Stage 4 pancreatic adenocarcinoma harbouring an FGFR2-TACC2 fusion mutation with complete response to erdafitinib a pan-fibroblastic growth factor receptor inhibitor

We report a case of a frail 68-year-old woman with stage 4 pancreatic carcinoma harbouring a fibroblastic growth factor receptor 2 (FGFR2) fusion who achieved a durable complete response after treatment with erdafitinib a pan-FGFR inhibitor. The FGFR2-TACC2 fusion was detected on comprehensive tumour somatic mutation profiling. There is ongoing complete response at 10 months after initiation of erdafitinib. Transient central serous retinopathy, grade 2 hyperphosphataemia and diarrhoea were the adverse events encountered.

How efficient is modern peri-urban nitrogen cycling: A case study

Urban centres acquire and accumulate many materials from their hinterland, among these are nutrient elements such as nitrogen (N). The popular North American vision of a peri-urban setting is one where urban food production, composting and re-cycling are assumed to limit urban accumulation of nutrients. This study quantifies this assumption using the Lower Fraser Valley (LFV) of British Columbia as an example, ideal because it is surrounded by mountains, ocean and an international border which collectively delimit the peri-urban boundaries. Nitrogen influxes are dominated by livestock feed imports to support dairy and poultry production (18000 tonnes N), followed by human food imports (9210 tonnes N), as well as 5410 tonnes N as fertilizer and 4690 tonnes N in atmospheric deposition. There is a transfer of 6700 tonnes N from agricultural to urban ecosystems displacing food imports, but food production contributes to the N footprint of the LFV. Nitrogen effluxes are dominated by sewage disposal (10400 tonnes N), solid waste disposal (7020 tonnes N) and atmospheric emissions (9460 tonnes N). The total influx is 15 kg N per person, the net influx is 3.1 kg N per person. Per unit land area, these are a total influx of 24 kg N/ha and a net influx of 4.7 kg N/ha. The atmospheric emissions are 4.7 kg N per person and 7.2 kg/ha. The N in soil is mobile and it is assumed soil N is at a steady state concentration, thus the surplus N is lost from the soil, probably by leaching and runoff. The Fraser River is estimated to acquire and transport 5230 tonnes N from the region into the ocean each year, in addition to 10300 tonnes N from sewage outfall. This is coupled with effluxes of phosphorus (estimated previously), and the result probably has an impact on the coastal waters. There is little reuse of imported N and current waste management practices including composting and combustion do little to improve N efficiency.

Phosphorus flows in a peri-urban region with intensive food production: A case study

Excess phosphorus (P) in peri-urban regions is an emerging issue, whereas there is global depletion of quality mined supplies of P. The flow of P across the landscape leading to regional surpluses and deficits is not well understood. We computed a regional P budget with internal P flows in a fairly discreet peri-urban region (Lower Fraser Valley, BC) with closely juxtaposed agricultural and non-agricultural urban ecosystems, in order to clarify the relationship between food production, food consumption and other activities involving use of P (e.g. keeping pets and horses and using soaps). We hypothesized changes that might notably improve P efficiency in peri-urban settings and wider regions. Livestock feed for the dairy and poultry sectors was the largest influx of P: the peri-urban land is too limited to grow feed grains and they are imported from outside the region. Fertilizer and import of food were the next largest influxes of P and a similar amount of P flows as food from the agricultural to urban ecosystems. Export of horticultural crops (berries and greenhouse crops) and poultry represented agricultural effluxes that partially offset the influxes. P efficiency was lower for horticultural production (21%) than animal production (32%), the latter benefited from importing feed crops, suggesting a regional advantage for animal products. There was 2.0, 3.8, 5.7 and 5.6 tonnes imported P per $ million farm cash receipts for horticulture, dairy, poultry meat and eggs. Eliminating fertilizer for corn and grass would reduce the ratio for the dairy industry. The net influx, dominated by fertilizer, animal feed and food was 8470 tonnes P per year or 3.2 kg P per person per year, and of this the addition to agricultural soils was 3650 tonnes P. The efflux in sewage effluent to the sea was 1150 tonnes P and exported sewage solids was 450 tonnes P. Municipal solid waste disposal was most difficult to quantify and was about 1800 tonnes P, 80% of which was partly reused in the urban regions and partly sequestered in landfill, which may be considered an efflux or a surplus. Reuse of rendering waste for feeding poultry significantly reduced P importation, but no rendering waste is used for cattle due to health concerns. Sensitivity analysis showed that variation in human population and the amount of P consumed per person in chicken and dairy products had the most influence on the total movement of P from agricultural to urban-ecosystems. There are current farm practices that mitigate P surpluses and new technologies are being developed to further reduce farm imbalances. However, current waste management policies that promote practices such composting of home wastes and exporting of poultry manure and biosolids to semiarid rangeland do little to enhance overall P cycling because the P is not returned to the farms producing feed and food for the peri-urban region. Sequestering in landfills may be a better solution until better ways are found to return surplus P.

Identification of Comprehensive Geriatric Assessment Based Risk Factors for Malnutrition in Elderly Asian Cancer Patients

PURPOSE

Elderly cancer patients are at increased risk for malnutrition. We aim to identify comprehensive geriatric assessment (CGA) based clinical factors associated with increased nutritional risk and develop a clinical scoring system to identify nutritional risk in elderly cancer patients.

PATIENTS AND METHODS

CGA data was collected from 249 Asian patients aged 70 years or older. Nutritional risk was assessed based on the Nutrition Screening Initiative (NSI) checklist. Univariate and multivariate logistic regression analyses were applied to assess the association between patient clinical factors together with domains within the CGA and moderate to high nutritional risk. Goodness of fit was assessed using Hosmer-Lemeshow test. Discrimination ability was assessed based on the area under the receiver operating characteristics curve (AUC). Internal validation was performed using simulated datasets via bootstrapping.

