The risk of venous thromboembolism in renal cell carcinoma patients with residual tumor thrombus

BACKGROUND

The clinical importance of tumor thrombus in patients with renal cell carcinoma is unknown. We sought to determine the long-term risk of venous thromboembolism (VTE) in patients with residual tumor thrombus postextraction, and to evaluate the impact of residual tumor thrombus on overall survival.

PATIENTS/METHODS

A cohort study of patients with stage III-IV renal cell carcinoma undergoing nephrectomy was undertaken. The primary endpoint was the risk of VTE during a 2-year follow-up period. The secondary endpoint was 2-year overall survival.

RESULTS

A total of 170 surgical renal cell carcinoma patients were included, 97 (57.1%) of whom had tumor thrombus. Patients with residual tumor thrombus following surgery had a higher risk of developing VTE than those with complete tumor thrombus resection (hazard ratio [HR] 8.7, 95% confidence interval [CI] 1.7-43.4) and no tumor thrombus (HR 6.5, 95% CI 1.7-24.7). Patient with residual tumor thrombus did not have worse overall survival than those with tumor thrombus completely resected or those without tumor thrombus.

CONCLUSIONS

The presence of residual tumor thrombus is an important risk factor for VTE among renal cell carcinoma patients.

Increased risk of preoperative venous thromboembolism in patients with renal cell carcinoma and tumor thrombus

BACKGROUND

The clinical impact of a tumor thrombus in renal cell carcinoma (RCC) patients awaiting radical nephrectomy and thrombectomy is unknown.

OBJECTIVE

To determine the incidence of venous thromboembolism (VTE) in RCC patients with tumor thrombus prior to nephrectomy.

PATIENTS AND METHODS

We conducted a retrospective cohort study including all late-stage (stage 3-4 excluding T1-2 N0M0) RCC patients who underwent radical nephrectomy at our institution between 1 January 2005 and 1 July 2012. Tumor thrombus was defined as the presence of an intraluminal filling defect in the renal vein, hepatic vein, portal vein, or inferior vena cava, directly extending from a renal mass detected on computed tomography.

RESULTS

A total of 176 patients were included in the study. Fifty-three (30.1%) patients had tumor thrombus diagnosed on imaging Three patients with tumor thrombus (5.7%; 95% confidence interval [CI] 1.4-16.8) developed a VTE while awaiting radical nephrectomy, whereas none (0%; 95% CI 0-2.9) of the patients without a tumor thrombus had an event (P = 0.026). All three events were deep vein thrombosis. Times from tumor thrombus diagnosis to VTE were 5, 15 and 21 days.

CONCLUSIONS

Tumor thrombus on imaging is a frequent finding among RCC patients awaiting nephrectomy. The presence of tumor thrombus in these patients increases the incidence of preoperative VTE.

The neoadjuvant management of bladder cancer in Canada: A survey of genitourinary medical oncologists

285

Background: The uptake of neoadjuvant chemotherapy (NC) for the treatment of stage II/III bladder cancer remains variable despite evidence supporting its use. The aim of this study is to better understand the use of NC in Canada to facilitate standardization of practice and develop a platform for clinical trials.

Methods: The survey was initially tested on a subset of medical oncologists. It was then e-mailed to 30 medical oncologists across Canada who primarily treat bladder cancer.

Results: In total, 25 (83%) surveys were completed. Respondents were 92% academic based, 100% full time, and 52% in practice for >10 years. The majority of referrals for all stages came from urologists with 4 respondents (16%) seeing 5-10 cases/yr, 10 (40%) seeing 11-15/yr, 5 (20%) seeing 16- 20/yr and 6 (24%) seeing >20/yr. Of these 8 reported having only 1-2 referrals for NC; 7 had 3-4 NC referrals; 7 had 5-6 NC referrals; and 2 reported seeing >6 referrals/year. Patients referred for NC tended to be younger (50-65); Performance Status (PS) 0/1; T-stage T3a/T3b; or nodal status N1/N2. 96% indicated they do offer NC to selected patients as both standard of care and to downsize tumors. Key factors cited for not offering NC were: Age >85, PS 3/4; T-stage T2a or T4a; Nodal status: N3; GFR <40ml/min. Main baseline staging modalities included CT chest/abdomen/pelvis, bone scan and cystoscopy. Gemcitabine/cisplatin was most commonly used with 20% using high-dose MVAC. Six (27%) reported doing midway staging with CT abdomen/pelvis and cystoscopy; 36% report staging after completion of chemo. Average time from last chemotherapy to cystectomy was 4-6 wks, with no patients being offered adjuvant chemotherapy postoperatively.

