (64.6%) pt, had venous involvement, 5 (22.7%) had arterial, and 3 (13.6%), both. In the first phase, 20 (90.9%) completed 4 cycles of FOL, 6 (27.3%) required dose-reduction and dose was delayed in 12 (54.5%). Stable disease (SD) was achieved in 10 (52.6%), partial response (PR) in 8 (42.1%) and disease progression (PD) in 1 (5.3%) pt. Of 21 pt that entered the second phase, 18 (85.7%) completed 6 cycles of Gem/RT, 5 (26.3%) required dose-reduction and dose was delayed in 6 (31.6%). SD was achieved in 10 (55.6%), PR in 3 (16.7%) and PD in 5 (27.8%). All pt experienced at least one grade 1 adverse event (AE) and 12 (54.5%) at least one grade 3/4 AE, of which neutropenia was the most common-11 (50%). Of the 15 (68.1%) pt who underwent surgical resection, 12 (80%) achieved R0 margins and 5 (33.3%) required vascular reconstruction. The R0 rate among pt that received >1 cycle of FOLFIRINOX was 54.5%. Adjuvant chemotherapy was offered to 6/15 pt (40%). The PFS and OS will be reported. Conclusions: An R0 resection rate of 54.5% with this limited sample size is significant at the 10% level. Neoadjuvant FOLFIRINOX followed by concomitant Gem/RT was well-tolerated. The study will be amended to include adjuvant FOL in line with the PRODIGE intergroup adjuvant study results. Clinical trial information: NCT01897454 .

Clinical characteristics and outcomes of patients with advanced hepatocellular carcinoma treated with immunotherapy: A “real world” retrospective study

e16644

Background: Advanced hepatocellular carcinoma (HCC) is an aggressive malignancy with dismal prognosis. Newer agents, including immunotherapy (IO), have been granted accelerated approval for patients previously treated or unable to tolerate sorafenib. However, information outside clinical trials is scarce. This study aims to describe clinical characteristics and outcomes of HCC patients treated with IO. Methods: HCC patients treated with IO were identified using the institutional software, Clinical Looking Glass. Data regarding demographics, clinical and treatment characteristics were collected by chart review. Neutrophil/lymphocyte ratio (NLR) and AFP were collected at IO treatment initiation and considered low if below 4 and 400, respectively. Progression-free survival (PFS) was defined as time from treatment initiation to progression of disease or death, and overall-survival (OS) as time from IO initiation to death from any cause. Disease characteristics were analyzed using descriptive statistics, PFS and OS were plotted using Kaplan-Meier curves. Results: 52 patients with a median age of 64.5 years and male predominance (38, 73.1%) were identified. There were 24 (54.5%) Hispanics, 9 (20.5%) Non-Hispanic Blacks, 7 (15.9%) Non-Hispanic White and 4 (9.1%) Asians. Cirrhosis present in 41 (83.7%), median MELD of 8 (IQ: 7-10). 37 (77.1%) patients had ECOG 0-1. Hepatitis B and C and B infection were encountered in 12 (24.5%) and 22 (44%) patients, respectively. Intravascular invasion present in 16 (34.8%) and extrahepatic metastases in 7 (14.9%). Local treatment was provided to 29 (59.2%) and radiation to 14 (28.6%). First line treatment (tx1) was Sorafenib in 29 (55.8%) and Nivolumab in 21 (40.4%). Nivolumab was second line treatment or beyond (tx2) in 31 (59.6%). Median PFS was 6.2 (3.1-10.6) months and it did not differ between tx1 and tx2 (8 vs 5.9 months, p = 0.90). Median OS was 13.2 months; there was a tendency towards higher survival rates in patients that were treated in tx2 (11.8 vs 14.3 months, 0 = 0.59) and in patients with low NLR (14.8 vs 9.2 months, p = 0.14). Median OS was higher in patients with low AFP at IO treatment initiation (15.7 vs. 9.2 months, p = 0.03). Conclusions: In this multiethnic cohort, the “real world” experience of the benefit of IO in HCC is encouraging, with a median OS exceeding one year. NLR showed potential as a possible biomarker. Expanded data may elucidate the differences if any, between use of IO as front vs. second line therapy, in PFS and OS.

The impact of biologic agents in patients with metastatic colorectal cancer by race/ethnicity

156

Background: Biologic agents have shown to improve overall survival (OS) in patients with metastatic colorectal cancer (mCRC). However, minority racial/ethnic groups were underrepresented in clinical trials. A retrospective study in a racially-diverse population diagnosed between 2000 - 2011, done by our group, reported a survival benefit with biologics; but, a subgroup analysis suggested that it was restricted to Non-Hispanic whites (NHW) only. This study aims to compare OS in patients with mCRC treated with chemotherapy and biologic agents (CBT) among racial/ethnic groups. Methods: Patients diagnosed with mCRC between 2012-2018 and treated with CBT at 3 cancer centers in the Bronx, NY were identified. Clinical data was collected by retrospective review for demographics (age at metastasis, gender and race/ethnicity categorized as Non-hispanic Black (NHB), NHW or Hispanic), pathological/ treatment characteristics (tumor grade, primary location, chemotherapy regimen, biologic agent). Cases without available race/ethnicity were excluded. OS was measured as time from mCRC diagnosis to death (verified from the National Death Index) and was compared among racial/ethnic groups using Kaplan-Meier curves. Results: A total of 278 patients; of whom 84 (42.4%) were Hispanic, 70 (35.4%) NHB and 44 (22.2%) NHW were included. The median age at diagnosis was 60 years and did not differ among racial/ethnic groups (62.5 vs 55.5 vs 56 years, p=0.07). There was a female predominance in NHB and Hispanics. Bevacizumab was more frequently used in Hispanics and NHB compared to NHW (95.2% vs. 92.9% vs. 77.3%, p=0.003, respectively). There were no differences in the frequency of cetuximab and panitumumab use. Median OS did not differ by racial/ethnic groups (21 in NHW vs. 22.8 in Hispanics and 28.6 months in NHB, p=0.40). Conclusions: Minority groups attain a similar survival benefit from the addition of biologics compared to NHW. Population-based studies are required to confirm these results.

