Mental health and academic outcomes over the first year at university in international compared to domestic Canadian students

OBJECTIVE

To compare risk factors and associated mental health and academic outcomes between international and domestic students.

PARTICIPANTS

Canadian university undergraduate students.

METHODS

Electronic surveys were completed at university entry and the end of first year. Surveys assessed demographics, risk factors, symptoms of mental disorders, and access to support. Academic outcomes were obtained from university databases.

RESULTS

International students had comparable or lower rates of clinically significant anxiety, depression, and insomnia. Domestic female students reported the highest screening rates for common mental disorders. However, international students were more likely to report having attempted suicide. International students felt less connected to the university community and had lower academic performance. Psychosocial risk factor profiles and proportions accessing mental health services were similar.

CONCLUSIONS

The scope of mental health need appears more similar than different between international and domestic students; however, international students may benefit from targeted academic and social support initiatives.

The feasibility and effectiveness of a novel online mental health literacy course in supporting university student mental health: a pilot study

BACKGROUND

There is a need for effective universal approaches to promote and support university student mental health that are scalable and sustainable. In this pilot study we assess the feasibility and acceptability of a fully-digitalized, comprehensive mental health literacy course co-created with and tailored to the needs of undergraduate students. We also explore preliminary associations with mental health and positive behaviour change.

METHODS

An accredited online mental health literacy course was developed using state-of-the-art pedagogical principles and a reverse mentorship approach. The course was offered as an interdisciplinary undergraduate elective. Students completed an online survey before and after the 12-week course that collected demographic information and assessed mental health knowledge, emotional self-awareness, mental health, stigma, and health-related behaviors using validated measures. Dependent group t-tests were used to compare pre- and post-course levels of knowledge, mental health, sleep quality and substance use. Mental health outcomes of students who completed the course were compared to an age and sex-matched sample of students not enrolled in the course and who completed the same survey measures over the same academic year. Multivariable linear regression was used to examine the effect of course participation on outcomes at follow-up.

RESULTS

The course had good uptake and was positively reviewed by participants. Specifically, students found the course engaging, relevant, and applicable, and agreed they would recommend it to their peers. Among course participants there was improvement in mental health knowledge (p < 0.001) and emotional self-awareness (p = 0.02) at course completion. Compared to the matched comparison group, taking the course was associated with reduced alcohol (β = - 0.41, p = 0.01) and cannabis use (β = - 0.35, p = 0.03), and improved sleep quality (β = 1.56, p = 0.09) at the end of the term.

CONCLUSIONS

Findings suggest that delivering mental health literacy as an online accredited course may be an acceptable and effective way of promoting university student mental health through improved knowledge, emotional self-awareness, and healthy lifestyle choices. As the course is expanded to larger and more diverse student cohorts we will be able to further examine the short and long-term effectiveness of the course in supporting student mental health and the underlying mechanisms.

Enhanced toxicity to chemoradiation in a patient with Anti-Jo-1-antisynthetase syndrome

Appropriate counseling of patients with autoimmune connective tissue disorders (ACTDs) is often challenging for radiation oncologists, especially regarding anticipated side-effects of radiation treatment. These patients can have highly variable and unpredictable sequelae from radiation therapy, and the uncertainty builds when radiation is convoluted by the addition of concurrent chemotherapy. While many patients may experience a mild intensification of toxicity above what is expected, some patients experience much more severe toxicity. These patients become critical learning cases, enabling a better understanding of the delicate and complex ways in which radiation response is altered in the context of ACTDs while allowing other patients with similar ACTD profiles to benefit from past experience. Our report makes an important contribution to this space by describing a particularly severe case of toxicity that manifested in such a patient and the ensuing clinical decision-making. Comprehensive genotyping of classic pharmacokinetic and pharmacodynamic pathway genes (including mutations in DPD and CDA) did not reveal any signatures that might explain her enhanced toxicity and we demonstrate that severe toxicity can still manifest in the era of modern conformal radiation treatments for rectal cancer. We urge caution in the treatment of patients with rare ACTDs, but also emphasize that curative treatment should not be withheld in such patients. We conclude by advocating for the development and maintenance of a prospective multiinstitutional database of patients with ACTDs to help inform and improve future practice.

Use of a real-world data approach to rapidly generate outcomes data following a case study of a novel treatment combination in pancreatic adenocarcinoma

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Background: We use a real-world data approach to report on safety and benefits on metastatic pancreatic cancer pts who were treated with a MEK inhibitor plus hydroxychloroquine (HCQ) after exhausting all other treatment options. MEK inhibition acts on the KRAS pathway, which in turn increases autophagy as a resistance mechanism, furthermore, HCQ inhibits autophagy causing a cytotoxic effect. This combination was shown to diminish tumor volume in xenograft mouse models and a partial response in one heavily pre-treated patients was reported. Methods: XCELSIOR is an IRB approved, patient-centric, real-world data and outcomes registry for developing operational and analytic methods in precision oncology. Searching the XCELSIOR database, we identified 14 pts for whom this regimen had been considered. As part of their participation in XCELSIOR, these patients shared access to their full medical records, which were collected, processed, and abstracted into a 21 CFR 11 compliant database for analysis. We additionally collected de-identified data on 12 pts treated with this combination from five academic centers. Three more patients are expected to start treatment soon. Results: Between March 2018 and January 2020, 15 patients treated with the trametinib/HCQ combination and 3 patients treated with cobimetinib/HCQ were identified in XCELSIOR and five academic institutions. The median age at diagnosis was 64 (range 43-74) and 56% were male. For patients treated with trametinib/HCQ, the median time on treatment was 67 days (range 5-172 days), 11 patients were treated for more than 30 days (median time 97 days). The median PFS for this group was 2.9 months and the median OS was 7.4 months. The clinical benefit rate was 60% for the 10 evaluable patients treated with trametinib/HCQ, 1 patient had a partial response (previously published), 5 had stable disease (for at least 8 weeks) and 4 had progressive disease (physician reported). 2/3 patients treated with cobimetinib/HCQ were on treatment for more than 30 days and all three had progressive disease within 7 weeks. The most common side effects were Grade 1 fatigue and Grade 1/2 rash for both combinations. An additional 3 patients will start treatment soon and will be included in the analysis. Conclusions: Combinatorial MEK and autophagy inhibition was well tolerated in heavily treated metastatic pancreatic cancer patients. Trametinib/HCQ demonstrates some clinical benefit for this group. We demonstrate the feasibility of utilizing real-world data in precision oncology. Clinical trial information: NCT03793088 .

