Enhancement Patterns of Metastatic Intrahepatic Cholangiocarcinoma and Outcomes after Chemotherapy and Radiation

PURPOSE/OBJECTIVE(S)

Patients with metastatic intrahepatic cholangiocarcinoma (M1-iCCA) have a poor prognosis with a 5-year survival rate of less than 20%. Definitive doses of radiation therapy (RT) after upfront chemotherapy (chemo/RT) in this patient population have shown to prolong survival by reducing the risk of tumor-related liver failure compared to chemotherapy alone. Our group has also identified a baseline radiographic feature, the arterial enhancement pattern, which has pathological and prognostic associations for iCCA. We tested the hypothesis that baseline arterial enhancement is independently associated with survival outcomes for patients who receive chemo/RT or chemo alone.

MATERIALS/METHODS

Patients with M1-iCCA from 2010 to 2021 were included in this retrospective study. Patients were grouped into those who underwent chemo alone and those who underwent chemo/RT. The inclusion criteria included confirmed diagnosis of M1-iCCA, availability of baseline multi-phasic computed tomography (CT), and follow-up for at least six months or until death. Tumor arterial enhancement patterns were categorized as previously described into hypovascular or hypervascular, where the tumors that were hypervascular had either peripheral enhancement or central enhancement. Mean tumor density in Hounsfield units was recorded for each patient. Survival was estimated using the Kaplan Meier method, and Cox proportional models were used to adjust for prognostic variables.

RESULTS

A total of 281 patients with iCCA were identified and 229 had evaluable CT scans. Demographic and baseline characteristics of patient groups are shown in the Table. On univariate analysis, patient age, ECOG performance status (PS) at diagnosis, treatment type, and arterial enhancement patterns associated with overall survival (OS). On multivariable analysis, the arterial enhancement pattern independently associated with OS after accounting for covariates. Patients with hypervascular tumors had prolonged OS compared to those with hypovascular tumors (HR = 0.72, [0.54 - 0.96], p = 0.02). Prolonged OS was also observed in the chemo/RT group compared to the chemo alone group (HR = 0.37, [0.25-0.54], p< 0.0001).

CONCLUSION

Baseline enhancement patterns of M1-iCCA were prognostic in the contexts of chemo alone and chemo/RT. This imaging-based biomarker may improve the ability to stratify patients for therapeutic management.

Surfaceome profiling enables isolation of cancer-specific exosomal cargo in liquid biopsies from pancreatic cancer patients

Background

Detection of circulating tumor DNA can be limited due to their relative scarcity in circulation, particularly while patients are actively undergoing therapy. Exosomes provide a vehicle through which cancer-specific material can be enriched from the compendium of circulating non-neoplastic tissue-derived nucleic acids. We carried out a comprehensive profiling of the pancreatic ductal adenocarcinoma (PDAC) exosomal 'surfaceome' in order to identify surface proteins that will render liquid biopsies amenable to cancer-derived exosome enrichment for downstream molecular profiling.

Patients and methods

Surface exosomal proteins were profiled in 13 human PDAC and 2 non-neoplastic cell lines by liquid chromatography-mass spectrometry. A total of 173 prospectively collected blood samples from 103 PDAC patients underwent exosome isolation. Droplet digital PCR was used on 74 patients (136 total exosome samples) to determine baseline KRAS mutation call rates while patients were on therapy. PDAC-specific exosome capture was then carried out on additional 29 patients (37 samples) using an antibody cocktail directed against selected proteins, followed by droplet digital PCR analysis. Exosomal DNA in a PDAC patient resistant to therapy were profiled using a molecular barcoded, targeted sequencing panel to determine the utility of enriched nucleic acid material for comprehensive molecular analysis.

Results

Proteomic analysis of the exosome 'surfaceome' revealed multiple PDAC-specific biomarker candidates: CLDN4, EPCAM, CD151, LGALS3BP, HIST2H2BE, and HIST2H2BF. KRAS mutations in total exosomes were detected in 44.1% of patients undergoing active therapy compared with 73.0% following exosome capture using the selected biomarkers. Enrichment of exosomal cargo was amenable to molecular profiling, elucidating a putative mechanism of resistance to PARP inhibitor therapy in a patient harboring a BRCA2 mutation.

Conclusion

Exosomes provide unique opportunities in the context of liquid biopsies for enrichment of tumor-specific material in circulation. We present a comprehensive surfaceome characterization of PDAC exosomes which allows for capture and molecular profiling of tumor-derived DNA.

Prognostic value of carbohydrate antigen 19-9 in patients undergoing resection of biliary tract cancer

BACKGROUND

The clinical significance of abnormally high levels of carbohydrate antigen (CA) 19-9 after resection of biliary tract cancer (BTC) is not well established. The aim of this study was to determine the prognostic value of CA19-9 normalization in patients undergoing resection of BTC with curative intent.

METHODS

Patients with BTC undergoing resection with curative intent (1996-2015) were divided into those with normal preoperative CA19-9 level (normal CA19-9 group), those with an abnormally high preoperative CA19-9 level (over 37 units/ml) and normal postoperative CA19-9 level (normalization group), and those with an abnormally high preoperative CA19-9 level and abnormally high postoperative CA19-9 level (non-normalization group). Overall survival (OS) was analysed and predictors of OS were determined.