RESULTS

Among the 249 patients, 184 (74%) had moderate to high nutritional risk. Multivariate logistic regression analysis identified stage 3-4 disease (Odds Ratio [OR] 2.54; 95% CI, 1.14-5.69), ECOG performance status of 2-4 (OR 3.04; 95% CI, 1.57-5.88), presence of depression (OR 5.99; 95% CI, 1.99-18.02) and haemoglobin levels <12 g/dL (OR 3.00; 95% CI 1.54-5.84) as significant independent factors associated with moderate to high nutritional risk. The model achieved good calibration (Hosmer-Lemeshow test's p = 0.17) and discrimination (AUC = 0.80). It retained good calibration and discrimination (bias-corrected AUC = 0.79) under internal validation.

CONCLUSION

Having advanced stage of cancer, poor performance status, depression and anaemia were found to be predictors of moderate to high nutritional risk. Early identification of patients with these risk factors will allow for nutritional interventions that may improve treatment tolerance, quality of life and survival outcomes.

Comprehensive Geriatric Assessment (CGA) based risk factors for increased caregiver burden among elderly Asian patients with cancer

OBJECTIVE

This study aims to identify Comprehensive Geriatric Assessment (CGA) based risk factors to help predict caregiver burden among elderly patients with cancer.

MATERIALS AND METHOD

The study evaluated 249 patients newly diagnosed with cancer, aged 70years and above, who attended the geriatric oncology clinic at the National Cancer Centre Singapore between 2007 and 2010.

RESULTS

Out of 249 patients, 244 patients had information available on family caregiver burden and were analysed. On univariate analysis, ADL dependence, lower IADL scores, ECOG performance status of 3-4, higher fall risk, lower scores in dominant hand grip strength test and mini mental state examination, polypharmacy, higher nutritional risk, haemoglobin <12g/dL and presence of geriatric syndromes were significantly associated with mild to severe caregiver burden. On multivariate analysis, only ECOG performance status of 3-4 (odds ratio [OR], 4.47; 95% confidence interval [CI], 2.27-8.80) and haemoglobin <12g/dL (OR, 2.38; 95% CI, 1.14-4.99) were associated with an increased probability of mild to severe caregiver burden. The model achieved a good fit (Hosmer-Lemeshow's p=0.196) and discrimination (area under the curve [AUC]=0.742; bias-corrected AUC=0.737). Based on this, patients were stratified into 3 risk groups with different proportion of patients with increased caregiver burden (low risk: 3.9% vs intermediate risk: 18.8% vs high risk: 39.6%; p<0.001).

CONCLUSION

ECOG performance status and haemoglobin were associated with increased caregiver burden among elderly patients with cancer. Using these two factors in the clinic may help clinicians identify caregivers at risk and take preventive action to mitigate that.

Phase III study of pasireotide long-acting release in patients with metastatic neuroendocrine tumors and carcinoid symptoms refractory to available somatostatin analogues

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27–1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89–4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 – not reached) with pasireotide versus 6.8 months (5.6 – not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20–0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

Cutaneous versus non-cutaneous angiosarcoma: clinicopathologic features and treatment outcomes in 60 patients at a single Asian cancer centre

BACKGROUND

Angiosarcoma (AS) is an uncommon soft tissue sarcoma with dismal prognosis that presents either cutaneously (C-AS) or non-cutaneously (NC-AS). We compared the clinical features and treatment outcomes between these 2 groups.

METHODS

A single-centre study evaluating 60 AS patients between 2002 and 2012 was performed.

RESULTS

The median age was 70 years. C-AS of the scalp or face comprised 66% of patients. C-AS patients were older than NC-AS (median age 74 vs. 56 years; p < 0.001). Proportionately more C-AS patients presented with non-metastatic disease (86 vs. 50%; p = 0.007). Amongst resected C-AS and NC-AS patients, rates of positive surgical margins (53 vs. 50%; p = 1.00) and adjuvant therapy (25 vs. 43%; p = 0.626) were not significantly different, though proportionately fewer C-AS patients relapsed (36 vs. 78%; p = 0.038). Paclitaxel was the most common agent in first line palliative systemic therapy, achieving an objective response rate of 56%. Median overall survival was 11.2 months, with no significant difference between C-AS and NC-AS (11.3 vs. 9.8 months; p = 0.895).

CONCLUSION

Distinct from AS in the West, our series demonstrates a clear preponderance of scalp AS. Disparities in clinical characteristics between C-AS and NC-AS did not translate into survival differences.

Identification of comprehensive geriatric assessment based risk factors for malnutrition in elderly Asian patients with cancer

9552

Background: Elderly patients with cancer are at increased risk for poor nutrition. Malnutrition is associated with increased morbidity and mortality. There is limited information on the clinical risk factors for malnutrition in elderly Asian cancer patients. We aim to identify comprehensive geriatrics assessment (CGA) based clinical factors in elderly Asian cancer patients associated with an increase in malnutrition risk. Methods: CGA data was collected from 249 Asian patients aged 70 years or older who attended the outpatient oncology clinics at the National Cancer Centre Singapore. Nutritional status, one of the seven domains of CGA, was assessed based on the DETERMINE nutritional risk index. Univariate and multivariate logistic regression analyses were applied to assess the association between patient clinical factors together with domains within the CGA and moderate to high nutritional risk. Goodness of fit was assessed using Hosmer-Lemeshow test and discrimination ability assessed based on the area under the receiver operating characteristics curve (AUC). Internal validation was performed using simulated datasets via bootstrapping. Results: Among the 249 patients, 184 (74%) had moderate to high nutritional risk. Multivariate logistic regression analysis identified stage 3–4 disease (Odds Ratio [OR] 2.54; 95% CI, 1.14-5.69), ECOG performance status of 2-4 (OR 3.04; 95% CI, 1.57–5.88), presence of depression as measured by geriatric depression scale (OR 5.99; 95% CI, 1.99-18.02) and haemoglobin levels <12 g/dL (OR 3; 95% CI 1.54-5.84) as significant independent factors associated with moderate to high nutritional risk. The model achieved good calibration (Hosmer-Lemeshow test’s p = 0.17) and discrimination (AUC = 0.80). It retained good calibration and discrimination (bias-corrected AUC = 0.79) under internal validation. Conclusions: Having advanced stage of cancer, poor performance status, depression and anaemia were found to be independent predictors of moderate to high nutritional risk. Early identification of patients with these risk factors will allow for nutritional interventions which may improve treatment tolerance, quality of life and survival outcomes.

