[Preliminary application of postoperative fast track transfer to intensive care unit for the geriatric hip fractures under enhanced recovery after surgery]

Objective: To develop a fast track transfer to intensive care unit (ICU) for the perioperative high-risk elderly patients after hip fracture surgery and analyze the preliminary clinical effect of the application. Methods: From January 2014 to December 2017, before the application of postoperative fast track transfer to ICU, the clinical data of 195 elderly patients with hip fracture were included in a retrospective analysis. Among 195 hip fracture patients, 18 were transferred to ICU post operation (non-fast track group). Multivariate logistic regression analysis was applied to investigate relevant risk factors for transferring to ICU after hip fracture surgery. Based on risk factors acquired from the analysis and clinical experience, the fast track transfer to ICU for the perioperative high-risk elderly patients after hip fracture surgery was constructed according to the preliminary and experiential criteria. From January 2018 to December 2019, the clinical data of 70 patients (fast track group) who were transferred to ICU after hip fracture surgery through the fast track were collected and compared with non-fast track group. Results: Multivariate regression analysis revealed that American Society of Anesthesiologists classification(≥Ⅲ) (OR=4.260, 95%CI:1.157-15.683, P=0.029), pre-hospital stage (≥48 h) (OR=4.301, 95%CI:1.212-15.266, P=0.024), hemoglobin concentration at admission(<90 g/L) (OR=7.979, 95%CI:1.936-32.889, P=0.004), coronary heart disease as one comorbidity(OR=6.063, 95%CI:1.695-21.693, P=0.006) were independent risk factors for transferring to ICU after hip fracture surgery. There were no significant difference in gender, age, fracture type, hemoglobin concentration at admission and time of pre-hospital stage between the non-fast track group and fast track group(all P>0.05). However, the number of comorbidities in the fast track group was significantly higher than that in the non-fast track group (Z=-1.995, P=0.046). The time to surgery, postoperative hospital stay, and length of hospital stay in fast track group were all significantly less than those in non-fast track group (Z=-2.121, -2.726, -3.130, all P<0.05). Also, there were fewer medical consultations needed and fewer patients who stayed in ICU more than or equal to 2 nights in fast track group than that in non-fast track group(all P<0.05). There were no significant difference in the rate of patients who transferred from the general ward to ICU after transferring from ICU to the general ward, the proportion of patients who received more than or equal to 4 departments, operation time, hospitalization expense, mortality during hospitalization, 30-day mortality and 90-day mortality after operation between the two groups(all P>0.05). Conclusions: The fast track constructed in this study can reduce time to surgery, postoperative hospitalization stay and length of hospitalization stay for the perioperative high-risk elderly patients with hip fractures and is a specific clinical application of eras concept based on multidisciplinary team.

Abstract 2923: Targeting the polycomb repressive complex-2 related proteins in nasopharyngeal carcinoma

Aberrant hypermethylation of tumor suppressor genes is common in nasopharyngeal carcinoma (NPC), which is also enriched in denovo methylation at PCR2-related gene loci. PRC2 complex has three core subunits: embryonic ectoderm development (EED), enhancer of Zeste 1/2 (EZH1/2) and suppressor of Zeste 12 (SUZ12), which can mediate gene silencing. This study investigated the pharmacological effect of targeting EED and EZH2 in NPC cell lines (C666-1, C17C, NPC43 and HK1) and an immortalized normal nasopharyngeal epithelial cell line (NP69), either alone or concomitantly with other drugs. The relevance and prognostic significance of EED, SUZ12, EZH2 and H3K27me3 expression were determined in 100 NPC samples. EZH2 and EED was strongly expressed in EBV-positive NPC cell lines (C666-1, C17C and NPC43), but weakly in EBV negative cell line HK1 and NP69. The effect of EED inhibitor (EED226) and EZH2 inhibitor (EPZ-6438) on cell growth was tested in C666-1, NPC43 and HK1. Treatment with EED226 reduced the level of H3K27me3, with only minimal/ modest inhibition on NPC cell growth at 72hr. Drug combinations of PRC2-targeting agents with other epigenetic modulators or chemotherapy drugs were evaluated at, and near their IC50 concentrations in C666-1 and NPC43. Three combinations indicated synergistic effect: (i) EPZ-6438 and HDAC inhibitor (TSA) (synergy score, SS = 12.636); (ii) EED226 and gemcitabine (SS = 10.285); (iii) DNMT inhibitor (AZA) and EED226 (SS = 7.336). RNA-seq analysis were done after treatment with 5M of EED226 for 3, 7 and 14 days. GO enrichment analysis, KEGG pathway enrichment analysis and Artificial Neural Network (ANN) were used for bioinformatics analysis. EED226 at low dose mainly affected the cell-adherence related genes at 3-7 days after treatment, and MHC protein complex and cell cycle related genes were significantly changed after longer drug exposure (7-14 days) in NPC cells. ANN predicted a combination therapy of EED226 and LEE011 (CDK4/6 inhibitor) and we demonstrated a synergistic inhibitory effect on cell growth when EED226 was combined with LEE011 in C666-1 and HK1 cells at 72hr, with the respective combination index (CI) of ED50 &lt; 0.7. In conclusion, EED226 can significantly down- regulate the level of H3K27me3 at low dose, but with minimal growth inhibitory effect as monotherapy. EED and EZH2 inhibitor have synergistic effect when combined with chemotherapy and other epigenetic modulators and CDK4/6 inhibitors in vitro. Validation in vivo model of NPC is warranted. Data on the prognostic of PRC2-related protein significance in advanced NPC will be presented.

