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Brown TJ, Yablonovitch A, Till JE, Yen J, Kiedrowski LA, Hood R, O'Hara MH, Teitelbaum U, Karasic TB, Schneider C, Carpenter EL, Nathanson K, Domchek SM, Reiss KA. The Clinical Implications of Reversions in Patients with Advanced Pancreatic Cancer and Pathogenic Variants in BRCA1, BRCA2, or PALB2 after Progression on Rucaparib. Clin Cancer Res 2023; 29:5207-5216. [PMID: 37486343 PMCID: PMC10806928 DOI: 10.1158/1078-0432.ccr-23-1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/13/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE PARP inhibitors (PARPi) provide an effective maintenance option for patients with BRCA- or PALB2-mutated pancreatic cancer. However, mechanisms of PARPi resistance and optimal post-PARPi therapeutic strategies are poorly characterized. EXPERIMENTAL DESIGN We collected paired cell-free DNA samples and post-PARPi clinical data on 42 patients with advanced, platinum-sensitive pancreatic cancer who were treated with maintenance rucaparib on NCT03140670, of whom 32 developed progressive disease. RESULTS Peripherally detected, acquired BRCA or PALB2 reversion variants were uncommon (5/30; 16.6%) in patients who progressed on rucaparib. Reversions were significantly associated with rapid resistance to PARPi treatment (median PFS, 3.7 vs. 12.5 months; P = 0.001) and poor overall survival (median OS, 6.2 vs. 23.0 months; P < 0.0001). All patients with reversions received rechallenge with platinum-based chemotherapy following PARPi progression and experienced faster progression on this therapy than those without reversion variants (real-world time-to-treatment discontinuation, 2.4 vs. 5.8 months; P = 0.004). Of the patients who progressed on PARPi and received further chemotherapy, the OS from initiation of second-line therapy was significantly lower in those with reversion variants than in those without (5.5 vs. 12.0 months, P = 0.002). Finally, high levels of tumor shedding were independently associated with poor outcomes in patients who received rucaparib. CONCLUSIONS Acquired reversion variants were uncommon but detrimental in a population of patients with advanced BRCA- or PALB2-related pancreatic ductal adenocarcinoma who received maintenance rucaparib. Reversion variants led to rapid progression on PARPi, rapid failure of subsequent platinum-based treatment, and poor OS of patients. The identification of such variants in the blood may have both predictive and prognostic value. See related commentary by Tsang and Gallinger, p. 5005.
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Affiliation(s)
- Timothy J Brown
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jacob E Till
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Ryan Hood
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark H O'Hara
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ursina Teitelbaum
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas B Karasic
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles Schneider
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica L Carpenter
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine Nathanson
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan M Domchek
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kim A Reiss
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Reiss KA, Mick R, Teitelbaum U, O'Hara M, Schneider C, Massa R, Karasic T, Tondon R, Onyiah C, Gosselin MK, Donze A, Domchek SM, Vonderheide RH. Niraparib plus nivolumab or niraparib plus ipilimumab in patients with platinum-sensitive advanced pancreatic cancer: a randomised, phase 1b/2 trial. Lancet Oncol 2022; 23:1009-1020. [PMID: 35810751 PMCID: PMC9339497 DOI: 10.1016/s1470-2045(22)00369-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Establishing alternatives to lifelong chemotherapy for patients with advanced pancreatic cancer has been proposed to address chemotherapy resistance and cumulative toxicity. Poly(ADP-ribose) polymerase (PARP) inhibitors have shown efficacy in this setting, and concurrent immune checkpoint blockade could offer synergistic tumour control. The aim of this study was to test the safety and antitumour activity of maintenance with PARP inhibition combined with immune checkpoint blockade in patients with advanced pancreatic cancer who had a stable response to platinum-based chemotherapy. METHODS We conducted an open-label, randomised, phase 1b/2 study of niraparib plus anti-PD-1 (nivolumab) or anti-CTLA-4 (ipilimumab) therapy for patients with advanced pancreatic cancer whose cancer had not progressed after at least 16 weeks of platinum-based therapy. Patients were randomly assigned (1:1) via permuted block randomisation (block sizes 2 and 4) to niraparib 200 mg orally per day plus either nivolumab 240 mg intravenously every 2 weeks (later changed to 480 mg intravenously every 4 weeks based on manufacturer update) or ipilimumab 3 mg/kg intravenously every 4 weeks for four doses. The primary endpoints were safety and progression-free survival at 6 months. Treatment groups were not compared for activity, which was assessed in each group against a clinically meaningful progression-free survival at 6 months of 44% (null hypothesis). Superiority of a treatment regimen could be declared if 6-month progression-free survival was 60%, and inferiority if 6-month progression-free survival was 27%. All patients who received at least one dose of study treatment and had at least one post-treatment assessment of response according to Response Evaluation Criteria in Solid Tumours version 1.1 were included in the efficacy population. The safety population consisted of all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT03404960, and enrolment is completed and follow-up is ongoing. FINDINGS 91 patients were enrolled between Feb 7, 2018, and Oct 5, 2021 and were randomly assigned to niraparib plus nivolumab (n=46) or niraparib plus ipilimumab (n=45). Of these patients, 84 were evaluable for the progression-free survival endpoint (niraparib plus nivolumab=44; niraparib plus ipilimumab=40). Median follow-up was 23·0 months (IQR 15·0-31·5). 6-month progression-free survival was 20·6% (95% CI 8·3-32·9; p=0·0002 vs the null hypothesis of 44%) in the niraparib plus nivolumab group; and 59·6% (44·3-74·9; p=0·045) in the niraparib plus ipilimumab group. Ten (22%) of 46 patients in the niraparib plus nivolumab group and 23 (50%) of 45 patients in the niraparib plus ipilimumab group had a grade 3 or worse treatment-related adverse event. The most common grade 3 or worse adverse events in the niraparib plus nivolumab group were hypertension (in four [8%] patients), anaemia (two [4%]), and thrombocytopenia (two [4%]) whereas in the niraparib plus ipilimumab group these were fatigue (in six [14%]), anaemia (five [11%]), and hypertension (four [9%]). There were no treatment-related deaths. INTERPRETATION The primary endpoint of 6-month progression-free survival was met in the niraparib plus ipilimumab maintenance group, whereas niraparib plus nivolumab yielded inferior progression-free survival. These findings highlight the potential for non-cytotoxic maintenance therapies in patients with advanced pancreatic cancer. FUNDING Bristol Myers Squibb, GlaxoSmithKline, the Basser Center Young Leadership Council, The Konner Foundation, The Pearl and Philip Basser Innovation Research Award, the Anonymous Foundation, and the US National Institutes of Health.