Long-term survival of combined ablation therapy and tremelimumab with or without durvalumab in advanced hepatocellular carcinoma

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Background: Immune checkpoint inhibitor therapy has recently been approved for the treatment of patients with Hepatocellular Cancer (HCC). Data on long-term survival is lacking and the predictors of good outcomes are unknown. The combination of locoregional therapies (transarterial chemoembolization or radiofrequency ablation) plus tremelimumab (trem) with or without durvalumab (durva) was studied in patients with advanced HCC. We report the long-term survival and analyze predictors of good response in two trials of immune checkpoint and ablation treatment in advanced HCC. Methods: Adult patients (pts) with pathologically confirmed HCC with advanced or sorafenib refractory disease who satisfied the eligibility criteria were enrolled in the studies (NCT02821754, NCT01853618). They received treatment with trem, 10 mg per kilogram every 4 weeks for six doses followed by 3 monthly infusions (23 pts) or trem 75 mg flat dose every 28 days for four doses and then durva 1500 mg flat dose every 28 days (35 pts). Subtotal radiofrequency or chemoablation was done on day 36. Results: The average overall survival in the 58 pts was 10.1 months (range 0.9 to 74.2 months); 41.6% were alive at 12 months and 5.5 % were alive at 61 months. A select group of patients had exceptional overall survivals up to 67 months. Predictors of improved overall survival included the presence of higher grade immune related (irAEs) (OR 0.235, p = 0.075) and a partial or stable disease response per RECIST. No new late toxic effects were noted during this long term follow up. Conclusions: Impressive overall survival times of up to 68.8 months were observed with ICI and subtotal ablation in patients with advanced HCC; the presence of irAEs and the tumor response per RECIST may be predictive of better overall survivals. To our knowledge this has not been previously reported in the literature. Clinical trial information: NCT02821754,NCT01853618 .

Predictors of mental health and academic outcomes in first-year university students: Identifying prevention and early-intervention targets

BACKGROUND

Although there is growing interest in mental health problems in university students there is limited understanding of the scope of need and determinants to inform intervention efforts.

AIMS

To longitudinally examine the extent and persistence of mental health symptoms and the importance of psychosocial and lifestyle factors for student mental health and academic outcomes.

METHOD

Undergraduates at a Canadian university were invited to complete electronic surveys at entry and completion of their first year. The baseline survey measured important distal and proximal risk factors and the follow-up assessed mental health and well-being. Surveys were linked to academic grades. Multivariable models of risk factors and mental health and academic outcomes were fit and adjusted for confounders.

RESULTS

In 1530 students surveyed at entry to university 28% and 33% screened positive for clinically significant depressive and anxiety symptoms respectively, which increased to 36% and 39% at the completion of first year. Over the academic year, 14% of students reported suicidal thoughts and 1.6% suicide attempts. Moreover, there was persistence and overlap in these mental health outcomes. Modifiable psychosocial and lifestyle factors at entry were associated with positive screens for mental health outcomes at completion of first year, while anxiety and depressive symptoms were associated with lower grades and university well-being.

CONCLUSIONS

Clinically significant mental health symptoms are common and persistent among first-year university students and have a negative impact on academic performance and well-being. A comprehensive mental health strategy that includes a whole university approach to prevention and targeted early-intervention measures and associated research is justified.

Pre-pubertal bipolar disorder: origins and current status of the controversy

BACKGROUND

Evidence from epidemiological, clinical and high-risk studies has established that the peak period of risk for onset of bipolar disorder spans late adolescence and early adulthood. However, the proposal of the existence of a pre-pubertal form of bipolar disorder manifesting in early childhood created substantial debate. In this narrative review, the literature and contributing factors pertaining to the controversy surrounding the proposed pre-pubertal bipolar disorder subtype are discussed. The resolution of the debate and lessons learned are highlighted.

MAIN BODY

In the mid 1990s US researchers proposed that chronic irritability and explosive temper in pre-pubertal children with pre-existing ADHD and/or other learning and developmental disorders might represent a variant of mania. A number of factors contributed to this proposal including severely ill children with no diagnostic home given changes in the ADHD DSM diagnostic criteria and over-reliance on symptoms and structured interviews rather than on a clinical assessment incorporating developmental history, social context and clinical course. Prospective studies of children at high familial risk did not support the proposed pre-pubertal bipolar phenotype; but rather provided convergent evidence that bipolar disorder onset in adolescence and early adulthood not uncommonly preceded by sleep and internalizing symptoms and most often debuting as depression in adolescence (after puberty). Epidemiological studies of population and hospital discharge data provided evidence that the pre-pubertal bipolar phenotype was largely a US driven phenomenon.

CONCLUSIONS

Psychiatric diagnosis is particularly challenging given the current lack of objective biomarkers. However, validity and utility of clinical diagnoses can be strengthened if all available predictive information is used to formulate a diagnosis. As in other areas of medicine, critical information required to make a valid diagnosis includes developmental history, clinical course, family history and treatment response-weighed against the known trajectories of classical disorders. Moreover, given that psychiatric disorders are in evolution over childhood and adolescence and symptoms, in of themselves, are often non-specific, a thorough clinical assessment incorporating collateral history and psychosocial context is paramount. Such an approach might have avoided or at least brought a more timely resolution to the debate on pre-pubertal mania.

The numerical translation of verbal probability expressions by patients and clinicians in the context of peri-operative risk communication

Shared decision-making is central to the pre-operative consent process and accurate communication of risk is dependent on a clear understanding of numerical information by both the patient and clinician. The risk of an adverse event or complication is often described using verbal probability expressions but how these are interpreted by clinicians and patients in the pre-operative setting has not been studied. We asked patients and clinicians to assign a numerical translation (as a percentage) for seven verbal probability expressions in relation to the probability of a major peri-operative complication occurring. In total, data from 290 patients and 57 clinicians were analysed. There was a wide range in percentages assigned by patients to all verbal probability expressions. Patients assigned a wider range of percentage values to each of the verbal probability expressions and these were all significantly higher than those assigned by clinicians: median (IQR [range]) negligible risk 5% (1-15 [0-100]) vs. 0% (0-0 [0-5]); minimal risk 5% (2-10) [0-100]) vs. 1% (0-1 [0-10]); low risk 10% (3-10 [0-100]) vs. 1% (0-2) [0-10]); standard risk 20% (10-40) [0-100]) vs. 1% (1-5) [0-30]); moderate risk 33% (20-50) [0-100]) vs. 5% (3-10) [0-80]); high risk 70% (30-90 [0-100]) vs. 15% (10-40) [1-75]); and very high risk 90% (50-95 [0-100]) vs. 40% (20-50 [5-100]), respectively (p < 0.005 for all comparisons). There is considerable variation in the numerical translation of verbal probability expressions by both patients and clinicians. This suggests that verbal probability expressions should not be used in isolation as part of doctor-patient discussions regarding peri-operative risk.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Allogeneic Mesenchymal Stromal Cells (MSCs) are of Comparable Efficacy to Syngeneic MSCs for Therapeutic Revascularization in C57BKSdb/db Mice Despite the Induction of Alloantibody