A multicenter, randomized, blinded, phase III study of pasireotide LAR versus octreotide LAR in patients with metastatic neuroendocrine tumors (NET) with disease-related symptoms inadequately controlled by somatostatin analogs

4031

Background: The novel somatostatin analog (SSA) pasireotide has a broader binding profile than currently available SSA (octreotide and lanreotide). Results from a phase III study (NCT00690430) of pasireotide LAR (P) vs octreotide LAR (O) in patients (pts) with NET and disease-related symptoms uncontrolled by the maximum approved dose of available SSA are shown. Methods: Pts (N=110) were randomized and stratified by predominant symptom at baseline (diarrhea [D], flushing [F], or D+F) 1:1 to P (60 mg IM) or O (40 mg IM) q28d. Primary objective was symptom response at month (M) 6. Secondary objectives included tumor response and safety. Progression-free survival (PFS) was an exploratory analysis. Results: 53 and 57 pts were enrolled in the P and O arms when the study was halted due to an interim analysis suggesting futility for symptom response. Baseline characteristics were similar between arms. Majority of primary tumor locations were small intestine (72% and 81% in the P and O arms). Symptom response at M6 was 9/43 (21%) and 12/45 (27%) in the P and O arms, odds ratio 0.73 (95% CI, 0.27-1.97; p=0.53). Median numbers of D/day and F/2 weeks and change in symptom from baseline to M6 are in Table. Hyperglycemia (11% vs 0%), diarrhea (9% vs 7%), and abdominal pain (2% vs 9%) were the most common grade 3/4 AEs in the P vs O arms in the core phase, and 7 (13%) and 4 (7%) pts discontinued due to AEs. Median investigator-assessed PFS was 11.8 months and 6.8 months in the P and O arms (HR=0.46; p=0.045). Conclusions: P and O showed a similar safety profile except for the higher frequency of hyperglycemia in P. Pts on P had PFS 5 months longer than pts on O (investigator assessment), despite no differences in symptom response rates. These results warrant a large phase III trial to clarify the role of P as a therapy for NET. Clinical trial information: NCT00690430. [Table: see text]

A Phase 1 dose-finding and pharmacodynamic study of rapamycin in combination with bevacizumab in patients with unresectable hepatocellular carcinoma

BACKGROUND & AIMS

Preclinical studies have demonstrated the additive effect of rapamycin with bevacizumab for hepatocellular carcinoma treatment. We conducted a Phase 1 study to evaluate the safety and pharmacokinetics of the combination in patients with hepatocellular carcinoma.

METHODS

Adult participants with advanced hepatocellular carcinoma received intravenous bevacizumab (5mg/kg every 14 days) and oral rapamycin (1-6 mg/day; 3+3 dose escalation design). Computed tomography assessed tumour response and treatment safety. Pharmacokinetics assessment established rapamycin blood concentrations pre- and post-dose. Dynamic contrast-enhanced computed tomography analysed the tumour region for blood flow, permeability surface area product, fractional intravascular blood volume and extracellular-extravascular volume.

RESULTS

Twenty-four participants were treated. There were two dose limiting toxicities with rapamycin 5mg: grade 3 thrombocytopenia and grade 3 mucositis. The maximally tolerated dose of rapamycin was 4 mg. Adverse events (grade 1-2) included hyperglycaemia (83%), thrombocytopenia (75%), fatigue (46%), mucositis (46%), anorexia (42%), diarrhoea (33%) and proteinuria (12.5%). Of 20 evaluable participants, one reached complete response that lasted 4.5 months, two reached partial response, 14 reached stable disease and three had progressive disease. Median overall survival was 9.4 months; progression-free survival was 5.5 months. Dose level and steady state area under the concentration time curve for hour zero to infinity of rapamycin correlated inversely with blood flow rate and change in permeability-surface area. After 22 days of treatment, there were significant reductions from baseline in blood flow rate, permeability-surface area and fractional intracellular blood volume.

CONCLUSIONS

The recommended Phase 2 dose of rapamycin is 4 mg in combination with bevacizumab. Evidence of anti-vascular activity was observed together with promising clinical activity.

Geriatric high-grade soft tissue sarcoma (G-HG STS): An analysis of 116 patients (pts) evaluating prognostic factors and clinical outcomes stratified by histology

10051

Background: STS in geriatric pts is not well studied. We evaluated prognostic factors and clinical outcomes in elderly pts with HG STS. Methods: Single centre retrospective study. G-HG STS pts defined as age > 65 yrs seen in our centre from 2002 - 2011 with complete medical records were identified. Charlson age-comorbidity score was assessed for each pt. Results: 116 pts from 4 most common HG STS histo-types representing 69% of pts in the geriatric STS cohort were analysed; leiomyosarcoma (LMS, 14%), non well-differentiated liposarcoma (nWD-LPS, 9%), angiosarcoma (AS, 30%), and undifferentiated pleomorphic sarcoma (UPS, 47%). Median age was 72 yrs, 81% presented with localised disease; of 78% of these localised pts who had curative surgery, 49% received adjuvant therapy, of whom 92% had radiotherapy (RT) only. AS arises more commonly from the head/neck region (p<0.001) and fewer receive curative surgery (p=0.006). In 43 pts who had metastases either at diagnosis or relapse, 33% received first-line palliative chemotherapy with a response rate of 27% in evaluable pts. At a median follow-up of 15.8 mths, overall survival (OS) for the entire cohort was 25.1 mths, 30.5 vs 3.9 mths in pts presenting with localised vs metastatic disease respectively (p<0.0001). In pts who had curative surgery for localised disease, overall relapse-free survival (RFS) was 17.7mths; 26.8 mths vs 16.0 mths vs 7.3 mths vs 12.5 mths in LMS, nWD-LPS, AS and UPS respectively. In univariate analysis, adjuvant RT, non-head/neck primary and sarcoma subtype were associated with improved RFS. In multivariate analysis, adjuvant RT (p<0.001), sarcoma subtypes AS (p=0.011) and UPS (0.012) vs LMS remained significant. In pts with metastatic HG STS either at diagnosis or relapse, overall median OS was 5.9 mths; 5.9 mths (LMS), 30.5 mths (nWD-LPS), 6.4 mths (AS) and 4.3 mths (UPS). In univariate analysis, presence of bone metastases was significantly associated with inferior OS (p=0.0029). Charlson score did not correlate with RFS or OS. Conclusions: Prognosis of G-HG STS appears poor particularly in AS and UPS. Adjuvant RT improves outcomes in this group of pts and should not be omitted based on age alone.