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Affiliation(s)
- Kim A Reiss
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA.
| | - Rosemarie Mick
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, PA, USA
| | - Ursina Teitelbaum
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Mark O'Hara
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Charles Schneider
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Ryan Massa
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Thomas Karasic
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Rashmi Tondon
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Pathology, University of Pennsylvania, PA, USA
| | - Chioma Onyiah
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Mary Kate Gosselin
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Alyssa Donze
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Susan M Domchek
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
| | - Robert H Vonderheide
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Medicine, University of Pennsylvania, PA, USA
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Soulen M, Eads J, Teitelbaum U, Damjanov N, Schneider C. Abstract No. 28 Radiosensitization for TARE: does duration of chemotherapy affect PFS? J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Soulen M, Eads J, Teitelbaum U, Damjanov N, Schneider C. Abstract No. 246 CapTemY90 for grade 2 liver-dominant NET metastases. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Arscott WT, Nead KT, Bear A, Venigalla S, Shabason J, Lukens JN, Plastaras JP, Wojcieszynski A, Metz J, O’Hara M, Reiss KA, Teitelbaum U, Loaiza-Bonilla A, Drebin J, Lee MK, Shroff SG, Ben-Josef E. Concurrent Nab-paclitaxel and Radiotherapy: Novel Radiosensitization for Borderline Resectable or Unresectable Pancreatic Cancer. Am J Clin Oncol 2021; 44:469-474. [PMID: 34310350 PMCID: PMC8404955 DOI: 10.1097/coc.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE This study evaluates the toxicity and tumor response with concurrent nab-paclitaxel chemoradiotherapy (CRT) compared with standard (5-fluorouracil or gemcitabine) CRT. MATERIALS AND METHODS Fifty patients with borderline resectable or unresectable pancreatic adenocarcinoma from 2014 to 2017 were divided into 2 groups: concurrent nab-paclitaxel (100 to 125 mg/m2 weekly) CRT (median: 2.1 Gy fraction size and 52.5 Gy total) or standard CRT (median: 1.8 Gy fraction size, 54.5 Gy total). The primary endpoint was toxicity, and secondary endpoints were local failure and conversion to resectability. Comparisons were made using rank-sum or Fisher exact test and multivariable competing risk regression for the cumulative incidence of local failure. RESULTS There were 28 patients in the nab-paclitaxel CRT group and 22 in the standard CRT group; 88% had the unresectable disease. The median follow-up was 18 months. The median duration of chemotherapy before concurrent CRT was 1.9 and 2.3 months in the nab-paclitaxel and standard CRT groups (P=0.337), and radiotherapy dose was 52.5 Gy (range, 52.5 to 59.4 Gy) and 54.5 Gy (range, 45.0 to 59.4 Gy), respectively. There were no statistically significant grade ≥2 toxicities. The nab-paclitaxel CRT group experienced a nonstatistically significant lower incidence of local failure (hazard ratio=0.91, 95% confidence interval: 0.27-3.03, P=0.536). More patients in the nab-paclitaxel CRT group proceeded to surgery (9/28 compared with 3/22 in the standard CRT, P=0.186); of which 6 (25%) in the nab-paclitaxel CRT and 2 (10%) in the standard CRT groups were initially unresectable. CONCLUSIONS Nab-paclitaxel CRT had similar toxicity compared with standard CRT in the treatment of borderline resectable or unresectable pancreatic cancer. Its use was associated with an arithmetically lower cumulative incidence of local failure and an arithmetically higher conversion to resectability, both of which were not statistically significant.
