Targeted Therapy and Immunotherapy Response Assessment with F-18 Fluorothymidine Positron-Emission Tomography/Magnetic Resonance Imaging in Melanoma Brain Metastasis: A Pilot Study

Introduction

This pilot study aimed at exploring the utility of the proliferation tracer F-18 fluorothymidine (FLT) and positron-emission tomography (PET)/magnetic resonance imaging (MRI) (FLT–PET/MRI) for early treatment monitoring in patients with melanoma brain metastasis (MBM) who undergo targeted therapy or immunotherapy.

Material and Methods

Patients with newly diagnosed MBM underwent baseline and follow-up FLT–PET/MRI scans at 3–4 weeks of targeted therapy or immunotherapy. Up to six measurable brain lesions ≥1.0 cm per subject, as identified on T1-weighted post-gadolinium images, were included for quantitative analyses. The maximum SUV of each lesion was divided by the mean SUV of the pons to obtain the SUV ratio (SUVR).

Results

Five enrolled subjects underwent the baseline FLT–PET/MRI study in which the MBM showed a median size of 1.7 cm (range 1.0–2.9) and increased metabolic activity with SUVR of 9.9 (range 3.2–18.4). However, only two subjects (cases #1 and #2) returned for a follow-up scan. At baseline, a total of 22 lesions were analyzed in all five subjects, which showed a median size of 1.7 cm (range 1.0–2.9) and median SUVR of 9.9 (range 3.2–18.4). At follow-up, case #1 was a 55-year-old man who received targeted BRAF inhibitor and MEK inhibitor therapy with dabrafenib and trametinib. Fused PET/MRI data of six measured lesions demonstrated a significant reduction in MBM proliferative activity (median −68%; range −38 to −77%) and size (median −23%; range −4 to −55%) at three weeks of therapy. Nevertheless, the subject eventually progressed and died 13 months after therapy initiation. Case #2 was a 36-year-old man who received immunotherapy with nivolumab and ipilimumab. The five measured MBM lesions showed a mixed response at both proliferative and morphologic imaging at 1-month follow-up. Some lesions demonstrated interval decrease while others interval increase in proliferative activity with a median −44% (range −77 to +68%). On MRI, the size change was +7% (range −64 to +50%). The therapy was switched to dabrafenib and trametinib, which led to a partial response. The patient is still alive 16 months following therapy initiation.

Conclusion

The five cases presented show the potential benefit of hybrid FLT–PET/MRI for the diagnosis of MBM and treatment monitoring of targeted therapy and immunotherapy. However, further studies are required to assess their complementary role in distinguishing true progression from pseudoprogression.

Symptom incidence, distress, cancer-related distress, and adherence to chemotherapy among African American women with breast cancer

BACKGROUND

There is a persistent racial survival disparity between African American (AA) and white women with breast cancer. There is evidence that symptom incidence, associated distress, and overall cancer-related distress may be unexplored, important contributing factors. The purpose of the current study was to: 1) describe and compare the number of chemotherapy-related symptoms and associated distress among AA women with breast cancer over the course of chemotherapy at 3 time points (at baseline before initiating chemotherapy, midpoint, and at the completion of chemotherapy); and 2) to describe the relationship between the number of chemotherapy-related symptoms and overall cancer distress compared with the ability to receive at least 85% of the prescribed chemotherapy within the prescribed timeframe.

METHODS

Descriptive, comparative, and correlational analyses of symptom incidence, symptom distress, cancer-related distress, and prescribed chemotherapy dose received among a cohort of AA women receiving chemotherapy for breast cancer were performed.

RESULTS

AA women (121 women) experienced worsening symptoms from baseline to midpoint in chemotherapy and then stabilized for the duration of therapy. The inability to receive 85% of the prescribed chemotherapy within a prescribed time point was found to be significantly correlated with midpoint symptom distress.