RESULTS

The normal CA19-9 group (180 patients) and normalization group (74) had better OS than the non-normalization group (58) (3-year OS rate 70·4, 73 and 31 per cent respectively; both P < 0·001). The normal CA19-9 and normalization groups had equivalent OS (P = 0·880). On multivariable analysis, factors associated with worse OS were lymph node metastases (hazard ratio (HR) 1·78; P = 0·014) and abnormally high postoperative CA19-9 level (HR 3·16; P < 0·001). In the normalization group, OS did not differ after R0 versus R1 resection (3-year OS rate 69 versus 62 per cent respectively; P = 0·372); in the non-normalization group, patients with R1 resection had worse OS (3-year OS rate 36 and 20 per cent for R0 and R1 respectively; P = 0·032).

CONCLUSION

Non-normalization of CA19-9 level after resection of BTC with curative intent was associated with worse OS. R1 resection was associated with a particularly poor prognosis when CA19-9 levels did not normalize.

Biologic mesh spacer placement facilitates safe delivery of dose-intense radiation therapy: A novel treatment option for unresectable liver tumors

INTRODUCTION

Patients with unresectable liver tumors who fail initial treatment modalities have a poor prognosis (<1 yr). Although effective, delivery of high dose radiation therapy to these tumors is limited by proximity of radiosensitive bowel. We have previously reported that placement of a biologic mesh spacer (BMS) can effectively displace the bowel allowing for dose-intense radiation to be delivered with low short-term toxicity. The purpose of this study was to assess and report the long-term safety and oncologic outcomes of this cohort.

METHODS

From 2012 to 2014 seven patients with unresectable hepatic malignancy (6 IHCC, 1 CRLM) underwent BMS (acellular human dermis) placement (2 open, 5 MIS) prior to radiation therapy. Prospective registry data were reviewed for tumor and treatment details, progression, metastasis and survival. RTOG guidelines were used to define radiation toxicities.

RESULTS

Mean patient age was 50.4 years (30-62 years) and 4 patients were male (57.1%). Prior to surgery, all patients had been treated for an average of 12.5 months with surgery, chemotherapy, radiation and/or TACE. After surgery, all patients recovered well and received a mean radiation dose of 76.1 Gy (58.1-100 Gy) over 13-25 fractions. 1 patient received SBRT; 4 fractions, 10 Gy each. Maximum dose delivered was 100 Gy (Biologic Equivalent Dose of 140 Gy, α/β = 10). Mean time to initiation of radiation therapy was 24 days (12-48 days) from surgery. No significant GI toxicity was recorded, and no GI bleeding or ulcers were observed. Mean follow-up after XRT was 18.2 months (5.5-31 months). Three patients had no loco-regional progression of disease. 2 patients had infield progression of liver disease and another had progressive lymphadenopathy. 3 patients developed pulmonary metastasis, at a mean time to distant failure of 3 months. There are 4 survivors over 2-years from surgery.

CONCLUSION

For patients with unresectable liver tumors, placement of a BMS enhances the safety and efficacy of high-dose radiotherapy, providing a survival benefit via delay in time to progression compared to traditional treatments with no significant short or long term GI toxicity.