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Affiliation(s)
| | - Kevin T. Nead
- Departments of Radiation Oncology
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | | | | | - Jeffrey Drebin
- Surgery, University of Pennsylvania
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Reiss KA, Mick R, O'Hara MH, Teitelbaum U, Karasic TB, Schneider C, Cowden S, Southwell T, Romeo J, Izgur N, Hannan ZM, Tondon R, Nathanson K, Vonderheide RH, Wattenberg MM, Beatty G, Domchek SM. Phase II Study of Maintenance Rucaparib in Patients With Platinum-Sensitive Advanced Pancreatic Cancer and a Pathogenic Germline or Somatic Variant in BRCA1, BRCA2, or PALB2. J Clin Oncol 2021; 39:2497-2505. [PMID: 33970687 DOI: 10.1200/jco.21.00003] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Olaparib, a poly (ADP-ribose) polymerase (PARP) inhibitor (PARPi), is approved as maintenance therapy for patients with advanced pancreatic cancer (PC) and a germline BRCA1 or BRCA2 pathogenic variant (PV). This investigator-initiated, single-arm phase II study assessed the role of the PARPi rucaparib as maintenance therapy in advanced PC with germline or somatic PV in BRCA1, BRCA2, or PALB2. PATIENTS AND METHODS Eligible patients had advanced PC; germline (g) or somatic (s) PVs in BRCA1, BRCA2, or PALB2, and received at least 16 weeks of platinum-based chemotherapy without evidence of platinum resistance. Chemotherapy was discontinued and patients received rucaparib 600 mg orally twice a day until progression. The primary end point was the progression-free survival (PFS) rate at 6 months (PFS6). Secondary end points included safety, ORR, disease control rate, duration of response, and overall survival. RESULTS Of 46 enrolled patients, 42 were evaluable (27 gBRCA2, seven gBRCA1, six gPALB2, and two sBRCA2). PFS6 was 59.5% (95% CI, 44.6 to 74.4), median PFS was 13.1 months (95% CI, 4.4 to 21.8), and median overall survival was 23.5 months (95% CI, 20 to 27). The PFS at 12 months was 54.8%. ORR of the 36 patients with measurable disease was 41.7% (3 complete responses; 12 partial responses; 95% CI, 25.5 to 59.2), and disease control rate was 66.7% (95% CI, 49.0 to 81.4). Median duration of response was 17.3 months (95% CI, 8.8 to 25.8). Responses occurred in patients with gBRCA2 (41%, 11 out of 27), gPALB2 (50%, 3 out of 6), and sBRCA2 (50%, 1 out of 2). No new safety signals were noted. CONCLUSION Maintenance rucaparib is a safe and effective therapy for platinum-sensitive, advanced PC with a PV in BRCA1, BRCA2, or PALB2. The finding of efficacy in patients with gPALB2 and sBRCA2 PVs expands the population likely to benefit from PARPi beyond gBRCA1/2 PV carriers.
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Affiliation(s)
- Kim A Reiss
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemarie Mick
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark H O'Hara
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ursina Teitelbaum
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Thomas B Karasic
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Charles Schneider
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stacy Cowden
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Traci Southwell
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Janae Romeo
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Natallia Izgur
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Zain M Hannan
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rashmi Tondon
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Katherine Nathanson
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert H Vonderheide
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Max M Wattenberg
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gregory Beatty
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Susan M Domchek
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Varughese LA, Lau-Min KS, Cambareri C, Damjanov N, Massa R, Reddy N, Oyer R, Teitelbaum U, Tuteja S. DPYD and UGT1A1 Pharmacogenetic Testing in Patients with Gastrointestinal Malignancies: An Overview of the Evidence and Considerations for Clinical Implementation. Pharmacotherapy 2020; 40:1108-1129. [PMID: 32985005 PMCID: PMC8796462 DOI: 10.1002/phar.2463] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastrointestinal (GI) malignancies are among the most commonly diagnosed cancers worldwide. Despite the introduction of targeted and immunotherapy agents in the treatment landscape, cytotoxic agents, such as fluoropyrimidines and irinotecan, remain as the cornerstone of chemotherapy for many of these tumors. Pharmacogenetics (PGx) is a rapidly evolving field that accounts for interpatient variability in drug metabolism to predict therapeutic response and toxicity. Given the significant incidence of severe treatment-related adverse events associated with cytotoxic agents, utilizing PGx can allow clinicians to better anticipate drug tolerability while minimizing treatment interruptions or delays. In this review, the PGx profiles of drug-gene pairs with potential impact in GI malignancy therapy - DPYD-5-fluorouracil/capecitabine and UGT1A1-irinotecan - and the available clinical evidence of their roles in reducing severe adverse events are discussed. Considerations for clinical implementation, such as optimal laboratory workflows, electronic health record integration, and stakeholder engagement, as well as provider education, are addressed. Last, exploratory PGx markers in GI malignancy treatment are described. As the PGx knowledge base rapidly evolves, pharmacists will be vital in leveraging their pharmacology knowledge and clinical skills to implement PGx testing in the clinic.
