Safety and Efficacy of Oxaliplatin Pressurized Intraperitoneal Aerosolized Chemotherapy (PIPAC) in Colorectal and Appendiceal Cancer with Peritoneal Metastases: Results of a Multicenter Phase I Trial in the USA

BACKGROUND

Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) is a laparoscopic locoregional treatment for peritoneal metastases (PM) from colorectal cancer (CRC) or appendiceal cancer (AC) in patients who cannot undergo cytoreductive surgery (CRS). While PIPAC has been studied in Europe and Asia, it has not been investigated in the USA.

PATIENTS AND METHODS

We evaluated PIPAC with 90 mg/m2 oxaliplatin alone (cycle 1) and preceded by systemic chemotherapy with fluorouracil (5-FU) and leucovorin (LV) (cycle 2-3) as a multicenter prospective phase I clinical trial (NCT04329494). The primary endpoint was treatment-related adverse events (AEs). Secondary endpoints included survival and laparoscopic, histologic, and radiographic response.

RESULTS

12 patients were included: 8 with CRC and 4 with AC. Median prior chemotherapy cycles was 2 (interquartile range (IQR) 2-3). All patients were refractory to systemic oxaliplatin-based chemotherapy. Median peritoneal carcinomatosis index (PCI) was 28 (IQR 19-32). Six (50%) of twelve patients completed three PIPAC cycles. No surgical complications or dose-limiting toxicities were observed. Two patients developed grade 3 treatment-related toxicities (one abdominal pain and one anemia). Median overall survival (OS) was 12.0 months, and median progression-free survival (PFS) was 2.9 months. OS was correlated with stable disease by Response Evaluation Criteria in Solid Tumors (RECIST) criteria but not with laparoscopic response by PCI or histologic response by peritoneal regression grading system (PRGS).

CONCLUSIONS

This phase I trial in the USA demonstrated safety, feasibility, and early efficacy signal of PIPAC with oxaliplatin and chemotherapy in patients with PM from AC or CRC who are refractory to standard lines of systemic chemotherapy.

Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes

PURPOSE/OBJECTIVE(S)

Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC.

MATERIALS/METHODS

In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations.

RESULTS

Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation.

CONCLUSION

Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.

Multicenter dose-escalation Phase I trial of mitomycin C pressurized intraperitoneal aerosolized chemotherapy in combination with systemic chemotherapy for appendiceal and colorectal peritoneal metastases: rationale and design

Objectives

Peritoneal metastasis (PM) from appendiceal cancer or colorectal cancer (CRC) has significant morbidity and limited survival. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) is a minimally invasive approach to treat PM. We aim to conduct a dose-escalation trial of mitomycin C (MMC)-PIPAC combined with systemic chemotherapy (FOLFIRI) in patients with PM from appendiceal cancer or CRC.

Methods

This is a multicenter Phase I study of MMC-PIPAC (NCT04329494). Inclusion criteria include treatment with at least 4 months of first- or second-line systemic chemotherapy with ineligibility for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Exclusion criteria are: progression on chemotherapy; extraperitoneal metastases; systemic chemotherapy intolerance; bowel obstruction; or poor performance status (ECOG>2). Escalating MMC-PIPAC doses (7-25 mg/m2) will be administered in combination with standard dose systemic FOLFIRI. Safety evaluation will be performed on 15 patients (dose escalation) and six expansion patients: 21 evaluable patients total.

Results

The primary endpoints are recommended MMC dose and safety of MMC-PIPAC with FOLFIRI. Secondary endpoints are assessment of response (by peritoneal regression grade score; Response Evaluation Criteria in Solid Tumors [RECIST 1.1], and peritoneal carcinomatosis index), progression free survival, overall survival, technical failure rate, surgical complications, conversion to curative-intent CRS-HIPEC, patient-reported outcomes, and functional status. Longitudinal blood and tissue specimens will be collected for translational correlatives including pharmacokinetics, circulating biomarkers, immune profiling, and single-cell transcriptomics.

Conclusions

This Phase I trial will establish the recommended dose of MMC-PIPAC in combination with FOLFIRI. Additionally, we expect to detect an early efficacy signal for further development of this therapeutic combination.