CONCLUSIONS

The main findings of the current study were that AA women experience a deterioration in symptom distress over the course of chemotherapy from baseline (before chemotherapy) to the midpoint, which was found to be associated with less adherence to chemotherapy overall. Thus, the incidence and management of physical and emotional symptoms, as measured through a multidimensional symptom measurement tool, may be contributing to breast cancer dose disparity and should be explored further. Cancer 2017;123:2061-2069. © 2017 American Cancer Society.

Abstract C25: The effect of longitudinal symptom distress and overall cancer distress on the ability of African American women to receive prescribed breast cancer chemotherapy without delay

Background: Racial breast cancer survival disparity is attributed, in part, to disparity in breast cancer treatment. Cancer related distress and symptom incidence and associated distress is historically higher than comparative white women during breast cancer chemotherapy and may influence the ability of African American women to receive full dose and timely chemotherapy. Therefore symptom incidence, distress and overall cancer related distress may be under recognized as a potential etiology of racial survival disparity.

Objective: To describe the incidence and severity of symptoms and overall cancer-related distress in African American women and the association of symptom and cancer-related distress to adherence (receiving full dose prescribed without delay) to prescribed chemotherapy over three time points (baseline, midpoint and completion).

Methods: A descriptive, correlational analysis was conducted of longitudinal data from a recently completed randomized controlled trial of a psycho-educational intervention entitled the Adherence, Communication, Treatment and Support (ACTS) to encourage adherence to chemotherapy for African American women with breast cancer. In the ACTS Trial we assessed symptom incidence and severity and overall cancer-related distress as potential moderators of women's willingness and/or ability to receive timely and full dose chemotherapy. We measured change of symptom incidence and severity and cancer-related distress at three time points: pre-chemotherapy (Time 1); midpoint of chemotherapy (Time 2) and completion of chemotherapy (Time 3). The Cancer Distress Thermometer (DT) was used to measure cancer-related distress; the total number of symptoms (TOTNS) and the McCorkle Symptom Distress Scale (SDS) total score were to measure symptom incidence and severity, respectively. Adherence data in terms of the number of days delayed related to the patient, clinician, and overall were extracted from medical records. Random coefficient modeling was used for analysis to accommodate the variability in the timing of treatment cycles at the key time points.

Results: Subjects (n=142) were diagnosed with any stage invasive breast cancer and were undergoing chemotherapy. Results were based on 131 patients with evaluable data over at least two time points. DT, SDS, and TOTNS significantly changed over time suggesting that SDS and TOTNS increases linearly over time (SDS: b1=0.03324, p<.001; TOTNS: b1=0.02686, p<.001), whereas DT showed a slight decrease (b1=-0.00414, p=.044). Overall cancer-related distress was not significantly associated with clinical delays but was positively related to patient delays (b1=0.2445, p=.034) and total delays (b1=0.5445, p=.018). Overall total number of symptoms and symptom distress was positively related to clinical delays (b1=0.1438, p=.037) and total delays (b1=0.1669, p=.044).

Conclusions: Worsening in number of symptoms, overall cancer-related distress and symptom distress over the course of chemotherapy was demonstrated among African American women receiving breast cancer chemotherapy. Worsening symptom and cancer-related distress was associated with lack of ability to receive full dose chemotherapy at the prescribed time.

Implications for Practice: The influence of total number of symptoms, symptom distress and overall cancer-related distress on chemotherapy treatment delays is evident among this cohort of African American women receiving chemotherapy. Clinically this emphasizes the importance of close monitoring of cancer-related distress and symptom incidence and severity among African American women in order to allow timely breast cancer chemotherapy.

Citation Format: Melissa K. Yee, Susan Sereika, Margaret Quinn Rosenzweig. The effect of longitudinal symptom distress and overall cancer distress on the ability of African American women to receive prescribed breast cancer chemotherapy without delay. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C25.

Abstract A72: Models of patient navigation programs: Experience from the Cancer Disparities Research Partnership (CDRP) grantees

Purpose: To report the different models of patient navigation programs utilized and the experiences of the Cancer Disparities Research Partnership (CDRP) program.