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Affiliation(s)
- Lisa A. Varughese
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kelsey S. Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine Cambareri
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nevena Damjanov
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan Massa
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandi Reddy
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, Pennsylvania
| | - Randall Oyer
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, Pennsylvania
| | - Ursina Teitelbaum
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Bauman B, Mick R, Martinez E, Lawless TM, Zinck L, Sinclair P, Fuhrer M, O'Hara M, Schneider CJ, O'Dwyer P, Plastaras J, Teitelbaum U, Reiss KA. Efficacy of Oral Cryotherapy During Oxaliplatin Infusion in Preventing Oral Thermal Hyperalgesia: A Randomized Trial. J Natl Compr Canc Netw 2020; 17:358-364. [PMID: 30959472 DOI: 10.6004/jnccn.2018.7110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/21/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chemotherapy-induced oral thermal hyperalgesia (OTH) is a common and debilitating side effect of platinum-based anticancer agents. This study evaluated the efficacy of oral cryotherapy in preventing OTH during oxaliplatin chemotherapy infusion. METHODS Patients with gastrointestinal cancer treated with biweekly oxaliplatin (85 mg/m2 over 120 minutes) at Abramson Cancer Center at the University of Pennsylvania were randomized to receive oral cryotherapy (ice chips) during oxaliplatin infusion or standard-of-care treatment. All patients completed baseline questionnaires regarding oral and peripheral symptoms and on-treatment questionnaires on day 1 of each subsequent chemotherapy cycle. Those in the treatment arm were asked to document how long they kept the ice chips in their mouths (0, <30, 30, 60, 90, or 120 minutes) and to report their discomfort associated with oral cryotherapy. Evaluable patients were those who had completed at least 2 cycles of oxaliplatin therapy. RESULTS Of 62 randomized patients with a variety of gastrointestinal malignancies, 50 (25 per treatment arm) were evaluable for efficacy. The rate of patients with oral symptoms after the first treatment cycle was significantly lower in the intervention arm (n=8; 32%) than in the control arm (n=18; 72%), meeting the primary study objective (P=.01). The magnitude of difference in symptom scores before versus after the first treatment cycle was significantly less in the intervention versus control arm (P=.001). No difference in oral symptoms over time was seen between the intervention and control groups (P=.20), although a high attrition rate was noted. Duration of ice chip exposure was associated with improved oral symptoms over time (P=.02). CONCLUSIONS Oral cryotherapy is a tolerable and cost-effective method of diminishing OTH in patients receiving oxaliplatin chemotherapy, and seems to be most effective in the early stages of treatment.
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Affiliation(s)
| | - Rosemarie Mick
- aAbramson Cancer Center.,bDepartment of Biostatistics, Epidemiology, and Informatics
| | | | | | | | | | | | - Mark O'Hara
- aAbramson Cancer Center.,cDepartment of Medicine, and
| | | | - Peter O'Dwyer
- aAbramson Cancer Center.,cDepartment of Medicine, and
| | - John Plastaras
- aAbramson Cancer Center.,dDepartment of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Kim A Reiss
- aAbramson Cancer Center.,cDepartment of Medicine, and
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Yu S, Agarwal P, Mamtani R, Symecko H, Spielman K, O’Hara M, O’Dwyer PJ, Schneider C, Teitelbaum U, Nathanson KL, Domchek SM, Reiss KA. Retrospective Survival Analysis of Patients With Resected Pancreatic Ductal Adenocarcinoma and a Germline BRCA or PALB2 Mutation. JCO Precis Oncol 2019; 3:1-11. [PMID: 35100679 DOI: 10.1200/po.18.00271] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Germline mutations in the homologous recombination genes BRCA1, BRCA2, and PALB2 confer an increased risk for pancreatic ductal adenocarcinoma (PDAC). Tumors associated with mutations in homologous recombination genes are sensitive to DNA-damaging agents. We retrospectively studied patients with resected PDAC and a pathogenic germline mutation in one of these three genes. The planned analyses included overall survival (OS) and changes therein when platinum chemotherapy was used in the perioperative setting. MATERIALS AND METHODS Thirty-two individuals with pathogenic germline mutations in BRCA1, BRCA2, or PALB2 and resected PDAC (mutation positive) were matched in a 1:2 fashion to patients who were noncarriers or untested (mutation negative) by age, year of diagnosis, stage, and sex. Patients were identified via one of two available databases at University of Pennsylvania: the Basser Center for BRCA Registry or the electronic medical record. The primary outcome was OS. RESULTS Patients in the mutation-positive group had a median OS (mOS) of 46.6 months; those in the mutation-negative group had an mOS of 23.2 months (hazard ratio [HR], 0.49; 95% CI, 0.27 to 0.88). With platinum exposure in the perioperative setting, mOS in the mutation-positive group had not yet been met versus a mOS of 23.1 months in the mutation-negative group (HR, 0.12; 95% CI, 0.01 to 1.00). When neither group was treated with platinum, there was no significant OS difference between groups (HR, 0.52; 95% CI 0.12 to 2.24). Patients in the mutation-positive group who received perioperative treatment with platinum had a trend toward improved mOS compared with those who did not (HR, 0.15; 95% CI, 0.02 to 1.23; P = .07). CONCLUSION Platinum-based chemotherapy may confer a survival benefit in patients with resected PDAC and a pathogenic germline BRCA1, BRCA2, or PALB2 mutation. Knowledge of a germline mutation may be important to determine best choice of perioperative chemotherapy.
