The prognostic impact of reduced variant burden in elderly patients with acute myeloid leukemia treated with decitabine

Background/Aims

We evaluated the role of next-generation sequencing (NGS)-based disease monitoring for elderly patients diagnosed with acute myeloid leukemia (AML) who received decitabine therapy.

Methods

A total of 123 patients aged > 65 years with AML who received decitabine were eligible. We analyzed the dynamics of variant allele frequency (VAF) in 49 available follow-up samples after the fourth cycle of decitabine. The 58.6% VAF clearance (Δ, [VAF at diagnosis - VAF at follow-up] × 100 / VAF at diagnosis) was the optimal cut-off for predicting overall survival (OS).

Results

The overall response rate was 34.1% (eight patients with complete remission [CR], six of CR with incomplete hematologic recovery, 22 with partial responses, and six with morphologic leukemia-free status). Responders (n = 42) had significantly better OS compared with non-responders (n = 42) (median, 15.3 months vs. 6.5 months; p < 0.001). Of the 49 patients available for follow-up targeted NGS analysis, 44 had trackable gene mutations. The median OS of patients with ΔVAF ≥ 58.6% (n=24) was significantly better than that of patients with ΔVAF < 58.6% (n = 19) (20.5 months vs. 9.8 months, p = 0.010). Moreover, responders with ΔVAF ≥ 58.6% (n = 20) had a significantly longer median OS compared with responders with VAF < 58.6% (n = 11) (22.5 months vs. 9.8 months, p = 0.004).

Conclusions

This study suggested that combining ΔVAF ≥ 58.6%, a molecular response, with morphologic and hematologic responses can more accurately predict OS in elderly AML patients after decitabine therapy.

Underwater Endoscopic Mucosal Resection

Although an established standard, conventional endoscopic mucosal resection (EMR) has disseminated despite an absence of studies demonstrating the value of submucosal injection. Several consequences of poorly executed submucosal injection may increase the difficulty and risk of EMR. Underwater EMR (UEMR), an alternative resection method for colonic neoplasms, avoids the need for submucosal injections. In comparison with reported outcomes of EMR, UEMR achieves similar rates of complete resection with comparable safety, with lower rates of recurrence and fewer repeat procedures. UEMR also compares favorably with endoscopic submucosal dissection in terms of procedure time and rates of complete resection, recurrence, and complications.

[Positron emission tomography in germ cell tumors in men : Possibilities and limitations]

BACKGROUND

Conventional radiographic imaging may fail to safely distinguish clinical stage I from stage IIA germ cell cancer, to localize isolated tumor marker relapses, and to equivocally identify the viability of postchemotherapy residual masses.

OBJECTIVES

To provide an overview of the diagnostic value and limitations of functional imaging by positron emission tomography with 2‑deoxy-2-[fluorine-18]fluoro-D-glucose with computed tomography (¹⁸F-FDG-PET-CT) in male germ cell cancer.

MATERIALS AND METHODS

A narrative review based on a literature search of PubMed/MEDLINE for original articles published from 1990-2018 and conference proceedings of ASCO (American Society of Clinical Oncology) and EAU (European Association of Urology) annual meetings 2014-2017 is presented.

RESULTS

¹⁸F-FDG-PET-CT does not improve diagnostic accuracy compared to conventional CT imaging clinical stage (CS) I disease. Particularly PET-negativity of postchemotherapy residual masses of seminomas >3 cm in size guide decision-making against further additional treatment. Even PET-positive residues must not result in relapse. For nonseminoma, the value of PET imaging is reduced by potential mature teratoma components, which are commonly PET negative.

CONCLUSIONS

Current guidelines recommend ¹⁸F-FDG-PET-CT 6-8 weeks postchemotherapy for viability assessment of seminoma residues >3 cm in size. Exceptional circumstances, in which ¹⁸F-FDG-PET-CT may be helpful, include: (1) detection of active disease in CS IS, (2) viability assessment of residual masses >1 cm where complete secondary resection is impossible, (3) staging at marker relapse with unconspicuous conventional CT scan, (4) early response assessment during chemotherapy.

A predictive model for residual disease after (chemo) radiotherapy in oropharyngeal carcinoma: Combined radiological and clinical evaluation of tumor response

Background and purpose

Early detection of Residual disease (RD) is vital for salvage possibilities after (chemo) radiatiotherapy for oropharyngeal carcinoma (OPC). We standardized clinical investigation to test its added value to MRI response evaluation and investigated the benefit of FDG-PET/CT.