Human genome meeting 2016 : Houston, TX, USA. 28 February - 2 March 2016

O1 The metabolomics approach to autism: identification of biomarkers for early detection of autism spectrum disorder A. K. Srivastava, Y. Wang, R. Huang, C. Skinner, T. Thompson, L. Pollard, T. Wood, F. Luo, R. Stevenson O2 Phenome-wide association study for smoking- and drinking-associated genes in 26,394 American women with African, Asian, European, and Hispanic descents R. Polimanti, J. Gelernter O3 Effects of prenatal environment, genotype and DNA methylation on birth weight and subsequent postnatal outcomes: findings from GUSTO, an Asian birth cohort X. Lin, I. Y. Lim, Y. Wu, A. L. Teh, L. Chen, I. M. Aris, S. E. Soh, M. T. Tint, J. L. MacIsaac, F. Yap, K. Kwek, S. M. Saw, M. S. Kobor, M. J. Meaney, K. M. Godfrey, Y. S. Chong, J. D. Holbrook, Y. S. Lee, P. D. Gluckman, N. Karnani, GUSTO study group O4 High-throughput identification of specific qt interval modulating enhancers at the SCN5A locus A. Kapoor, D. Lee, A. Chakravarti O5 Identification of extracellular matrix components inducing cancer cell migration in the supernatant of cultivated mesenchymal stem cells C. Maercker, F. Graf, M. Boutros O6 Single cell allele specific expression (ASE) IN T21 and common trisomies: a novel approach to understand DOWN syndrome and other aneuploidies G. Stamoulis, F. Santoni, P. Makrythanasis, A. Letourneau, M. Guipponi, N. Panousis, M. Garieri, P. Ribaux, E. Falconnet, C. Borel, S. E. Antonarakis O7 Role of microRNA in LCL to IPSC reprogramming S. Kumar, J. Curran, J. Blangero O8 Multiple enhancer variants disrupt gene regulatory network in Hirschsprung disease S. Chatterjee, A. Kapoor, J. Akiyama, D. Auer, C. Berrios, L. Pennacchio, A. Chakravarti O9 Metabolomic profiling for the diagnosis of neurometabolic disorders T. R. Donti, G. Cappuccio, M. Miller, P. Atwal, A. Kennedy, A. Cardon, C. Bacino, L. Emrick, J. Hertecant, F. Baumer, B. Porter, M. Bainbridge, P. Bonnen, B. Graham, R. Sutton, Q. Sun, S. 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Yunus, F. Aghakhanian, S. S. Mokhtar, C. V. Lok-Yung, J. Bhak, M. Phipps, X. Shuhua, T. Yik-Ying, V. Kumar, H. Boon-Peng O50 Breast and ovarian cancer prevention: is it time for population-based mutation screening of high risk genes? I. Campbell, M.-A. Young, P. James, Lifepool O53 Comprehensive coverage from low DNA input using novel NGS library preparation methods for WGS and WGBS C. Schumacher, S. Sandhu, T. Harkins, V. Makarov O54 Methods for large scale construction of robust PCR-free libraries for sequencing on Illumina HiSeqX platform H. DoddapaneniR. Glenn, Z. Momin, B. Dilrukshi, H. Chao, Q. Meng, B. Gudenkauf, R. Kshitij, J. Jayaseelan, C. Nessner, S. Lee, K. Blankenberg, L. Lewis, J. Hu, Y. Han, H. Dinh, S. Jireh, K. Walker, E. Boerwinkle, D. Muzny, R. Gibbs O55 Rapid capture methods for clinical sequencing J. Hu, K. Walker, C. Buhay, X. Liu, Q. Wang, R. Sanghvi, H. Doddapaneni, Y. Ding, N. Veeraraghavan, Y. Yang, E. Boerwinkle, A. L. Beaudet, C. M. Eng, D. M. Muzny, R. A. Gibbs O56 A diploid personal human genome model for better genomes from diverse sequence data K. C. C. Worley, Y. Liu, D. S. T. Hughes, S. C. Murali, R. A. Harris, A. C. English, X. Qin, O. A. Hampton, P. Larsen, C. Beck, Y. Han, M. Wang, H. Doddapaneni, C. L. Kovar, W. J. Salerno, A. Yoder, S. Richards, J. Rogers, J. R. Lupski, D. M. Muzny, R. A. Gibbs O57 Development of PacBio long range capture for detection of pathogenic structural variants Q. Meng, M. Bainbridge, M. Wang, H. Doddapaneni, Y. Han, D. Muzny, R. Gibbs O58 Rhesus macaques exhibit more non-synonymous variation but greater impact of purifying selection than humans R. A. Harris, M. Raveenedran, C. Xue, M. Dahdouli, L. Cox, G. Fan, B. Ferguson, J. Hovarth, Z. Johnson, S. Kanthaswamy, M. Kubisch, M. Platt, D. Smith, E. Vallender, R. Wiseman, X. Liu, J. Below, D. Muzny, R. Gibbs, F. Yu, J. Rogers O59 Assessing RNA structure disruption induced by single-nucleotide variation J. Lin, Y. Zhang, Z. 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Gibbs P42 FANTOM5 web resource for the large-scale genome-wide transcription start site activity profiles of wide-range of mammalian cells T. Kasukawa, M. Lizio, J. Harshbarger, S. Hisashi, J. Severin, A. Imad, S. Sahin, T. C. Freeman, K. Baillie, A. Sandelin, P. Carninci, A. R. R. Forrest, H. Kawaji, The FANTOM Consortium P43 Rapid and scalable typing of structural variants for disease cohorts W. Salerno, A. English, S. N. Shekar, A. Mangubat, J. Bruestle, E. Boerwinkle, R. A. Gibbs P44 Polymorphism of glutathione S-transferases and sulphotransferases genes in an Arab population A. H. Salem, M. Ali, A. Ibrahim, M. Ibrahim P46 Genetic divergence of CYP3A5*3 pharmacogenomic marker for native and admixed Mexican populations J. C. Fernandez-Lopez, V. Bonifaz-Peña, C. Rangel-Escareño, A. Hidalgo-Miranda, A. V. Contreras P47 Whole exome sequence meta-analysis of 13 white blood cell, red blood cell, and platelet traits L. Polfus, CHARGE and NHLBI Exome Sequence Project Working Groups P48 Association of adipoq gene with type 2 diabetes and related phenotypes in african american men and women: The jackson heart study S. Davis, R. Xu, S. Gebeab, P Riestra, A Gaye, R. Khan, J. Wilson, A. Bidulescu P49 Common variants in casr gene are associated with serum calcium levels in koreans S. H. Jung, N. Vinayagamoorthy, S. H. Yim, Y. J. Chung P50 Inference of multiple-wave population admixture by modeling decay of linkage disequilibrium with multiple exponential functions Y. Zhou, S. Xu P51 A Bayesian framework for generalized linear mixed models in genome-wide association studies X. Wang, V. Philip, G. Carter P52 Targeted sequencing approach for the identification of the genetic causes of hereditary hearing impairment A. A. Abuzenadah, M. Gari, R. Turki, A. Dallol P53 Identification of enhancer sequences by ATAC-seq open chromatin profiling A. Uyar, A. Kaygun, S. Zaman, E. Marquez, J. George, D. Ucar P54 Direct enrichment for the rapid preparation of targeted NGS libraries C. L. Hendrickson, A. Emerman, D. Kraushaar, S. Bowman, N. Henig, T. Davis, S. Russello, K. Patel P56 Performance of the Agilent D5000 and High Sensitivity D5000 ScreenTape assays for the Agilent 4200 Tapestation System R. Nitsche, L. Prieto-Lafuente P57 ClinVar: a multi-source archive for variant interpretation M. Landrum, J. Lee, W. Rubinstein, D. Maglott P59 Association of functional variants and protein physical interactions of human MUTY homolog linked with familial adenomatous polyposis and colorectal cancer syndrome Z. Abduljaleel, W. Khan, F. A. Al-Allaf, M. Athar , M. M. Taher, N. Shahzad P60 Modification of the microbiom constitution in the gut using chicken IgY antibodies resulted in a reduction of acute graft-versus-host disease after experimental bone marrow transplantation A. Bouazzaoui, E. Huber, A. Dan, F. A. Al-Allaf, W. Herr, G. Sprotte, J. Köstler, A. Hiergeist, A. Gessner, R. Andreesen, E. Holler P61 Compound heterozygous mutation in the LDLR gene in Saudi patients suffering severe hypercholesterolemia F. Al-Allaf, A. Alashwal, Z. Abduljaleel, M. Taher, A. Bouazzaoui, H. Abalkhail, A. Al-Allaf, R. Bamardadh, M. Athar