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Affiliation(s)
- Shun Yu
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | | | - Ronac Mamtani
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Heather Symecko
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Kelsey Spielman
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Mark O’Hara
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Peter J. O’Dwyer
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Charles Schneider
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Ursina Teitelbaum
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Katherine L. Nathanson
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Susan M. Domchek
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
| | - Kim A. Reiss
- University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, West Chester, PA
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Binder KAR, Mick R, O'Hara M, Teitelbaum U, Karasic T, Schneider C, O'Dwyer PJ, Carpenter E, Pantel A, Makvandi M, Mankoff D, Nathanson K, Maxwell K, Cowden S, Fuhrer MJ, Romeo J, Beatty GL, Domchek S. Abstract CT234: A Phase II, single arm study of maintenance rucaparib in patients with platinum-sensitive advanced pancreatic cancer and a pathogenic germline or somatic mutation in BRCA1, BRCA2 or PALB2. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct234] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: PARP inhibitors have activity in multiple BRCA-related malignancies and have recently demonstrated dramatic efficacy as a maintenance strategy for platinum-sensitive ovarian cancer. Between 5-8% of patients with pancreatic cancer (PC) have a pathogenic mutation in BRCA1, BRCA2 or PALB2. Therefore, we initiated a single arm phase II clinical trial of maintenance monotherapy rucaparib in patients with advanced PC and a pathogenic germline or somatic BRCA or PALB2 mutation, whose cancer had not progressed following at least four months of platinum-based chemotherapy (NCT 03140670).
Methods: Patients were enrolled and treated with rucaparib 600mg PO BID until disease progression or unacceptable toxicity. The primary endpoint is progression free survival (PFS). Patients have previously received >4 months of platinum-based chemotherapy without evidence of disease progression. However, patients with a medical contraindication to receiving the full four months of platinum have been permitted to enroll at the discretion of the primary investigator. Responses were determined using RECIST v1.1.
Results: As of December 31st, 2018, we have enrolled 24 of the planned 42 patients, of which 19 are evaluable for PFS at the time of this interim analysis. For these patients, the mutational distribution includes: 13 germline BRCA2, 3 germline BRCA1, 2 germline PALB2, 1 somatic BRCA2. Patients were predominantly female (84.2%) with a median age of 61 years (range: 35-81). Patients had received a median of four months (range 0.5-32 months) of prior platinum therapy for advanced disease. All patients were evaluable for toxicity. Overall, treatment with rucaparib was well tolerated without dose limiting toxicities. The most common adverse events that were at least possibly related to treatment included nausea (grade 1, 41.6%; grade 2, 4.2%), dysgeusia (grade 1, 33.3%) and fatigue (grade 1, 25%). One patient required dose reduction for nausea. The median PFS was 9.1 months from the start of rucaparib therapy with an ORR of 36.8% (six PRs; one CR). Disease control rate (CR + PR + SD) was 89.5% for at least eight weeks. Two patients (10.5%) had progressive disease at first follow-up scan two months after beginning treatment. Eight patients have been on rucaparib for >6 months and two patients remain on treatment for >1 year (13 months and 15 months). The seven responding patients include those with germline BRCA2 mutations (4 patients), germline PALB2 mutations (2 patients) and somatic BRCA2 mutation (1 patient).
Conclusions: Based on these early data, maintenance rucaparib following induction with platinum-based chemotherapy shows encouraging disease control with minimal toxicity in patients with platinum-sensitive advanced PC and a pathogenic mutation in BRCA1, BRCA2 or PALB2.
Citation Format: Kim A. Reiss Binder, Rosemarie Mick, Mark O'Hara, Ursina Teitelbaum, Thomas Karasic, Charles Schneider, Peter J. O'Dwyer, Erica Carpenter, Austin Pantel, Mehran Makvandi, David Mankoff, Katherine Nathanson, Kara Maxwell, Stacy Cowden, Mary Jane Fuhrer, Janae Romeo, Gregory L. Beatty, Susan Domchek. A Phase II, single arm study of maintenance rucaparib in patients with platinum-sensitive advanced pancreatic cancer and a pathogenic germline or somatic mutation in BRCA1, BRCA2 or PALB2 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT234.