Clinical characteristics and outcomes of patients with advanced hepatocellular carcinoma treated with immunotherapy: A real-world retrospective study

557

Background: Advanced HCC is an aggressive malignancy with dismal prognosis. Newer agents, including immunotherapy (IT), have been granted accelerated approval. Information outside clinical trials is scarce. This study is aimed to describe the clinical characteristics and outcomes of HCC patients treated with IT. Methods: Patients with HCC treated with IT were identified using the institutional data-mining software, Clinical Looking Glass. Patient demographics, clinical, and treatment characteristics were collected. Progression-free survival (PFS) was defined as time from treatment initiation to disease progression or death, and overall-survival (OS) as time from diagnosis of advanced disease to death. PFS and OS were plotted using Kaplan-Meier curves. Results: A total of 52 patients; median age 64 years; male predominance (38, 73.1%) were identified. There were 24 (54.5%) Hispanics, 9 (20.5%) Non-Hispanic Blacks, 7 (15.9%) Non-Hispanic White and 4 (9.1%) Asians. Cirrhosis was seen in 41 (83.7%), and median MELD score was 8 (IQ: 7-10). Hepatitis B and C infection were encountered in 12 (24.5%) and 22 (44%) patients, respectively. Imaging evidence of intravascular invasion was seen in 16 (34.8%) and extrahepatic metastases in 7 (14.9%) cases. Local treatment was provided to 29 (59.2%) and radiation treatment to 14 (28.6%) patients. Nivolumab was used in all the cases, as first-line treatment in 17 (32.7%) and as ≥ second line in 35(67.3%). The median PFS was 6.2 (3.1-10.6) months and was similar in first-line and ≥ second line treatment (8 vs 5.9 months, p=0.90). The median OS was 24.2 (18-28) months; there was a tendency towards higher survival rates in patients that were treated in ≥ second line (16.8 vs 25.2 months, 0=0.07). Conclusions: In this multiethnic cohort, the “real world” experience of the benefit of IT in HCC is encouraging, with a median OS exceeding two years. Expanded data may elucidate the differences if any, between use of IT as front vs. second line therapy, in PFS and OS.

Assessment of Treatment With Sorafenib Plus Doxorubicin vs Sorafenib Alone in Patients With Advanced Hepatocellular Carcinoma: Phase 3 CALGB 80802 Randomized Clinical Trial

IMPORTANCE

Previous communication has reported significant improvement in overall survival (OS) when using doxorubicin plus sorafenib in the treatment of advanced hepatocellular cancer (HCC).

OBJECTIVE

To determine if doxorubicin added to sorafenib therapy improves OS, with stratification for locally advanced and metastatic disease.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded randomized phase 3 clinical trial was led by Alliance in collaboration with Eastern Cooperative Oncology Group-American College of Radiology Imaging Network, Canadian Cancer Trials Group, and Southwest Oncology Group. It was launched in February 2010 and completed in May 2015; data were also analyzed during this time frame. Patients with histologically proven advanced HCC, no prior systemic therapy, Child-Pugh grade A score, Eastern Cooperative Oncology Group performance status of 0 to 2 (later amended to 0-1), and adequate hematologic, hepatic, renal, and cardiac function were eligible. The OS primary end point had a final analysis planned with 364 events observed among 480 total patients with 90% power to detect a 37% increase in median OS.

INTERVENTIONS OR EXPOSURES

Patients received either 60 mg/m2 of doxorubicin every 21 days plus 400 mg of sorafenib orally twice daily or the sorafenib alone, adjusted to half doses for patients with bilirubin levels of 1.3 to 3.0 mg/dL.

MAIN OUTCOMES AND MEASURES

The primary end point was OS, and progression-free survival (PFS) was a secondary end point.

RESULTS

Of 356 patients included in the study, the mean (SD) age was 62 (10.1) years, and 306 (86.0%) were men. Although it was planned to include 480 patients, the study was halted after accrual of 356 patients (180 patients treated with doxorubicin plus sorafenib and 176 with sorafenib alone) with a futility boundary crossed at a planned interim analysis. Median OS was 9.3 months (95% CI, 7.3-10.8 months) in the doxorubicin plus sorafenib arm and 9.4 months (95% CI, 7.3-12.9 months) in the sorafenib alone arm (hazard ratio, 1.05; 95% CI, 0.83-1.31). The median PFS was 4.0 months (95% CI, 3.4-4.9 months) in the doxorubicin plus sorafenib arm and 3.7 months (95% CI, 2.9-4.5 months) in the sorafenib alone arm (hazard ratio, 0.93; 95% CI, 0.75-1.16). Grade 3 or 4 neutropenia and thrombocytopenia adverse events occurred in 61 (36.8%) and 29 (17.5%) patients, respectively, being treated with doxorubicin plus sorafenib vs 1 (0.6%) and 4 (2.4%) patients treated with sorafenib.

CONCLUSIONS AND RELEVANCE

This multigroup study of the addition of doxorubicin to sorafenib therapy did not show improvement of OS or PFS in patients with HCC.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01015833.

Association between neutrophil-lymphocyte ratio, socioeconomic status, and ethnic minority with treatment outcome in hepatocellular carcinoma

BACKGROUND

Patients with lower socioeconomic status (SES), ethnic minorities and elevated neutrophil-lymphocyte ratio (NLR) have been suggested to have worse outcomes in hepatocellular carcinoma (HCC). However, how changes in NLR after intervention relate to survival has not been elucidated.

OBJECTIVES

We evaluated the association of NLR with overall survival (OS) and progression-free survival (PFS) in a large institutional cohort of HCC.

METHODS

We reviewed all patients diagnosed with HCC between 2005-2016. The association between elevated NLR (> 4) and survival was examined with univariable and multivariable Cox regression.