Materials and methods

Radiological response evaluation using Ojiri-score was done for 234 patients with OPC, using MRI 12 weeks after (chemo) radiotherapy between 2010 and 2014. The presence of mucosal lesions and/or major complaints (still completely tube feeding-dependent and/or opiate-dependent because of swallowing problems) was scored as clinical suspicion (CS). Retrospectively, the performance of Ojiri to predict RD was compared to CS and both combined using Pearson Chi-squared. Of the whole group, FDG-PET/CT metabolic response (MR) was available in 50 patients.

Results

Twelve out of 234 patients (5.1%) had RD. Ojiri and CS had excellent negative predictive value (NPV) (98% and 100% respectively). The combination of CS and Ojiri reduced false positives by 32% (38-26 patients) without lowering NPV (98%). No patients with complete MR (n = 39) at the FDG-PET/CT had RD compared to 5 (45%) with partial MR.

Conclusion

For response evaluation in OPC, the combination of CS and Ojiri-score improved the predictive accuracy by reducing false positives compared to them individually. FDG-PET/CT is promising to further reduce false positives.

Comparison of residual cancer burden, American Joint Committee on Cancer staging and pathologic complete response in breast cancer after neoadjuvant chemotherapy: results from the I-SPY 1 TRIAL (CALGB 150007/150012; ACRIN 6657)

PURPOSE

Several pathologic staging systems characterize residual tumor in patients undergoing neoadjuvant chemotherapy for breast cancer. Pathologic complete response (pCR) is now accepted by the Food and Drug Administration as an endpoint for granting accelerated drug approval. Two other systems of post-neoadjuvant pathologic tumor staging-residual cancer burden (RCB) and the American Joint Committee on Cancer post-neoadjuvant therapy staging system (yAJCC)-have been developed to characterize residual tumors when patients do not achieve pCR. The optimal system and the ways in which these systems complement each other have not been fully determined.

METHODS

Using data from the I-SPY 1 TRIAL, we compared pCR, RCB, and yAJCC as predictors of early recurrence-free survival (RFS) to identify ways to improve post-neoadjuvant pathologic evaluation.

RESULTS

Among 162 patients assessed, pCR identified patients at lowest risk of recurrence, while RCB and yAJCC identified patients at highest risk. Hormone-receptor (HR) and HER2 subtypes further improved risk prediction. Recursive partitioning indicated that triple-negative or HER2+ patients with yAJCC III or RCB 3 have the highest recurrence risk, with an RFS of 27%. Our analysis also highlighted discrepancies between RCB and yAJCC stratification: 31% of patients had discrepant RCB and yAJCC scores. We identified differential treatment of lymph node involvement and tumor cellularity as drivers of these discrepancies.

CONCLUSIONS

These data indicate that there is benefit to reporting both RCB and yAJCC for patients in order to identify those at highest risk of relapse.

Retiform hemangioendothelioma in the infratemporal fossa and buccal area: a case report and literature review

We report a case of retiform hemangioendothelioma (RH) located in the infratemporal fossa and buccal area in a 13-year-old Korean boy. The tumor originated from the sphenoid bone of the infratemporal fossa area and spread into the cavernous sinus, orbital apex, and retro-nasal area with bone destruction of the pterygoid process. Tumor resection was conducted via Le Fort I osteotomy and partial maxillectomy to approach the infratemporal fossa and retro-nasal area. The diagnosis of RH was confirmed after surgery. In the presented patient, surgical excision was incomplete, and close follow-up was performed. There was no evidence of expansion or metastasis of the residual tumor in the 8 years after surgery. In cases of residual RH with low likelihood of expansion and metastasis, even though RH is an intermediate malignancy, close follow-up can be the appropriate treatment choice over additional aggressive therapy. To date, 29 papers and 48 RH cases have been reported, including this case. This case is the second reported RH case presenting as primary bone tumor and the first case originating in the oromaxillofacial area.

Simultaneous Detection of Disseminated and Circulating Tumor Cells in Primary Breast Cancer Patients

Purpose

Disseminated tumor cells (DTCs) from bone marrow (BM) are a surrogate of minimal residual disease (MRD) in primary breast cancer (PBC) patients and associated with an adverse prognosis. However, BM sampling is an invasive procedure. Although there is growing evidence that circulating tumor cells (CTCs) from the blood are also suitable for monitoring MRD, data on the simultaneous detection of DTCs and CTCs are limited.