Locally advanced pancreatic cancer: the role of definitive chemoradiotherapy

At the time of diagnosis, around 20% of patients with pancreatic cancer present at a resectable stage, 50% have metastatic disease and 30% have locally advanced tumour, non-metastatic but unresectable because of superior mesenteric artery or coeliac encasement. Despite advances in chemoradiotherapy and improved systemic chemotherapeutic agents, patients with locally advanced pancreatic cancer suffer from high rates of distant metastatic failure and from local progression, with a median survival time ranging from 5 to 11 months. In the past 30 years, modest improvements in median survival have been attained for these patients treated by chemoradiotherapy or chemotherapy protocols. The optimal therapy for patients with locally advanced pancreatic carcinoma remains controversial. This review aims to evaluate the role of radiotherapy for these patients.

Cell death/proliferation roles for nc886, a non-coding RNA, in the protein kinase R pathway in cholangiocarcinoma

We have recently identified nc886 (pre-miR-886 or vtRNA2-1) as a novel type of non-coding RNA that inhibits activation of protein kinase R (PKR). PKR's pro-apoptotic role through eukaryotic initiation factor 2 α (eIF2α) phosphorylation is well established in the host defense against viral infection. Paradoxically, some cancer patients have elevated PKR activity; however, its cause and consequence are not understood. Initially, we evaluated the expression of nc886, PKR and eIF2α in non-malignant cholangiocyte and cholangiocarcinoma (CCA) cells. nc886 is repressed in CCA cells and this repression is the cause of PKR's activation therein. nc886 alone is necessary and sufficient for suppression of PKR via direct physical interaction. Consistently, artificial suppression of nc886 in cholangiocyte cells activates the canonical PKR/eIF2α cell death pathway, suggesting a potential significance of the nc886 suppression and the consequent PKR activation in eliminating pre-malignant cells during tumorigenesis. In comparison, active PKR in CCA cells does not induce phospho-eIF2α nor apoptosis, but promotes the pro-survival nuclear factor-κB pathway. Thus, PKR has a dual life or death role during tumorigenesis. Similarly to the CCA cell lines, nc886 tends to be decreased but PKR tends to be activated in our clinical samples from CCA patients. Collectively from our data, we propose a tumor surveillance model for nc886's role in the PKR pathway during tumorigenesis.

The potential for poly (ADP-ribose) polymerase inhibitors in cancer therapy

The modulation of DNA repair pathways for therapeutic benefit in cancer has now become a reality with the development of poly (ADP-ribose) polymerase inhibitors (PARPi). PARP is involved in single-strand DNA breaks, which in the presence of defective homologous recombination repair lead to double-strand DNA breaks, the most lethal form of DNA damage. These agents therefore may be the drugs of choice for BRCA mutant breast and ovarian cancers. PARPi result in synergistic antitumor effects when combined with cisplatin, temozolomide, topoisomerase inhibitors and ionizing radiation. The indications for PARPi lie beyond BRCA mutations and may include genomic and functional defects in DNA repair and damage response pathways. Several PARPi are in the clinical development phase at this time and, given the recent failure of a phase III clinical trial of iniparib in triple-negative breast cancer, the identification of structural and functional differences between these inhibitors becomes critical. Acquired resistance to PARPi is being noted and represents an important limitation in this field. A concise review of the literature in this field is presented.

The role of PARP in DNA repair and its therapeutic exploitation

Historically, PARP inhibitors (PARPi) were developed to potentiate the cytotoxic effect of certain chemotherapeutic agents and are currently being investigated in combination with chemotherapy in diverse cancer types. These agents are also radiosensitisers and clinical trials of PARPi with concurrent radiation are required. It has long been recognised that defective DNA repair pathways lead to tumour susceptibility. Recent studies indicate that tumour cells with defective homologous recombination (HR) repair pathways, the classic example being BRCA mutations, are exquisitely sensitive to PARPi. Defects in HR are not restricted to BRCA-associated tumours and other cancer types may be enriched for HR defects and hence susceptible to PARP inhibition. The identification of predictive markers for sensitivity to PARP inhibition is a priority area for research.