Building a learning network to accelerate improvement in pancreas cancer care and outcomes: Canopy Cancer Collective

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Background: Pancreas cancer (PC) survival is among the lowest of all malignancies. While limited advances in treatment are a major driver of this reality, ample opportunity exists to improve outcomes by reducing care variation, providingcoordinated, comprehensive care, and accelerating research. Learning health networks (LHNs) improve outcomes in pediatric diseases through such mechanisms, yet are not widely implemented in adult care. We aimed to develop, implement, and collect initial outcomes of the first oncology LHN, the Canopy Cancer Collective (CCC). Methods: In 2019, we established CCC to apply to PC the LHN model, including core tenets of continuous quality improvement (QI), data-sharing, empowered interdisciplinary teams and a stakeholder community including individuals with PC, and focus on community-defined improvable “outcomes that matter”. Six care centers were selected to join the LHN, and engaged in a collaborative design process to co-create a set of improvement aims and change ideas. Center team members received training in basic QI methods/tools guided by the IHI Model for Improvement and were coached to apply these to local improvement efforts. LHN infrastructure and technology enabled sharing of new ideas, best practices, and results amongst centers. Eight more centers joined in 2021, and an outcomes database built and implemented. Results generated by this database will inform center-specific and Network-wide improvement efforts and allow the LHN to undertake research. Results: Currently, 14 care centers are active participants in the CCC LHN. Five key outcomes have been defined as key targets, and centers have co-created and tested change ideas organized around key drivers of excellent PC care including proactive, timely care, aligned/prepared multidisciplinary teams, informed, activated patients, and accurate diagnosis and disease classification. 100% of care centers are trained in QI methods and actively testing change ideas. For example, in May 2022, 11 centers reporting on monthly QI activities met on average 4 times to advance QI projects, deploying a mean of 2.9 plan-do-study-act (PDSA) cycles (range, 0-5) focused on key drivers and outcomes, including reduced time to treatment, increased trial enrollment, assessment of patient experience, and improved data capture. Conclusions: Building a sustainable LHN for PC centers is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Results lay the foundation for expansion not only in PC, but translation to other complex malignancies that will benefit from transformative, system-based approaches to outcome improvement.

Safety and efficacy of pressurized intraperitoneal aerosolized chemotherapy in appendiceal and colorectal cancer patients with peritoneal carcinomatosis: A first-in-US phase I study

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Background: Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) is being evaluated as a novel minimally invasive palliative treatment of peritoneal metastases (PM). Prior studies have established the feasibility and safety of repeated PIPAC treatments in gastrointestinal and gynecologic cancers. The goal of the present phase 1 trial was to establish the safety and feasibility of PIPAC oxaliplatin in a highly chemotherapy refractory colorectal and appendiceal cancer patient population. Methods: Patients with biopsy-proven peritoneal metastases from colorectal or appendiceal cancer underwent up to three PIPAC treatments using oxaliplatin (92 mg/m2) with a six-week interval at two academic centers. Patients with bowel obstruction, extra-peritoneal metastases, or poor performance status (ECOG>2) were excluded. PIPAC was nebulized over 5 min with a 30 min aerosol dwell time. Apart from the first PIPAC cycle, the patients also received a sensitizing dose of 5FU/LV (400mg/m2) within 24 hours of the procedure. Primary end point was safety as assessed by dose limiting toxicities within 6 weeks of the first PIPAC. Secondary endpoints included safety with the addition of 5FU/LV, efficacy, surgical morbidity, technical failure rate, progression-free and overall survival, pharmacokinetics (PK), and quality of life assessment. Results: A total of 8 patients were included: 5 colorectal; and 3 appendiceal. Median number of prior chemotherapy cycles was 2 (Interquartile range – IQR; 1.5-3.5). All patients were refractory to systemic oxaliplatin-based chemotherapy. Median time from diagnosis to PIPAC was 16 months (IQR; 5.6, 17.5) and Peritoneal Carcinomatosis Index was 29 (IQR; 20.5, 31.5). Five (62.5%) patients completed 3 PIPAC cycles while in 3 (37.5%) patients PIPAC was discontinued due to disease progression within the peritoneal cavity. No surgical complication or dose limiting toxicity was observed. Only one patient developed grade 3 treatment-related toxicity after first PIPAC (anemia), and another patient after second PIPAC (abdominal pain and anemia). At the completion of PIPAC treatment 5 patients had stable disease and 3 had disease progression. Pharmacokinetic, histologic response and preliminary survival data will be presented at the meeting. Conclusions: PIPAC with oxaliplatin is safe and feasible in a highly chemotherapy refractory cohort of appendiceal and colorectal carcinomatosis patients with or without sensitizing 5-FU/ LV. Clinical trial information: NCT04329494.