Intramuscular administration of mesenchymal stromal cells (MSCs) represents a therapeutic option for diabetic critical limb ischemia. Autologous or allogeneic approaches may be used but disease-induced cell dysfunction may limit therapeutic efficacy in the former. Our aim was to compare the efficacy of allogeneic and autologous MSC transplantation in a model of hindlimb ischemia in diabetes mellitus and to determine whether allogeneic transplantation would result in the activation of an immune response. MSCs were isolated from C57BL/6 (B6) and diabetic obese C57BKS^db/db mice. Phosphate-buffered saline (control group), and MSCs (1 × 10⁶) from B6 (allogeneic group) or C57BKS^db/db (syngeneic group) were administered intramuscularly into the ischemic thigh of C57BKS^db/db mice following the induction of hindlimb ischemia. MSCs derived from both mouse strains secrete several angiogenic factors, suggesting that the potential therapeutic effect is due to paracrine signaling. Administration of allogeneic MSCs significantly improved blood perfusion as compared with the control group on week 2 and 3, post-operatively. In comparison with the control group, syngeneic MSCs significantly improved blood perfusion at week 2 only. There was no statistical difference in blood perfusion between allogeneic and syngeneic MSC groups at any stages. There was no statistical difference in ambulatory and necrosis score among the three groups. Amputation of toes was only observed in the control group (one out of seven animals). Alloantibody was detected in three out of the eight mice that received allogeneic MSCs but was not observed in the other groups. In summary, we demonstrated comparable efficacy after transplantation of autologous and allogeneic MSCs in a diabetic animal model despite generation of an immune response.

The clinical trajectory of emerging bipolar disorder among the high-risk offspring of bipolar parents: current understanding and future considerations

BACKGROUND

Relatively little is known about the onset of bipolar disorder, yet the early illness course is already associated with significant morbidity and mortality. Therefore, characterizing the bipolar illness trajectory is key to risk prediction and early intervention advancement.

MAIN BODY

In this narrative review, we discuss key findings from prospective longitudinal studies of the high-risk offspring of bipolar parents and related meta-analyses that inform us about the clinical trajectory of emerging bipolar disorder. Challenges such as phenotypic and etiologic heterogeneity and the non-specificity of early symptoms and syndromes are highlighted. Implications of the findings for both research and clinical practice are discussed.

CONCLUSION

Bipolar disorder in young people at familial risk does not typically onset with a hypomanic or manic episode. Rather the first activated episode is often preceded by years of impairing psychopathological states that vary over development and across emerging bipolar subtype. Taking heterogeneity into account and adopting a more comprehensive approach to diagnosis seems necessary to advance earlier identification and our understanding of the onset of bipolar disorder.

Efficacy and tolerability of lithium in treating acute mania in youth with bipolar disorder: protocol for a systematic review

BACKGROUND

Epidemiological, clinical, and high-risk studies have provided evidence that the peak period for onset of diagnosable episodes of mania and hypomania starts in mid-to-late adolescence. Moreover, clinically significant manic symptoms may occur even earlier, especially in children at familial risk. Lithium is the gold standard treatment for acute mania in adults, yet to our knowledge, there is no published systematic review assessing lithium treatment of mania in children or adolescents. This is a major gap in knowledge needed to inform clinical practice.

AIM

As a working group within the ISBD Task Force on Lithium Treatment ( http://www.isbd.org/active-task-forces ), our aim is to complete a systematic review of the efficacy, tolerability, and acceptability of lithium compared with placebo and other active drugs in treating mania in children and adolescents diagnosed with bipolar disorder.

METHODS

We will include double- or single-blind randomized controlled trials in patients aged less than 18 years. No restrictions will be made by study publication date or language. Several electronic databases will be searched along with secondary sources such as bibliographies and trial registry websites for published and unpublished studies. Response rates to lithium compared with placebo or other active drugs will be the primary efficacy outcome. Primary tolerability and acceptability outcomes will be rates of serious adverse events and dropouts, respectively. Secondary outcomes will include rates of remission, severity of manic symptoms at different time points, and incidence of specific adverse events.

DISCUSSION

Findings from this systematic review are critically needed to inform clinical practice. We should not generalize findings from adult studies, as children and adolescents are undergoing accelerated physiological and brain development. Therefore, efficacy, tolerability, and acceptability of lithium treatment of acute mania in children compared to adults may be very different. This systematic review has been registered in PROSPERO (CRD42017055675).

Abstract 2653: Tremelimimab plus tumor ablation for patients with hepatocellular carcinoma: Clinical results, immunomonitoring analysis of peripheral T cells and tumor biopsies

Introduction: Ipilimumab, an anti-CTLA4 mAb, is the first immune-checkpoint inhibitor, to be approved by the FDA for the treatment of patients with melanoma. We performed a phase I/II clinical trial in patients with advanced hepatocellular carcinoma, who progressed on standard of care. Patients were treated with tremelimumab, another anti-CTLA4 mAb, and tumor ablation (radiofrequency ablation, cryoablation, and transcatheter arterial chemoembolization) to augment anti-tumor immunity. Peripheral blood mononuclear cells, viral load (HBV/HCV) and tumor biopsies were studied and clinical efficacy was correlated with immune monitoring results.

Methods: Patients with HCC were enrolled in a study of tremelimumab combined with tumor ablation performed on week 6. Tumor biopsies were performed at baseline and at time of RFA/TACE and analyzed by immunohistochemistry. Gene expression analysis was performed using Nanostring technology and QIAGEN's Ingenuity Pathway Analysis (IPA) software. Eleven-color flow cytometry was performed to study peripheral blood mononuclear cells obtained at baseline, after 4 and 8 weeks using the following antibodies: CD4, CD3, CD4, CD8, CD11c, CD14, CD19, CD20, CD25, CD38, CD45RA, CD56, CD123, CD127, CCR7, CCR4, CXCR3, PD-1, 4-1BB, TIM3, CTLA4, PD-L1, ICOS, HLA-DR, AFP- and survivin-HLA-A2 tetramer. HCV and HBV viral load was determined in serum samples.

Results: 27 patients were enrolled. 12 patients received TACE and 13 underwent tumor ablation during week 6 of tremelimumab therapy. Of N = 10 patients evaluable for response outside of TACE/RFA-treated lesion, 4 (40%) achieved confirmed partial responses. 6-week tumor biopsies showed clear increase in the number of CD3+ and CD8+ T cells in patients showing a clinical response only. Multi-color flow cytometry of PBMC revealed statistically significant changes after the 1st cycle in activated CD4+ and CD8+ T cells. The CD4/Treg and CD8/Treg ratio increased only in patients showing a clinical response. Both AFP and survivin specific CD8+ T cells were detected in HLA-A2+ patients, but there was no change in the frequency of these cells upon treatment. However PD1 expression increased over time both on AFP and survivin specific T cells. Finally, eight of 9 patients with quantifiable HCV experienced a marked reduction in viral load. 100% (N = 4) of HBV patients experienced a reduction in quantitative HBsAg. Pathway analysis conducted through IPA revealed that the top canonical pathways upregulated by treatment were T-cell receptor, Ephrin-A, IL-1, G-coupled protein, and IL-6 signaling.

Conclusions: Tremelimumab in combination with subtotal TACE or RFA leads to an accumulation of intratumoral CD8+ T cells, activation of CD4+ and CD8+ T cells in peripheral blood and reduction in HCV viral load and HBsAg in patients showing clinical response to therapy.