RESULTS

We identified 991 patients diagnosed with HCC. Lower SES and Hispanic and non-Hispanic Black ethnicity were significantly associated with lower NLR (p = 0.015 and 0.019, respectively). Elevated NLR, but not SES or ethnicity, was an independent predictor of worse OS (HR = 1.66, p < 0.001) and PFS (HR = 1.25, p = 0.032). The median OS in patients with elevated NLR was 8 months, compared to 42 months in patients with normal NLR. Patients with elevated NLR unresponsive to treatment and those with NLR that became elevated after treatment had significantly worse 3-year OS (47% and 44%, respectively), compared to patients whose NLR remained normal or normalized after treatment (72% and 80%, respectively; p < 0.01).

CONCLUSIONS

Our study showed that elevated NLR, but not SES or ethnicity, is an independent prognostic marker for OS and PFS in patients with HCC. NLR trends following intervention were highly predictive of outcome. NLR is easy to obtain and would provide valuable information to clinicians in evaluating prognosis and monitoring response after procedures.

Vaccinia-based oncolytic immunotherapy Pexastimogene Devacirepvec in patients with advanced hepatocellular carcinoma after sorafenib failure: a randomized multicenter Phase IIb trial (TRAVERSE)

Pexastimogene devacirepvec (Pexa-Vec) is a vaccinia virus-based oncolytic immunotherapy designed to preferentially replicate in and destroy tumor cells while stimulating anti-tumor immunity by expressing GM-CSF. An earlier randomized Phase IIa trial in predominantly sorafenib-naïve hepatocellular carcinoma (HCC) demonstrated an overall survival (OS) benefit. This randomized, open-label Phase IIb trial investigated whether Pexa-Vec plus Best Supportive Care (BSC) improved OS over BSC alone in HCC patients who failed sorafenib therapy (TRAVERSE).

129 patients were randomly assigned 2:1 to Pexa-Vec plus BSC vs. BSC alone. Pexa-Vec was given as a single intravenous (IV) infusion followed by up to 5 IT injections. The primary endpoint was OS. Secondary endpoints included overall response rate (RR), time to progression (TTP) and safety.

A high drop-out rate in the control arm (63%) confounded assessment of response-based endpoints. Median OS (ITT) for Pexa-Vec plus BSC vs. BSC alone was 4.2 and 4.4 months, respectively (HR, 1.19, 95% CI: 0.78–1.80; p = .428). There was no difference between the two treatment arms in RR or TTP. Pexa-Vec was generally well-tolerated. The most frequent Grade 3 included pyrexia (8%) and hypotension (8%). Induction of immune responses to vaccinia antigens and HCC associated antigens were observed.

Despite a tolerable safety profile and induction of T cell responses, Pexa-Vec did not improve OS as second-line therapy after sorafenib failure. The true potential of oncolytic viruses may lie in the treatment of patients with earlier disease stages which should be addressed in future studies.

ClinicalTrials.gov: NCT01387555

Centers with more therapeutic modalities are associated with improved outcomes for patients with hepatocellular carcinoma

Background

Higher facility volume is correlated to better overall survival (OS), but there is little knowledge on the effect of facility treatment modality number on OS in hepatocellular carcinoma (HCC).

Methods

This is a retrospective analysis of data from the National Cancer Database (NCDB) from 2004-2014 on patients with non-metastatic HCC. Treatment modalities assessed were surgical resection, transplantation, ablation, radioembolization, stereotactic body radiation therapy (SBRT), single-agent chemotherapy, and multi-agent chemotherapy. Facilities were dichotomized at the median of the listed treatment modalities.

Results

There were a total of 112,512 patients with non-metastatic HCC. Of a total of 1,230 sites, 830 (67.5%) used four or fewer modalities. Average survival for patients treated at facilities using fewer modalities was 12.0 and 23.5 months for those treated at facilities with more modalities [hazard ratio (HR) =0.52, 95% confidence interval (CI): 0.51-0.53, P<0.001]. After adjusting for facility volume, liver function, tumor and patient characteristics and other prognostic factors in a multivariable Cox model, treatment at a multi-modality facility still provided a survival advantage (HR =0.60, 95% CI: 0.52-0.70, P<0.001). This benefit also persisted after propensity score matching. Sensitivity analysis varying the cut point from 2 to 6 modalities for dichotomization showed that the benefit persisted. Subgroup stratified analyses based on stage showed that the benefit in OS was highest for patients with stage I and II (P≤0.002) but was not significant for stage III or IVa.

Conclusions

Institutions that offered more treatment modalities had improved OS for patients with non-metastatic HCC, especially for those with stage I and II.

Cost and effectiveness of genetic testing in metastatic colorectal cancer (mCRC) at Montefiore Medical Center (MMC)

e15043

Background: Upfront testing for MSI, and mutations in KRAS, NRAS, and BRAF is recommended. The most cost-effective way of obtaining this information remains unclear. We examined cost of broad next generation sequencing (NGS), in comparison to hotspot (HT) and individual target (IT) testing in patients with mCRC with Medicare (MC) and commercial insurance (CI) at MMC. As a surrogate of effectiveness, we hypothesize that patients with NGS are more likely to enroll in clinical trials. Methods: Cost of individual and hotspot tests were derived from known reimbursement rates with insurances affiliated with MMC. Due to ongoing changes in current procedural terminology for NGS, we used known reimbursement amounts from our patients. We applied these costs to a model population of 1,000,000 people. We then evaluated clinical trial enrollment of patients who had either NGS or hotspot/individual testing. Results: MC costs for IT, HT, NGS testing were $1,504, $752, and $4,680 respectively. CI costs were $1,910, $814, $2,366 for IT, HT, and NGS testing respectively. When applied to our model population, NGS cost $914,604 and $1,131,016 more than individual and hot spot testing respectively for MC patients, and $21,432 and $72,924 more for CI patients. Analysis of effectiveness included 136 patients, wherein 8% of those with NGS (n = 5/61) were enrolled in clinical trials as a result of testing compared to 1% of those with HT/IT (n = 1/75). Conclusions: Broad spectrum NGS costs more than individual or hot spot testing in mCRC. However, patients with NGS testing were more likely to be enrolled in clinical trials, suggesting the need for studies to further evaluate ideal testing modality. [Table: see text]