Ampullary neuroendocrine tumors: A window into a rare tumor using a national database

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Background: Ampullary neuroendocrine tumors (NET) make up < 1% of all gastrointestinal NETs. Information about their behavior and prognosis is reliant on small case series. This study set out to describe the population of patients who are diagnosed with ampullary NETs and compare them to patients with duodenal and pancreatic head NETs. Methods: The National Cancer Database (2004 – 2016) was queried for patients with ampullary, duodenal, and pancreatic head NETs. Clinicopathologic and treatment characteristics were compared. Subset analysis was performed on patients who underwent surgery. Kaplan Meier (KM) analysis and Cox regression were used to analyze the survival of patients with ampullary NETs. Results: Overall, 872 patients were identified with ampullary NET, 9692 with duodenal NET, and 6562 with pancreatic head NET. Patients with ampullary NET had an average age of 60.9 +/- 14.5 years, were evenly split among men and women (N = 437, 50.1% vs N = 435, 49.9%, respectively), and primarily Caucasian (N = 663, 76.0%). 72.1% underwent local tumor destruction or surgery (N = 629). Most did not receive radiation (N = 832, 95.4%), chemotherapy (N = 627, 71.9%), or hormone therapy (N = 788, 90.4%). Patients with ampullary NETs had more poorly differentiated tumors (N = 119, 13.6%) than patients with duodenal (N = 159, 1.6%) or pancreatic head (N = 602, 9.2%) NETs. Patients with ampullary NETs had more positive lymph nodes (N = 288, 33%) than patients with duodenal (N = 915, 9.4%) or pancreatic head (N = 1381, 21%) NETs. At five years, the overall survival for patients with ampullary, duodenal, and pancreatic head NETs was 57%, 68%, and 46%, respectively. Within the surgical population, five-year survival for patients with ampullary (N = 367), duodenal (N = 991), and pancreatic head (N = 1961) NETs was 60%, 74%, and 72%, respectively. When compared, there was a statistically significant difference between the mean overall survival of patients with ampullary (98 +/- 4.7 months), duodenal (112 +/- 2.5 months), and pancreatic head (108 +/- 1.7 months) NETs (p < 0.001). In the cox regression analysis, sex, Charlson-Deyo score, lymph node positivity, lymph-vascular invasion, mitotic rate, chromogranin A level, 5-HIAA level, and tumor size did not correlate with survival. Increasing age (HR 1.04, CI 1.01 – 1.07, p = 0.008) and worse tumor differentiation (poorly differentiated HR 3.33, CI 1.38 – 8.04, p = 0.008 and undifferentiated HR 8.31, CI 2.77 – 24.92, p < 0.001 compared to well differentiated) were associated with increased mortality. Conclusions: This study sheds light on a rare tumor histology. When compared to patients who underwent surgical resection for duodenal or pancreatic head NETs, patients with ampullary NETs had a significantly worse prognosis. Identifying prognostic factors allows us to create more concrete treatment recommendations and provide patients with improved prognostic information.

The timing and the dose of advanced care planning in patients with resectable pancreatic cancer: Who makes the call?

