The impact of rare cancer and early-line treatments on the benefit of comprehensive genome profiling-based precision oncology

BACKGROUND

Comprehensive genome profiling (CGP) serves as a guide for suitable genomically matched therapies for patients with cancer. However, little is known about the impact of the timing and types of cancer on the therapeutic benefit of CGP.

MATERIALS AND METHODS

A single hospital-based pan-cancer prospective study (TOP-GEAR; UMIN000011141) was conducted to examine the benefit of CGP with respect to the timing and types of cancer. Patients with advanced solid tumors (>30 types) who either progressed with or without standard treatments were genotyped using a single CGP test. The subjects were followed up for a median duration of 590 days to examine therapeutic response, using progression-free survival (PFS), PFS ratio, and factors associated with therapeutic response.

RESULTS

Among the 507 patients, 62 (12.2%) received matched therapies with an overall response rate (ORR) of 32.3%. The PFS ratios (≥1.3) were observed in 46.3% (19/41) of the evaluated patients. The proportion of subjects receiving such therapies in the rare cancer cohort was lower than that in the non-rare cancer cohort (9.6% and 17.4%, respectively; P = 0.010). However, ORR of the rare cancer patients was higher than that in the non-rare cancer cohort (43.8% and 20.0%, respectively; P = 0.046). Moreover, ORR of matched therapies in the first or second line after receiving the CGP test was higher than that in the third or later lines (62.5% and 21.7%, respectively; P = 0.003). Rare cancer and early-line treatment were significantly and independently associated with ORR of matched therapies in multivariable analysis (P = 0.017 and 0.004, respectively).

CONCLUSION

Patients with rare cancer preferentially benefited from tumor mutation profiling by increasing the chances of therapeutic response to matched therapies. Early-line treatments after profiling increase the therapeutic benefit, irrespective of tumor types.

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

Comparison of chemotherapeutic treatment outcomes of advanced extrapulmonary neuroendocrine carcinomas and advanced small-cell lung carcinoma

BACKGROUND

The chemotherapy for small-cell lung carcinoma (SCLC) has been adopted for advanced extrapulmonary neuroendocrine carcinomas (EP-NECs). The aim of this study was to clarify the efficacy of standard SCLC regimens when used to treat EP-NECs and to compare the outcome with that for SCLC.

METHODS

We reviewed the medical records of 136 patients (41 with EP-NEC and 95 with SCLC) who were treated using a platinum-containing regimen for advanced disease between January 2000 and October 2008 at our hospital.

RESULTS

The primary site of the EP-NEC was the gastrointestinal tract in 18 patients (GI tract group); the liver, biliary tract or pancreas in 16 patients (HBP group), and other sites in 7 patients ('others' group). The response rate in the SCLC patients was 77.8%, and the response rate in the EP-NEC patients was 30.8% (37.5% in the GI tract group, 12.5% in the HBP group, and 57.1% in the 'others' group). The median survival time for the SCLC patients was 13.6 months, while that for the EP-NEC patients was 9.2 months (14.9 months in the GI tract group, 7.8 months in the HBP group, and 8.9 months in the 'others' group). A multivariate analysis demonstrated that a poor performance status, liver involvement, and the treatment regimen were independent unfavorable prognostic factors.

CONCLUSION

The response rate and prognosis of the patients with advanced EP-NECs were worse than those of the patients with SCLC in this study. The Eastern Cooperative Oncology Group performance status, liver involvement, and treatment regimen had a larger impact on the prognosis than the primary tumor site, as demonstrated by multivariate analysis.

Construction and validation of a practical prognostic index for patients with metastatic pancreatic adenocarcinoma

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Background: The aim of the present study was to determine prognostic factors in patients with metastatic pancreatic adenocarcinoma (PC) receiving systemic chemotherapy and to construct and validate a prognostic index for metastatic PC.

Methods: The relationship between patient characteristics and outcome was examined by multivariate regression analyses of data from 409 consecutive patients with metastatic pancreatic adenocarcinoma who had been treated with a gemcitabine- containing regimen (GEM alone: 302 patients, GEM + cisplatin (CDDP): 39, GEM + 5-flurorouracil (5-FU): 27, GEM + S-1:41), and we stratified the patients into three risk groups according to the number of prognostic factors they had for a poor outcome. A validation data set obtained from 145 patients who had been treated with agents other than GEM (5-FU + CDDP, MTX+5- FU, docetaxel, UFT, S-1, CPT-11) was analyzed. The prognostic index was applied the each of the patients.