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Affiliation(s)
| | | | - Mark O'Hara
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Janae Romeo
- University of Pennsylvania, Philadelphia, PA
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Lubner S, Feng Y, Mulcahy M, O'Dwyer P, Giang GY, Hinshaw JL, Deming D, Klein L, Teitelbaum U, Payne J, Engstrom P, Stella P, Meropol N, Benson A. E4206: AMG 706 and Octreotide in Patients with Low-Grade Neuroendocrine Tumors. Oncologist 2018; 23:1006-e104. [PMID: 29853660 PMCID: PMC6192662 DOI: 10.1634/theoncologist.2018-0294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 03/08/2017] [Indexed: 12/23/2022] Open
Abstract
LESSONS LEARNED Rate of progression-free survival at a particular point in time, i.e., a landmark analysis, is a difficult endpoint for a heterogenous malignancy such as neuroendocrine cancer.Landmark analyses can also be complicated by evolution in the standard of care during the conduct of a clinical trial.Improvements in biomarker development would be useful in developing future clinical trials in NET to better tailor individualized therapies and assess for possible efficacy endpoints. BACKGROUND Neuroendocrine tumors (NETs) are rare malignancies of the gastrointestinal (GI) tract that are highly vascularized and overexpress vascular-endothelial growth factor (VEGF). Sunitinib has demonstrated efficacy in the pancreatic subset of NET. This study explored the activity of another oral VEGF inhibitor, AMG 706 or motesanib, a multikinase inhibitor that targets receptor tyrosine kinases, including VEGFR1, VEGFR2, VEGFR3, KIT, RET, and PDGFR (IC50s = 2, 3, 6, 8, 59, and 84 nM, respectively). METHODS This was a single-arm, first-line, phase II study run through the Eastern Cooperative Oncology Group. Patients with low-grade NET (as defined by central confirmation of Ki-67 of 0%-2%) were administered a flat dose of 125 mg per day orally combined with octreotide long acting-repeatable (LAR) for patients who had been on a stable dose. The primary objective was to determine the 4-month progression-free survival (PFS). RESULTS Forty-four patients were evaluated per protocol. The 4-month PFS was 78.5%. The partial response rate was 13.6% (6/44), stable disease was 54.5% (24/44), 9.1% (4/44) had progressive disease, and 10/44 were not evaluable for response. Common toxicities included fatigue, hypertension, nausea, and headache, and most were grade 1-2. Median PFS was 8.7 months, and overall survival was 27.5 months. CONCLUSION Motesanib (AMG 706) demonstrated a 4-month PFS that met the per-protocol definition of efficacy. Fatigue and hypertension were the most common toxicities, and few grade 3-4 toxicities were encountered. The progression-free survival of 8.7 months in all NETs merits further study.
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Affiliation(s)
- Sam Lubner
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin, USA
| | - Yang Feng
- Eastern Cooperative Oncology Group-American College of Radiology Imaging Network, Boston, Massachusetts, USA
| | - Mary Mulcahy
- Northwestern University, Evanston, Illinois, USA
| | - Peter O'Dwyer
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Dustin Deming
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin, USA
| | | | | | | | - Paul Engstrom
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | | | - Neal Meropol
- Flatiron Health, New York, New York, USA
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA; Flatiron Health, New York, New York, USA
| | - Al Benson
- Northwestern University, Evanston, Illinois, USA
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Soulen M, Teitelbaum U, van Houten D, Deitrick G, Damjanov N, Gabriel C, O’Hara M, Cengel K, Mondschein J, Dagli M, Metz D. 3:36 PM Abstract No. 265 Safety and feasibility of integrating yttrium-90 radioembolization with capecitabine-temozolomide for grade 2 liver-dominant metastatic neuroendocrine tumors (CapTemY90): final report. J Vasc Interv Radiol 2018. [DOI: 10.1016/j.jvir.2018.01.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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13
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Shabason JE, Chen J, Apisarnthanarax S, Damjanov N, Giantonio B, Loaiza-Bonilla A, O'Dwyer PJ, O'Hara M, Reiss KA, Teitelbaum U, Wissel P, Drebin JA, Vollmer C, Kochman M, Mick R, Vergara N, Jhala N, Doucette A, Lukens JN, Plastaras JP, Metz JM, Ben-Josef E. A phase I dose escalation trial of nab-paclitaxel and fixed dose radiation in patients with unresectable or borderline resectable pancreatic cancer. Cancer Chemother Pharmacol 2018; 81:609-614. [PMID: 29362902 DOI: 10.1007/s00280-018-3519-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/09/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Patients with locally advanced pancreatic cancer typically have poor outcomes, with a median survival of approximately 16 months. Novel methods to improve outcomes are needed. Nab-paclitaxel (Abraxane) has shown efficacy in pancreatic cancer and is FDA-approved for metastatic disease in combination with gemcitabine. Nab-paclitaxel is also a promising radiosensitizer based on laboratory studies, but it has never been clinically tested with definitive radiotherapy for locally advanced pancreatic carcinoma. METHODS We performed a phase 1 study using a 3 + 3 dose escalation strategy to determine the safety and tolerability of dose-escalated nab-paclitaxel with fractionated radiotherapy for patients with unresectable or borderline resectable pancreatic cancer. Following induction chemotherapy with two cycles of nab-paclitaxel and gemcitabine, patients were treated with weekly nab-paclitaxel and daily radiotherapy to a dose of 52.5 Gy in 25 fractions. Final dose-limiting toxicity (DLT) determination was performed at day 65 after the start of radiotherapy. RESULTS Nine patients received nab-paclitaxel at a dose level of either 100 mg/m2 (n = 3) or 125 mg/m2 (n = 6). There were no observed grade 3 gastrointestinal toxicities. One DLT (grade 3 neuropathy) was observed in a patient who received 125 mg/m2 of nab-paclitaxel. Other grade 3 toxicities included fatigue (11%), anemia (11%) and neutropenia (11%). No grade 4 toxicities were observed. Following chemoradiotherapy, four patients (borderline resectable, n = 2 and unresectable, n = 2) underwent surgical resection, all with negative margins and with significant treatment effect with limited tumor viability. CONCLUSIONS The combination of fractionated radiation and weekly full dose nab-paclitaxel was safe and well-tolerated.