Quality of life of elderly patients undergoing concomitant chemoradiation therapy for head and neck cancers, including assessment of geriatric parameters

6100

Background: Data on the quality of life of older patients undergoing concomitant chemoradiation therapy (CCRT) for head and neck (H&N) cancer are very scarce and no study has focused specifically on them. Furthermore, no study has assessed the contribution of geriatric symptoms to their quality of life. Methods: We prospectively assessed patients aged 65 and older undergoing curative intent CCRT for H&N cancers, either alone or adjuvantly after surgery. We used the Quality of life-Radiation Therapy Instrument (QOL-RTI), with its H&N module (Trotti et al., 1998). In addition we created a 12-items senior adult questionnaire (SAQ). Patients were assessed at baseline, at 4 weeks, at the end of treatment (EOT), and 2 months after EOT (recovery). Results: Fifty patients were enrolled. Median age was 69 years (range 65-87). Eighty-two percent of patients had locally advanced stage IV disease. Twenty-eight percent had prior surgery. All patients were treated with IMRT, 92% at 70 Gy. The most frequent chemotherapy regimen was cisplatin q3wks (58%), followed by weekly carboplatin (24%). Patients had on average 4 comorbidities (CIRS-G), 54% of them a grade 3 or 4 disease. Forty-four percent were independent in IADL, and 98% were ECOG PS 0 or 1. The baseline scores were QOL-RTI: 7.72 (SD 1.36), H&N module 7.7 (SD 2.16), SAQ 8.21 (SD 1.54). At EOT, the scores were 6.22 (1.26), 4.59 (1.82), 7.38 (1.38) respectively, and at recovery 7.17 (1.25), 6.06 (1.66), 7.96 (1.16). The scores paralleled functional evolution, as 24% of patients had an ECOG PS 2 and 76% were IADL dependent at EOT; 16% ECOG 2-3 and 55% IADL dependent at recovery. Cronbach alphas for the 3 QOL measures were 0.88, 0.89, and 0.81, suggesting adequate internal consistency reliability. The SAQ was low-to-moderately correlated with the other two QOL measures (r=0.22 to 0.59) at different points of assessment. Conclusions: Older H&N cancer patients experience significant impact of CCRT on their function, and on their quality of life on all three measures. Most recover after two months, although some may take longer. A geriatric module adds significant information to the general QOL-RTI and H&N questionnaires.

Analysis of prognostic factors of comprehensive geriatric assessment and development of a clinical scoring system in elderly Asian patients with cancer

PURPOSE

To determine the impact of each comprehensive geriatric assessment (CGA) domain on overall survival (OS) and develop a prognostic scoring system for elderly patients with cancer.

PATIENTS AND METHODS

A retrospective analysis of CGA data collected from 249 consecutive patients with cancer who attended the outpatient geriatric oncology clinic at the National Cancer Center Singapore age 70 years or older was performed. Univariate and multivariate analyses were performed using Cox proportional hazards method to identify significant prognostic factors within the CGA. A simple nomogram to predict OS was developed using regression coefficients from the multivariate model. Concordance between predicted and observed response of the individual patient score was evaluated by means of Harrell's c-index. Calibration was performed using simulated data via bootstrap.

RESULTS

Median age of the patients was 77 years (range, 70 to 94 years). In our model, age (hazard ratio [HR], 1.04; 95% CI, 1.01 to 1.07), abnormal albumin level (HR, 1.97; 95% CI, 1.23 to 3.15), poor Eastern Cooperative Oncology Group performance status (≥ 2 v < 2: HR, 1.77; 95% CI, 1.15 to 2.72), abnormal geriatric depression scale status (HR, 1.81; 95% CI, 1.29 to 2.56), high malnutrition risk (high v low risk: HR, 1.84; 95% CI, 1.17 to 2.87), and advanced disease stage (late v early: HR, 1.71; 95% CI, 0.98 to 2.95) were independent predictors of survival.

CONCLUSION

Results confirm the importance of the CGA in assessment of elderly patients with cancer. The development of this nomogram incorporating these prognostic factors helps predict OS of patients, for further intervention.

Sunitinib (SUTENT, SU11248) suppresses tumor growth and induces apoptosis in xenograft models of human hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common and third deadliest primary neoplasm. Since HCC is a particularly vascular solid tumor, we determined the antitumor and antiangiogenic activities of sunitinib malate, a potent inhibitor of two receptors involved in angiogenesis - vascular endothelial growth factor receptor (VEGFR) and platelet-derived growth factor receptor (PDGFR). In the present study, we reported that treatment of HepG2 and SK-Hep-1 cells with sunitinib led to growth inhibition and apoptosis in a dose-dependent fashion. Sunitinib inhibited phosphorylation of VEGFR-2 at Tyr951 and PDGFR-beta at Tyr1021 both in vitro and in vivo. Sunitinib also suppressed tumor growth of five patient-derived xenografts. Sunitinib-induced tumor growth inhibition was associated with increased apoptosis, reduced microvessel density and inhibition of cell proliferation. This study provides a strong rationale for further clinical investigation of sunitinib in patients with hepatocellular carcinoma.

