A call to action in thoracic transplant surgical training

Thoracic organ recovery and implantation is increasing in complexity. Simultaneously the logistic burden and associated cost is rising. An electronic survey distributed to the surgical directors of thoracic transplant programs in the United States indicated dissatisfaction amongst 72% of respondents with current procurement training and 85% of respondents favored a process for certification in thoracic organ transplantation. These responses highlight concerns for the current paradigm of training in thoracic transplantation. We discuss the implications of advancements in organ retrieval and implant for surgical training and propose that the thoracic transplant community might address the need through formalized training in procurement and certification in thoracic transplantation.

Moral Injury and Suicide Ideation Among Combat Veterans: The Role of Trauma-Related Shame and Collective Hatred

Introduction

Exposure to potentially morally injurious events (PMIEs) among combat veterans has been acknowledged as a significant stressful combat event that may lead to mental health problems, including suicide ideation (SI). Several studies have examined the risk and protective factors that can explain the conditions in which PMIEs may contribute to the development and maintenance of SI. However, the contribution of social-emotional factors has yet to be examined.

Objectives

In the current study, we examined the association between PMIE-Self and SI among combat veterans and explored the mediating role of trauma-related shame and the moderation role of collective hatred in this association.

Methods

A volunteer sample of 336 Israeli combat veterans was recruited, completing self-report questionnaires in a cross-sectional study.

Results

indicated that PMIE-Self was positively associated with SI, and trauma-related shame mediated this association. Moreover, collective hatred moderated both their direct (PMIE -SI) and indirect (PMIE-Shame-SI) association. Notably, collective hatred had an inverse role for each of the associations. Thus, collective hatred was found to comprise both a risk and a protective factor for SI following PMIE-Self.

Conclusions

The current findings highlight the crucial contribution of trauma-related shame and collective hatred to the association between moral injury and suicidality. Moreover, the findings demonstrate that even years after their military service release, combat veterans exposed to PMIEs may still feel consumed by painful memories and maintain premonitions of a foreshortened future. Furthermore, the findings help to better understand the dynamics of collective hatred and the challenge of modifying it.

Disclosure

No significant relationships.

Extracorporeal Membrane Oxygenation Dependent COVID19 Hospital Transfers

Introduction

The World Health Organization has recorded over 8 Million cases of COVID19 as of October 2020. Despite receiving appropriate lung protective ventilation and medical treatment, some of these patients develop refractory hypoxemia and acute respiratory distress syndrome . Extracorporeal membrane oxygenation has been recognized as a lifesaving therapy for patients with ARDS secondary to COVID19. There are few centers in the United States equipped with the necessary staff and the experience to take care of such critically ill patients. Some patients are too ill to be transferred with conventional mechanical ventilation, and they require interhospital transport while on ECMO.

Case Report

We have developed a highly specialized ECMO Deployment Team dedicated to the cannulation and transport of COVID19 patients while on venous-venous (VV) ECMO or venous-arterial (VA) ECMO. We use routine bedside ECMO cannulation via bilateral femoral vessels configuration at the outside hospital. The patient is stabilized and transported by air or ground to one of our affiliated hospitals.Here we present a series of five patients who were cannulated by our team at an outside institution and transported while on ECMO support to one of our three system hospitals. Patient ages ranged between 49-64 years old. Four patients required VV ECMO for severe hypoxemia secondary to COVID19 ARDS. One patient required VA ECMO due to viral myocarditis secondary to COVID19. Time on ECMO ranged from 9-33 days. Three of the five patients recovered successfully and were discharged home, rehab or LTAC. One patient is still currently on ECMO and one patient is deceased. There were no reported or documented transmission of COVID19 to the members of the ECMO deployment team.

Summary

The potential for survival of the critically ill due to COVID19 often demands a higher level of care. However, stable transport to an appropriate institution presents a limiting factor. Our method of a dedicated ECMO Deployment Team appears to provide favorable outcome for these patients.

Pooled safety and efficacy of inclisiran in patients with statin intolerance (ORION-10 and ORION-11)

Introduction

Statin-associated side effects prevent a substantial proportion of patients from being adequately treated with statin therapy and achieving adequate LDL-C reductions. Phase 3 trials showed that inclisiran, a new siRNA, durably lowers LDL-C by ≥50% on top of maximally tolerated statin therapy.

Purpose

To evaluate inclisiran's tolerability and LDL-C lowering effects among individuals who were not receiving statin therapy mainly because of statin intolerance.

Methods

The Phase 3 ORION-10 and ORION-11 trials randomized patients with established ASCVD (or risk-equivalents) with LDL-C >70 mg/dl despite maximally tolerated statins to inclisiran or placebo (1:1). Inclisiran sodium 300 mg was administered s.c. at baseline, three months later, then every six months. The primary efficacy endpoints were % change in LDL-C from baseline to Day 510 and time adjusted % change in LDL-C from baseline after Day 90 and up to Day 540. Absolute LDL-C reductions were secondary endpoints. This analysis included individuals who were not on statin therapy at baseline.