Citation Format: Ashish Uppala, Mei ElGindi, Firouzeh Korangy, Drew Pratt, David Venzon, Austin Duffy, Oxana Rusher, David Kleiner, Elliot Levy, Bradford Wood, Tim Greten. Tremelimimab plus tumor ablation for patients with hepatocellular carcinoma: Clinical results, immunomonitoring analysis of peripheral T cells and tumor biopsies. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2653.

Abstract 5015: Pretreatment carcinoembryonic antigen levels predict survival in patients with rectal adenocarcinoma

Background: Population-based studies have reported elevated Carcinoembryonic Antigen (CEA) level as an independent prognostic factor in patients with colon cancer, thus supporting inclusion of CEA-based C stage in classical TNM staging for colon cancer. However, the effect of C-stage incorporation on outcomes for patients with rectal adenocarcinoma is unknown.

Methods: The Surveillance, Epidemiology and End Result (SEER) database was used to collect data from 2004 to 2007 for patients with rectal adenocarcinoma by topography code C20.9 and histology codes 8140-8144, 8210-8211, 8220-8221, 8260-8263, 8440, 8480-8481, and 8490. CEA stage C0 = normal CEA or C1 = elevated CEA was assigned to patients with known pretreatment CEA levels. Observed survival (OS) by American Joint Committee on Cancer (AJCC) stages I-IV and CEA stage C0 or 1 was determined using Kaplan Meier method. Relative survival (RS) as a net measure of cancer survival adjusted for sex, race, age and date was calculated in addition to observed survival (OS). Log-rank was used to compare observed survival. Z-test with corresponding p values was used to compare 5-year relative survival.

Results: We identified 25,241 patients with a record of histologically confirmed invasive rectal adenocarcinoma. Approximately half (N = 13,151) of these patients had records of pretreatment CEA levels: N = 6,360 stage C1, N = 6,690 stage C0 and a small number (101) with borderline CEA levels. Mean age at diagnosis was similar in both groups, 64.2 for C0 and 64.7 for C1. Among patients with C1 disease the leading AJCC stage was distant metastatic, stage IV (33.8%) followed by 25.8% stage III, 20.7% stage II, 13.8% stage I, and 5.9% unknown stage. In contrast to CI disease, the most common stage for C0 was stage I (35.2%), and only 6.3% of patients with C0 were diagnosed with stage IV disease. Observed survival by each of I-IV AJCC TNM stages was decreased for C1 stage relative to C0, p&lt;0.001. The 5-year OS by AJCC TNM stage for C1 was as follows: 56.7% for IC1 (CI = 53.3-59.9), 55.4% for IIC1 (CI = 52.7-58.1), and 53.4% for IIIC1 (CI = 51.0-55.8). The 5-year OS by AJCC TNM stage for C0 was 75.8% for IC0 (CI = 74.1-77.5), 68.8% for IIC0 (CI = 66.5-71.0), 65.4% for IIIC0 (63.3-67.5). Stage shifting was observed with IIIC0 disease, which had superior OS as compared to stage IIC1 and IC1 (p&lt;0.001). For stage IV disease, the 5-year OS for C0 was more than double the 5 year OS for C1, 20.8 (17.1-24.9) vs. 7.9 (6.8-9.1), p&lt;0.001. In concordance with this OS data, the 5-year relative survival analysis also showed a significant difference between C1 and C0 stages of rectal adenocarcinoma in the respective AJCC TNM stages, p&lt;0.001.

Conclusion: Our study suggests that pretreatment CEA levels predict survival in patients with rectal adenocarcinoma, in accordance with previous data in colon cancer. Therefore, our study supports C-stage inclusion in AJCC TNM staging for this neoplasm. Further prospective confirmatory studies are warranted.

Citation Format: Oxana V. Makarova-Rusher, Julius Strauss, Susanna Ulahannan, Chul Kim, Jaydira Del Rivero, Austin Duffy, Tim F. Greten. Pretreatment carcinoembryonic antigen levels predict survival in patients with rectal adenocarcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 5015.

Abstract 3421: Epidemiology and survival in patients with extragastric signet ring carcinoma

Background: Signet ring carcinoma (SRC) is a distinct histological phenotype of adenocarcinoma. There are only a few published studies specifying the epidemiology of SRC with extragastric presentation. The purpose of our study was to define the most common primary sites of extragastric SRC, determine the incidence, and to compare survival by primary site and disease stage.

Methods: The Surveillance Epidemiology and End Result (SEER) database was examined from 2000 to 2012 in order to identify SRC histology (8490) and determine its most common primary sites, incidence, and survival by site and stage. The five most common primary extragastric sites were identified by utilizing ICD-0-3/WHO 2008 classification. Age-adjusted incidence rates for extragastric SRC were calculated and compared to gastric SRC. Relative survival (RS) and overall survival (OS) at 1 and 3 years were analyzed by primary site and stage using Kaplan-Meier method. Chi-square test was used for categorical variables.

Results: A total of 24,522 histologically confirmed cases of SRC were identified, and SRC comprised 0.5% of all malignant neoplasms. Among cases with known histological grade, 89.7% had poorly differentiated tumors. Overall, digestive system origin was recorded for 90% of SRC cases. Approximately half (44.2%) of primary SRC tumors were detected outside of the stomach. The most common primary sites for extragastric SRC were colon (40.5%), esophagus (11.9%), rectum (9.8%), lung/bronchus (7.3%), and pancreas (4.7%). The incidence rates for common extragastric SRC were much lower than for gastric SRC, and were higher for males than females (p&lt;0.001). Incidence profile differed by gender as breast was among top five SRC anatomical sites for females. Clinically, distant metastatic disease was more often diagnosed in patients with pancreatic (66.3%) and lung/bronchus (73.8%) SRC than SRC of the stomach (43.5%) (p&lt;0.01). Survival varied substantially by primary site. Pancreatic SRC had the worst survival and colorectal the most favorable. For example, among patients with stage IV disease, 1-year RS was 43.9% (95% CI = 41.1-46.6) for colorectal, 25.5% (95% CI = 20.6-30.6) for lung/bronchus, 20.9% (95% CI = 16.2-26.1) for esophageal, and only 10.7% (95% CI = 6.5-15.9) for pancreatic primary SRC. In concordance with 1-year RS, 3-year RS was 9.9% (95% CI = 8.2-11.9) for colorectal vs. 0.0% for pancreatic SRC.

Conclusion: Our study indicated that extragastric SRC most commonly occurs in the colorectum, esophagus and lung/bronchus. We confirmed that the primary site substantially impacts survival. Thus, development of unique molecular or histologic markers may help to identify the organ of origin and thereby determine prognosis in these phenotypically similar neoplasms.

Citation Format: Chul Kim, Susanna Ulahannan, Julius Strauss, Jaydira Del Rivero, Austin Duffy, Tim F. Greten, Oxana V. Makarova-Rusher. Epidemiology and survival in patients with extragastric signet ring carcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3421.