Management of hepatocellular carcinoma in Asia: consensus statement from the Asian Oncology Summit 2009

Asia has a disproportionately large share of the world's hepatocellular carcinoma (HCC), mainly because of the endemic status of chronic hepatitis B and C viruses, which leads to liver cirrhosis and an increased risk of HCC. This etiological factor presents important opportunities for prevention, early detection, diagnosis, and treatment of HCC. This consensus statement reviews the available medical evidence for management of HCC in Asia, and gives treatment recommendations that are adapted to resource availability in this diverse region with disparate health-care delivery systems.

Phase I study of SIR-sphere plus sorafenib as first-line treatment in patients with nonresectable hepatocellular carcinoma: The Asia-Pacific Hepatocellular Carcinoma Trials Group protocol 05 (AHCC05)

e15538

Background: Sorafenib has been shown to significantly prolong survival in patients with nonresectable hepatocellular carcinoma (HCC) without however significant tumour regression. The addition of radio-ablative therapy could confer additional survival benefit. This phase I trial was carried out to ascertain the toxicities and safety of this combination and was designed as a prelude to a phase II trial. Methods: Eligible patients were administered SIR-sphere (max dose 3 GBq) and subsequently given Sorafenib therapy (400mg bd) either 14 days (Cohort 1: first 3 patients) or 11 days (Cohort 2: subsequent patients) later. Assessment was carried out for 30 days after commencement of Sorafenib. Results: 10 patients were recruited into this phase I trial. The second patient became ineligible for sorafenib therapy after SIR-sphere due to pulmonary bleeding not related to radio-therapy and was excluded from assessment. The characteristics of the patients are in the Table. At the end of the study period, there was no adverse events (AE) of grade 3 or 4 for Cohort 1 and 3 for Cohort 2. The only serious adverse event (SAE) recorded was from Cohort 2. Conclusions: Starting sorafenib 14 days after SIR-sphere therapy is associated fewer AEs and SAEs. The phase II trial has commenced withsorafenib starting 14 days after SIR-sphere. [Table: see text]

[Table: see text]

An exploratory analysis of comprehensive geriatric assessment results and overall survival in 233 consecutive elderly cancer patients

9504

Background: Performance status (PS) is the main clinical parameter used by most oncologists to assess the ability of elderly cancer patients to tolerate chemotherapy and estimate prognosis. The results of comprehensive geriatric assessment (CGA) for elderly cancer patients were analyzed to investigate the impact of each CGA functional, physical, cognitive, and affective domain on overall survival in relation to performance status. Methods: CGA was used for 233 consecutive elderly cancer patients aged 70 and above. CGA tools included the Katz index of daily activities independence (ADL), instrumental activities of daily living (IADL), mini-mental state examination (MMSE), geriatric depression scale (GDS), Charlson comorbidity risk index, get up and go test, and mini-nutritional assessment. Geriatric syndrome is defined as any high risk of falls, depression, dementia, increased functional dependence, or malnutrition. Eastern Cooperative Oncology Group (ECOG) scale was used to grade PS. Cancer type and stage were also analyzed. Log rank test was used to compare overall survival and hazard ratio (HR) derived using Cox regression method. Univariate and multivariate analyses were done to assess impact of ECOG status, presence of geriatric syndrome, stage of disease and cancer type on overall survival. Results: All 233 patients were included in the analysis, median age 77 (70 - 93), all had solid tumors and predominant tumors comprising 79% of diagnoses were colorectal, lung and breast, 50% had advanced metastatic disease. ECOG grades 2,3,4 (HR 0.28, 95% CI 0.14 - 0.55), dependent IADL status (HR 0.30, 95% CI 0.11 - 0.83), presence of geriatric syndrome (HR 0.42 95% CI 0.26 - 0.69), poor cognition (HR 0.53 95% CI 0.36 - 0.77), or advanced disease (HR 0.30 95% CI 0.14 - 0.65) was associated with inferior overall survival in univariate analysis. Only poor ECOG status, presence of a geriatric syndrome and advanced disease predicted adversely for overall survival in multivariate analysis. Poor cognition (MMSE score <24) in those with borderline ECOG 2 status was associated with poorer survival (HR 0.38 95% CI 0.33 - 0.90). Conclusions: Utility of CGA will improve the assessment of the elderly cancer patient.

No significant financial relationships to disclose.

Sorafenib and rapamycin induce growth suppression in mouse models of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide. Vascular endothelial growth factor, platelet derived growth factor and the Raf/mitogen-activated protein kinase/extracellular signal regulated kinase (Raf/MEK/ERK) signalling pathway regulates the growth, neovascularization, invasiveness and metastatic potential of HCC. In this study, we investigated the in vivo antitumour activity and mechanisms of action of sorafenib tosylate on four patient-derived HCC xenografts. Sorafenib dosed at 50 mg/kg and 100 mg/kg inhibited tumour growth by 85% and 96%, respectively. Sorafenib-induced growth suppression and apoptosis were associated with inhibition of angiogenesis, down-regulation of phospho-platelet-derived growth factor receptor beta Tyr1021, phospho-eIF4E Ser209, phospho-c-Raf Ser259, c-Raf, Mcl-1, Bcl-2, Bcl-x and positive cell cycle regulators, up-regulation of apoptosis signalling kinase-1, p27 and p21. Expression of IGF-1Rbeta and phosphorylation of c-Raf Ser338, MEK1/2 Ser217/221 and ERK1/2 Thr202/Tyr204 were increased by sorafenib treatment. Phosphorylation of mammalian target-of-rapamycin (mTOR) targets (p70S6K, S6R and 4EBP1) was reduced by sorafenib in sorafenib-sensitive lines but activated in sorafenib-less-sensitive 10-0505 xenograft. Sorafenib-induced phosphorylation of c-met, p70S6K and 4EBP1 was significantly reduced when 10-0505 cells were co-treated with anti-human anti-HGF antibody, suggesting that treatment with sorafenib leads to increased HGF secretion and activation of c-met and mTOR targets. Treatment of 10-0505 tumours with sorafenib plus rapamycin resulted in growth inhibition, inhibition of vascular endothelial growth factor receptor-2 phosphorylation, increased apoptosis and completely blocked sorafenib-induced phosphorylation of mTOR targets and cyclin B1 expression. These data also provide a strong rationale for clinical investigation of sorafenib in combination with mTOR inhibitors in patients with HCC.