Acknowledgement of grant: Direct grant for research, The Chinese University of Hong Kong (#2018.012).

Citation Format: Junyu ZHU, Lili Li, Connie W. Hui, Joanna H. Tong, Raymond Chan, Chi Hang Wong, Qiyong Ai, Edwin P. Hui, Anthony T. Chan, Kwok Wai Lo, Qian Tao, Brigette B. Ma. Targeting the polycomb repressive complex-2 related proteins in nasopharyngeal carcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2923.

Regorafenib in Chinese patients with metastatic colorectal cancer: Subgroup analysis of the phase 3 CONCUR trial

BACKGROUND AND AIM

In the phase 3 CONCUR trial (NCT01584830), regorafenib improved overall survival (OS) versus placebo in Asian patients with treatment-refractory metastatic colorectal cancer (mCRC). We conducted a post hoc subgroup analysis of Chinese patients in CONCUR.

METHODS

Adults with mCRC progressing despite at least two prior treatment regimens and Eastern Cooperative Oncology Group performance status 0-1 were randomized 2:1 to regorafenib 160 mg once daily or placebo for the first 3 weeks of each 4-week cycle. Dose modifications were permitted. The primary endpoint was OS. Secondary endpoints included progression-free survival, objective overall response, disease control rate, and safety.

RESULTS

A total of 172 Chinese patients were randomized and treated (regorafenib n = 112, placebo n = 60). OS was significantly improved with regorafenib versus placebo (8.4 vs 6.2 months, respectively; hazard ratio [HR] 0.56, 95% CI 0.39-0.80; one-sided P = 0.000632), as was progression-free survival (HR 0.32, 95% CI 0.22-0.47; one-sided P < 0.000001). The most common drug-related grade ≥ 3 treatment-emergent adverse events (TEAEs; regorafenib, placebo) were hand-foot skin reaction (19%, 0%), hypertension (13%, 3%), hypophosphatemia (7%, 0%), increased alanine aminotransferase (6%, 0%), and increased aspartate aminotransferase (5%, 0%). In patients receiving regorafenib and placebo, respectively, TEAEs led to treatment discontinuation in 14% and 7%, dose reduction in 39% and 0%, and dose interruption in 64% and 20%.

CONCLUSIONS

This retrospective analysis showed that regorafenib provided an OS benefit over placebo for Chinese patients with previously treated mCRC. TEAEs were consistent with the regorafenib safety profile and manageable with treatment modifications.

Pre-treatment intravoxel incoherent motion diffusion-weighted imaging predicts treatment outcome in nasopharyngeal carcinoma

PURPOSE

To evaluate whether pre-treatment intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) can predict treatment outcome after 2 years in patients with nasopharyngeal carcinoma (NPC).

METHOD

One hundred and sixty-one patients with newly diagnosed NPC underwent pre-treatment IVIM-DWI. Univariate Cox regression analysis was performed to evaluate the correlation of the mean values of the pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction and apparent diffusion coefficient with local relapse-free survival (LRFS), regional relapse-free survival (RRFS), distant metastases-free survival (DMFS) and disease-free survival (DFS). Significant diffusion parameters, together with staging, age, gender and treatment as confounding factors, were added into a multivariate model. The area under the curves (AUCs) of significant parameters for disease relapse were compared using the Delong test.

RESULTS

Disease relapse occurred in 30 % of the patients at a median follow-up time of 52.1 months. The multivariate analysis showed that high D and T-staging were correlated with poor LRFS (p = 0.042 and 0.020, respectively) and poor DFS (p = 0.023 and 0.001, respectively); low D* and high T-staging with poor RRFS (p = 0.020 and 0.033, respectively); and high N-staging with poor DMFS (p = 0.006). D with the optimal threshold of ≥0.68 × 10^-3 mm²/s and T-staging showed similar AUCs (AUC = 0.614 and 0.651, respectively; p = 0.493) for predicting disease relapse.

CONCLUSION

High D and low D* were predictors of poor locoregional outcome but none of the diffusion parameters predicted DMFS in NPC.