Biological activity of bevacizumab and erlotinib in patients with advanced hepatocellular carcinoma (HCC)

4522

Purpose: HCC is the fifth most common solid tumor worldwide and the incidence is rising in western countries. Current standard of care for advanced HCC is sorafenib based on median survival (MS) of 10.7 months (mos), median time to progression 5.5 mos. HCC are highly vascular tumors, and due to the prevalence of vascular endothelial growth factor and epidermal growth factor receptors in HCC, a phase II single-arm open-label trial of B and E in patients (pts) with HCC has been completed. Patients and Methods: Eligibility criteria include biopsy-proven unresectable HCC, Child-Pugh class A or B cirrhosis, bilirubin ≤2.0 mg/dL, transaminase (TA) levels ≤5 times the upper limit of normal, platelets ≥50,000/μL and Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≤2. Prior allowed therapies are surgery, external radiotherapy, ablation, transarterial chemoembolization (TACE) and 1 systemic therapy. Pts received B 10 mg/kg every 14 days plus E 150 mg orally daily. Results: The primary endpoint was the percent of pts alive and progression-free after 16 weeks of therapy (PFS16) based on historic median PFS of 3 to 5 mos. Response was evaluated by RECIST. 57 pts have been enrolled and were evaluable for analysis on an intent to treat basis. For all pts, the median age was 62.8 years (range 29–82), 44 (77%) male, 25 (43.9%) Caucasian; 25 (43.9%); ECOG PS of 0, 31 (54.4%) pts PS of 1. 14 pts (24.6%) had prior therapy (6 sorafenib). Of the 57 pts enrolled, 14 (28%) had confirmed partial responses, 31 (62%) had stable disease and 5 (10%) had progressive disease. PFS16, was 73% (95% CI 60%, 84%). The median PFS is 7.9 mos (95% CI 5.7, 9.5) and the OS is 12.8 mos, 95% CI (9.5, 17.9). 6 pts were removed for toxicity; there was one on-study death. The most common grade 1 or 2 toxicities are folliculitis, anorexia, diarrhea, dry skin, and epistaxis. Grade 3 or 4 toxicities were transaminase elevation, diarrhea, fatigue, hyperkalemia, hypertension, proteinuria, pulmonary embolus, leukoencephalopathy and gastrointestinal bleed. Conclusions: The combination of B and E appears to have significant clinically meaningful activity in HCC. A multi-institution randomized phase II trial is planned.

[Table: see text]

Morphoproteomic depiction of constitutively activated mTOR and ERK pathways in adenocarcinoma of the large intestine: A pilot study

14580

Background: Preclinical studies have demonstrated a role for the mammalian target of rapamycin (mTOR) pathway in intestinal tumorigenesis. However, the mTOR and its related ERK pathway in human adenocarcinoma of the large intestine (ALI) have been little examined. Methods: To assess morphoproteomic alterations of ALI, tissue materials from three patients with ALI were analyzed in the present study. Antibody probes used included phosphorylated (p)-mTOR (Ser-2448) and one of its downstream effectors, p-p70S6K (Thr-389); bcl-2, which undergoes mTOR-dependent phosphorylative inactivation; and p-extracellular signal-regulated kinase (ERK)1/2 (Thr-202/Tyr-204), a co-activator of p-p70S6K. The intensity of the chromogenic signal and the cellular compartmentalization (plasmalemmal, cytoplasmic, and/or nuclear) were assessed and scored on a scale of 0–3+. Results: Moderate to strong (up to 2+ or 3+) expression of p-mTOR and its substrate, p-p70S6K, and p-ERK1/2 was present in all three cases. We also found plasmalemmal translocation of p-mTOR and nuclear translocation of p-p70S6K and p-ERK1/2, indicating constitutive activation of these protein analytes and their corresponding signal transduction pathways. We did not detect bcl-2 expression in any of these cases. Conclusions: Morphoproteomic analysis reveals constitutive activation of the mTOR and ERK pathways in ALI as evidenced by the collective commonalities of expression of p-mTOR, p-p70S6K, and p- ERK1/2 and the plasmalemmal translocation of p-mTOR and nuclear translocation of p-p70S6K and p-ERK1/2. The absence of bcl-2 expression in this context is noteworthy. These findings coincide with the preclinical data on the efficacy of rapamycin and a rapamycin analogue against colon cancer cell lines and xenograft models. Although preliminary, these observations of morphoproteomic alterations represent the first in primary human ALI specimens according to a review of the literature. The present pilot study offers a starting point for further studies (we are currently conducting a confirmatory study with larger series of cases) and the design of clinical trials using such small molecule inhibitors(e.g. rapamycin, RAD001) in a combinational strategy against ALI.

No significant financial relationships to disclose.

Mucinous cystadenocarcinoma (mca) of the appendix: Role of adjuvant therapy

15131

Introduction: MCA is the most common (non-carcinoid) appendiceal cancer. Adjuvant 5-fluorouracil (5-FU) based systemic chemotherapy (ASC) is often considered for MCA cases after surgery, extrapolating data from colon cancer. Patients (pts) with peritoneal disease are considered for regional perfusional therapy. However, the role of adjuvant therapy in this setting has not yet been established. Methods: Retrospective analysis of cases with the diagnosis of MCA. Pts treated with curative intent and subsequent adjuvant therapy [ASC or Intraperitoneal Hyperthermic Chemotherapy (IPHC)] were included. Pts who received surgery alone were compared to those who received surgery in combination with adjuvant therapy. Estimation of the survival distribution of each group was performed using the Kaplan-Meier method. Statistical assessment of observed differences in the survival distributions was per the log-rank test. Analyses were also performed adjusting for age and sex using the stratified log rank test. A 0.05 nominal significance level was used in all testing. Results: A total of 34 consecutive pts were treated between 8/1973 and 4/2005 for MCA. Pt characteristics were: 15 males (44%), median age 50 yrs (range 27–79), 33 (97%) Caucasian, 30 (88%) had peritoneal metastasis at diagnosis. All patients underwent surgical resection; 26 (76%) underwent >1 of the following procedures. Surgeries were: right hemicolectomy (n=20, 58%), appendectomy (n=16, 47%), total abdominal hysterectomy (n=9, 26%), ileocolectomy (n=4, 11%) or debulking (n=12, 35%). Eight pts (23%) underwent IHPC with 5-FU (n=5), Mitomycin (n=2) or Yttrium90 (n=1). Thirteen patients (38%) underwent ASC: 5-FU based (n=12) or Paclitaxel/ Carboplatin (n=1). Pts who underwent surgery alone had a median survival of 40 months. Pts who had surgery and also received ASC or IPHC had a median survival of 53 months. There was no statistical difference in the overall survival between the groups after adjusting for age, sex and stage differences (p=0.1). Conclusions: MCA is an aggressive tumor; optimally treated with radical surgery even at an advanced stage. Larger studies are required to determine the value of ASC or IPHC in this setting.