Cost and effectiveness of genetic testing in metastatic colorectal cancer (mCRC) at Montefiore Medical Center (MMC)

643

Background: Upfront testing for MSI, and mutations in KRAS, NRAS, and BRAF is recommended. The most cost-effective way of obtaining this information remains unclear. We examined cost of broad next generation sequencing (NGS), in comparison to hotspot (HT) and individual target (IT) testing in patients with mCRC with Medicare (MC) and commercial insurance (CI) at MMC. As a surrogate of effectiveness, we hypothesize that patients with NGS are more likely to enroll in clinical trials. Methods: Cost of individual and hotspot tests were derived from known reimbursement rates with insurances affiliated with MMC. Due to ongoing changes in current procedural terminology for NGS, we used known reimbursement amounts from our patients. We applied these costs to a model population of 1,000,000 people. We then evaluated clinical trial enrollment of patients who had either NGS or hotspot/individual testing. Results: MC costs for IT, HT, NGS testing were $1,504, $752, and $4,680 respectively. CI costs were $1,910, $814, $2,366 for IT, HT, and NGS testing respectively. When applied to our model population, NGS cost $914,604 and $1,131,016 more than individual and hot spot testing respectively for MC patients, and $21,432 and $72,924 more for CI patients. Analysis of effectiveness included 136 patients, wherein 8% of those with NGS (n = 5/61) were enrolled in clinical trials as a result of testing compared to 1% of those with HT/IT (n = 1/75). Conclusions: Broad spectrum NGS costs more than individual or hot spot testing in mCRC. However, patients with NGS testing were more likely to be enrolled in clinical trials, suggesting the need for studies to further evaluate ideal testing modality. [Table: see text]

Excision repair cross-complementing group-1 (ERCC1) gene induction in peripheral blood mononuclear cells as a marker of outcome in patients with colorectal cancer treated with oxaliplatin

542

Background: Oxaliplatin is a third generation platinum agent that confers tumoricidal effect by forming platinum-DNA adducts and is an integral part of the standard of care regimens for patients with colorectal cancer (CRC). Tissue resistance to oxaliplatin appears to be multifactorial, with the nucleotide excision repair (NER) pathway playing a major role. We have previously demonstrated that Excision Repair Cross-Complementing group-1 (ERCC1), can be induced in colorectal cell lines on exposure to Oxaliplatin and high levels confer resistance to apoptosis. We aim to further this knowledge by analyzing gene expression in vivo, using PBMC as a surrogate, to assess ERCC1 as a biomarker of sensitivity to Oxaliplatin therapy. Methods: Patients with CRC who received oxaliplatin were consented to blood (PBMC) sampling at 0, 2, 48 hours, and 14 days during any cycle of chemotherapy. ERCC1 gene expression was quantified by qPCR (quantitative real time polymerase chain reaction) and WB (western blotting). Clinical benefit from oxaliplatin was determined using the parameters of relapse free survival (RFS) for limited stage and progression free survival (PFS) for mCRC. Results: Fifty-four patients were enrolled on study, 25 (46.3%) had mCRC. Twenty-four patients were included in final analysis based on clinical data. Thirteen (52%) had an increase in ERCC expression from baseline, while 11 (48%) showed no change or decrease. Median PFS was 190 and 237 days respectively (log-rank test HR 2.35, CI 1.005-5.479; p = 0.0182). In the 29 patients with limited stage disease, 19 (65.5%) had an induction of ERCC. However, in these patients change in expression did not correlate with RFS. We did not find any significant correlation of PFS with baseline expression of ERCC1 in either group. Conclusions: We confirm our hypothesis that the ERCC1 gene is induced in vivo in a sub-population of patients on treatment with Oxaliplatin. This induction can serve as a potential marker of resistance to oxaliplatin based chemotherapy in mCRC as evidenced by the significant difference in PFS. Further analyses of the influence of ERCC1 polymorphisms on outcomes is underway.

High neutrophil-to-lymphocyte ratio as an independent adverse prognostic factor in racial minorities with hepatocellular carcinoma

218

Background: An elevated neutrophil-to-lymphocyte ratio (NLR) has been shown to portend poor prognosis in various types of cancer, including hepatocellular carcinoma (HCC). However, studies that evaluated the prognostic significance of NLR did not include large numbers of Blacks and Hispanics. This single-center, retrospective study conducted on a large, racially diverse cohort explores the utility of NLR in predicting outcomes in minority populations. Methods: We identified patients (pts) diagnosed with HCC at our institution between the years 2000 and 2016. We calculated NLR at the time of diagnosis and divided pts into two groups: high NLR (NLR > 3) and low NLR (NLR ≤3). Demographics, clinical characteristics, MELD/MELD-Na scores, ALBI scores and AFP levels were collected. Survival analysis was conducted using the Kaplan-Meier method. Cox proportional-hazards model was used for multivariate analysis. Results: 751 pts with HCC were included in this study. 542 (72%) were male. Median age was 61 years. 43% were Hispanic, 33% Black, 22% White and 2% Other. NLR was high in 246 pts (32.7%, mean 6.0 ± 3.8) and low in 505 pts (67.2%, mean 1.69 ± 0.7). Overall survival (OS) was significantly lower in the high NLR group (median survival 25.4 vs 49.6 months, HR 1.75, 95% CI 1.41-2.17, P < 0.01). Subgroup analysis showed differences remained significant in the Hispanic group (n = 259, HR 1.93, 95% CI 1.30-2.86, P < 0.01) and the Black group (n = 194, HR 1.99, 95% CI 1.28-3.09, P < 0.01). The high NLR group had significantly higher MELD scores (mean 12.1 ± 5.0 vs 10.1 ± 3.8, P < 0.01), MELD-Na scores (13.9 ± 5.6 vs 11.3 ± 4.4, P < 0.01), ALBI scores (-2.05 ± 0.7 vs -2.28 ± 0.6, P < 0.01) and AFP levels (median 28.9 vs 46.9, P = 0.02). An NLR > 3 on multivariate analysis remained significantly associated with worse OS (HR 1.31; 95% CI 1.03-1.68; P = 0.02) after adjusting for age, gender, AFP and MELD-Na. Conclusions: NLR > 3 at the time of diagnosis had a strong correlation with poor OS in a large, racially diverse cohort of pts with HCC. This correlation held true for both Hispanic and Black patients, who have been previously underrepresented in similar studies. Our findings support the utility of NLR as a prognostic tool in HCC.