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Affiliation(s)
- Jacob E Shabason
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Jerry Chen
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Nevena Damjanov
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bruce Giantonio
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arturo Loaiza-Bonilla
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Peter J O'Dwyer
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark O'Hara
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kim A Reiss
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ursina Teitelbaum
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Wissel
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloane Kettering Cancer Center, New York, NY, USA
| | - Charles Vollmer
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Kochman
- Gastroenterology Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rosemarie Mick
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Norge Vergara
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nirag Jhala
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Abigail Doucette
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - John N Lukens
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - James M Metz
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
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Clasen SC, Ky B, O'Quinn R, Giantonio B, Teitelbaum U, Carver JR. Fluoropyrimidine-induced cardiac toxicity: challenging the current paradigm. J Gastrointest Oncol 2017; 8:970-979. [PMID: 29299356 PMCID: PMC5750187 DOI: 10.21037/jgo.2017.09.07] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/08/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fluoropyrimidine chemotherapy [5-fluorouracil (5-FU) and capecitabine] are commonly used agents in the treatment of various solid malignancies. However, their use has been limited by cardiac toxicity, presenting as a wide spectrum of asymptomatic (e.g., EKG changes) and symptomatic (e.g., chest pain) manifestations related to coronary vasospasm leading to myocardial ischemia. Historically, patients with suspected coronary vasospasm have been treated with traditional acute ischemic workup and various combinations of anti-anginal therapies. In addition, most patients typically are not rechallenged with fluoropyrimidine after experiencing initial cardiovascular side-effects with resulting interruption of planned chemotherapy regimens. METHODS We report a case series of 11 consecutive patients in a single-center with suspected fluoropyrimidine-induced coronary vasospasm who were successfully rechallenged with the culprit drug to allow for planned chemotherapy completion. Our protocol utilized rechallenge with bolus infusional regimen of intravenous fluoropyrimidine chemotherapy and oral capecitabine with cardioprotective pretreatment with two calcium blockers and long-acting oral nitrate therapy. RESULTS We were successfully able to continue and complete the previously planned first-line chemotherapy regimen for all 11 patients with minimal therapeutic interruption. There have been no cardiac events or evidence of recurrent coronary spasm after completion of therapy with discontinuation of prophylactic medications upon therapy completion. CONCLUSIONS We report a single-institution experience of successful rechallenge with fluoropyrimidines with careful cardiac monitoring and the combined use of calcium channel blockers and long-acting nitrates. With further study, this algorithm can be used to safely continue fluoropyrimidines, a potentially curative regimen in the treatment of many solid tumors.
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Affiliation(s)
- Suparna C Clasen
- Cardio-oncology in the Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bonnie Ky
- Cardio-oncology in the Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rupal O'Quinn
- Cardio-oncology in the Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bruce Giantonio
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ursina Teitelbaum
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Carver
- Cardio-oncology in the Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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15
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Boimel PJ, Berman AT, Li J, Apisarnthanarax S, Both S, Lelionis K, Larson GL, Teitelbaum U, Lukens JN, Ben-Josef E, Metz JM, Plastaras JP. Proton beam reirradiation for locally recurrent pancreatic adenocarcinoma. J Gastrointest Oncol 2017; 8:665-674. [PMID: 28890817 DOI: 10.21037/jgo.2017.03.04] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Local recurrence following definitive treatment for pancreatic adenocarcinoma is common and can be associated with significant morbidity and mortality. Retreatment options for these patients are limited. Proton beam reirradiation (PRT) may limit dose and toxicity to previously irradiated normal tissues in patients without evidence of metastatic disease. METHODS Between 8/2010-2/2015, 15 patients with isolated, locally-recurrent pancreatic cancer were treated with PRT. Acute toxicity was graded using CTC v 4.0 and defined as occurring within 90 days. Kaplan-Meier survival analysis was performed from the start of PRT. A log-rank test was used to compare survival with or without concurrent chemotherapy. RESULTS Median follow-up was 15.7 months [2-48] from the start of PRT. The median clinical target volume (CTV) was 71 cc [15-200]. Ten (67%) patients received concurrent chemotherapy. Median PRT dose was 59.4 Gy (37.5-59.4 Gy). The median time interval from the prior treatment course was 26.7 months (7-461.3). There was a rate of 13% acute ≥ grade 3 toxicities attributed to PRT. The median overall survival (OS) was 16.7 months (95% CI, 4.7-36) and OS at 1 year was 67%. The "in-field" failure free survival at one year was 87%. The locoregional progression free survival (LPFS) and distant metastasis free survival (DMFS) at 1 year was 72% and 64% respectively. Concurrent chemotherapy was associated with a higher median survival. CONCLUSIONS PRT was well tolerated, resulted in prolonged clinical outcomes compared to historical controls, and should be considered as a treatment option with concurrent chemotherapy in selected patients with locally-recurrent pancreatic cancer.