Targeting the microenvironment of pancreatic cancer: overcoming treatment barriers and improving local immune responses

Historically, patients diagnosed with metastatic pancreatic cancer have faced a grim prognosis. The survival benefit seen with systemic chemotherapies and even combinations thereof have been disappointing. However, growing data suggest that the microenvironment of pancreatic cancer may be contributing to this poor prognosis. This microenvironment has a dense fibrotic stroma, and is hypoxic and highly immunosuppressive, all of which pose barriers to treatment. Newer strategies looking to disrupt the fibrotic stroma, target hypoxic areas, and improve local immune responses in the tumor microenvironment are currently undergoing clinical evaluation and seem to offer great promise. In addition to these therapies, preclinical work evaluating novel cytotoxic agents including nanoparticles has also been encouraging. While much research still needs to be done, these strategies offer new hope for patients with pancreatic cancer.

A phase I study of selumetinib (AZD6244/ARRY-142866), a MEK1/2 inhibitor, in combination with cetuximab in refractory solid tumors and KRAS mutant colorectal cancer

BACKGROUND

KRAS mutations are clinically important predictors of resistance to EGFR-directed therapies in colorectal cancer (CRC). Oncogenic activation of the RAS/RAF/MEK/ERK signaling cascade mediates proliferation independent of growth factor signaling. We hypothesized that targeting MEK with selumetinib could overcome resistance to cetuximab in KRAS mutant CRC.

METHODS

A phase I study (NCT01287130) was undertaken to determine the tolerability, and pharmacokinetic profiles of the combination of selumetinib and cetuximab, with an expanded cohort in KRAS-mutant CRC.

RESULTS

15 patients were treated in the dose escalation cohort and 18 patients were treated in the expansion cohort. Two dose-limiting toxicities were observed. One grade 3 acneiform rash and one grade 4 hypomagnesemia occurred. The most common grade 1 and 2 adverse events included rash, nausea/vomiting, diarrhea, and fatigue. The maximum tolerated dose was established at selumetinib 75 mg p.o. BID and cetuximab 250 mg/m(2) weekly following a 400 mg/m(2) load. Best clinical response in the dose escalation group included 1 unconfirmed partial response in a patient with CRC and stable disease (SD) in 5 patients (1 squamous cell carcinoma of the tonsil, 1 non-small cell lung cancer, and 3 CRC), and in the KRAS-mutant CRC dose expansion cohort, of the 14 patients who were evaluable for response, 5 patients had SD and 9 patients had progressive disease.

CONCLUSIONS

The combination of selumetinib and cetuximab is safe and well tolerated. Minimal anti-tumor activity was observed in KRAS-mutant refractory metastatic CRC. Further investigations might be warranted in other cancer subtypes.

A single-center evaluation of the risk for colonization or bacteremia with piperacillin-tazobactam- and cefepime-resistant bacteria in patients with acute leukemia receiving fluoroquinolone prophylaxis

Fluoroquinolone prophylaxis is indicated to prevent neutropenic fever in patients with acute leukemia. However, fluoroquinolone use has been associated with development of multi-drug-resistant Pseudomonas aeruginosa and extended spectrum β-lactamase producing gram-negative bacilli. Due to a presumed risk of multi-drug resistance associated with fluoroquinolone prophylaxis, patients admitted to our hospital with neutropenic fever receive empiric carbapenem therapy until cultures are negative for 72 h or identification of an organism. Our study seeks to identify the incidence of multi-drug-resistant organism colonization and bacteremia among patients who receive fluoroquinolone prophylaxis and to evaluate duration of empiric carbapenem therapy. A retrospective review of adult patients with acute leukemia receiving a fluoroquinolone as outpatient infection prophylaxis, admitted to our tertiary cancer center for treatment of neutropenic fever was completed. Surveillance and blood cultures were reviewed for antibiotic resistance. Duration of empiric carbapenem therapy was reviewed. One hundred patients and 177 admissions for neutropenic fever were included. Six patients harbored a piperacillin-tazobactam-resistant organism found during routine surveillance. Among these patients, two bacteremias were identified, one of which was a piperacillin-tazobactam-resistant organism. Five bacteremias were identified among 83 patients with negative surveillance cultures. Among the bloodstream infections, five organisms isolated were fluoroquinolone resistant. No cefepime-resistant organism was isolated on surveillance or bloodstream cultures. Adherence to the institution guideline of narrowing antibiotics after 72 h of negative cultures occurred in only 13% of neutropenic fever cases. The average duration of carbapenem therapy in 177 neutropenic fever episodes was 4.4 days. Our findings show that among our patient population, there is a low risk of bacteremia with a piperacillin-tazobactam-resistant or cefepime-resistant organism. However, prompt de-escalation of carbapenem therapy needs to be reiterated within hospital practice.

Undulator beamline of the Brockhouse sector at the Canadian Light Source

The Brockhouse project at the Canadian Light Source plans the construction of three beamlines, two wiggler beamlines, and one undulator beamline, that will be dedicated to x-ray diffraction and scattering. In this work, we will describe the undulator beamline main components and performance parameters, obtained from ray tracing using XOP-SHADOW codes. The undulator beamline will operate from 4.95 to 21 keV, using a 20 mm period hybrid undulator placed upstream of the wiggler in the same straight section. The beamline optics design was developed in cooperation with the Brazilian Synchrotron - LNLS. The beamline will have a double crystal monochromator with the options of Si(111) or Si(311) crystal pairs followed by two mirrors in the KB configuration to focus the beam at the sample position. The high brilliance of the undulator source will produce a very high flux of ~10(13) photons/s and high energy resolution into a small focus of 170 μm horizontal and 20-60 μm vertical, depending on the optical configuration and energy chosen. Two multi-axis goniometer experimental stations with area detectors and analyzers are foreseen to enable diffraction, resonant and inelastic scattering experiments, and SAXS/WAXS experiments with high resolution and time resolving capabilities.

Fibrolamellar hepatocellular carcinoma in the USA, 2000-2010: A detailed report on frequency, treatment and outcome based on the Surveillance, Epidemiology, and End Results database

OBJECTIVE

Epidemiological and clinical information on fibrolamellar hepatocellular carcinoma (fHCC) is scarce. We performed a Surveillance, Epidemiology and End Results (SEER) database analysis with the aim of collecting information to better understand the biology and clinical aspects of this rare disease.

DESIGN

Incidence trends, race- and age-specific rates, tumor size, first course surgery and five-year relative survival of 191 US cases (SEER) diagnosed with fHCC during 2000-2010 were compared to cases with hepatocellular carcinoma (HCC), HCC-not otherwise specified (HCC-NOS) and other HCC-types.