Bridging therapy effectiveness in the treatment of hepatocellular carcinoma prior to orthotopic liver transplantation

Background

Orthotopic liver transplantation (OLT) is the most effective treatment for hepatocellular carcinoma (HCC) in patients with underlying cirrhosis and portal hypertension. Availability of OLT is limited by donor-organ shortages, which increase patient waiting time until OLT. A variety of bridging therapies (BT) have been used to halt tumor progression in patients on the OLT waiting list. Despite complete radiologic responses following BT, viable tumor is often present in explants.

Methods

Treatment outcomes were evaluated in 50 patients who had a total of 125 BT for treatment of 93 nodules. Success of BT was assessed by radiologic response compared to histopathological examination of explanted livers.

Results

Pre-transplant treatments included: transcatheter arterial chemoembolization (TACE), alcohol ablation (ETOH), radiofrequency ablation (RFA), microwave ablation (MWA), selective internal radiation therapy (SIRT) and stereotactic body radiation therapy (SBRT). Fifty-nine (64%) nodules had a complete radiographic response to therapy; however, only 28 nodules (30%) had complete tumor necrosis (CTN) on explant examination. Ten nodules with CTN were treated with TACE alone. Seven of the 28 nodules with CTN were treated with TACE and RFA. Three of seven nodules treated with TACE and SIRT had CTN. Patients underwent a mean of 2.5 BTs. Six of 50 patients (12%) had no residual HCC in their explants. Five of those six patients (83%) had complete response (CR) on pre-transplant imaging.

Conclusions

Although favorable radiologic responses are seen following BT, viable HCC is seen in the majority of liver explants and radiographic imaging cannot always accurately predict pathological response. This underscores the need for aggressive treatment of patients who otherwise may not be eligible for OLT.

The neutrophil to lymphocyte ratio as a prognostic factor among a diverse population with advanced pancreatic cancer

e15729

Background: The neutrophil to lymphocyte ratio (NLR), a marker of systemic inflammatory response, has been suggested as a prognostic marker in patients with pancreatic adenocarcinoma (PAC). Black and Hispanic patients have been underrepresented in studies evaluating the significance of NLR in PAC. We investigated the prognostic significance of NLR in patients with advanced PAC treated at the Montefiore-Einstein Center for Cancer Care (MECCC) in the Bronx, NY. Methods: We included patients who were chemotherapy naive and treated for unresectable or metastatic PAC at MECCC between 2006 and 2015. Demographics, clinical characteristics and treatment data were collected. Overall survival was determined by the Kaplan-Meier method and Cox proportional-hazards models were built to assess survival differences adjusting for clinically relevant and statistically significant variables. Results: 201 patients were included in the study. Median age was 65 (range 32, 90). 52% were male. 41 were White (19%), 71 Black (33%), 71 Hispanic (33%), and 33 Other (15.3%). 66 (30.6%) had unresectable disease and 135 (62.5%) metastatic disease. An NLR ≥ 4 was associated with a worse OS compared to an NLR ≤ 4 (median 10 vs. 16.4 months; HR 1.895; 95% CI 1.390, 2.585; P < 0.0001). Predictors of worse OS on univariate analysis were ever smoker status (HR 1.365; P = 0.05), metastatic disease (HR 1.736; P = 0.001), and albumin ≤ 3.5 g/dL (HR 2.558; P< 0.0001). An NLR ≥ 4 on multivariate analysis remained significantly associated with worse OS (HR 1.665; 95% CI 1.188, 2.334; P = 0.003) after adjusting for age, gender, ever smoker status, metastatic disease, and albumin. Conclusions: In a cohort with significant minority patient representation, an NLR ≥ 4 was associated with significantly worse overall survival in patients with advanced pancreatic cancer. An elevated NLR in advanced PAC may be an important independent predictor to risk stratify patients and predict poor OS in future analyses.

Phase I Trial of Triapine-Cisplatin-Paclitaxel Chemotherapy for Advanced Stage or Metastatic Solid Tumor Cancers

Ribonucleotide reductase (RNR) is an enzyme involved in the de novo synthesis of deoxyribonucleotides, which are critical for DNA replication and DNA repair. Triapine is a small-molecule RNR inhibitor. A phase I trial studied the safety of triapine in combination with cisplatin–paclitaxel in patients with advanced stage or metastatic solid tumor cancers in an effort to capitalize on disrupted DNA damage repair. A total of 13 patients with various previously treated cancers were given a 96-h continuous intravenous (i.v.) infusion of triapine (40–120 mg/m²) on day 1, and then 3-h i.v. paclitaxel (80 mg/m²) followed by 1-h i.v. cisplatin (50–75 mg/m²) on day 3. This combination regimen was repeated every 21 days. The maximum tolerated dose (MTD) for each agent was identified to be triapine (80 mg/m²), cisplatin (50 mg/m²), and paclitaxel (80 mg/m²). Common grade 3 or 4 toxicities included reversible anemia, leukopenia, thrombocytopenia, or electrolyte abnormalities. The combination regimen of triapine–cisplatin–paclitaxel resulted in no objective responses; however, five (83%) of six patients treated at the MTD had stable disease between 1 and 8 months duration. This phase I study showed that the combination regimen of triapine–cisplatin–paclitaxel was safe and provides a rational basis for a follow-up phase II trial to evaluate efficacy and progression-free survival in women with metastatic or recurrent uterine cervix cancer.