Background: The CDRP Program was developed to address U.S. cancer health disparities among minority/underserved populations by increasing participation in cancer clinical trials and one of the main components was the development of a PN program at each site, which addressed the specific needs of its disparity populations.

Methods: The 6 different CDRP sites across the country implemented different models for a patient navigation program, including a lay navigator model, a professional model, and a combination of both. Centinela Freeman Hospital used a lay navigator model consisting of locally trained community lay health workers as navigators. Four sites (Laredo Medical Center, New Hanover Regional Medical Center, Singing River Health System and UPMC McKeesport Hospital) used a professional approach with navigators who were either registered nurses and/or social workers. Rapid City Regional Hospital used a combination and novel approach by combining both community members and health professionals. The community navigators served as a liaison between the health professionals and the community.

Results: Within these 3 models of patient navigation, a total of 3,480 cancer patients were navigated (65% were Non-Hispanic Whites, while only 35% were ethnic minorities). A total of 1,644 patients enrolled in clinical trials and only 264 (16%) patients had been navigated, but the majority of these navigated patients participating in clinical trials were racial/ethnic minorities (58% were American Indian, black/African American, and Hispanic/Latino). Most grantees felt that patient navigation improved the overall cancer care experience for patients, by increasing the likelihood that patients would successfully complete treatment, improving patient's understanding of their disease, establishing rapport between patients and their healthcare providers, and also guiding patients to choose between various cancer treatment options (including clinical trials). The patient navigators built trust in the community, and in certain situations, such as in the Native American population, the navigators were able to address the concerns of tribal health councils to help endorse clinical trials and encourage enrollment. Although the specific duties of the navigators differed across sites, the primary role of the navigators remained the same - to help guide patients through the cancer screening and treatment process, assist patients in overcoming various barriers to care, and facilitate participation in clinical trials.

Conclusions: There are various models of the patient navigation program which is one strategy used to address cancer disparities, and the type of model that works best is dependent on the patient population being served, specific goals of the program, the existing infrastructure of the hospital, and sources of funding available. A successful patient navigation program may improve access and accrual of racial/ethnic minority patients into cancer clinical trials.

Citation Format: Melissa K. Yee, Rosemary Wong, Dwight E. Heron. Models of patient navigation programs: Experience from the Cancer Disparities Research Partnership (CDRP) grantees. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A72. doi:10.1158/1538-7755.DISP13-A72

The degree of segmental aneuploidy measured by total copy number abnormalities to predict survival and recurrence in superficial gastroesophageal adenocarcinoma

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Background: Prognostic biomarkers are needed for superficial gastroesophageal adenocarcinoma (EAC) to predict clinical outcomes and select therapy. Although recurrent mutations have been characterized in EAC, little is known about their clinical and prognostic significance. Aneuploidy is predictive of clinical outcome in many malignancies but has not been evaluated in superficial EAC. SNP arrays offer the opportunity to evaluate segmental aneuploidy at high resolution throughout the genome. Methods: We quantified copy number changes in 41 superficial EAC using Affymetrix SNP 6.0 arrays. We identified recurrent chromosomal gains and losses and calculated the total copy number abnormality (CNA) count for each tumor as a measure of aneuploidy. We correlated CNA count with overall survival and time to first recurrence in univariate and multivariate analyses. Results: Recurrent segmental gains and losses involved multiple genes, including: HER2, EGFR, MET, CDK6 , KRAS (recurrent gains); and FHIT, WWOX, CDKN2A/B, SMAD4, RUNX1 (recurrent losses). There was a 40-fold variation in CNA count across all cases. Tumors with the lowest and highest quartile CNA count had significantly better overall survival (p=0.032, log rank test) and time to first recurrence (p=0.010, log rank test) compared to those with intermediate CNA counts. In multivariate Cox analysis, there was a 3.4-fold (95% CI, 1.1–10.4) increased hazard of death among cases with intermediate CNA counts after adjusting for other predictors of survival (N stage, angiolymphatic invasion and tumor size). Similarly, there was a 7.3-fold (95% CI, 1.5-34) increased risk of recurrence for these patients. Conclusions: SNP arrays facilitate the assessment of recurrent chromosomal gain and loss and allow high resolution, quantitative assessment of segmental aneuploidy (total CNA count).The non-monotonic association of segmental aneuploidy with survival has been described in other tumors such as breast and ovarian carcinoma. The degree of segmental aneuploidy is a promising prognostic biomarker in a potentially curable form of EAC.