No significant financial relationships to disclose.

Phase II study of weekly docetaxel in combination with capecitabine (C) in advanced gastric (AGA) and gastro-esophageal adenocarcionma (AGEA)

15139

Background: Chemotherapy regimens for AGA and AGEA have shown considerable toxicity and most require continuous IV administration. Both D and C are active agents in AGA. D upregulates thymidine phosphorylase, the enzyme which catalyzes the conversion of C to 5-FU, with preclinical evidence of synergy for the combination. A phase I study of D and C showed acceptable tolerability and activity in patients (pts) with AGA (Ramanathan et al., 2005). This multi-institutional phase II trial evaluates the combination of D and C in 1st or 2nd line treatment of AGA and AGEA. Methods: Pts with AGA/AGEA who received ≤ 1 prior chemotherapy regimen were eligible. D 30 mg/m2 on d 1, 8 and C 825 mg/ m2 BID were administered on days 1–14 of a 21 day cycle. The one stage study design had an accrual goal of 40 pts. The primary endpoint was to detect a 50% improvement in median survival in previously untreated pts to 10 months (mo), by one-sided log-rank test at level a = 0.05. Results: Enrollment is complete with 40 pts, all are evaluable for response and toxicity. Pt characteristics: 79% male; 94% with ECOG performance status 0/1; median age 60 yrs (34–84), 32 pts (80%) were previously untreated. Overall response rate is 25% with 1CR and 9 PR. The projected median time to progression (TTP) and survival are 6.2 and 7.8 mo respectively. Dose modifications were required in 9%. Median cycles administered 4 (range 1–10). Grade 3/4 adverse events include: diarrhea (13%), hand-foot syndrome (13%), dehydration (6%), abd pain, anorexia, fatigue, febrile neutropenia, gastric ulcer, hyperglycemia, vertigo, and vomiting (3% each). Conclusion: The combination of D and C is well tolerated and active. The preliminary TTP (6.2 mo) and survival (7.8 mo) compare favorably with published regimens for 1st line therapy, but did not meet study endpoint. The combination of D and C is an easily administered outpatient regimen for AGA and AGEA and may be worthy of further investigation with a targeted agent. (Funded by Sanofi-Aventis and Roche Pharmaceuticals).

No significant financial relationships to disclose.

A single institution experience with neuroendocrine tumors

15164

Background: ABSTRACT Introduction: . The aim of this study was to analyze demographic, therapy, tumor and clinical outcomes of all cases of neuroendocrine cancer at a tertiary cancer and determine the the markers that may better correlate with outcomes than histologic grade. Patients and Methods: With IRB approval , 126 charts with a diagnosis of neuroendocrine carcinoma were identified between 1–1-1999 and 1–1-2004. Ninety-five cases were selected on the basis of complete availability of baseline, therapy and at least one time point of followup data. Patient demographics, therapy details, TNM stage, tumor marker and survival data were collected. Tumors were graded as well, moderate and poorly differentiated and by site of origin. We attempted to correlate the outcome with NCAM(neural cell adhesion molecule-CD56) status, which is a homophylic binding glycoprotein to have a role in cell adhesion. Descriptive statistics and frequency tables were used to describe the data and kaplan meier methods were used to estimate the median survival. Results: There were 28 patients with lung primaries, 25 had primaries in the gut (extra pancreatic),11 had pancreatic primaries, 31 cases had unknown primaries or primaries at sites other than the lungs or the gastrointestinal tract. The estimated median survival for the whole sample was 34 months.(95% C I :20,54) and the 2 year survival rate was 55.3 %.The estimated median survival for CD56 positive group was 11 months(95% C.I :3,38) and that for CD 56 unknown group was 36(95% C .I :20,n/a). A significant difference in survival between CD56 positive group and CD56 unknown was found,based on log-rank test>(P=.02). Baseline characteristics were as follows: M:F 48:47; 19 were well differentiated, 4 were moderately differentiated and 36 of 95 tumors were poorly differentiated, the differentiation was not known in 36 cases. Surgery with curative intent was done in 52 of the patients(54.74%) and 52 received (54.74%)t chemotherapy, 4 patients(4.2%) received chemoembolization and 2 patients(2.1%) received local ablative treatments. Conclusion: These data summarize our instutions experience with this rare malignancy. In our data survival was as expected in the literature and further investigation of the CD 56 status of all patients is underway.

No significant financial relationships to disclose.