Targeted Therapy for Hepatocellular Carcinoma

Hepatocellular cancer (HCC) is a leading cause of cancer death worldwide, and most patients who are diagnosed with HCC are ineligible for curative local therapy. The targeted agent sorafenib provides modest survival benefits in the setting of advanced disease. Novel systemic treatment options for HCC are sorely needed. In this review, we identify and categorize the drugs and targets that are in various phases of testing for use against HCC. We also focus on the potential for combining these agents with radiotherapy. This would help identify directions for future study that are likely to yield positive findings and improve outcomes for patients with HCC.

Bridging therapy effectiveness in the treatment of hepatocellular carcinoma prior to orthotopic liver transplantation

401

Background: Orthotopic liver transplantation (OLT) is the only curative intervention for both hepatocellular carcinoma (HCC) and underlying cirrhosis. OLT is limited by both donor organ shortages and long waitlists for transplant. In order to halt tumor progression, various bridging therapies (BT) have been utilized. Despite complete radiologic responses following BT, viable tumor is often present on explant analysis. We present an update of our experience and include novel bridging modalities. Methods: 35 patients were retrospectively evaluated in a transplant center prior to OLT for HCC. A total of 68 locoregional therapies were utilized. Success of BT was assessed by radiologic response and histopathological examination of the explanted livers. Results: 61 nodules were studied in liver explants. Pre-transplant treatments included: TACE, alcohol ablation (ETOH), radiofrequency ablation (RFA), microwave ablation, selective internal radiation therapy (SIRT) and stereotactic body radiation therapy (SBRT). Radiologically, 36 nodules (59 %) achieved complete response compared to 20 nodules (33%) on explant analysis. Approximately 1/3 of treated nodules with complete tumor necrosis (CTN) were treated with TACE + RFA. 60% of nodules (12/20) with CTN were treated with more than one bridging modality. 75% of nodules (3/4) treated with SIRT alone showed CTN. Patients underwent a mean of 2.2 BT. Four out of 35 (11%) patients had no residual HCC on explant analysis. Conclusions: Although favorable radiologic responses are seen following BT, viable HCC is often seen in liver explants. Newer strategies like SIRT may enhance locoregional control and should be explored as part of an aggressive approach for patients awaiting transplant. [Table: see text]

Phase III randomized study of sorafenib plus doxorubicin versus sorafenib in patients with advanced hepatocellular carcinoma (HCC): CALGB 80802 (Alliance)

192

Background: An exploratory analysis of a randomized phase II study in HCC comparing doxorubicin (D) alone to doxorubicin plus sorafenib (D+S) showed a significant improvement in overall survival favoring D+S (JAMA, 2011). The results appeared promising compared to the historic outcomes seen in the pivotal sorafenib (S) trials. CALGB 80802 was designed to determine if D+S improved survival compared to S alone. Methods: Patients with histologically proven advanced HCC, no prior systemic therapy and Child-Pugh A were randomized to receive D 60 mg/m2 every 21 days plus S 400 mg PO twice daily (D+S) or S alone. For bilirubin ≥ 1.3x normal, D and S doses were halved. D was maxed out at 360 mg/m2. The study was stratified by extent of disease (locally advanced; metastatic), the primary endpoint was overall survival (OS); and secondary endpoint progression-free survival (PFS). The final analysis was to occur when 364 events were observed among 480 total patients, with 90% power to detect a 37% increase in median OS (10.7 to 14.7 months; 1-sided α = 0.05). Results: The Alliance DSMB halted the study after accrual of 346 patients (173 on each of D+S and S) when a futility boundary was crossed at a planned interim analysis. With 107 events in each arm, median OS was 9.3 months (95%CI 7.1-12.9) for D+S, and 10.5 months (95% CI 7.4-14.3) for S with a hazard ratio (HR) 1.06 (95% CI 0.8-1.4) for D+S vs. S. Median PFS was 3.6 (95% CI 2.8-4.6) and 3.2 months (95% CI 2.3-4.1), respectively (HR = 0.90, 95% CI 0.72-1.2). There were 38 deaths on treatment: 18 on D+S and 20 on S. Among these 8 [sepsis (1), dysphagia (1), pneumonia (1), cardiac (2), hepatic failure (2), and not otherwise specified (1)] on D+S, and 3 [fatigue (1), hepatic failure (1), and a secondary malignancy (1)] on S, were at least possibly related to treatment. A maximum grade 3 or 4 only hematologic adverse events (AE) occurred in 37.8% of patients on D+S and 8.1% of patients on S. Non-hematologic AEs were comparable, in 63.6% and 61.5% of patients, respectively. Conclusions: The addition of D to S resulted in higher toxicity and did not improve OS or PFS. The S median OS of about 10 months is consistent with previous reports. NCI Grant U10CA180821 Clinical trial information: NCT01015833.

Multicenter Phase II Trial of Temsirolimus and Bevacizumab in Pancreatic Neuroendocrine Tumors

PURPOSE

There are few effective therapies for pancreatic neuroendocrine tumors (PNETs). Recent placebo-controlled phase III trials of the mammalian target of rapamycin (mTOR) inhibitor everolimus and the vascular endothelial growth factor (VEGF)/platelet-derived growth factor receptor inhibitor sunitinib have noted improved progression-free survival (PFS). Preclinical studies have suggested enhanced antitumor effects with combined mTOR and VEGF pathway-targeted therapy. We conducted a clinical trial to evaluate combination therapy against these targets in PNETs.

PATIENTS AND METHODS

We conducted a two-stage single-arm phase II trial of the mTOR inhibitor temsirolimus 25 mg intravenously (IV) once per week and the VEGF-A monoclonal antibody bevacizumab 10 mg/kg IV once every 2 weeks in patients with well or moderately differentiated PNETs and progressive disease by RECIST within 7 months of study entry. Coprimary end points were tumor response rate and 6-month PFS.