397

Background:The timing and the extent of Advanced Care Planning (ACP) in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing curative-intent resection are generally dictated by the surgeon performing the operation. The aim of this study is to evaluate surgeons’ insights, perceptions, and biases regarding preoperative ACP. We hypothesize that many surgeons harbor significant reservations about extensive preoperative ACP. Methods:A qualitative investigation using 1:1 interviews with 40 open-ended questions were conducted with convenience sample. Data accrual continued until theme saturation was achieved. Grounded theory approach was used for data coding and analysis. Results:A total of 10 interviews were conducted with expert pancreatic surgeons from 6 medical centers—6 males and 4 females. The median number of years in practice was 15 (IQR 13-30) and the median number of pancreatic cancer cases performed per year was 52 (IQR 39-75). During preoperative counseling all surgeons discuss the possibility of recurrence and postoperative complications but attempt to motivate patients by emphasizing hope, optimism, and fact that surgery offers the only opportunity for cure. 90% of surgeons report no formal training in ACP. All surgeons report comfort with end of life conversations when death is imminent, but most lack experience with in-depth preoperative ACP. All surgeons emphasized that ACP should be led by a physician that both knows the patient well and understands the complexity of PDAC management. All surgeons recognized potential benefits of ACP, including delivery of goal-concordant care (60%), increased prognostic awareness (40%), and better life planning (40%). 50% report discussing in-depth ACP related to perioperative complications, but not long-term oncologic outcome. 80% of surgeons report that they actively steer away from in-depth ACP during preoperative counseling. Barriers to in-depth ACP reported by surgeons include taking away hope (70%), lack of time (50%) and concern for sending “mixed messages” (50%). Further, 50% of surgeons perceived that extensive preoperative ACP is not appropriate for patients with PDAC undergoing curative-intent resection. Most surgeons (60%) believe that ACP should occur as a process throughout the disease and in-depth discussions were more appropriate during postoperative visits (30%) and/or recurrence (60%). Conclusions:Despite recognizing potential benefits, most pancreatic surgeons report actively avoiding in-depth ACP conversations prior to curative-intent surgery. Surgeons had difficulty articulating the best time for ACP and felt that ACP should occur as a continuum throughout the course of treatment, with the depth of the discussion echoing the disease progression and patients’ readiness for such conversation. Future studies could evaluate patients’ perspective on the timing and the dose of ACP.

Liver-directed treatments of liver-dominant metastatic leiomyosarcoma

PURPOSE

The purpose of this study was to determine the safety and efficacy of liver-directed therapies in patients with unresectable metastatic leiomyosarcoma to the liver. Liver-directed therapies included in this study were transarterial chemoembolization with doxorubicin eluting beads (DEB-TACE), yttrium-90 (Y90) radioembolization, and percutaneous microwave ablation.

METHODS

This is a single institution retrospective study of unresectable metastatic leiomyosarcoma to the liver treated with DEB-TACE, radioembolization, or microwave ablation. DEB-TACE was performed using 70-150 or 100-300 µ doxorubicin-loaded drug-eluting LC beads. Radioembolization was performed using Y90 glass microspheres. Electronic medical records were retrospectively reviewed to evaluate clinical and biochemical toxicities, tumor response on imaging, overall survival (OS), and liver progression-free survival (PFS).

RESULTS

A total of 24 patients with metastatic leiomyosarcoma to the liver who underwent liver-directed treatment were identified (8 males, 16 females; average age, 62.8±11.4 years). Of these patients, 13 underwent DEB-TACE, 6 underwent Y90, and 5 underwent ablation. Three patients received a combination of treatments: one received Y90 followed by DEB-TACE, one received ablation followed by DEB-TACE, and one received ablation followed by Y90. Of the 24 patients, 19 received prior chemotherapy. At 3-month follow-up, grade 1 or 2 lab toxicities were found in 20 patients; 3 patients had grade 3 toxicities. A grade 3 clinical toxicity was reported in one patient. MELD score was 7.5±1.89 at baseline and 8.8±4.2 at 3 months. Median OS was 59 months (95% CI, 39.8-78.2) from diagnosis, 27 months (95% CI, 22.9-31.0) from development of liver metastasis, and 9 months (95% CI, 0-21.4) from first liver-directed treatment. Median liver PFS was 9 months (95% CI, 1.4-16.6).

CONCLUSION

Treatment with liver-directed therapies for patients with unresectable metastatic leiomyosarcoma to the liver is safe and can improve overall survival, with OS after liver-directed therapy being similar to patients who underwent surgical resection.

Safety and efficacy of biweekly gemcitabine in combination with capecitabine (GemCap) in elderly and frail patients (pts) with resected pancreatic cancer (PC)