Increased fat synthesis and limited apolipoprotein B cause lipid accumulation in the liver of broiler chickens exposed to chronic heat stress

Chronic heat stress can enhance fat synthesis in broilers, and excessive triglyceride (TG) synthesized by the liver needs to be transported to extrahepatic tissues by very low density lipoprotein (VLDL) otherwise will accumulate in the liver, which may even result in hepatic steatosis. To investigate the molecular mechanisms by which chronic heat stress enhances fat synthesis and results in lipid accumulation in the liver of chickens, 144 broilers (Arbor Acres, 28-day-old) were randomly allocated to the normal control (NC, 22°C), heat stress (HS, consistent 32°C), or pair-fed (PF, 22°C) groups for a 14-D trial. The 7 D of heat exposure significantly increased the respiratory rate, relative weight of abdominal fat, the levels of glucose, TG, corticosterone, insulin, and VLDL in plasma, as well as the levels of TG, total cholesterol, acyl-CoA carboxylase (ACC), and fatty acid synthase (FAS) in the liver, and mRNA expression levels of carbohydrate response element-binding protein (ChREBP), ACC, FAS, and microsomal triglyceride transfer protein (MTTP) in comparison with the other 2 groups. After 14 D of heat exposure, the relative weights of abdominal fat and liver and levels of TG and FAS in the liver were significantly higher in the HS group than in the other 2 groups, and there were no significant differences in the respiratory rate, plasma corticosterone concentration, apolipoprotein B (ApoB) level in the liver, and mRNA expression levels of key genes of fat synthesis among the 3 groups. In conclusion, chronic heat exposure activated LXRα pathway and enhanced fat synthesis in the liver after 7 D of heat exposure. After 14 D of heat exposure, heat-stressed broilers exhibited an adaptation to the high temperature in parameters of stress and fat synthesis gene expression levels. Moreover, chronic heat stress resulted in lipid accumulation in the liver of broilers, which is probably because the limited ApoB was not enough to transport the excessive TG synthesized by the liver in chronic heat-stressed broilers.

Dietary taurine supplementation enhances antioxidative capacity and improves breast meat quality of broiler chickens

1. The aim of this study was to determine the effect of dietary taurine supplementation on growth performance, meat quality and antioxidant responses in breast muscle of broiler chickens.2. A total of 72 Arbor Acres broiler chickens (28-day-old) with similar body weight were randomly allocated into two groups, and fed either 0 g/kg (control; C) or 5 g/kg taurine-supplemented diets (TS) for 14 days.3. The results showed that TS had no effect on growth performance or chemical composition of breast muscle in broilers. The drip and cooking losses were significantly decreased (P < 0.05), and the pH_24h of breast muscle were increased (P < 0.05) in the TS group. Meanwhile, broilers in the TS group exhibited significantly higher (P < 0.05) scavenging activities of superoxide and 2,2-diphenyl-1-picrylhydrazyl radicals, and lower (P < 0.05) contents of carbonyl, malondialdehyde, and 4-hydroxynonenal. TS increased (P < 0.05) total antioxidant capacity and superoxide dismutase activities. Moreover, TS significantly upregulated (P < 0.05) the mRNA expressions of nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase 1, NAD(P)H quinone dehydrogenase 1, superoxide dismutase, catalase, and glutathione peroxidase.4. These findings suggested that TS enhanced antioxidative capacity and improved breast meat quality of broilers via activating the Nrf2 pathway.

The alleviative effects and related mechanisms of taurine supplementation on growth performance and carcass characteristics in broilers exposed to chronic heat stress

To investigate the alleviative effects and molecular mechanisms of taurine supplementation on growth performance and carcass characteristics in broilers exposed to chronic heat stress, 144 male Arbor Acres broilers (28 d old) were randomly distributed to positive control (PC, 22°C, basal diet), heat stress (HS, consistent 32°C, basal diet), or heat stress + taurine (HS + T, consistent 32°C, basal diet + 5.00 g/kg taurine) groups, with 6 cages per group and 8 birds per cage. Chronic heat stress significantly decreased body weight, average daily gain, and average daily feed intake, and increased cloacal temperature and feed conversion ratio (FCR, P < 0.05). Though taurine supplementation tended to decrease the FCR in the HS + T group compared with the HS group after 14 d of heat exposure (P = 0.071), there were no significant alleviative effects of taurine supplementation on the increased cloacal temperature and decreased growth performance in chronic heat-stressed broilers (P > 0.05). After 7 and 14 d of heat exposure, taurine supplementation significantly increased the proportion of breast muscle and hormone-sensitive lipase activity in the abdominal fat (P < 0.05), and decreased the mRNA expressions of muscle atrophy F-box protein (MAFbx) and muscle ring-finger protein-1 (MuRF1) in breast muscle compared with the HS group (P < 0.05). After 7 d of heat exposure, taurine supplementation significantly increased serum non-esterified fatty acid concentration (P < 0.05), and decreased the mRNA expressions of acetyl-CoA carboxylase 1c (ACC) and muscular isoform of carnitine palmitoyl transferase 1 (M-CPT1) compared with the HS group (P < 0.05). In addition, the mRNA expressions of M-CPT1 and ribosomal protein S6 kinase, 70 kDa (p70S6K) in the HS + T group were significantly higher than those of the other two groups after 14 d of heat exposure (P < 0.05). In conclusion, taurine supplementation can improve carcass characteristics of chronic heat-stressed broilers by facilitating lipolysis for energy, enhancing protein synthesis, and suppressing protein degradation of the breast muscles.