RESULTS

A total of 58 patients were enrolled, and 56 patients were eligible for response assessment. Confirmed response rate (RR) was 41% (23 of 56 patients). PFS at 6 months was 79% (44 of 56). Median PFS was 13.2 months (95% CI, 11.2 to 16.6). Median overall survival was 34 months (95% CI, 27.1 to not reached). For evaluable patients, the most common grade 3 to 4 adverse events attributed to therapy were hypertension (21%), fatigue (16%), lymphopenia (14%), and hyperglycemia (14%).

CONCLUSION

The combination of temsirolimus and bevacizumab had substantial activity and reasonable tolerability in a multicenter phase II trial, with RR of 41%, well in excess of single targeted agents in patients with progressive PNETs. Six-month PFS was a notable 79% in a population of patients with disease progression by RECIST criteria within 7 months of study entry. On the basis of this trial, continued evaluation of combination mTOR and VEGF pathway inhibitors is warranted.

Survival analysis of Hispanics in a cohort of patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) appears to have worse prognosis among Hispanics and other ethnic minorities in the United States. We investigated the overall survival (OS) of Hispanics with HCC and compared it with non-Hispanic (NH) whites and NH blacks.

METHODS

Patients diagnosed and treated for HCC at an urban medical center between 2000 and 2011 were identified from the institutional cancer registry. A Cox proportional-hazard model was used to assess survival differences between Hispanics, NH whites, and NH blacks after adjusting for clinically and statistically significant variables.

RESULTS

A total of 681 patients were identified, 24 of whom were excluded due to inability to confirm the diagnosis of HCC based on radiologic criteria and 24 due to unavailable ethnicity data. The remaining 633 patients were used for analysis. Of this final cohort, 49% (n = 309) were Hispanic, 23% (n = 144) were NH white, and 28% (n = 180) were NH black. The median OS among Hispanics was 16.3 months and was similar to that of NH whites (14.0 months) and NH blacks (17.3 months) (P = 0.76). Multivariate analysis revealed a hazard ratio for death for Hispanics of 0.78 (95% confidence interval 0.58-1.07, P = .12) when compared with NH whites and a hazard ratio for death of 0.89 (95% confidence interval 0.68-1.19, P = 0.46) when compared with NH blacks.

CONCLUSIONS

In contrast to previous reports, Hispanics with HCC from this cohort experienced similar OS when compared with NH whites and NH blacks.

A model of comparative effectiveness research (CER): The impact of biologic agents in a cohort of patients from ethnic minorities with metastatic colorectal cancer (mCRC)

591

Background: The role of biologic agents in the treatment of mCRC has been studied in clinical trials. These studies included ≥ 90% patients (pts) of white race. Hispanics and blacks were largely underrepresented. CER allows exploration of the impact of biologic agents in a cohort composed largely of pts from minorities. We present the results of a cohort of pts served by Montefiore Einstein Cancer Center (MECC) in Bronx, NY. Methods: Pts diagnosed and treated for mCRC from January 2000 to December 2011 were identified using data from the MECC Cancer Registry. Pts demographic and clinical characteristics were extracted from pts medical records. A Cox proportional–hazard model was used to assess survival differences between pts treated with chemotherapy alone vs. pts treated with chemotherapy plus biologics. Results: A total of 293 pts where identified; 45% were black, 27% were Hispanic, and 28% were white. Of the pts receiving biologics, 90% received bevacizumab and 50% received cetuximab or panitumumab. The median overall survival was 15.2 months in the chemotherapy alone group and 25.6 months chemotherapy + biologics group (p=0.003). Univariate analysis showed that 1 metastatic site vs. ≥ 2, CEA <40 ng/mL, receiving ≥ 2 lines of chemotherapy and exposure to biologics were independently associated with longer survival. Multivariate analysis of the whole cohort (n=290), which included all ethnic groups, showed that exposure to biologics offered a survival benefit (HR of 0.70, 95%CI 0.52–0.93, p=0.02), after adjusting for gender, age, CEA, number of metastatic sites and lines of chemotherapy received. Subgroup analysis based on ethnicity showed survival benefit for Whites (HR of 0.38, 95%CI 0.22–0.66, P=0.001) but not for Hispanics (HR of 0.65, 95%CI 0.35–01.23, p=0.18) nor Blacks (HR of 1.04, 95%CI 0.63–1.70, p=0.87). Conclusions: In this cohort weighted heavily towards ethnic minorities, the addition of biologics to chemotherapy was associated with longer survival, an effect mainly driven by whites. Hispanics and blacks did not seem to benefit from exposure to biologics. An effort should be made to include minority pts in ongoing clinical trials.

Multicenter phase II trial of temsirolimus (TEM) and bevacizumab (BEV) in pancreatic neuroendocrine tumor (PNET)

4032

Background: PNET has long had few effective therapies other than chemotherapy. Placebo-controlled phase III trials of the mTOR inhibitor everolimus and the VEGF/PDGF receptor inhibitor sunitinib noted improved progression-free survival (PFS). However, objective response rates (RR) with these agents are still <10%. Preclinical studies suggest enhanced anti-tumor effects with combined mTOR and VEGF targeted therapy. Methods: We conducted a phase II trial of the mTOR inhibitor TEM (25 mg IV q week) and the VEGF-A monoclonal antibody BEV (10 mg/kg IV q 2 weeks) in patients (pts) with well or moderately differentiated PNET and progressive disease by RECIST within 7 months of study entry. Co primary endpoints were RR and 6-month PFS. Planned enrollment was 50 patients, with interim analysis for futility after the first 25 evaluable pts. Pts had no prior mTOR or VEGF targeted agents, ECOG PS 0-1, and adequate hematologic and organ function. Continued octreotide was allowed, but not required. Prior interferon, embolization, and ≤ 2 chemotherapy regimens were allowed. Results: 55 pts were eligible for response assessment. Confirmed PR was documented in 20 of 55 patients (37%). 44 of 55 (80%) patients were progression-free at 6 months. Of 49 pts evaluable for this endpoint, 12 month PFS is 49%. 15 patients remain on therapy. For evaluable patients, the most common grade 3-4 adverse events attributed to therapy were hypertension (18%), hyperglycemia (13%), fatigue (11%). leukopenia (9%), headache (9%), proteinuria (7%), and hypokalemia (7%). Conclusions: The combination of TEM/BEV has substantial activity in a multi-center phase II trial with RR of 37%, well in excess of single targeted agents in PNET. 6-month PFS was a notable 80% in a population of patients with RECIST criteria progression within 7 months of study entry. Phase III trials of combined VEGF/mTOR inhibition in PNET should be pursued. Clinical trial information: NCT01010126.