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Affiliation(s)
- Pamela J Boimel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Jonathan Li
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | | | - Stefan Both
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York, USA
| | - Kristi Lelionis
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | | | - Ursina Teitelbaum
- Department of Hematology Oncology, University of Pennsylvania, Philadelphia, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - James M Metz
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
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Levy JL, Sudheendra D, Dagli M, Mondschein JI, Stavropoulos SW, Shlansky-Goldberg RD, Trerotola SO, Teitelbaum U, Mick R, Soulen MC. Percutaneous biliary drainage effectively lowers serum bilirubin to permit chemotherapy treatment. Abdom Radiol (NY) 2016; 41:317-23. [PMID: 26867914 DOI: 10.1007/s00261-015-0580-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE For digestive tract cancers, the bilirubin threshold for administration of systemic chemotherapy can be 5 or 2 mg/dL (85.5 or 34.2 μmol/L) depending upon the regimen. We examined the ability of percutaneous biliary drainage (PBD) in patients with malignant biliary obstruction to achieve these clinically relevant endpoints. METHODS 106 consecutive patients with malignant biliary obstruction and a baseline serum bilirubin >2 mg/dL underwent PBD. Time to achieve a bilirubin of 5 mg/dL (85.5 μmol/L), 2 mg/dL (34.2 μmol/L), and survival was estimated by Kaplan-Meier analysis. Potential technical and clinical prognostic factors were subjected to univariate and multivariate analysis. Categorical variables were analyzed by the log rank test. Hazard ratios were calculated for continuous variables. RESULTS Median survival was 100 days (range 1-3771 days). Among 88 patients with a pre-drainage bilirubin >5 mg/dL, 62% achieved a serum bilirubin ≤5 mg/dL within 30 days and 84% within 60 days, median 21 days. Among 106 patients with a pre-drainage bilirubin >2 mg/dL, 37% achieved a serum bilirubin ≤2 mg/dL by 30 days and 70% within 60 days, median 43 days. None of the technical or clinical factors evaluated, including pre-drainage bilirubin, were significant predictors of time to achieve a bilirubin ≤2 mg/dL (p = 0.51). Size and type of biliary device were the only technical variables found to affect time to bilirubin of 5 mg/dL (p = 0.016). CONCLUSION PBD of malignant obstruction achieves clinically relevant reduction in serum bilirubin in the majority of patients within 1-2 months, irrespective of the pre-drainage serum bilirubin, sufficient to allow administration of systemic chemotherapy. However, the decision to undergo this procedure for this indication alone must be considered in the context of patients' prognosis and treatment goals.
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Affiliation(s)
- Jennifer L Levy
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Deepak Sudheendra
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mandeep Dagli
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey I Mondschein
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Scott O Trerotola
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ursina Teitelbaum
- Division of Gastrointestinal Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Rosemarie Mick
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Soulen
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Radiology, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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Datta J, McMillan MT, Shang EK, Mamtani R, Lewis RS, Kelz RR, Teitelbaum U, Plastaras JP, Drebin JA, Fraker DL, Karakousis GC, Roses RE. Omission of Adjuvant Therapy After Gastric Cancer Resection: Development of a Validated Risk Model. J Natl Compr Canc Netw 2015; 13:531-41. [DOI: 10.6004/jnccn.2015.0073] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Grover S, Jones JA, Teitelbaum U, Apisarnthanarax S. Radiation recall myositis: two sites, one patient. Pract Radiat Oncol 2014; 5:39-42. [PMID: 25413426 DOI: 10.1016/j.prro.2014.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 03/18/2014] [Accepted: 03/20/2014] [Indexed: 12/25/2022]
Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Joshua A Jones
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ursina Teitelbaum
- Department of Medicine, Division of Medical Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Berman A, Barsky A, Mick R, Metz J, Ben-Josef E, Teitelbaum U, Williams N, Kucharczuk J, Margolis D, Plastaras J. Perioperative Complications After Neoadjuvant Chemoradiation for Locally Advanced Esophageal Cancer: A Comparison of Platinum/5-FU (PF) and Carboplatin/Paclitaxel (PT). Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Soulen M, Deitrick G, van Houten D, Stavropoulos S, Teitelbaum U, Giantonio B. Feasibility of combining capecitabine and temozolomide with yttrium 90 radioembolization (CapTemY90) for intermediate grade neuroendocrine tumors. J Vasc Interv Radiol 2014. [DOI: 10.1016/j.jvir.2013.12.429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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21
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Levy J, Shlansky-Goldberg R, Stavropoulos W, Trerotola S, Mondschein J, Dagli M, Sudheendra D, Teitelbaum U, Mick R, Soulen M. Is percutaneous biliary drainage effective in lowering serum bilirubin for chemotherapy? J Vasc Interv Radiol 2014. [DOI: 10.1016/j.jvir.2013.12.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Jones JA, Patel VB, Goldsmith B, Teitelbaum U, Plastaras JP. Diffusely Metastatic Digital Papillary Adenocarcinoma 11 Years After Initial Presentation Treated With Palliative Chemotherapy and Radiotherapy. J Clin Oncol 2013; 31:e386-9. [DOI: 10.1200/jco.2012.46.4693] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Joshua A. Jones
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vatsal B. Patel
- University of Connecticut School of Medicine, Farmington, CT
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