Surgical resection for pancreatic cancer: Correlates of margin positivity

4097

Background: Positive surgical margins (PSMs) occur in 20–40% of pancreatic cancer cases treated surgically. PSMs are associated with local recurrence and poor survival. Objectives: Correlate clinicopathological parameters with PSMs in pancreatic cancer patients (pts) undergoing surgical resection. Methods: Clinicopathological data for 71 pts who underwent surgical resection for pancreatic cancer from 1999–2005 were obtained. Data including location, AJCC stage, tumor size, type of resection, use of neoadjuvant therapy, grade, morphology, perineural and angiolymphatic invasion were correlated with PSMs and survival using logistic regression, Fisher-exact test and log-rank test. Results: There were 29 males; median age was 65 years and median follow-up 14 months. Histologies were: adenocarcinoma (n = 67), sarcomatoid (n = 2), adenosquamous (n = 1) and mucinous cystadenocarcinoma (n = 1). Sites of disease were: head only (n = 56), head/uncinate (n = 7) and body/tail (n = 8). Surgical treatments included Whipple (n = 43), pylorus preserving Whipple (n = 18) distal pancreatectomy (n = 8) and total pancreatectomy (n = 2). Pathological AJCC stages were: ΙA (n = 4), ΙB (n = 2), ΙΙA (n = 14), ΙΙB (n = 48), and ΙΙΙ (n = 3). Neoadjuvant chemoradiation (CRT) was administered in 10 cases; 38 other pts received postoperative adjuvant therapy including CRT (n = 36)/chemotherapy only (n = 2). Overall median survival was 30 months and disease free survival 18.6 months. Nineteen cases (27%) had PSMs. PSMs were pancreatic transection line (n = 11), retroperitoneal margin (n = 9), bile duct (n = 1) and peripancreatic soft tissue (n = 2). On univariate analysis, PSM was associated with advanced AJCC stage (p = 0.02) and tumor location other than pancreatic head (p = 0.02). PSM rate was 10% (1/10) and 31% (18/61) for pts with/without neoadjuvant therapy, respectively (p = 0.27). On multivariate analysis, PSM correlated with AJCC stage (p = 0.04) and tumor location (p = 0.05). PSMs were not significantly related to survival or recurrence (p = 0.09). Conclusions: Advanced AJCC stage and tumor in pancreatic body/tail or uncinate are associated with PSMs following pancreatic cancer resection. Strategies to “downstage” with novel therapies prior to surgery should be investigated to facilitate a complete surgical resection.

[Table: see text]

Epithelial-mesenchymal transition (EMT) in resected pancreatic cancer

4094

Background: EMT plays an important role in tumor invasion and metastases; its detection may have prognostic significance. We examined expression of EMT related proteins in resected pancreatic cancers and correlated results with clinical outcome. Methods: Clinical data/surgical specimens from 34 consecutive pancreatic cancer patients (pts) who underwent pancreatectomy from 1996–2002 were included. Immunohistochemical staining for vimentin (Vim 3B4), E-cadherin (36B5), MIB1 and cytokeratin (CK-AE1/AE3) was performed on formalin fixed paraffin embedded tissues. Percentages of stained cells (cytoplasmic for vimentin and CK, nuclear for MIB1 and membranous for E-cadherin) were recorded. The results were correlated with clinicopathological parameters and survival. Survival analysis (log-rank test, Cox-proportional hazard model), categorical data analysis (Pearson’s chi-square, logistic regression) and Kendall’s tau were performed at the significance level of 0.05. Results: Clinical data/specimens from 34 pts were included: 13 males, median age 66 (range 38–84); SEER stage 1 (2 pts), 2 (27 pts), 3 (5 pts); histological grade 1 (4), 2 (13), 3 (16), 4 (1). Median survival was 15 months (95% CI: 11–24 months). Sixteen pts had adjuvant chemoradiotherapy, 4 pts had chemotherapy, 1 pt had radiation. IHC Results: vimentin (11.8%), MIB1 (100%), E-cadherin (91%) and CK (100%). There was a significant negative association between vimentin and E-cadherin expression (Kendall’s tau = −0.47, p = 0.0024). Vimentin expression correlated with histological grade (exact chi-square p = 0.0247). No associations were found between these proteins and SEER stage, age, treatment or smoking. Univariate analysis revealed histological grade 50% (p = 0.0039) and MIB1 expression >10% (p = 0.0224) were related to better survival. Multivariate analysis using Cox-proportional hazard model revealed the following significant variables: histological grade (hazard ratio (HR) = 11.8, p = 0.0001), age (HR = 1.1, p = 0.0053), MIB1 (HR = 0.9, p = 0.0003) and adjuvant chemotherapy (HR = 0.2, p = 0.0288). Conclusion: Decreased E-cadherin expression (<50% expression) was associated with poorer survival; E-cadherin expression had an inverse correlation with vimentin. Acknowledgement: Supported by OSI Pharmaceuticals.