4628

Background: ESPAC-4 study showed that GemCap conferred a survival benefit over gemcitabine monotherapy in resected PC patients. ESPAC-4 included patients with median age of 65 years (37-81) and ECOG performance status (PS) of 0 (43%), 1 (54%) and 2 (2%) who received a median cumulative dose of gemcitabine of 15,000 mg/m2, capecitabine. Here we present our experience with an adopted biweekly regimen of GemCap in patients who were ≥ 75 years and those who were deemed not suitable for ESPAC-4 regimen. Methods: Patients ≥ 75 years with resected PC, ECOG PS of 0-2 and no prior treatments were included. Patients were treated with a modified regimen of gemcitabine (1000-2000 mg/m2) every 2 weeks and capecitabine (800-1000 mg/m2) day 1-7 every 2 weeks. Patients were evaluated for progression-free survival (PFS), overall survival (OS) and sites of recurrence. Toxicities were graded according to NCI CTCAE v5.0. Results: Thirty-five (22M, 13F) patients, ≥ 75 (median age 79) treated with biweekly Gem-Cap adjuvant treatment. 7 (28%) patients had ECOG PS of 1 and 28 (72%) had ECOG PS of 2. There were 5, 7 and 16 patients with stage I, II and III disease. Nine patients (25%) had R1 and 26 (75%) had R0 resection. The median PFS and OS were 8.0 months and 22.0 months. Nine (25%) had local recurrence, 21 (60%) had metastatic disease and 3 (8.6%) had NED. Two patients were lost to follow-up. The most frequent toxicities were grades 1-2 anemia (20%), thrombocytopenia (8%) and hand-foot syndrome (HFS) (10%). Grade ≥3 included diarrhea (4%) and HFS (1%) with no treatment-related discontinuations. Treatment compliance was 100%. Delays were necessary in 7% of cases and dose reduction was required in 4% of cases. There was no treatment related death. Conclusions: This schedule of biweekly GemCap regimen suggests an acceptable option in for elderly, frail patients with PC and warrants further exploration in patients not suitable for FOLFIRINOX, full dose GemCap or a clinical trial. This regimen required fewer dose reduction, omission or delays and allowed to administer pegylated-filgrastim. Previous studies have also shown decreased toxicity and equal efficacy of 7/7 schedule of capecitabine. Moreover, fewer visits to oncology and related expense do favor towards benefit. Additionally, this tolerable regimen is ideal to be combined with immunotherapy in clinical trials for this patient population.

Safety and outcomes of an oncologic robotic whipple program

393

Background: Robotic-assisted surgery is a new technology being used more commonly in surgical oncology. We evaluated the outcomes of robotic pancreaticoduodenectomy over time from a single U.S. cancer center. Methods: The Moffitt Cancer Center Tumor Registry was queried for robotic pancreaticoduodenectomy cases performed by two surgeons from 2012-2017 after IRB approval. Descriptive statistics and analyses with t-test and chi-square test were performed. Results: 61 case were analyzed; the first cohort comprised 31 cases and the second cohort comprised the next 30 cases. The most common pre-operative diagnosis was adenocarcinoma. For the entire cohort, the estimated blood loss was 498mL, ASA class was 2.5, and OR duration 546 minutes. The first cohort had 14 conversions to open Whipple and the second cohort had 11. There were no anesthesia or surgical complications. There was one 30-day mortality and one R1 resection. There was no significant difference in EBL, OR transfusions, or post-op transfusions. There was a significant decrease in the operative time between the two cohorts. Additionally, there was a significant increase in total number of nodes examined in the second cohort, though no difference in the number of positive nodes. Conclusions: In selected patients, robotic pancreaticoduodenectomy is a safe alternative to open pancreaticoduodenectomy. Published data suggest a learning curve of approximately 60-80 cases. In our cohort we observed a significant decrease in OR time and an increase in lymph node retrieval after 31 cases, suggesting an earlier inflection point. Further studies are needed to examine additional follow-up and outcome variables. [Table: see text]

Factors affecting lymph node yield from patients undergoing colectomy for cancer

PURPOSE

Lymph node (LN) yield is a critical component of colon cancer staging and is often a surrogate for quality assessment in surgery. We investigated the impact of pathologists' training on LN harvest.

METHODS

This is a retrospective review on 137 patients undergoing elective colectomy for adenocarcinoma at a single institution from 2008 to 2009. We studied surgeon-, patient- and pathologist-derived factors, and identified independent variables affecting LN yield using logistic regression.

RESULTS

LN yield was similar between open and laparoscopic resections (21 versus 23, p = 0.54). Similarly, nodal counts were independent of tumor location (p = 0.08) and no difference was noted between colorectal and general surgeons (24 versus 21, p = 0.31). Strikingly, the number of LNs reported by PGY-1 pathology residents was significantly higher than those with two or more years of training (24 versus 19, p = 0.02). On logistic regression, only the reporting pathologists' year in training remained a significant predictor of the number of nodes reported (OR = 5.28, p = 0.0001).

CONCLUSIONS

LN retrieval in patients with colon cancer is inversely related to the interpreting pathologists' level of training.