RESULTS

While HCC-NOS incidence rates increased by 5.2% annually from 2000-2008 (p < 0.05) before leveling, the 1.3% change in fHCC incidence was not statistically significant. The rates of fHCC were similar across ethnic groups while HCC-NOS incidence rates were higher among non-whites. Although 16% of fHCC patients had primary tumors ≤5 cm compared to 37% of HCC-NOS cases five-year survival was better among fHCC (34%) than HCC-NOS cases (16%). Fibrolamellar HCC cases of 0-39 years of age were more likely to receive radiofrequency ablation, transplant or resection than HCC-NOS cases of that age. Survival was similar among fibrolamellar and HCC-NOS cases receiving surgery.

CONCLUSION

In this largest case series, fibrolamellar and HCC-NOS age- and race-specific incidence rates and time trends differed. Despite larger tumor size than HCC-NOS cases fibrolamellar cases received surgery more often and had better survival rates. Differences in co-morbidity may influence treatment. Studies of fHCC biology, including by age, are recommended.

Comparison of mortality following hospitalisation for ulcerative colitis in Scotland between 1998-2000 and 2007-2009

BACKGROUND

Scottish nationwide linkage data from 1998 to 2000 demonstrated high 3-year mortality in patients hospitalised with ulcerative colitis (UC).

AIM

To compare 3-year mortality, and factors related to mortality, in Scottish patients hospitalised with UC between 1998-2000 and 2007-2009.

METHODS

The Scottish Morbidity Records and linked datasets were used to assess 3-year mortality, standardised mortality ratio (SMR) and multivariate analyses of factors associated with 3-year mortality. The 3-year mortality was determined after four admission types: surgery-elective or emergency; medical-elective or emergency. Age-standardised mortality rates (ASR) were used to compare mortality rates between periods.

RESULTS

Ulcerative colitis admissions increased from 10.6 in Period 1 to 11.6 per 100 000 population per year in Period 2 (P = 0.046). Crude and adjusted 3-year mortality fell between time periods (crude 12.2% to 8.3%; adjusted OR 0.59, CI 0.42-0.81, P = 0.04). Adjusted 3-year mortality following emergency medical admission (OR 0.58, CI 0.39-0.87, P = 0.003) and in patients >65 years (38.8% to 28.7%, P = 0.02) was lower in Period 2. The SMR in period 1 was 3.04 and 2.96 in Period 2. Directly age-standardised mortality decreased from 373 (CI 309-437) to 264 (CI 212-316) per 10 000 person-years. On multivariate analysis, increasing age (50-64 years OR 7.11 (CI 2.77-18.27, P < 0.05); 65-74 years OR 14.70 (CI 5.65-38.25 P < 0.05); >75 years OR 46.42 (CI 18.29-117.78, P < 0.001) and co-morbidity (OR 3.02, CI 1.72-5.28, P < 0.001) were significantly associated with 3-year mortality in Period 2.

CONCLUSIONS

Comparisons of crude and adjusted mortality rates suggest significant improvement in outcome over the last decade - however, mortality remains high, and older age and co-morbidity are important predictors of outcome.

Attachment and temperament profiles among the offspring of a parent with bipolar disorder

INTRODUCTION

Attachment is associated both with the risk of developing a mood disorder and temperamental profile. Relatively little is known about these associations in children of a parent with bipolar disorder (BD). The present study is a preliminary analysis of the association between attachment, temperament and psychopathology among high-risk offspring.

METHODS

As part of an ongoing prospective cohort study, offspring from families with one parent with BD (HR) and offspring from families with unaffected parents (C) were clinically assessed using KSADS-PL format interviews annually. Validated self-report measures of perceived attachment and temperament were completed.

RESULTS

Perceived attachment did not differentiate HR from C offspring and did not predict psychopathology or mood disorder in particular. However, high emotionality significantly predicted the risk of psychopathology in HR offspring, where 1 standard deviation increase in emotionality significantly increased the hazard of psychopathology by a factor of 1.36 (p=0.0009) and mood disorder by a factor of 1.24 (p=0.02).

LIMITATIONS

Use of retrospective measures and low sample size for some models.

CONCLUSIONS

There may be no gross abnormalities in attachment among HR compared to C offspring. It remains unclear if emotionality is a barometer of illness or a true risk factor in this population. More longitudinal research is needed to advance understanding of the influential pathways by which psychosocial risk factors impact the development of BD. This research has implications for targeted early interventions in HR youth.

Second-line treatment in advanced pancreatic cancer: a comprehensive analysis of published clinical trials

BACKGROUND

There is currently no standard of care for the second-line treatment of advanced pancreatic cancer. The aim of this analysis was to compare the different therapeutic approaches in this setting.

METHODS

We carried out a systematic analysis of second-line studies in advanced pancreatic cancer that have progressed on or following gemcitabine and published or presented from 2000 to 2012.

RESULTS

Forty-four clinical trials (t) were identified; of which 34 met the inclusion criteria treating an aggregate total of 1503 patients (n). Patients who received treatments (t: 33; n: 1269) had a median overall survival (OS) of 6 months compared with 2.8 months for patients who received best supportive care only (t: 2; n: 234) (P = 0.013). The gemcitabine and platinum-based combination (t: 5; n: 154) provided a median progression-free survival and OS of 4 and 6 months compared with 1.6 and 5.3 for the rest of the regimens (t: 29; n: 1349) (P = 0.059 and 0.10, respectively) and 2.9 and 5.7 for the combination of 5-fluorouracil and platinum agents (t: 12; n: 450) (P = 0.60 and 0.22, respectively).

CONCLUSION(S)

Although not conclusive, these data showed that the advantage of second-line chemotherapy in pancreatic cancer is very limited and there is a need for more studies.

Hemorrhagic events in hepatocellular carcinoma patients treated with antiangiogenic therapies

The presence of cirrhosis increases the potential risk of hemorrhage for patients with hepatocellular carcinoma (HCC). We evaluated the relative risk for hemorrhage in patients with HCC treated with antiangiogenic agents. We performed a systematic review and meta-analysis of antiangiogenic studies in HCC from 1995 to 2011. For nonrandomized studies we compared bleeding risk with other HCC single-arm studies that did not include an antiangiogenic agent. To separate disease-specific factors we also performed a comparison analysis with renal cell cancer (RCC)) studies that evaluated sorafenib. Sorafenib was associated with increased bleeding risk compared to control for all grade bleeding events (odds ratio [OR] 1.77; 95% confidence interval [CI] 1.04, 3.0) but not grade 3-5 events in both HCC and RCC (OR 1.46; 95% CI 0.9, 2.36; P=0.45). When comparing the risk of bleeding in single-arm phase 2 studies evaluating antiangiogenic agents, this risk for all events (OR 4.34; 95% CI 2.16, 8.73) was increased compared to control.

CONCLUSION

This analysis of both randomized and nonrandomized studies evaluating an antiangiogenic agent in HCC showed that whereas the use of sorafenib was associated with an increased risk of bleeding in HCC, this was primarily for lower-grade events and similar in magnitude to the risk encountered in RCC.