RAD001 (everolimus) inhibits tumour growth in xenograft models of human hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide and highly resistant to available chemotherapies. Mammalian target of rapamycin (mTOR) functions to regulate protein translation, angiogenesis and cell cycle progression in many cancers including HCC. In the present study, subcutaneous patient-derived HCC xenografts were used to study the effects of an mTOR inhibitor, RAD001 (everolimus), on tumour growth, apoptosis and angiogenesis. We report that oral administration of RAD001 to mice bearing patient-derived HCC xenografts resulted in a dose-dependent inhibition of tumour growth. RAD001-induced growth suppression was associated with inactivation of downstream targets of mTOR, reduction in VEGF expression and microvessel density, inhibition of cell proliferation, up-regulation of p27(Kip1) and down-regulation of p21(Cip1/Waf1), Cdk-6, Cdk-2, Cdk-4, cdc-25C, cyclin B1 and c-Myc. Our data indicate that the mTOR pathway plays an important role in angiogenesis, cell cycle progression and proliferation of liver cancer cells. Our study provides a strong rationale for clinical investigation of mTOR inhibitor RAD001 in patients with HCC.

Predictors of outcome and treatment decisions of older patients with stage III non-small cell lung cancer

19574

Background: In treating Stage III non-small cell lung cancer in the elderly, oncologists often empirically adjust treatment without clear guidelines. Identifying patient characteristics that impact prognosis will aid in creating better treatment algorithms in this patient population. Methods: A retrospective analysis was done on older patients (age > 70) treated for Stage III NSCLC (excluding “wet” IIIB) at the H. Lee Moffitt Cancer. Cox multivariate analysis identified variables impacting progression free survival, overall survival, treatment chosen, treatment interruptions, and hospitalizations. Correlation and regression tree analysis (CART) was performed to create potential decision making models. Results: 213 patients were evaluable. Multivariate analysis identified ECOG performance status (hazard ratio = 1.52, p = 0.005) and nodal status (HR = 1.36, p = 0.001) as negatively associated with PFS while BMI (HR = 0.96, p = 0.02) was positively associated. ECOG performance status (HR = 2.26, p < 0.0001), nodal status (HR = 1.18, p = 0.08), and CIRS3 (having a comorbidity classified as severity 3; HR = 1.33, p = 0.02) were negatively associated with OS. BMI (HR = 0.95, p = 0.002) and CIRSmean (mean CIRS-G severity score; HR 0.61, p = 0.01) were positively associated with OS. These variables were also identified as the most significant splitters, along with smoking status and pulmonary function, in CART analyses. Trees using PFS and OS as outcomes were created with receiver operating curves (ROC) ranging from 0.64–0.75. A CART analysis targeting treatment modality chosen had ROCs ranging from 0.49–0.78. Conclusions: Our multivariate analysis found ECOG performance status, nodal status, and severe medical comorbidity as negatively associated with survival. Unexpectedly, BMI (at initial treatment), independent of weight loss, was found to be positively associated. Also, the splitter variables identified by CART analysis were very similar to the general multivariate model, but the weights differed in the various analyses and subgroups of patients. The CART analyses suggest that we can create decision making models with a range of applicability comparable to those commonly considered useful for clinical guidelines, i.e. about 60% of straightforward application.

No significant financial relationships to disclose.

A Randomized Phase II Trial of Single-Agent Gemcitabine, Vinorelbine, or Docetaxel in Patients with Advanced Non-small Cell Lung Cancer Who Have Poor Performance Status and/or Are Elderly

BACKGROUND

Patients with poor performance status and/or are elderly are frequently considered a compromised group at high risk of chemotherapy-related morbidities and less likely to benefit from treatment. We aimed to evaluate tolerability and efficacy of three single-agent regimens in these patients.

PATIENTS AND METHODS

Patients with advanced non-small cell lung cancer who had performance status 2/3 and/or were aged 70 and older were randomly assigned to receive gemcitabine, vinorelbine, or docetaxel. Objective response, toxicities, and quality of life were evaluated.

RESULTS

One hundred thirty-five patients were registered, of whom one was ineligible. Of the 134 patients, 43 received gemcitabine, 45 vinorelbine, and 46 docetaxel. The response rate was 16%, 20%, 22% for gemcitabine, vinorelbine, and docetaxel, respectively. The main grade 3/4 toxicities were fatigue (18%) and neutropenia (16%). There was improvement in global health scores, cough, and dyspnea for all treatment groups. The improvement in dyspnea was most marked in patients with performance status 3.

CONCLUSION

There was no significant advantage of any of the treatment arms over the rest. There was benefit seen with improvement of quality of life in patients who were able to receive more cycles of chemotherapy.

Phase II Trial of Gemcitabine and Cisplatin Sequentially Administered in Asian Patients With Unresectable or Metastatic Non-small Cell Lung Cancer

Introduction: The aim of this study was to assess toxicity and response in the sequential administration of gemcitabine followed by cisplatin in unresectable or metastatic non-small cell lung cancer. Materials and Methods: Twenty-three patients were enrolled in this study. Gemcitabine was given at 1250 mg/m2 on days 1 and 8, for four 21-day cycles, followed by cisplatin 40 mg/m2 on days 1, 8 and 15, for three further 28-day cycles. Results: There were 4 patients with partial responses, 5 patients with stable disease and 10 patients with progressive disease, giving a response rate of 21%. The median time to disease progression was 3.3 months. The median overall survival was 14.6 months. Toxicities graded 3 or 4 included anaemia (13.0%), neutropaenia (13.0%), supraventricular tachycardia (4.3%), and nausea and vomiting (4.3%). Conclusion: Although these results show similar efficacy to single-agent treatment regimens, the low toxicity profile and promising survival outcome with this regimen are important points for consideration. Key words: Anaemia, Neutropaenia, Supraventricular tachycardia

Phase II trial of gemcitabine and cisplatin sequentially administered in Asian patients with unresectable or metastatic non-small cell lung cancer

INTRODUCTION

The aim of this study was to assess toxicity and response in the sequential administration of gemcitabine followed by cisplatin in unresectable or metastatic non-small cell lung cancer.