Prediction of distant metastases from nasopharyngeal carcinoma: Improved diagnostic performance of MRI using nodal volume in N1 and N2 stage disease

PURPOSE

To determine if the magnetic resonance imaging (MRI) of the head and neck can predict distant metastases (DM) from nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

MRI examinations of 763 NPC patients were assessed for primary tumour stage (T), nodal stage (N), primary tumour volume (PTV) and total nodal volume (NV). The association between MRI and clinical parameters were examined in DM+ and DM- patients using logistic regression and for distant metastases free survival (DMFS) using cox regression. Optimum thresholds were assessed by receiver-operating characteristics analysis, and positive predictive value (PPV) and odds ratio (OR) calculated.

RESULTS

Distant metastases were present in 181/763 NPC patients (23.7%). Higher N stage and NV were the independent predictors of DM (p<0.001 and 0.018 respectively) and poor DMFS (p=0.001 and 0.030 respectively). Addition of NV (threshold≥32.8cm³) to the N stage improved the PPVs and ORs for DM in stage N1 (from 18.9% to 31.8% and 5.613 to 11.133 respectively) and stage N2 (from 40.4% to 60.8% and 16.189 to 36.979 respectively) but not in stage N3 (68.3% to 68.6% and 51.385 to 52.052 respectively).

CONCLUSION

MRI N stage and NV were independent predictors of DM and DMFS. The addition of NV in NPC patients with bulky N1 and N2 disease improved the ability of MRI to predict DM.

Diffusion-Weighted Imaging of Nasopharyngeal Carcinoma: Can Pretreatment DWI Predict Local Failure Based on Long-Term Outcome?

BACKGROUND AND PURPOSE

Pretreatment prediction of patients with nasopharyngeal carcinoma who will fail conventional treatment would potentially allow these patients to undergo more intensive treatment or closer posttreatment monitoring. The aim of the study was to determine the ability of pretreatment DWI to predict local failure in patients with nasopharyngeal carcinoma based on long-term clinical outcome.

MATERIALS AND METHODS

One hundred fifty-eight patients with pretreatment DWI underwent analysis of the primary tumor to obtain the ADC mean, ADC skewness, ADC kurtosis, volume, and T-stage. Univariate and multivariate analyses using logistic regression were performed to compare the ADC parameters, volume, T-stage, and patient age in primary tumors with local failure and those with local control, by using a minimum of 5-year follow-up to confirm local control.

RESULTS

Local control was achieved in 131/158 (83%) patients (range, 60.3-117.7 months) and local failure occurred in 27/158 (17%) patients (range, 5.2-79.8 months). Compared with tumors with local control, those with local failure showed a significantly lower ADC skewness (ADC values with the greatest frequencies were shifted away from the lower ADC range) (P = .006) and lower ADC kurtosis (curve peak broader) (P = .024). The ADC skewness remained significant on multivariate analysis (P = .044). There was a trend toward higher tumor volumes in local failure, but the volume, together with T-stage and ADC mean, were not significantly different between the 2 groups.

CONCLUSIONS

Pretreatment DWI of primary tumors found that the skewness of the ADC distribution curve was a predictor of local failure in patients with nasopharyngeal carcinoma, based on long-term clinical outcome.

Elucidating the prognostic significance of KRAS, NRAS, BRAF and PIK3CA mutations in Chinese patients with metastatic colorectal cancer

AIM

The prognostic significance of KRAS, NRAS, PIK3CA and BRAF mutations was evaluated in Chinese patients with metastatic colorectal cancer (CRC).

METHOD

Tumor samples from 183 patients were retrospectively tested for KRAS, NRAS, PIK3CA and BRAF mutations. Multivariate analysis was performed to determine the relationship between mutational status, drug response and survival.

RESULT

Over 70% of patients received two or more lines of chemotherapy, 50% had cetuximab and 18% had bevacizumab. The prevalence of KRAS, NRAS, BRAF and PIK3CA mutations was 45, 3.2, 5 and 20%, respectively. For the entire cohort, the median overall survival was 24 months (95% confidence interval [CI] = 20.4-26.4 months). Of the genes tested, only KRAS mutation was an independent prognostic factor with a multivariate hazard ratio of 1.5 (95% CI = 1.05-2.16, P = 0.03). In the subgroup of patients who received cetuximab-based therapy in the first-line setting, KRAS mutation was associated with a lack of response to chemotherapy (28% vs 66%, chi-square, P = 0.01). Patients with KRAS mutant tumors (or KRAS wild-type tumors that harbored BRAF and/or PIK3CA mutations) tended to have lower response rates to chemotherapy and/or cetuximab (P = not significant). The number of NRAS mutant cases was too small to allow any statistical analysis.

CONCLUSION

The prevalence of KRAS, NRAS, BRAF and PIK3CA mutations in this cohort is consistent with reports from non-Asian populations, and KRAS mutation has both prognostic and predictive significance in Chinese patients with metastatic CRC.