Gastric emptying and small bowel transit in male volunteers after i.m. ketorolac and morphine

Ten male volunteers were studied in a randomized, double-blind crossover trial. Each received ketorolac tromethamine 30 mg and morphine sulphate 10 mg i.m. at an interval of 2 weeks. After a standard radiolabelled meal, gastric emptying half-time (GE) and small intestinal transit time (SIT) were measured using a gamma camera. Small intestinal transit time was measured also from end-tidal breath hydrogen (ETH), and overall gastrointestinal motility by time to first flatus (TFF). Mean GE, SIT and TFF were significantly prolonged by morphine compared with ketorolac (P less than 0.03); ETH was prolonged also, but the difference was not significant. There were no significant correlations between SIT, ETH and TFF. Most subjects reported adverse effects after morphine, but only one after ketorolac.

APACHE II: preliminary report on 100 intensive care unit cases in University Hospital, Kuala Lumpur

A good overall assessment of the severity of illnesses of patients admitted to a general intensive care unit (ICU) is not without problems. The APACHE (acute physiology and chronic health evaluation) prognostic scoring system enables us to stratify acutely ill patients and compare efficiency of ICU therapy in different hospitals. This preliminary study carried out on 100 consecutive admissions to the ICU in University Hospital, Kuala Lumpur showed the spectrum of ICU admissions and the direct relationship between APACHE II score and mortality.

Megakaryocyte morphogenesis stimulated in vitro by whole and partially fractionated thrombocytopenic plasma: a model system for the study of platelet formation

Isolated guinea pig megakaryocytes were cultured in the presence of plasma from normal or thrombocytopenic rabbits. Thrombocytopenic but not normal plasma stimulated formation of long cytoplasmic processes and cytoplasmic fragmentation. Activity was found in the 60% to 80% ammonium sulfate fraction of thrombocytopenic plasma but not in the 0% to 60% fraction. The 60% to 80% fraction of normal plasma contained a small amount of activity. Both colchicine and vincristine inhibited the morphogenesis stimulated by thrombocytopenic plasma. Cytochalasin B and D both mimicked the thrombocytopenic plasma-induced morphological change and affected more megakaryocytes than did the thrombocytopenic plasma. Cytochalasin and thrombocytopenic plasma together had a synergistic effect, causing many megakaryocytes to form processes and break into cytoplasmic fragments 3 to 6 microns in diameter. Immunofluorescence staining with antitubulin antiserum showed that cytoplasmic processes formed in the presence of thrombocytopenic plasma contain microtubules and that fragments released by the megakaryocytes contain microtubule rings. A model for the cytoskeletal basis of platelet formation is proposed.

Differences in the X-ray sensitivity of cells in different regions of the sandwich, a diffusion-limited system for cell growth

The sandwich system was recently developed as a tumor analog; like spheroids, sandwiches are diffusion-limited multicellular systems which exhibit a necrotic center and a viable cell border. Using sandwiches of the 9L cell line, we compared the X-ray sensitivity of cells in the inner half of the viable border, adjacent to the necrotic center, with that of cells in the outer half of the viable border, adjacent ot the medium. No cells were hypoxic at the time of irradiation. The cells in the inner half of the viable border exhibited an increased radioresistance over cells in the outer half. The effect was dose multiplying with a multiplying factor of 1.5. Besides the sandwich studies, the X-ray sensitivity of 9L plateau monolayer cultures (induced by starvation) was compared to exponentially growing monolayer cultures. The plateau cultures exhibited an increased radioresistance over the exponentially growing cultures. The effect was also dose multiplying with a multiplying factor of 1.5.