Results

The trials included 252 (7.9% of the pooled trial populations; mean age 68; male 62%; lipid-lowering therapy 28%). AE rates and LDL-C reductions are shown in the Table. Overall, 12 (4.7%) patients had myalgia (4.8% in the inclisiran groups, 4.7% in the placebo groups). There were 8 discontinuations in the inclisiran groups (6.5%) and 3 in the placebo groups (2.3%). The placebo-adjusted mean reduction in LDL-C at Day 510 was 45.8%, an absolute reduction of 68.0 mg/dL (p<0.0001).

Conclusion

Among statin intolerant individuals in ORION-10 and 11, inclisiran potently and durably lowered LDL-C with an adverse event profile comparable to placebo. Inclisiran may represent a new and potent therapeutic option for patients with elevated LDL-C unable to tolerate statins.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The Medicines Company

P6193Dalcetrapib reduces incident diabetes in patients with recent acute coronary syndrome

Background

Among patients with acute coronary syndrome (ACS) who do not have diabetes, incident diabetes is common and associated with an adverse prognosis. Some data suggest that high density lipoprotein (HDL) has favourable effects on beta cell function and that cholesteryl ester transfer protein (CETP) inhibitors reduce incident type 2 diabetes in conjunction with increased HDL cholesterol (HDL-C) concentration. Dalcetrapib is a CETP inhibitor under ongoing evaluation as a potential cardiovascular therapy.

Purpose

We compared the effect of treatment with dalcetrapib or placebo on incident diabetes in patients with recent acute coronary syndrome (ACS).

Methods

In the dal-OUTCOMES trial, 15,871 patients were randomly assigned to treatment with dalcetrapib 600 mg or placebo daily, beginning 4–12 weeks after ACS. Absence of diabetes at baseline was based upon medical history, no use of diabetes medication, haemoglobin A1c <6.5%, and plasma glucose level <7 mmol/L (if measured under fasting conditions) or <11.1 mmol/L (if measured under non-fasting conditions). Among these patients, incident diabetes after randomization was defined by any diabetes-related adverse event, use of a diabetes medication, HbA1c ≥6.5%, or two measurements of plasma glucose ≥7 mmol/L (fasting) or ≥11.1 mmol/L (non-fasting). The association of incident diabetes with baseline and on-treatment HDL-C was determined.

Results

At baseline, 10621 patients (67% of the trial cohort) did not have diabetes and formed the analysis cohort. Over median follow-up of 31 months, incident diabetes was identified in 392 of 5314 patients (7.4%) assigned to dalcetrapib and 505 of 5307 (9.5%) assigned to placebo (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.66–0.87; P<0.001). This corresponds to an absolute reduction in incident diabetes of 2.1%, and a need to treat 47 patients (for 31 months) to prevent 1 case of diabetes. Kaplan-Meier estimates of the cumulative incidence of diabetes are shown in the Figure. Across both treatment groups, incident diabetes was inversely associated with baseline HDL-C (OR 0.98 for 1 mg/dL increase in baseline HDL-C; 95% CI 0.97–0.98, P<0.001). In the dalcetrapib group, there was a further inverse association of incident diabetes with the change in HDL-C on assigned treatment (OR 0.98 for 1 mg/dL increase in HDL-C from baseline; 95% CI 0.97–0.99, P=0.002). Dalcetrapib was safe and generally well-tolerated in the trial.

Conclusions

In patients with recent ACS who do not have diabetes at baseline, incident diabetes is common. Dalcetrapib treatment reduced the relative risk of incident diabetes by 24% and the absolute risk by 2.1% over a median of 31 months. The reduction in incident diabetes with dalcetrapib was associated with increased HDL-C on treatment.

Acknowledgement/Funding

The dal-OUTCOMES trial was funded by F. Hoffmann LaRoche

P1226Very low achieved low-density lipoprotein cholesterol level with alirocumab treatment after acute coronary syndrome: ODYSSEY OUTCOMES

Background

Recent guidelines for cholesterol management recognize uncertainty regarding long-term efficacy and safety of prolonged very low levels of LDL-C on treatment with a PCSK9 inhibitor, including risk of new-onset diabetes. ODYSSEY OUTCOMES used a treat-to-target approach to demonstrate reduction of coronary heart disease death, non-fatal myocardial infarction, ischaemic stroke, or unstable angina (MACE) with the PCSK9 inhibitor alirocumab (ALI) vs placebo (PBO) in 18,924 patients with recent acute coronary syndrome and elevated LDL-C despite intensive statin therapy. ALI was blindly adjusted (75 or 150 mg dose) to target LDL-C 0.6–1.3 mmol/L (25–50 mg/dL). To avoid sustained very low LDL-C, blind substitution of PBO for ALI was intended if 2 consecutive LDL-C levels were <0.39 mmol/L (15 mg/dL). Patients were followed for median of 2.8 years (maximum of 5 years).