Plasma Epstein-Barr viral DNA load at midpoint of radiotherapy course predicts outcome in advanced-stage nasopharyngeal carcinoma

BACKGROUND

To test the hypothesis that prognostication of treatment outcome is feasible by biomarker response at midcourse of chemoradiotherapy (CRT)/radiotherapy (RT), with respect to the plasma load of Epstein-Barr viral (EBV) DNA in nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

One hundred seven patients with stage IIB-IV NPC were prospectively studied. Plasma EBV DNA load was measured by quantitative PCR before therapy (pre-DNA), at completion of 4 weeks of CRT/RT (mid-DNA), and within 3 months of completion of therapy (post-DNA). The end points are post-DNA load, a recognized surrogate of survival, and clinical outcome.

RESULTS

Ninety-three percent of patients had detectable EBV DNA before therapy (median load = 972 copies/ml). EBV DNA became undetectable in 55 (51%) patients at the end of week 4 of therapy. Detectable mid-DNA was associated with worse clinical outcome (median follow-up time, 6.2 years), for distant failure [hazard ratio (HR) 12.02, 95% confidence interval (CI) 2.78-51.93; P < 0.0001], progression-free survival (PFS; HR 4.05, 95% CI 1.89-8.67, P < 0.0001), and overall survival (OS; HR 3.29, 95% CI 1.37-7.90, P = 0.0077). Seventy-four percent of all failures were associated with detectable mid-DNA, whereas 34% of all failures were associated with detectable post-DNA. Stratification by tumor stage (IIB, III, IV) has no significant prognostic effect.

CONCLUSIONS

Unfavorable EBV DNA response at midcourse of RT/CRT is an adverse prognosticator for treatment outcome, is linked to majority of all failures, and discriminates outcome better than tumor stage. The data could provide a basis for trial design that addresses alteration of therapy intensity during the latter phase of CRT, and adjuvant therapy. Validation studies are awaited.

Abstract B273: Multicenter Phase II study of MK-2206 in previously treated patients (pts) with recurrent and metastatic nasopharyngeal carcinoma (NPC): Mayo Clinic Phase II Consortium (Protocol: MC1079)

Background: NPC is endemic to Asia and over 40% of cases harbor PIK3CA amplification. MK2206 is an allosteric AKT inhibitor with activity in NPC in vitro.

Methods: Pts who had progressed after palliative chemotherapy (chemo) for metastatic or recurrent NPC, received oral MK-2206 at 200 mg on Days 1, 8, 15 & 22 of each 28-day cycle until disease progression. Plasma samples were collected at serial time points during cycle 1 for EBV DNA analysis, archived tumor samples were collected where feasible. The primary dual endpoints (2-stage design) consisted of RECIST-defined tumor response rate (RR) and 6-month (m) progression-free survival (PFS) rate. Secondary endpoints were overall survival (OS), PFS and adverse events (AEs).

Results: Of the 21 pts enrolled, the median age was 47 years (range: 32-67), 91% were male, 81% had prior radiotherapy and 81% had &gt; 1 prior line of palliative chemo. At the time of analysis, 20 out of 21 pts have ended treatment. The best responses were: 1 partial response (PR, 5%) lasting 4 ms; 10 stable disease (SD, 50%), 9 progressive disease (PD, 45%). The 6-m PFS rate was 38.9% (95% CI: 18.1-59.3%) and median PFS was 2.7 ms (95% CI: 0.9-7.2 ms). The 6-m OS rate was 67.9% (95% CI: 41.8-84.1%) and median survival has not been reached. In 7 pts who had SD more than or equal to 6 ms, the duration of treatment ranged from 6.4-13.9 ms. Of the 21 pts evaluable for AEs, 12 pts (57%) had at least one grade 3 AE [[Unable to Display Character: &#8211;]] macular rash (6 pts - 29%), dysphagia (2 pts - 10%), hyperglycemia (2 pts - 10%) (see Table 1). The tumor samples of 7 pts were analyzed by FISH; 3 showed PIK3CA amplification, including 1 pt with chromosome 3 polysomy. Amongst these pts, 1 had SD more than 6ms, 1 had SD more than 12 ms, and 1 is still on treatment. Pts who had SD less than 6 m or PD did not have PIK3CA amplification.

Conclusions: MK2206 is well tolerated and has signs of activity in unselected pts with NPC. Preliminary results suggest that PIK3CA amplification may be related to prolonged disease stabilization from MK2206, and analysis for other PIK3CA gene alterations in more samples will be undertaken. Result of the plasma EBV DNA result will be presented.

Epigenetic therapy using belinostat for patients with unresectable hepatocellular carcinoma: a multicenter phase I/II study with biomarker and pharmacokinetic analysis of tumors from patients in the Mayo Phase II Consortium and the Cancer Therapeutics Research Group

PURPOSE

Epigenetic aberrations have been reported in hepatocellular carcinoma (HCC). In this study of patients with unresectable HCC and chronic liver disease, epigenetic therapy with the histone deacetylase inhibitor belinostat was assessed. The objectives were to determine dose-limiting toxicity and maximum-tolerated dose (MTD), to assess pharmacokinetics in phase I, and to assess activity of and explore potential biomarkers for response in phase II.