Materials and Methods

We determined the presence of DTCs using immunocytochemistry and the pan-cytokeratin antibody A45-B/B3. CTCs were determined simultaneously using a reverse transcription-polymerase chain reaction–based assay (AdnaTest Breast Cancer) and CellSearch (at least one CTC per 7.5 mL blood). We compared the detection of DTCs and CTCs and evaluated their impact on disease-free and overall survival.

Results

Of 585 patients, 131 (22%) were positive for DTCs; 19 of 202 (9%) and 18 of 383 (5%) patients were positive for CTCs, as shown by AdnaTest and CellSearch, respectively. No significant association was observed between DTCs and CTCs (p=0.248 and p=0.146 as shown by AdnaTest and CellSearch, respectively). The presence of DTCs (p=0.046) and the presence of CTCs as shown by CellSearch (p=0.007) were predictive of disease-free survival.

Conclusion

Our data confirm the prognostic relevance of DTCs and CTCs in patients with PBC. As we found no significant relationship between DTCs and CTCs, prospective trials should include their simultaneous detection. Within those trials, the question of whether or not DTCs and CTCs are independent subpopulations of malignant cell clones should be determined by molecular characterization.

Irradiation of donor mononuclear cells for treatment of chemorefractory metastatic solid cancers: a community-based immune transplant pilot study

Purpose

Chemotherapy has demonstrated ability to generate tumor antigens secondary to induction of apoptosis, against which human leukocyte antigen-compatible, irradiated, related donor mononuclear cells may be administered with immune stimulation to activate antigen presenting and cytotoxic T cells, while minimizing risk of graft-versus-host disease (GVHD). The present study endeavours to describe feasibility and efficacy of this treatment, specifically in the community setting.

Materials and Methods

Eligible patients had rapidly progressive, chemorefractory metastatic solid tumors. Treatment consisted of intravenous etoposide and cyclosporine for three days followed by granulocyte-macrophage colony-stimulating factor for 5 days. The following week, 5×10⁷ haploidentical or more closely matched irradiated donor mononuclear cells were given weekly for 10 weeks along with interleukin-2.

Results

Three patients were enrolled, and the regimen was well-tolerated, with no GVHD observed. All patients had clinical response, despite advanced and heavily pretreated disease.

Conclusion

The above-outlined protocol demonstrates favorable tolerability and efficacy, and appears to be feasible in the community setting. While the optimal chemotherapy, immunostimulation, and irradiation regimens may be further optimized, future investigation appears warranted, and may include community oncology programs.

Value of carcinoembryonic antigen and cytokeratins for the detection of recurrent disease following curative resection of colorectal cancer

AIM: To evaluate the efficacy of postoperative serial assay of carcinoembryonic antigen (CEA) and cytokeratins for the detection of recurrent disease in patients with colorectal adenocarcinoma after radical surgery.

METHODS: Between 1993 and 2000, 120 patients with colorectal adenocarcinoma underwent radical surgery in the Department of Surgical Gastroenterology, Federal University of São Paulo-Escola Paulista de Medicina, São Paulo, Brazil. Periodic postoperative evaluation was performed by assaying markers in peripheral serum, colonoscopy and imaging examination. Presence of CEA was detected using the Delfia^® method with 5 μg/L threshold, and cytokeratins using the LIA-mat^® TPA-M Prolifigen^® method with 72 U/L threshold.

RESULTS: In the first postoperative year, patients without recurrent disease had normal levels of CEA (1.5 ± 0.9 μg/L) and monoclonal tissue polypeptide antigen-M (TPA-M, 64.4 ± 47.8 U/L), while patients with recurrences had high levels of CEA (6.9 ± 9.8 μg/L, P < 0.01) and TPA-M (192.2 ± 328.8 U/L, P < 0.05). During the second postoperative year, patients without tumor recurrence had normal levels of CEA (2.0 ± 1.8 μg/L) and TPA-M (50.8 ± 38.4 U/L), while patients with recurrence had high levels of CEA (66.3 ± 130.8 μg/L, P < 0.01) and TPA-M (442.7 ± 652.8 U/L, P < 0.05). The mean follow-up time was 22.3 mo. There was recurrence in 23 cases. Five reoperations were performed without achieving radical excision. Rises in tumor marker levels preceded identification of recurrences: CEA in seven (30%) and TPA-M in eleven individuals (48%).

CONCLUSION: Intensive follow-up by serial assay of CEA and cytokeratins allows early detection of colorectal neoplasm recurrence.