Purpose

We report the efficacy and safety of ALI in patients who reached very low LDL-C (consecutively <0.39 mmol/L), compared with matched patients from the PBO group.

Methods

Of 9462 patients randomized to receive ALI, 730 (7.7%) reached very low LDL-C and had substitution of PBO a median 8.3 months after randomization. Using propensity score matching, they were compared (3:1) with 2152 patients initially assigned to PBO. Propensity score matching was also used to compare the incidence of new-onset diabetes in 525 patients without diabetes at baseline who had very low LDL-C levels on ALI with 1675 matched patients in the PBO group. Neurocognitive events and haemorrhagic stroke were also evaluated in relation to very low LDL-C.

Results

Overall, ALI reduced the incidence of MACE (9.5% vs 11.1%; HR 0.85, 95% CI 0.78–0.93; P<0.001). Characteristics used in propensity score matching (and associated with very low LDL-C on ALI) included sex (male), diabetes (present), baseline LDL-C and lipoprotein(a) (lower), region (Asia), statin treatment, smoking, hypertension, and body mass index. Despite being switched to PBO, patients with very low LDL-C on ALI had fewer MACE than matched patients from the PBO group (6.4% vs 8.5%; HR 0.71, 95% CI 0.52–0.98; P=0.039; Figure). Very low LDL-C on ALI was not associated with risk of new-onset diabetes, compared with matched patients from the PBO group (15.1% vs 13.0%; HR 1.10, 95% CI 0.85–1.43; P=0.46). There was no association of very low LDL-C on ALI with neurocognitive events or haemorrhagic stroke.

Conclusions

The overall efficacy of ALI on cardiovascular outcomes was not diminished by the patients who had blinded substitution of PBO for sustained very low LDL-C. Despite a short duration of active treatment, these patients had fewer MACE than matched controls from the PBO group. No adverse consequence of very low LDL-C was identified. However, because patients with sustained very low LDL-C were switched to PBO, the long-term safety of more prolonged very low LDL-C, including risk of new-onset diabetes, deserves further study.

Acknowledgement/Funding

Funded by Sanofi and Regeneron Pharmaceuticals

PKK deficiency in B cells prevents lupus development in Sle lupus mice

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the production of autoantibodies that can result in damage to multiple organs. It is well documented that B cells play a critical role in the development of the disease. We previously showed that protein kinase C associated kinase (PKK) is required for B1 cell development as well as for the survival of recirculating mature B cells and B-lymphoma cells. Here, we investigated the role of PKK in lupus development in a lupus mouse model. We demonstrate that the conditional deletion of PKK in B cells prevents lupus development in Sle1Sle3 mice. The loss of PKK in Sle mice resulted in the amelioration of multiple classical lupus-associated phenotypes and histologic features of lupus nephritis, including marked reduction in the levels of serum autoantibodies, proteinuria, spleen size, peritoneal B-1 cell population and the number of activated CD4 T cells. In addition, the abundance of autoreactive plasma cells normally seen in Sle lupus mice was also significantly decreased in the PKK-deficient Sle mice. Sle B cells deficient in PKK display defective proliferation responses to BCR and LPS stimulation. Consistently, B cell receptor-mediated NF-κB activation, which is required for the survival of activated B cells, was impaired in the PKK-deficient B cells. Taken together, our work uncovers a critical role of PKK in lupus development and suggests that targeting the PKK-mediated pathway may represent a promising therapeutic strategy for lupus treatment.

Patients' understanding of how genotype variation affects benefits of tamoxifen therapy for breast cancer

BACKGROUND

CYP2D6 is a critical enzyme in the metabolism of tamoxifen and potentially a key determinant in breast cancer outcomes. Our study examined patients' beliefs about how the CYP2D6 genotype would affect their prognoses.

METHODS

Women enrolled in a pharmacogenomic clinical trial and on tamoxifen for prevention or treatment of breast cancer underwent CYP2D6 genotyping (EM = extensive, IM = intermediate, PM = poor metabolizing alleles). The informed consent said that the purpose of the trial was to examine effects of dose adjustment based on genotype, but that clinical benefits were uncertain. Our embedded sub-study surveyed 320 patients prior to receiving their genotypes. We experimentally manipulated 6 vignettes to describe hypothetical tamoxifen treatment (no or yes) and hypothetical genotype (EM, IM or PM). For each vignette, women gave their perceived recurrence risk (RR; 0-100%).