Comparative analysis of monocytic and granulocytic myeloid-derived suppressor cell subsets in patients with gastrointestinal malignancies

Myeloid-derived suppressor cells (MDSC) are a heterogenous population of cells comprising myeloid progenitor cells and immature myeloid cells, which have the ability to suppress the effector immune response. In humans, MDSC have not been well characterized owing to the lack of specific markers, although it is possible to broadly classify the MDSC phenotypes described in the literature as being predominantly granulocytic (expressing markers such as CD15, CD66, CD33) or monocytic (expressing CD14). In this study, we set out to perform a direct comparative analysis across both granulocytic and monocytic MDSC subsets in terms of their frequency, absolute number, and function in the peripheral blood of patients with advanced GI cancer. We also set out to determine the optimal method of sample processing given that this is an additional source of heterogeneity. Our findings demonstrate consistent changes across sample processing methods for monocytic MDSC, suggesting that reliance upon cryopreserved PBMC is acceptable. Although we did not see an increase in the population of granulocytic MDSC, these cells were found to be more suppressive than their monocytic counterparts.

Acrometastasis as the Initial Presentation of a KRAS-Positive Colon Cancer

The propensity of colon cancer to metastasize to bones is very low compared to prostate, breast or lung cancer. The reason for this is not yet understood, although an explanation for the osteotropism of certain primaries has been offered by the ‘seed and soil’ concept, suggesting that the bone microenvironment provides a favorable ‘soil’ for metastasis and proliferation of some tumor cells (‘seeds’) [1]. Here, we report an unusual case of colon cancer with metastasis to the finger at initial presentation, and exophytic sclerotic lesions to other bones. The incidence of metastases to fingers/toes (acrometastases) is reported to be only 0.1%, even after including involvement of primary sites other than the colon. The etiology and characteristics of acrometastases are reviewed in this case report.

S100A9 a new marker for monocytic human myeloid-derived suppressor cells

Myeloid-derived suppressor cells (MDSC) are a heterogeneous population of cells that negatively regulate the immune response during tumour progression, inflammation and infection. Only limited data are available on human MDSC because of the lack of specific markers. We have identified members of the S100 protein family-S100A8, S100A9 and S100A12 - specifically expressed in CD14(+) HLA-DR(-/low) MDSC. S100A9 staining in combination with anti-CD14 could be used to identify MDSC in whole blood from patients with colon cancer. An increase in the population of CD14(+) S100A9(high) MDSC was observed in the peripheral blood from colon cancer patients in comparison with healthy controls. Finally, nitric oxide synthase expression, a hallmark of MDSC, was induced in CD14(+) S100A9(high) upon lipopolysaccharide/interferon-γ stimulation. We propose S100 proteins as useful markers for the analysis and further characterization of human MDSC.

Locally advanced cancer of the esophagus, current treatment strategies, and future directions

For patients with locally advanced esophageal cancer no clear standard of care exists. Notwithstanding several negative phase III studies the data provide support for so-called trimodality treatment and this is probably the most common approach. Even the role of surgery has been questioned. These alternative approaches are set against a changing epidemiological background whereby adenocarcinoma has become the predominant tumor type, at least in the western world. In recent times an emphasis has been placed on the better selection of patients, predominantly based on data that shows a markedly improved survival in those who exhibit a response to neo-adjuvant therapy. In this article we review the major studies and discuss new approaches to the management of patients with locally advanced cancer of the esophagus.

Pretreatment of endothelial progenitor cells with osteopontin enhances cell therapy for peripheral vascular disease

Tissue necrosis resulting from critical limb ischemia (CLI) leads to amputation in a significant number of patients. Autologous cell therapy using angiogenic cells such as endothelial progenitor cells (EPCs) holds promise as a treatment for CLI but a limitation of this treatment is that the underlying disease etiology that resulted in CLI may also contribute to dysfunction of the therapeutic EPCs. This study aimed to elucidate the mechanism of EPC dysfunction using diabetes mellitus as a model and to determine whether correction of this defect in dysfunctional EPCs ex vivo would improve the outcome after cell transplantation in the murine hind limb ischemia model. EPC dysfunction was confirmed in a homogenous population of patients with type 1 diabetes mellitus and a microarray study was preformed to identify dysregulated genes. Notably, the secreted proangiogenic protein osteopontin (OPN) was significantly downregulated in diabetic EPCs. Furthermore, OPN-deficient mice showed impaired recovery following hind limb ischemia, suggesting a critical role for OPN in postnatal neovascularization. EPCs isolated from OPN KO mice showed decreased ability to adhere to endothelial cells as well as impaired angiogenic potential. However, this dysfunction was reversed upon exposure to recombinant OPN, suggesting that OPN may act in an autocrine manner on EPCs. Indeed, exposure of OPN knockout (KO) EPCs to OPN was sufficient to induce the secretion of angiogenic proteins (IL-6, TGF-α, and FGF-α). We also demonstrated that vascular regeneration following hind limb ischemia in OPN KO mice was significantly improved upon injection of EPCs preexposed to OPN. We concluded that OPN acts in an autocrine manner on EPCs to induce the secretion of angiogenic proteins, thereby playing a critical role in EPC-mediated neovascularization. Modification of cells by exposure to OPN may improve the efficacy of autologous EPC transplantation via the enhanced secretion of angiogenic proteins.

A role for MRP8 in in stent restenosis in diabetes

OBJECTIVE

The most common cause of death in diabetes mellitus is cardiovascular disease. Patients frequently undergo vascular intervention such as stenting. The occurrence of in stent restenosis (ISR) has been reduced by the use of drug eluting stents in non-diabetic patients but the incidence of restenosis and stent thrombosis remains higher in diabetic patients. We investigated the pathogenesis of in stent restenosis in an animal model of type 2 diabetes mellitus.

METHODS AND RESULTS

Stents were placed in Zucker Fatty rat (ZFR) and wild type rat carotid arteries, and tissues were harvested 14 days post surgery for morphometric analysis. Unstented carotid arteries from both groups were harvested for microarray analysis. In vitro apoptosis, proliferation and migration assays were performed on rat and human aortic endothelial cells (EC). ZFRs developed an exaggerated intimal response to stent placement compared to wild type controls 14 days post stent placement. MRP8 and MRP14 were up-regulated in unstented ZFR carotid arteries in comparison to controls. Expression of MRP8/14 was also elevated in EC exposed to high glucose conditions. EC function was impaired by high glucose concentrations, and this effect could be mimicked by MRP8 over-expression. MRP8 knockdown by shRNA significantly restored EC function after exposure to high glucose concentrations. MRP8 expression in glucose exposed cells was also inhibited using pharmacological blockade of glucose-induced pathways.

CONCLUSIONS

EC dysfunction caused by elevated glucose levels could be mimicked by MRP8/14 over-expression and reversed/prevented by MRP8 knockdown. Thus, MRP8/14 likely plays a role in exaggerated ISR in diabetes mellitus, and MRP8 inhibition may be useful in improving outcome after stent placement in diabetes mellitus.