PATIENTS AND METHODS

Major eligibility criteria included histologically confirmed unresectable HCC, European Cooperative Oncology Group performance score ≤ 2, and adequate organ function. Phase I consisted of 18 patients; belinostat was given intravenously once per day on days 1 to 5 every 3 weeks; dose levels were 600 mg/m(2) per day (level 1), 900 mg/m(2) per day (level 2), 1,200 mg/m(2) per day (level 3), and 1,400 mg/m(2) per day (level 4). Phase II consisted of 42 patients. The primary end point was progression-free survival (PFS), and the main secondary end points were response according to Response Evaluation Criteria in Solid Tumors (RECIST) and overall survival (OS). Exploratory analysis was conducted on pretreatment tumor tissues to determine whether HR23B expression is a potential biomarker for response.

RESULTS

Belinostat pharmacokinetics were linear from 600 to 1,400 mg/m(2) without significant accumulation. The MTD was not reached at the maximum dose administered. Dose level 4 was used in phase II. The median number of cycles was two (range, one to 12). The partial response (PR) and stable disease (SD) rates were 2.4% and 45.2%, respectively. The median PFS and OS were 2.64 and 6.60 months, respectively. Exploratory analysis revealed that disease stabilization rate (complete response plus PR plus SD) in tumors having high and low HR23B histoscores were 58% and 14%, respectively (P = .036).

CONCLUSION

Epigenetic therapy with belinostat demonstrates tumor stabilization and is generally well-tolerated. HR23B expression was associated with disease stabilization.

Abstract 4602: Preclinical evaluation of the AKT inhibitor MK2206 in nasopharyngeal carcinoma cell lines

MK2206 is an allosteric inhibitor of AKT with potent activity in cancer cell lines that exhibit genetic aberrations in the PI3K-AKT-PTEN pathway. AKT is frequently activated in nasopharyngeal carcinoma (NPC), while PIK3CA amplification is found in 40-70% of NPC tissues. The preclinical activity of MK2206 was evaluated in NPC cell lines: HONE-1-EBV, HONE-1, CNE-2, HNE-1, and 2 cell lines with PIK3CA amplifications, HK-1 and C666-1. All 6 cell lines showed increased basal level of activated (p-)AKT(ser473), p-GSK3β, p-mTOR, pi-p70S6K and p-4EBP1, except in C666-1 cells where p-70S6K and p-4EBP1 were weakly expressed. Basal expression of p-MAPK was most pronounced in HK-1, CNE-2 and HONE-1-EBV, and weakly expressed in C666-1 and HONE-1. The effect on cell growth was evaluated by exposing cells to increasing concentrations (conc) of MK2206 (100pM, 2nM, 20nM, 0.2µM, 2µM, 30µM) for up to 72 hrs followed by MTT assay. Over 95% of growth inhibition was achieved in all cell lines with respective IC50 values of: CNE-2=0.39µM, HK-1 = 0.48µM, HONE-1= 1.51µM, C666-1= 1.64µM, HNE-1= 1.92µM, HONE1-EBV= 2.36µM. CNE-2, HONE-1-EBV and C666-1 were selected for assessing the effect on AKT signaling, apoptosis, cell cycle and synergism with chemotherapy. Treatment of these cells with MK2206 at IC50 conc for 15 and 24 hours, resulted in G1 arrest in CNE-2 and HONE-1-EBV, and G2 arrest in C666-1 cells. Apoptosis (increased cleaved PARP) was detected in CNE-2 cells only. MK2206 reduced the expression of p-AKT, p-mTOR, p-BAD, p-FKHD and p-GSK3β in CNE-2, HONE-1-EBV and C666-1 cells, while the level of p-4EBP1 level was significantly reduced in C666-1 and CNE-2 cells only. The effect on p-70S6K expression in all 3 cell lines was minimal. MK2206 increased expression of p-MAPK in HONE1-EBV-1 and C666-1 cells, but not CNE-2 cells. A supra-additive effect on cell growth was observed when cisplatin was added to MK2206, while the effect of adding paclitaxel to MK2206 was minimal in all 3 cell lines. Our result suggests that MK2206 has activity in NPC in vitro. The increased expression of p-MAPK observed in some cell lines suggests the presence of compensatory MAPK activation as described with mTOR inhibitors in other cancers. MK-2206 is currently under clinical investigation in recurrent NPC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4602. doi:1538-7445.AM2012-4602

A study of circulating interleukin 10 in prognostication of unresectable hepatocellular carcinoma

BACKGROUND

The level of circulating interleukin 10 (IL-10) is elevated in a proportion of patients with hepatocellular carcinoma (HCC). The objective of the current study was to evaluate the prognostic significance of serum the IL-10 level in patients with unresectable HCC.

METHODS

Patients with unresectable HCC who provided serum at the time of diagnosis were enrolled prospectively in the study. The level of circulating IL-10 in serum samples was determined by enzyme-linked immunosorbent assay. The association of the IL-10 level with overall survival was evaluated in relation to sociodemographics, liver function, hepatitis B viral load, and tumor staging.