Conclusions: The majority of GU MO in Canada would offer NC. Stage, PS, renal function, and comorbidities were the biggest determinants of offering NC, while age played a lesser role. The number of overall referrals for NC, however, remains relatively low. We plan to survey urologists in Canada to determine if differences in attitudes about NC or barriers to referrals account for the low number of referrals.

No significant financial relationships to disclose.

Results of a phase II study of single-agent nab-paclitaxel in platinum-refractory second-line metastatic urothelial carcinoma (UC)

241

Background: There is currently no standard second-line chemotherapy for platinum- refractory UC. Both paclitaxel and docetaxel are commonly used but response rates are < 20% and no survival advantage has been shown. In this multi-institutional phase II study, we evaluated the efficacy and tolerability of a new albumin-bound nanoparticle formulation of paclitaxel, known as Abraxane (ABI-007) as a single agent in patients with platinum-refractory metastatic UC.

Methods: Patients with measurable UC, progressing on or after first-line platinum-based chemotherapy were enrolled onto this two-stage trial. ABI-007 was given at 260 mg/m2 IV q3weekly until progression. Clinical evaluation, CBC and blood chemistries were performed every cycle with restaging CT scans every 2 cycles.

Results: Accrual is now complete with 48 patients enrolled. Baseline characteristics: Male: Female 40:8; median age 68; ECOG Performance Status 0:1:2, 15:24:8. 248 cycles were delivered: median 5.5 cycles/pt with 17/48 pts (35%) requiring dose reductions. Most frequent adverse events (AE) were alopecia (12%), fatigue (12%), pain (12%), neuropathy (9%) and nausea (4%). The most frequent grade 3+ AE were pain (45%), hypertension (14%), fatigue (8%), joint stiffness (5%), neuropathy (4%) and weakness (4%). Forty patients are evaluable for response: 1 (2.5%) complete response (CR), 11 (28%) partial responses (PR), 9 (23%) stable disease (SD) and 20 (49%) progressive disease. One patient was inevaluable for response, 7 patients are too early for evaluation.

Conclusions: Single-agent ABI-007 was well tolerated with a response rate (CR+PR) of 33% (12/36) and a clinical benefit rate (CR+PR+SD) of 58% (21/36), representing one of the highest reported response rates to date in the second-line UC setting. These results suggest further study of ABI-007 in urothelial carcinoma is warranted.

No significant financial relationships to disclose.

A phase II study of single agent abraxane as second-line therapy in patients with advanced urothelial carcinoma

e16058

Background: Metastatic urothelial cancer progressing on or after first-line platinum-based chemotherapy is incurable and has a very poor prognosis. There is no standard second-line therapy, but the taxanes including paclitaxel, have previously shown activity. Abraxane (ABI-007) is a novel well tolerated albumin-bound nanoparticle formulation of paclitaxel. The goal of this study was to determine the efficacy and tolerability of single agent Abraxane in the second-line metastatic urothelial cancer setting. Methods: Patients with measureable metastatic urothelial cancer, who progressed on or after first-line cisplatin based chemotherapy were enrolled onto this phase II, two-stage multicenter trial. Patients received Abraxane 260 mg/m2 intravenously every 3 weeks. Clinical evaluation, CBC and blood chemistries were performed every cycle and restaging CT scans every 2 cycles. Results: Fourteen patients have been enrolled to date. Patient demographics: M: F 12:2; mean age 64 (range 45–80); ECOG 0:1:2 4:5:5. A total of 57 cycles, avg 4 cycles/ patient (range 1–9) have been administered. There were three dose delays due to neuropathy, pain, and low neutrophil count respectively. There were two dose reductions due to fatigue and neuropathy. Most frequent adverse events (AE) were fatigue, alopecia, anorexia, cough and joint pain; the most frequent grade 3+ AE were fatigue, joint pain, hypertension, joint stiffness and back pain. Fourteen patients are currently evaluable for best response using RECIST criteria. There have been 5 partial responses (PR), 5 stable disease (SD) and 4 progressive disease (PD). Conclusions: Single agent Abraxane was well tolerated in the 2nd line, cisplatin refractory/resistant metastatic urothelial cancer setting. Preliminary efficacy results are encouraging with a clinical benefit rate of 71% (10 out of 14 evaluable pts having either SD or PR). Stage 1 response criteria have been met and accrual is ongoing to a total of 48 patients.

No significant financial relationships to disclose.