[Table: see text]

Phase I, pharmacokinetic (PK), pharmacodynamic study of paricalcitol [19-nor-1 alpha, 25-(OH)2 D2] in combination with gemcitabine [2’,2’ difluorodeoxycytidine] in patients with advanced malignancies

12010

Background: Calcitriol+ gemcitabine (gem) combination results in synergistic anti-tumor effect in preclinical models. Cytidine deaminase (CDD) inactivates gem into 2’,2’-difluorodeoxyuridine (dFdU) and its overexpression may lead to gem resistance. Calcitriol decreases CDD activity in peripheral blood mononuclear cells (PBM). Paricalcitol is cytotoxic in vitro and synergistic with several chemotherapeutic agents, including gem. We are conducting a phase I study of paricalcitol + fixed-dose gem. Objectives: The primary aim is to determine maximum tolerated dose (MTD) of the combination in patients (pts) with advanced cancer. Secondary aims are to evaluate toxicity, the effect of paricalcitol on gem PK, CDD activity in PBM and clinical outcome. Methods: Each cycle is 4 weeks: Gem 800 mg/m2 (over 80 min) weekly × 3, starting day 1; paricalcitol weekly, 24 h prior to gem, starting day 7. Standard 3+3 dose-escalation schema is used. Planned paricalcitol doses are 0.24, 0.72, 1.20, 1.8, 2.4 μg/kg, and 25% increments till MTD. Gem PK and CDD activity (PBM) are studied on days 1 and 8. Paricalcitol PK studies are obtained on day 7. Results: Fourteen pts with the following cancers: pancreatic (n=3), colon (n=3), lung (n=5), esophageal (n=1), bladder (n=1) and unknown primary (n=1) have been enrolled. No dose limiting toxicities have occurred. Median of 2 cycles were delivered (range 1–9). Grade 3 toxicities: anemia (n=3 pts), neutropenia (n=5), thrombocytopenia (n=3), thrombosis (n=2), anorexia (n=1), hypophosphatemia (n=1), dehydration (n=1), syncope (n=1), pneumonia (n=1) and chills (n=1). Grade 4 toxicities: anemia (n=1) and neutropenia (n=1). Hypercalcemia (> grade 1) did not occur. Stable disease occurred in 2 and progressive disease in 3. Conclusions: MTD was not reached at 1.8 μg/kg of paricalcitol with gem 800 mg/m2/week. Dose escalation is ongoing. PK data will be presented at meeting. Supported by NIH grants CA67267 and CA85142.

[Table: see text]

The PACT trial: Interim results of a randomized trial of TNFerade biologic plus chemoradiation (CRT) compared to CRT alone in locally advanced pancreatic cancer (LAPC)

4102

Background: TNFerade is a second-generation replication-deficient adenovector, carrying the transgene encoding human TNF-α, regulated by the stress-inducible promoter Egr-1. In a phase I trial of TNFerade + radiation in 36 patients with advanced or refractory solid tumors, a 47% objective tumor response rate was observed, including 100% complete responses in 3 stage 4 melanoma patients, with 2/3 disease-free at >3.5 years. Methods: This controlled phase II trial randomizes 74 patients with newly diagnosed unresectable LAPC to 5-wks of TNFerade (4 × 1011 pu via weekly intratumoral injection) + CRT (5-FU [200 mg/m2/day CIV × 5 days/wk] and 50.4 Gy radiation) or CRT alone. All patients receive maintenance gemcitabine. Endpoints: Progression-free survival, safety, radiographic tumor response, CA 19–9 and survival. Results: In dose escalation (n=50) dose-limiting toxicities occurred in 3 patients at 1 × 1012 pu (pancreatitis in 2 and biliary obstruction), setting the MTD at 4 × 1011 pu. Compared with the first two cohorts (n=30), the MTD (n = 11) was associated with greater locoregional control and progression-free survival, a higher rate of stable or decreasing CA 19–9, improved overall survival (median = 11.2), and a high (45%) resection rate. Accrual continues in the randomized phase of the study at 20+ centers. The most frequent adverse events in the first 16 enrolled patients have been nausea (75%), abdominal pain (63%), constipation (50%), anemia (38%), diarrhea (38%), vomiting (38%), and weight loss (38%), with no significant difference in severity or frequency between the TNFerade + CRT and CRT groups. No thromboembolic events have been reported. Serum TNF-alpha levels have remained low (peak = 45.3 pg/mL, in a CRT patient). CA 19–9 has been stable (no change > 100 U/mL) or decreased in all but one CRT patient. Conclusions: These initial data indicate that TNFerade plus CRT, given as weekly intratumoral injections to patients with LAPC, is feasible and tolerable compared to CRT alone. With continued accrual, comparative tumor response and toxicity data will be available and updated.

No significant financial relationships to disclose.

Cardiac function after chemoradiation for esophageal cancer: comparison of heart dose-volume histogram parameters to multiple gated acquisition scan changes

In this paper we determine if preoperative chemoradiation for locally advanced esophageal cancer leads to changes in cardiac ejection fraction. This is a retrospective review of 20 patients treated at our institution for esophageal cancer between 2000 and 2002. Multiple gated acquisition cardiac scans were obtained before and after platinum-based chemoradiation (50.4 Gy). Dose-volume histograms for heart, left ventricle and left anterior descending artery were analyzed. Outcomes assessed included pre- and postchemoradiation ejection fraction ratio and percentage change in ejection fraction postchemoradiation. A statistically significant difference was found between median prechemoradiation ejection fraction (59%) and postchemoradiation ejection fraction (54%) (P = 0.01), but the magnitude of the difference was not clinically significant. Median percentage volume of heart receiving more than 20, 30 and 40 Gy were 61.5%, 58.5% and 53.5%, respectively. Our data showed a clinically insignificant decline in ejection fraction following chemoradiation for esophageal cancer. We did not observe statistically or clinically significant associations between radiation dose to heart, left ventricle or left anterior descending artery and postchemoradiation ejection fraction.