RESULTS

In total, 222 patients were recruited; of these, 82.4% were positive for hepatitis B virus surface antigen, and 65.8% had Barcelona Clinic Liver Cancer stage C disease. The mean log IL-10 level was 1.1 pg/mL, and 146 patients had an IL-10 level >1 pg/mL (high IL-10 group). The high IL-10 group had worse overall survival than the low IL-10 group (5.0 months vs 14.9 months; hazard ratio, 2.192; P < .0001). The IL-10 level was associated with worse hepatic function and with a high alanine transaminase (ALT) level. The IL-10 level remained an independent prognostic factor (hazard ratio, 1.824; P = .0005) after adjustment for sociodemographics, tumor staging, treatment, Child-Pugh stage, and ALT level. The IL-10 level also subdivided patients into 2 populations with distinct survival (10.2 months vs 3.5 months; P = .0027).

CONCLUSIONS

The serum IL-10 level was identified as an independent prognostic factor for unresectable HCC. The current findings suggested that an elevated IL-10 level may be related to hepatic injury caused by cirrhotic processes rather than tumor load. The authors concluded that the IL-10 level offers additional prognostic value to the existing tumor staging systems.

Abstract 2190: ADAMTS8 at 11q25 is a tumor suppressor antagonizing Ras-signaling and methylated in multiple carcinomas

As opposed to most matrix metalloproteinases which facilitate tumor progression, a growing list of ADAMTS secreted protease members was reported to display tumor suppressive properties with their expressions frequently altered in diverse types of tumors. Here, ADAMTS8 was shown to be located at an LOH locus at 11q25 by array CGH. We further showed that ADAMTS8 was frequently downregulated or silenced in multiple cancer cell lines while broadly expressed in normal tissues. Analysis on the methylation status of the ADAMTS8 promoter CpG island showed that methylation was cancer-specific and ADAMTS8 methylation was correlated with the silencing of ADAMTS8. In addition, expression of ADAMTS8 could be restored with pharmacological or genetic demethylation and hence indicating that CpG methylation directly contributes to the downregulation of ADAMTS8. Aberrant methylation was also frequently detected in primary NPC, gastric and colorectal tumors, but seldom in normal tissues. Ectopic expression of ADAMTS8 led to marked inhibition of cell growth in colony formation assays and cell migration in wound healing assay along with the reduction of phosphorylated ERK protein. The inhibitory effect on tumor cell growth and Ras-ERK pathway by ADAMTS8 indicates its role as a functional tumor suppressor.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2190. doi:10.1158/1538-7445.AM2011-2190

Update on the management and therapeutic monitoring of advanced nasopharyngeal cancer

Despite being potentially curable at an early stage, more than 50% of patients who have nasopharyngeal carcinoma present with advanced locoregional disease, which results in a poor prognosis. This article discusses key advancements in the management of nasopharyngeal cancer, including the incorporation of concurrent chemoradiotherapy, new radiotherapy delivery techniques in the form of conformal and intensity-modulated radiotherapy, and salvage options for locoregional recurrence. New cytotoxic and targeted therapies that have resulted in improved survival in the metastatic setting are also described. The use of Epstein-Barr virus DNA for the prognostication and monitoring of nasopharyngeal cancer and the role of new diagnostic imaging techniques are also discussed.

Randomized phase II trial of concurrent cisplatin-radiotherapy with or without neoadjuvant docetaxel and cisplatin in advanced nasopharyngeal carcinoma

PURPOSE

To compare the toxicities, tumor control, survival, and quality of life of nasopharyngeal cancer (NPC) patients treated with sequential neoadjuvant chemotherapy followed by concurrent cisplatin-radiotherapy (CRT) or CRT alone.

PATIENTS AND METHODS

Previously untreated stage III to IVB NPC were randomly assigned to (1) neoadjuvant docetaxel 75 mg/m(2) and cisplatin 75 mg/m(2) every 3 weeks for two cycles, followed by cisplatin 40 mg/m(2)/wk concurrent with radiotherapy, or (2) CRT alone. Planned accrual was 30 patients per arm to detect 20% difference of toxicities based on 95% CIs.

RESULTS

From November 2002 to November 2004, 65 eligible patients were randomly assigned to neoadjuvant chemotherapy followed by CRT (n = 34) or CRT alone (n = 31). There was a high rate of grade 3/4 neutropenia (97%) but not neutropenic fever (12%) during neoadjuvant chemotherapy. No significant differences in rates of acute toxicities were observed between the two arms during CRT. Dose intensities of concurrent cisplatin, late RT toxicities and quality of life scores were comparable in both arms. The 3-year progression-free survival for neoadjuvant versus control arm was 88.2% and 59.5% (hazard ratio = 0.49; 95% CI, 0.20 to 1.19; P = .12). The 3-year overall survival for neoadjuvant versus control arm was 94.1% and 67.7% (hazard ratio = 0.24; 95% CI, 0.078 to 0.73; P = .012).

CONCLUSION

Neoadjuvant docetaxel-cisplatin followed by CRT was well tolerated with a manageable toxicity profile that allowed subsequent delivery of full-dose CRT. Preliminary results suggested a positive impact on survival. A phase III study to definitively test this neoadjuvant-concurrent strategy is warranted.