Changing demographics of locally advanced breast cancer: Data from a regional cancer centre

10780

Background: Locally advanced breast cancer (LABC) (including inflammatory breast cancer (IBC)) accounts for less than 5% of women diagnosed with breast cancer in North America each year. This population of women continues to represent a challenge in terms of timely diagnosis and treatment. Methods: A retrospective database was developed using the American Joint Committee on Cancer (AJCC)2002 staging classification for all women who presented to TOHRCC with LABC between Jan 1/02 - April 1/05. Information was abstracted from clinic charts and the patient self-reported health questionnaires. Results: These results reflect the demographics of the first 50 women entered into our database. Median age at presentation was 57 years (range 28–88); 62% were post-menopausal and 28% had a 1st/2nd degree relative with breast cancer. Clinical diagnosis was made by: self-detection (79%); mammography (5%), routine physical exam (9%) and CT scan (2%). Clinical tumour stage at presentation was: IIIA (25.6%); IIIB (53.5%) and IIIC (9.3%). The majority of women were diagnosed with infiltrating ductal carcinoma (72%). Women with T4d tumours (IBC) (38%) tended to be younger (54.5 vs 59.2 years); presented earlier (2.7 vs. 6.3 months); had larger tumours at the time of diagnosis (9.7 vs 5.5 cm); were more likely grade III (30 vs 20%) and were more often ER negative (42.1% vs 33.3%) and PR negative (63.2% vs. 50%). Only 13% of women in this database were tested for HER-2 of whom 70% were positive. Conclusions: This data utilizing the new AJCC (2002) staging system reflects important shifts in LABC that will influence clinical care in the future. Compared to historical databases, patients tended to be younger and have more aggressive disease including ER negative and HER-2 positive disease. Supplemental microarray studies to further explore this entity are planned. We will present clinical management outcomes in an additional submission.

No significant financial relationships to disclose.

Phase I study of OGX-011, a second generation antisense oligonucleotide (ASO) to clusterin, combined with cisplatin and gemcitabine as first-line treatment for patients with stage IIB/IV non-small cell lung cancer (NSCLC)

17078

Background: The clusterin gene is frequently expressed in NSCLC and encodes a cytoprotective chaperone protein that promotes cell survival and is upregulated in response to apoptotic stimuli such as chemotherapy. OGX-011 is an ASO that binds to clusterin mRNA thus potently regulating expression and chemosensitizing cancer cells. Previous Phase I studies of OGX-011 identified biologically active doses of 480mg to 640mg. The objective of this multi-center Phase I study was to define the Phase 2 dose of OGX-011 in combination with standard chemotherapy. Methods: Patients (pts) with chemotherapy-naive advanced stage IIIB/IV NSCLC were potentially eligible. OGX-011 is given as a 2hr IV infusion weekly after 3 loading doses (days -7, -5, and -3). OGX-011 dose escalation was planned to a maximum of 640mg. Cisplatin was given at 75 mg/m2 IV day 1 and gemcitabine 1250mg/m2 IV days 1 and 8, on a 21-day schedule up to 6 cycles. Pharmacokinetic profiling was done in cycle 1. Results: Between Jan 2004 and Apr 2005, 10 patients were enrolled. Median age 62 yrs (49–75); 4 female. ECOG 0/1: 3/7. Stage IIIB/IV: 1/9. 9 of 10 pts completed at least one cycle; 1 withdrew after one dose of OGX-011 due to progressive disease (PD). Of the 9 pts, 6 received ≥ 5 cycles and 3 received 2–4 cycles (2 patients discontinued due to PD and 1 at the pts request). Median follow-up: 5.0m (1.6 - 6.7m). As of Jan 2006, 2 pts had a PR; 5 had SD; 2 had PD. 4 pts had 5 serious adverse events: elevated creatinine, hypoxia, pneumonia, pleural effusion, and febrile neutropenia. 3 pts had Gr 3 hyponatremia. Gr 3/4 hematological toxicities in 10–40% and 10–20%, respectively. No dose-limiting toxicities noted; 7 pts received OGX-011 at 640 mg. A proportional increase in OGX-011exposure (Cmax and AUC0-inf) from 480 to the 640 mg was noted with no apparent effect on GEM/CIS. Conclusions: OGX-011 was well tolerated and can be given at biologically active doses (640 mg) with standard GEM/CIS chemotherapy for patients with advanced NSCLC. A multicenter Phase II trial of this combination is underway. Sponsored by OncoGenex Technologies, Inc. with Isis Pharmaceuticals Inc.