Results: The multivariate regression analyses revealed that the presence of pain (hazard ratio (HR): 1.692), peritoneal dissemination (HR:1.756), liver metastasis (HR:1.423), and an elevated serum CRP level by > 1.0 mg/dl (HR:1.540) significantly contributed to a shorter survival time. The patients were stratified into three groups according to their number of risk factors and their outcomes of the three groups were significantly different. The median survival times (MSTs) of the low-, intermediate-, and high-risk groups were 11.1, 7.3, and 3.2 months, respectively. When the prognostic index was applied to the validation data set, the respective outcomes of the three groups were found to be significantly differed from each other. The MSTs of the low-, intermediate-, and high-risk groups were 8.6, 5.2, and 2.3 months, respectively.

Conclusions: Pain, peritoneal dissemination, liver metastasis, and an elevated serum CRP value are important prognostic factors for patients with metastatic pancreatic adenocarcinoma.

No significant financial relationships to disclose.

Extrapulmonary neuroendocrine tumors: An institutional experience of 337 patients at the National Cancer Center Hospital in Japan

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Background: Extrapulmonary neuroendocrine tumors (EPNET) are a rare and heterogeneous disease entity, and little information regarding these tumors is available. The aim of the present study was to clarify the clinical behavior, treatment strategy, and outcome of EPNET arising from various primary sites.

Methods: We retrospectively reviewed the medical records of 337 patients with pathologically confirmed NET arising from extrapulmonary site between January 2000 and December 2008 at the National Cancer Center Hospital of Japan.

Results: The major primary tumor site was the rectum followed by the pancreas and stomach. Among the gastrointestinal tract tumors, 113 patients had NET from the foregut, 92 patients from the hindgut, and only 4 patients from the midgut. The median patient age was 60 years, and 57% of the patients were male. The histologic grade was as follows: 39% were well-differentiated neuroendocrine tumors (WDNET); 20% were well-differentiated neuroendcrine carcinomas (WDNEC); 33% were poorly differentiated neuroendocrine carcinomas (PDNEC); and 8% were mixed exocrine-endocrine tumors (Mixed). Most NETs from the rectum or duodenum are WDNET, whereas the ratio of PDNEC was high among NET from the genital organs or esophagus. The treatment strategy was associated with the clinical stage or the primary organ; in particular, 94% of the localized rectal NET were resected endoscopically. The 2-year survival rate for all the patients were 70%. A multivariate analysis demonstrated that distant disease of clinical stage and PDNEC of histological grade had a stronger impact on a poor outcome than the primary tumor site. The 2-year survival rate among the patients with WDNET, WDNEC and PDNEC were 97%, 80% and 36%, respectively, and 94%, 72%, and 32% of the patients had localized, regional, and distant disease, respectively.

Conclusions: Japanese patients with EPNET have different clinicopathological features such as the primary organ or treatment procedure compared with previous reports in Western countries. Identifying the precise clinical stage and histological grade of patients with NET is essential because these factors influence the patient outcome.

No significant financial relationships to disclose.

Incidence and risk factors for cholangitis during systemic chemotherapy among patients with advanced biliary tract cancer

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Background: Patients with biliary tract cancer (BTC) have a high risk of developing cholangitis. In patients with advanced BTC receiving systemic chemotherapy, cholangitis might interfere with the execution of the treatment. Furthermore, cholangitis during severe immunosuppression might develop into lethal complications such as sepsis or shock. Purpose: To determine the incidence of cholangitis among patients with advanced BTC undergoing systemic chemotherapy and to identify risk factors for the development of cholangitis.

Methods: We reviewed the records of 301 patients with advanced BTC who received systemic chemotherapy at our hospital between February 2002 and July 2009. The clinical data of patients treated with gemcitabine monotherapy (GEM) as a first-line chemotherapy was retrieved.

Results: One hundred and thirty-one patients were successfully followed up throughout the entire GEM treatment. Forty-three patients had intrahepatic BTC (32.8%), 28 had extrahepatic BTC (21.4%), 11 had hilar BTC (8.4%), 7 had ampullary cancer (5.3%), and 42 had gallbladder cancer (32.1%). Interventional radiological treatment or biliary reconstruction for biliary obstruction was performed in 50 patients (37.9%) prior to the start of chemotherapy. The median time to GEM treatment failure was 126 days. Cholangitis developed in 30 patients (22.9%) during GEM, and severe cholangitis developed in 10 patients (7.6%). The median time to the first episode of cholangitis from the start of chemotherapy was 65 days. Chemotherapy was discontinued because of cholangitis in 4 patients (3.1%), but no deaths as a result of cholangitis occurred. A multivariate analysis using a logistic regression model demonstrated that the presence of hilar obstruction (p=0.0002, OR: 10.748), the loss of sphincter of Oddi function (p=0.0005,OR: 8.960), and the presence of internal biliary drainage (p=0.007, OR: 4.472) were independent risk factors of cholangitis.

Conclusions: The incidence of cholangitis during GEM treatment was 22.9% among the advanced BTC patients in this study. Hilar obstruction, the loss of sphincter of Oddi function, and internal biliary drainage may be risk factors of cholangitis.

No significant financial relationships to disclose.