MATERIALS AND METHODS

Twenty-three patients were enrolled in this study. Gemcitabine was given at 1,250 mg/m2 on days 1 and 8, for four 21-day cycles.

RESULTS

There were 4 patients with partial responses. 5 patients with stable disease and 10 patients with progressive disease, giving a response rate of 21%. The median time to disease progression was 3.3 months. The median overall survival was 14.6 months. Toxicities graded 3 or 4 included anaemia (13.0%), neutropaenia (13.0%), supraventricular tachycardia (4.3%), and nausea and vomiting (4.3%).

CONCLUSION

Although these results show similar efficacy to single-agent treatment regimens, the low toxicity profile and promising survival outcome with this regimen are important points for consideration.

Neuroimpairment, activity limitation, and participation restriction among children with cerebral palsy in Hong Kong

OBJECTIVES

To study children with cerebral palsy in Hong Kong, their neuroimpairment, activity limitation, and participation restriction in society. Parents' opinion on current medical and rehabilitation services was also sought.

DESIGN

Systematic survey using questionnaires.

SETTING

Four associations in Hong Kong: Child Assessment Service, Hong Kong Association for Parents of Children with Physical Disabilities, Association of Parents of the Severely Mentally Handicapped, and Hong Kong Physically Handicapped and Able-Bodied Association.

PARTICIPANTS

Parents of children with cerebral palsy.

MAIN OUTCOME MEASURES

Neuroimpairment, activity limitation, and participation restriction.

RESULTS

Information from 181 children with cerebral palsy was analysed. Among them, 56% were boys. The mean age was 7 years 6 months (standard deviation, 3 years 11 months). The most common diagnostic type was spastic cerebral palsy. Co-morbidities in children with cerebral palsy were common. Limitation in daily activities including mobility and self-care tasks was considerable and this posed great stress to parents when taking care of their children. Children's participation in both social and leisure activities was regarded as a low priority. A high percentage (70%) of parents reported difficulty in travelling. The reasons involved problems in transportation, building access (entry and exit), and attitudes of the general public. These environmental factors restricted the social participation of the children and their families. Over 75% of parents were satisfied with the current medical and rehabilitation services.

CONCLUSIONS

Children with cerebral palsy have multiple and complex needs. The findings of this study may serve as a reference for parents, service providers, and policy makers to work in partnership to achieve a more comprehensive health-care service for children with cerebral palsy and to facilitate better integration into the community.

Pharmacogenetic profiling across the irinotecan pathway in Asian patients with cancer

AIMS

The aim of this exploratory study was to investigate associations between irinotecan pharmacokinetic parameters and allelic variants in genes encoding for drug transporters and drug metabolizing enzymes that are involved in irinotecan disposition in Asian patients with cancer.

METHODS

Irinotecan was administered at 100 mg m(-2) over 90 min on a weekly schedule to 29 nasopharyngeal carcinoma patients and pharmacokinetic analysis was performed during the first cycle. All patients were genotyped for allelic variants in genes encoding drug metabolizing enzymes (CYP3A4, CYP3A5, UGT1A1) and drug transporters (ABCB1, ABCC2 and ABCG2) that are involved in irinotecan disposition.

RESULTS

Of the six candidate genes that were analyzed, 11 genetic variants were found. Significant genotypic-phenotypic associations were apparent only for transporter genes. The C(max) of irinotecan was significantly lower in patients carrying the CC genotype at exon 26 of the ABCB1 gene compared with those harbouring at least one variant allele (P = 0.047). Patients harbouring the wild type ABCG2 CTCA genotype were associated with significantly higher values for relative extent of conversion (REC) of irinotecan to SN-38 compared with patients carrying at least one deletion CTCA allele (P = 0.019).

CONCLUSIONS

The present exploratory study shows that genetic polymorphisms in drug transporter genes, particularly in ABCB1 and ABCG2 genes, may be important in influencing the pharmacokinetics of irinotecan and its metabolites. The predictive value of the identified allelic variants in the ABCG2 and ABCB1 genes on irinotecan disposition should be further investigated in a larger patient population as well as in other ethnic populations.

A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome

BACKGROUND

Decompressive surgery and steroid injection are widely used forms of treatment for carpal tunnel syndrome (CTS) but there is no consensus on their effectiveness in comparison to each other. The authors evaluated the efficacy of surgery vs steroid injection in relieving symptoms in patients with CTS.

METHODS

The authors conducted a randomized, single blind, controlled trial. Fifty patients with electrophysiologically confirmed idiopathic CTS were randomized and assigned to open carpal tunnel release (25 patients) or to a single injection of steroid (25 patients). Patients were followed up at 6 and 20 weeks. The primary outcome was symptom relief in terms of the Global Symptom Score (GSS), which rates symptoms on a scale of 0 (no symptoms) to 50 (most severe). Nerve conduction studies and grip strength measurements were used as secondary outcome assessments.

RESULTS

At 20 weeks after randomization, patients who underwent surgery had greater symptomatic improvement than those who were injected. The mean improvement in GSS after 20 weeks was 24.2 (SD 11.0) in the surgery group vs 8.7 (SD 13.0) in the injection group (p < 0.001); surgical decompression also resulted in greater improvement in median nerve distal motor latencies and sensory nerve conduction velocity. Mean grip strength in the surgical group was reduced by 1.7 kg (SD 5.1) compared with a gain of 2.4 kg (SD 5.5) in the injection group.

CONCLUSION

Compared with steroid injection, open carpal tunnel release resulted in better symptomatic and neurophysiologic outcome but not grip strength in patients with idiopathic carpal tunnel syndrome over a 20-week period.