The impact of 18F-FDG PET/CT on assessment of nasopharyngeal carcinoma at diagnosis

The aim of this study was to determine whether the use of whole-body (18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET)/CT alters staging and management of nasopharyngeal carcinoma (NPC) when compared with current staging practice. 52 patients with Stage III-IV NPC without distant metastases on chest X-ray/CT, abdominal ultrasound or bone scan were recruited for the study. Whole-body (18)F-FDG PET/CT and MRI of the head and neck were performed. The scans were compared for extent of the primary tumour (PT), cervical nodal metastases (CNM) and distant metastases (DM). Any discordance in results was assessed with respect to staging and impact on management. MRI and (18)F-FDG PET/CT scans were discordant in 28 (54%) patients. There was discordance in the extent of PT at 28 sites; in all sites, MRI showed more extensive tumour involving the nasopharynx (n = 8), skull base (n = 14), brain (n = 4) and orbit (n = 2). There was also variation among the extent of CNM in four nodes of the retropharyngeal region, with the nodes being positive on MRI. (18)F-FDG PET /CT did not identify any additional distant metastases but did identify a second primary tumour in the colon. The additional use of (18)F-FDG PET/CT did not "up-stage" the overall stage or change management in any patient. In conclusion, there is discordance between MRI and (18)F-FDG PET/CT, and the additional use of (18)F-FDG PET/CT for the current assessment of NPC at diagnosis does not appear to be justified in this cohort of patients.

Nasopharyngeal Cancers: Which Method Should be Used to Measure these Irregularly Shaped Tumors on Cross-Sectional Imaging?

PURPOSE

To determine whether the standard techniques of measuring tumor size and change in size after treatment could be applied to the measurement of nasopharyngeal cancers, which are often irregular in shape.

METHODS AND MATERIALS

The standard measurements of bidimensional (BDM) (World Health Organization criteria) and unidimensional (UDM) (Response Evaluation Criteria in Solid Tumors [RECIST] criteria), together with the maximum depth of the tumor perpendicular to the pharyngeal wall (DM), were acquired from axial magnetic resonance images of primary nasopharyngeal carcinoma in 44 patients at diagnosis and in 29 of these patients after treatment. Tumor volume measurements (VM), acquired from the summation of areas from the axial magnetic resonance images, were used as the reference standard.

RESULTS

There was a significant association between VM and BDM with respect to tumor size at diagnosis (p = 0.002), absolute change in tumor size after treatment (p < 0.001), and percentage change in tumor size after treatment (p = 0.044), but not between VM and UDM. There was also a significant association between VM and DM with respect to percentage change in tumor size after treatment (p = <0.0001) but not absolute change (p = 0.222).

CONCLUSION

When using simple measurements to assess irregularly shaped nasopharyngeal cancers, the BDM should be used to measure size at diagnosis and the BDM and percentage change in size with treatment. Unidimensional measurement does not reflect size or change in size, and therefore the RECIST criteria may not be applicable to all tumor shapes. The use of DM requires further evaluation.

Plasma Epstein-Barr viral deoxyribonucleic acid quantitation complements tumor-node-metastasis staging prognostication in nasopharyngeal carcinoma

PURPOSE

To evaluate the effect of combining circulating Epstein-Barr viral (EBV) DNA load data with TNM staging data in pretherapy prognostication of nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

Three hundred seventy-six patients with all stages of NPC were studied. Pretreatment plasma/serum EBV DNA concentrations were quantified by a polymerase chain reaction assay. Determinants of overall survival were assessed by multivariate analysis. Survival probabilities of patient groups, segregated by clinical stage (I, II, III, or IV) alone and also according to EBV DNA load (low or high), were compared.

RESULTS

Pretherapy circulating EBV DNA load is an independent prognostic factor for overall survival in NPC. Patients with early-stage disease were segregated by EBV DNA levels into a poor-risk subgroup with survival similar to that of stage III disease and a good-risk subgroup with survival similar to stage I disease.

CONCLUSION

Pretherapy circulating EBV DNA load is an independent prognostic factor to International Union Against Cancer (UICC) staging in NPC. Combined interpretation of EBV DNA data with UICC staging data leads to alteration of risk definition of patient subsets, with improved risk discrimination in early-stage disease. Validation studies are awaited.

Plasma ammonia in patients with acute leukemia

Plasma ammonia level (PAL) was studied in 43 cases of acute leukemia (AL). PAL was 39.21 +/- 26.2 mumol/L in normal controls and 38.8 +/- 16.6 mumol/L in leukemic patients before chemotherapy. High PAL was found in 40 cases after chemotherapy. Six cases showed clinical manifestations due to severe hyperammonemia, including dizziness, lethargy, confusion, coma and mental changes of various degree, and there was also respiratory alkalosis. After ammonia-trapping therapy, 4 of the 5 patients recovered. The authors believe that high PAL is not uncommon after chemotherapy in leukemic patients. Respiratory alkalosis and unexplained mental and neurologic changes following intensive chemotherapy are useful clues for the diagnosis of hyperammonemia syndrome. Early diagnosis and treatment with ammonia-trapping may improve the rates of remission and survival.