Who benefits from radiotherapy for gastric cancer? A meta-analysis

4093

Background: Randomized trials have demonstrated significant survival benefits with the use of adjuvant (including neoadjuvant) chemotherapy or chemoradiotherapy for gastric cancer. The importance of adjuvant radiotherapy (RT) remains unclear. Here we perform an up-to-date meta-analysis of randomized trials testing the use of radiotherapy for resectable gastric cancer. Methods: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for randomized trials testing adjuvant RT for resectable gastric cancer. Hazard ratios describing the impact of adjuvant RT on overall survival (OS) and disease-free survival (DFS) were extracted directly from the original studies or calculated from survival curves. Pooled estimates were obtained using the inverse variance method. Subgroup analyses were performed to determine if the efficacy of RT varies with chemotherapy use, RT timing, geographic region, type of nodal dissection performed, and lymph node status. Results: Thirteen studies met all inclusion criteria and were used for this analysis. Adjuvant RT was associated with a significant improvement in both OS (HR=0.78, 95% CI: 0.70 to 0.86, p<0.001) and DFS (HR=0.71, 95% CI: 0.63 to 0.80, p<0.001). In the five studies that tested adjuvant chemoradiotherapy against adjuvant chemotherapy, similar effects were seen for OS (HR=0.83, 95% CI: 0.67 to 1.03, p=0.087) and DFS (HR=0.77, 95% CI: 0.91 to 0.65, p=0.002). Available data did not reveal any subgroup of patients that does not benefit from adjuvant RT. Conclusions: In randomized trials for resectable gastric cancer, adjuvant RT provides an approximately 20% improvement in both DFS and OS. Available data do not reveal a subgroup of patients that does not benefit from adjuvant RT. Further study is required to optimize the implementation of adjuvant RT for gastric cancer with regards to patient selection and integration with systemic therapy.

Who benefits from adjuvant radiation therapy for gastric cancer? A meta-analysis

PURPOSE

Large randomized trials have demonstrated significant survival benefits with the use of adjuvant chemotherapy or chemoradiation therapy for gastric cancer. The importance of adjuvant radiation therapy (RT) remains unclear. We performed an up-to-date meta-analysis of randomized trials testing the use of RT for resectable gastric cancer.

METHODS AND MATERIALS

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for randomized trials testing adjuvant (including neoadjuvant) RT for resectable gastric cancer. Hazard ratios describing the impact of adjuvant RT on overall survival (OS) and disease-free survival (DFS) were extracted directly from the original studies or calculated from survival curves. Pooled estimates were obtained using the inverse variance method. Subgroup analyses were performed to determine whether the efficacy of RT varies with chemotherapy use, RT timing, geographic region, type of nodal dissection performed, or lymph node status.

RESULTS

Thirteen studies met all inclusion criteria and were used for this analysis. Adjuvant RT was associated with a significant improvement in both OS (HR = 0.78, 95% CI: 0.70-0.86, P<.001) and DFS (HR = 0.71, 95% CI: 0.63-0.80, P<.001). In the 5 studies that tested adjuvant chemoradiation therapy against adjuvant chemotherapy, similar effects were seen for OS (HR = 0.83, 95% CI: 0.67-1.03, P=.087) and DFS (HR = 0.77, 95% CI: 0.91-0.65, P=.002). Available data did not reveal any subgroup of patients that does not benefit from adjuvant RT.

CONCLUSION

In randomized trials for resectable gastric cancer, adjuvant RT provides an approximately 20% improvement in both DFS and OS. Available data do not reveal a subgroup of patients that does not benefit from adjuvant RT. Further study is required to optimize the implementation of adjuvant RT for gastric cancer with regard to patient selection and integration with systemic therapy.

Value of noncontrast CT immediately after transarterial chemoembolization of hepatocellular carcinoma with drug-eluting beads

PURPOSE

To retrospectively evaluate the presence and distribution patterns of contrast agent retention in the liver on noncontrast computed tomography (CT) immediately following chemoembolization with drug-eluting beads (DEBs).

MATERIALS AND METHODS

From 2008 to 2010, 95 patients with 224 liver lesions had chemoembolization performed with DEBs and a noncontrast CT examination of the liver performed immediately after embolization. Of these, 85 patients with 193 lesions were included. The postembolization CT scan was reviewed by a diagnostic radiologist, and the presence of contrast agent retention within the lesion was assessed. Varying patterns of contrast agent retention were defined.

RESULTS

Of the 193 lesions included, 146 (76%) retained contrast medium. Aside from some contrast medium in vessels, very little if any contrast medium was seen in the surrounding liver. Various patterns of contrast agent retention were noted within lesions. In a single case, repeat imaging was obtained 6 hours later, which demonstrated washout of contrast agent in a lesion that had retained contrast agent on the postprocedure CT scan. Of significance, 13 additional foci of contrast agent retention were identified on postchemoembolization CT scans that, on retrospective review of preprocedure imaging, represented enhancing lesions not previously identified.

CONCLUSIONS

Noncontrast CT after chemoembolization with DEBs demonstrates contrast agent retention in 76% of cases, without significant contrast medium seen in the adjacent liver parenchyma. The presence or absence of contrast agent retention may prove to be useful in evaluating accurate targeting of a lesion.