[Table: see text]

A phase II study of the antisense oligonucleotide GTI-2040 plus docetaxel and prednisone as first line treatment in hormone refractory prostate cancer (HRPC)

13015

Background: Despite initial responses to chemotherapy, median survival in HRPC remains a dismal 18 mos. Novel therapeutic approaches are clearly needed. The enzyme ribonucleotide reductase (RNR) composed of 2 subunits, R1 and R2 is essential for DNA synthesis and repair. The R2 subunit is often overexpressed in tumors increasing their malignant potential and promoting drug resistance. GTI-2040 (Lorus Therapeutics, Canada) is an antisense oligonucleotide to the R2 subunit downregulating its expression. In preclinical studies, GTI-2040 has shown antitumor activity in prostate cancer xenografts, synergy and non-overlapping toxicity with the taxanes. It is therefore a rational choice for combination with docetaxel in HRPC. Objectives: To determine efficacy of this regimen using PSA response rate. Secondary objectives include: duration of response, TTP, objective tumor response rate, safety and tolerability. Pharmacokinetic (PK) studies will be performed. PBMC will be used to determine RNR activity and R2 subunit quantitation. Methods: HRPC patients with PS 0–2, adequate organ function and no prior chemotherapy were treated with GTI-2040 5mg/kg/d continuous infusion for 14d, docetaxel 75 mg/m2 IV every 21d, and prednisone 5mg twice daily. Results: Twenty-two pts in 5 centers have been enrolled. Pts have received a total of 107 cycles to date. Median age 63 (52–77); median baseline PSA 140 (26–1256); ECOG 0:1:2: 14:7:1; prior radiotherapy in 14 pts. Pts received a median of 5 cycles (2–10). Grade 3/4 hematologic toxicities were lymphophenia (10pts), leukopenia (7pts), and neutropenia (7pts). Anemia (any grade) was seen in 19 pts across 92 cycles. Most frequent non-hematologic toxicities were fatigue and pain. PSA responses seen in 9/22 pts. Objective tumor response:1 PR, 9 SD, 3 PD, 3 off due to toxicity prior to objective response measurement, 3 no measureable lesions, 3 to be assessed. 19 pts off treatment: 9 PD, 4 toxicity (1 toxic death), 2 completed 10 cycles, 2 at investigator’s discretion and 2 withdrew consent. Three pts remain on study. Median TTP estimated at 17 wks. Accrual has been sufficient to meet stage 1 requirements. Final response, toxicity, pK, RNR and R2 subunit analysis will be available and presented.

No significant financial relationships to disclose.

Randomized phase II study of two doses of gefitinib in hormone-refractory prostate cancer: a trial of the National Cancer Institute of Canada-Clinical Trials Group

PURPOSE

Overexpression of the epidermal growth factor receptor has been demonstrated in advanced prostate cancer and is associated with a poor outcome. A multi-institutional, randomized, phase II study was undertaken by the National Cancer Institute of Canada-Clinical Trials Group to evaluate the efficacy and toxicity of two doses of oral gefitinib in patients with minimally symptomatic, hormone-refractory prostate cancer (HRPC).

PATIENTS AND METHODS

Between July and November 2001, 40 patients with HRPC and increasing prostate-specific antigen (PSA) or progression in measurable disease who had not received prior chemotherapy were randomly assigned to 250 mg (n = 19) or 500 mg (n = 21) oral gefitinib daily continuously. The primary end points were PSA response rate and objective measurable response. Functional Assessment of Cancer Therapy Prostate Cancer Subscale (FACT-P) quality-of-life questionnaires were completed at baseline and during treatment.

RESULTS

None of the patients demonstrated a PSA or objective measurable response. Five (14.3%) of 35 assessable patients had stable PSA (one patient at 250 mg and four patients at 500 mg), and five patients (14.3%) had a best response of stable disease (duration, 2.5 to 16.8 months). No significant effect on the rate of increase in PSA was seen. The most common drug-related nonhematologic toxicities observed were grade 1 to 2 diarrhea (250 mg, 65%; 500 mg, 56%), fatigue (250 mg, 29%; 500 mg, 33%), and grade 1 to 2 skin rash (250 mg, 24%; 500 mg, 39%). FACT-P scores decreased during treatment, indicating worsening of symptoms compared with baseline.

CONCLUSION

Gefitinib did not result in any responses in PSA or objective measurable disease at either dose level. Gefitinib has minimal single-agent activity in HRPC.

Is there a role for chemotherapy in prostate cancer?

There is evidence from randomised-controlled trials that patients with symptomatic hormone-refractory prostate cancer may experience palliative benefit from chemotherapy with mitoxantrone and prednisone. This treatment is well tolerated, even by elderly patients, although the cumulative dose of mitoxantrone is limited by cardiotoxicity. Treatment with docetaxel or paclitaxel, with or without estramustine, appears to convey higher rates of prostate-specific antigen response in phase II trials, but is more toxic. Large phase III trials comparing docetaxel with mitoxantrone have completed accrual. There is no role for chemotherapy in earlier stages of disease except in the context of a well-designed clinical trial.