Concurrent chemoradiotherapy followed by surgery in locally advanced squamous cell carcinoma of the oesophagus: a single centre experience

INTRODUCTION

Data on combined modality treatment for locally advanced squamous cell carcinoma of the oesophagus involving Asian patients are limited.

MATERIALS AND METHODS

A retrospective study of 56 consecutive patients with this condition treated with concurrent chemoradiotherapy followed by surgery in a single tertiary institution in Singapore was performed.

RESULTS

The median overall survival of the entire cohort was 14.1 months [95% confidence interval (CI); range, 8.6 to 19.6 months]. In patients who underwent successful oesophagectomy after chemoradiotherapy (n = 17), the median survival was 27.8 months compared to 9.8 months for those who did not have surgery (n = 39) (P = 0.046, log-rank test). The median time to first relapse for the entire cohort was 16.1 months (95% CI, 7.7 to 24.5 months). The time to first relapse was 23.9 months in the subgroup of patients with successful surgery and 12.1 months in the group which did not (P = 0.147, log-rank test). The high proportion of patients who were medically unfit for surgery or declined surgery may have conferred a selection bias.

CONCLUSION

Concurrent chemoradiotherapy followed by surgery is feasible in selected patients. The benefit of adding of surgery to chemoradiotherapy is still controversial and we await the results of randomised controlled trials comparing chemoradiotherapy with surgery versus chemoradiotherapy alone.

Adrenal insufficiency in intestinal obstruction from carcinomatosis peritonei--a factor of potential importance in symptom palliation

Corticosteroids are used in the management of intestinal obstruction (IO) in carcinomatosis peritonei. There is considerable overlap in the symptoms experienced in IO and functional adrenal insufficiency (AI). The success of symptom palliation in IO may be related to the presence of AI. The aim of this preliminary study was to evaluate the incidence of functional adrenal insufficiency in patients with IO and its relation to clinical outcome and symptom control. Twenty-nine consecutive patients with IO and carcinomatosis peritonei from gastrointestinal cancers admitted to our inpatient service between January and October 2002 were analyzed. They were screened for AI using the short corticotropin stimulation test. Thirteen patients (45%) had functional AI. Differences in characteristics of patients with normal adrenal function (Group 1) and adrenal insufficiency (Group 2) were not statistically significant. Time taken to control symptoms in Group 2 was longer. Mean duration of hospitalization per month of survival was two times longer in Group 2 relative to Group 1 (7.9 versus 4.0 days, P=0.011). Functional AI may be caused by cytokines produced in advanced cancer mediating direct adrenal suppression. Prompt corticosteroid therapy in the presence of AI may facilitate IO symptom palliation.

Phase II study of irinotecan (CPT-11) as salvage therapy for advanced nasopharyngeal carcinoma

BACKGROUND

This Phase II study was designed to evaluate the efficacy and safety of irinotecan in patients with advanced nasopharyngeal carcinoma (NPC).

METHODS

Patients with disseminated, undifferentiated NPC that progressed during or within 3 months of platinum-based and/or taxane-based regimen were eligible. Irinotecan at a dose of 100 mg/m(2) was administered on Days 1, 8, and 15 every 28 days, up to a maximum of 6 cycles, until disease progression or the appearance of intolerable toxicity.

RESULTS

Twenty-eight patients were evaluable for toxicity and response. Patient characteristics were as follows: The median age was 46.5 years (range, 40.3-71.6 years), the median number of prior lines of chemotherapy was 2 (range, 1-9), the majority of patients (89%) had good Eastern Cooperative Oncology Group performance status (0-1), and the majority of patients (82.1%) had >/= 2 sites of distant metastases. A total of 79 cycles of irinotecan with a median of 3 cycles per patient were administered. Toxicity > Grade 3 included neutropenia in 5 patients (17%), anemia in 5 patients (17%), and diarrhea in 4 patients (14%). The best response outcomes were 4 patients (14%) who achieved partial responses and 1 patient (4%) who achieved stable disease. Global quality-of-life scores were stable during treatment. Using the Kaplan-Meier method, the median progression-free survival was 3.9 months, and the median overall survival was 11.4 months. The partial responders had a durable response (range, 5.7-12.2 months).

CONCLUSIONS

Results from this trial suggest that irinotecan is an active salvage agent with modest toxicity in patients with advanced NPC who are refractory to platinum/taxane-based chemotherapy. Studies combining irinotecan with other active agents in the first-line setting are warranted.

Concurrent chemoradiotherapy in locoregionally recurrent nasopharyngeal carcinoma

PURPOSE

To analyze the results of concurrent chemoradiotherapy in patients with locoregional recurrent nasopharyngeal carcinoma.

METHODS AND MATERIALS

We performed a retrospective analysis of 35 patients with locoregional recurrent nasopharyngeal carcinoma referred to our department between March 1994 and November 2002. Most patients were male (77%), Chinese (97%), and had undifferentiated carcinoma (89%). Most had extensive locally recurrent Stage rT3-T4 disease (66%) with a median age at recurrence of 49 years (range, 35-69 years). A repeat course of radiotherapy was given concurrently with cisplatin, with cisplatin/5-fluorouracil as consolidation treatment. Significant morbidities were present, including cranial nerve palsies due to extensive recurrent local disease before treatment of the recurrence.

RESULTS

The response rate to concurrent chemoradiotherapy was 58% (29% complete response and 29% partial response). The 5-year progression-free and overall survival rate, calculated using the Kaplan-Meier method, was 15% and 26%, respectively. Only 3 patients developed systemic metastases. Grade 3-4 acute toxicities included emesis (9%) and neutropenia (14%), and Grade 3-4 late toxicities consisted of temporal lobe necrosis (3%), cranial neuropathy (6%), and endocrine abnormalities (14%).

CONCLUSION

Concurrent chemoradiotherapy is feasible in a selected group of patients with locoregional recurrent NPC, but the risk of major late toxicities is significant.