Using Systems Engineering for the Development of Decision Making Support Systems (DMSS)

Decision Making Support Systems (DMSS) can mitigate the risks involved in highly uncertain processes where novelty is high, such as NPD resource management. However such systems manipulate complex organisational information and require embedding within the business it operates within. There is a risk of poor acceptance in the business if the DMSS does not take into account a number of business related considerations. Utilising a systems approach literature was analysed, from which a set of considerations pertinent to the development of DMSS was elicited. Through the assessment of a number of System Development Methodologies (SDM), it was found that no one System Development Methodology (SDM) took into account all considerations identified. There is therefore a clear gap in current research and a real need for such a methodology which addresses the considerations identified.

Hematologic improvement in dogs with parvovirus infection treated with recombinant canine granulocyte-colony stimulating factor

Previously, dogs with canine parvovirus-induced neutropenia have not responded to treatment with recombinant human granulocyte-colony stimulating factor (rhG-CSF). However, recombinant canine G-CSF (rcG-CSF) has not been previously evaluated for treatment of parvovirus-induced neutropenia in dogs. We assessed the effectiveness of rcG-CSF in dogs with parvovirus-induced neutropenia with a prospective, open-label, nonrandomized clinical trial. Endpoints of our study were time to recovery of WBC and neutrophil counts, and duration of hospitalization. 28 dogs with parvovirus and neutropenia were treated with rcG-CSF and outcomes were compared to those of 34 dogs with parvovirus and neutropenia not treated with rcG-CSF. We found that mean WBC and neutrophil counts were significantly higher (P < 0.05) in the 28 dogs treated with rcG-CSF compared to disease-matched dogs not treated with rcG-CSF. In addition, the mean duration of hospitalization was reduced (P = 0.01) in rcG-CSF treated dogs compared to untreated dogs. However, survival times were decreased in dogs treated with rcG-CSF compared to untreated dogs. These results suggest that treatment with rcG-CSF was effective in stimulating neutrophil recovery and shortening the duration of hospitalization in dogs with parvovirus infection, but indicate the need for additional studies to evaluate overall safety of the treatment.

Developing better treatments in hepatocellular carcinoma

The marked heterogeneity of hepatocellular carcinoma (HCC), particularly with regard to the etiology and severity of the underlying cirrhosis, makes clinical trial design in this disease very challenging. In addition, despite the global burden of HCC, there have been relatively few randomized studies. The major advance in medical therapy in HCC has been the benefit of sorafenib, as demonstrated in two Phase III studies. However, the benefit is small, and new therapies to augment or replace sorafenib are urgently needed. These newer therapies, as well as the progress made in two important areas – clinical trial design and molecular characterization – are the subject of this article.

Advanced hepatocellular carcinoma: which staging systems best predict prognosis?

PURPOSE

The purpose of cancer staging systems is to accurately predict patient prognosis. The outcome of advanced hepatocellular carcinoma (HCC) depends on both the cancer stage and the extent of liver dysfunction. Many staging systems that include both aspects have been developed. It remains unknown, however, which of these systems is optimal for predicting patient survival.

PATIENTS AND METHODS

Patients with advanced HCC treated over a 5-year period at Memorial Sloan-Kettering Cancer Center were identified from an electronic medical record database. Patients with sufficient data for utilization in all staging systems were included. TNM sixth edition, Okuda, Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP), Chinese University Prognostic Index (CUPI), Japan Integrated Staging (JIS), and Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire (GETCH) systems were ranked on the basis of their accuracy at predicting survival by using concordance index (c-index). Other independent prognostic variables were also identified.

RESULTS

Overall, 187 eligible patients were identified and were staged by using the seven staging systems. CLIP, CUPI, and GETCH were the three top-ranking staging systems. BCLC and TNM sixth edition lacked any meaningful prognostic discrimination. Performance status, AST, abdominal pain, and esophageal varices improved the discriminatory ability of CLIP.

CONCLUSION

In our selected patient population, CLIP, CUPI, and GETCH were the most informative staging systems in predicting survival in patients with advanced HCC. Prospective validation is required to determine if they can be accurately used to stratify patients in clinical trials and to direct the appropriate need for systemic therapy versus best supportive care. BCLC and TNM sixth edition were not helpful in predicting survival outcome, and their use is not supported by our data.

Abstract 3718: A Phase II Study of Sorafenib plus Cetuximab in colorectal cancer (CRC) expressing epidermal growth factor receptor (EGFR) and mutated K-ras

Background: The presence of K-ras mutation predicts for a lack of response to EGFR-directed therapies in CRC. We hypothesized that a drug capable of inhibiting Raf kinase, which is downstream of Ras, could restore tumor sensitivity to cetuximab. We conducted a Phase II single-arm optimal two-stage design trial of cetuximab, a monoclonal antibody directed against EGFR, in combination with sorafenib, a small molecule inhibitor of VEGFR2 and Raf kinase, in patients with EGFR-positive (+) CRC bearing K-ras mutations.

Trial Design: Objectives were to determine clinical benefit rate (CBR) (CR+PR+SD for 4 months) and PFS. Eligible patients were ≥ 18 years old and had histologically documented EGFR+ metastatic CRC bearing K-ras mutations which had recurred or progressed following at least one prior chemotherapy regimen; measurable disease; ECOG PS 0-1; adequate bone marrow, hepatic and renal function. Patients previously treated with an EGFR inhibitor were excluded. Cetuximab was given IV at 400 mg/m2 initially as a loading dose on week 1, followed by 250 mg/m2 weekly, in 28-day cycles. Sorafenib was self-administered orally at 400 mg BID. Radiologic assessment was performed at baseline and every 2 cycles; response was determined based on RECIST criteria. Changes in tumor vascularity were evaluated by dynamic contrast-enhanced MRI (DCE-MRI) at baseline and after 2 cycles.

Results: A total of 9 patients received at least 2 cycles of therapy and were evaluable for response. The median age was 51 years (range 21-81 years), and all patients had an ECOG PS of 1 and had received prior FU, oxaliplatin, irinotecan, and bevacizumab. Rash, electrolyte abnormalities, hypertension, and diarrhea were the most common toxicities. Grade 2 and 3 toxicities (number of patients in parentheses) were hypophosphatemia (5), hypokalemia (1), hypomagnesemia (1), acneiform rash (2), hand-foot syndrome (1), diarrhea (3), transaminitis (2), hyperbilirubinemia (1), lymphopenia (6), hypertension (1), anemia (1), and hypoalbuminemia (4). The only grade 4 events were lymphopenia (1) and hypokalemia (1). Although no patients had objective responses, 3 patients had stable disease for 6, 6 and 4 months respectively. DCE-MRI results showed reduction in the parameters of permeability, with decrease in ktrans and kep values. Quantitative biomarker analysis with determination of plasma angiogenic factors is ongoing.

Conclusions: Sorafenib in combination with cetuximab is well tolerated in CRC patients and was associated with disease stabilization in 3 of 9 patients with EGFR+ CRC bearing K-ras mutations. Sorafenib plus cetuximab may have a role in the treatment of patients with CRC bearing Kras mutations. We have met the response goals for the first stage of the trial, and accrual continues for the second stage.

Funded by NCI Contract No. HHSN261200800001E.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3718.