RESULTS

Women believed that genotype would not affect their RR if they did not take tamoxifen (p = 0.06). However, women believed that if prescribed tamoxifen, genotype would affect their RR (22% if EM, 30% if IM and 40% if PM, p < 0.001).

CONCLUSION

Women believed that extensive tamoxifen metabolizers had better prognoses, despite study materials stating uncertainty about any benefit. The rapidly changing nature of genomic science calls for caution when communicating clinical utility.

Tumor oxygenation and radiosensitization by pentoxifylline and a perflubron emulsion carbogen breathing

Oxygen tension measurements were made in three tumors: (i) the murine FSaII fibrosarcoma, (ii) the rat 9L gliosarcoma and (iii) the rat 13672 mammary adenocarcinoma using a pO2 histograph. Tumor oxygenation measurements were made while the animals breathed air or breathed carbogen (95% oxygen/5% carbon dioxide). Pentoxifylline or a perflubron emulsion was administered to the animals and tumor oxygen measurements were repeated under both breathing conditions. Both pentoxifylline and the perflubron emulsion improved the oxygenation of the FSaII fibrosarcoma under air breathing conditions but did not alter the oxygen profiles of either rat tumor compared with air breathing alone. Carbogen breathing increased the oxygenation of all tumors. Pentoxifylline administration did not change the oxygen profiles of the tumors under carbogen breathing conditions but administration of the perflubron emulsion increased the oxygenation of all three tumors under carbogen breathing conditions compared with carbogen breathing alone. Co-administration of pentoxifylline and the perflubron emulsion enhanced the radiation response of the Lewis lung tumor to daily fractionated radiation under air breathing conditions with a dose modifying factor of 1.65 and under carbogen breathing conditions with a dose modifying factor of 2.25. Over a range of perflubron emulsion doses, pentoxifylline increased the growth delay of the Lewis lung tumor in a constant manner. These results indicate that pentoxifylline and the perflubron emulsion have the largest impact on the oxygenation of more hypoxic tumors and that administration of the perflubron emulsion/carbogen breathing is the most effective means of increasing tumor oxygenation and radiation response.

Decreased tumor oxygenation after cyclophosphamide, reoxygenation and therapeutic enhancement with a perflubron emulsion carbogen breathing

Oxygen profiles of the rat mammary 13672 carcinoma were determined using a pO2 histograph prior to treatment and 24 h and 48 h after i.p. administration of a single dose of cyclophosphamide (300 mg/kg). The tumors were severely hypoxic at 24 h post the administration of cyclophosphamide. There was little increase in oxygenation of the tumors at 48 h post therapy compared with 24 h post therapy indicating that reoxygenation after cyclophosphamide was occurring very slowly in this tumor. Carbogen breathing improved the oxygenation of the tumors under each of the conditions studied. Administration of the perflubron emulsion (8 ml/kg) produced little or no change in the oxygenation of the tumors under normal air breathing conditions. However, the addition of carbogen breathing to administration of the perflubron emulsion increased the oxygenation of the tumors to levels equal to or greater than carbogen breathing at the mean/median pO2's. Perhaps most significantly, administration of the perflubron emulsion with carbogen breathing increased the oxygenation of the most hypoxic regions of the tumors but carbogen breathing alone did not. The growth delay of the Lewis lung carcinoma increased with increasing dose.of the perflubron emulsion along with cyclophosphamide (3 x 150 mg/kg) and carbogen breathing (6 h). This combination treatment was most effective when the cyclophosphamide was prepared in the perflubron emulsion. The number of lung metastases decreased in a manner parallel with increased efficacy of the treatment toward the primary tumor.

Safety, tolerability, pharmacokinetics and pharmacodynamics of AZD8055 in advanced solid tumours and lymphoma

Background:

This study assessed the safety, tolerability, pharmacokinetics and pharmacodynamics of the first-in-class dual mammalian target of rapamycin complex (mTORC)1/mTORC2 inhibitor, AZD8055.

Methods:

Patients with advanced solid malignancies or lymphomas were recruited into this phase I, open-label, dose-escalation study of AZD8055 starting at 10 mg twice-daily oral dosing (BID).

Results:

Forty-nine patients received AZD8055. Dose-limiting toxicities were reported at 40 mg (n=1), 90 mg (n=1) and 120 mg (n=3) BID; all were grade 3 rises in transaminases, reversible in all patients, apart from one who had liver metastases. The maximum tolerated dose was defined as 90 mg BID. The most frequent adverse events assessed to be related to AZD8055 were increased alanine aminotransferase (22%), increased aspartate aminotransferase (22%) and fatigue (16%). AZD8055 was rapidly absorbed (median t_max ∼0.5 h) and exposure increased with increasing doses. Seven patients had stable disease for ⩾4 months. Partial metabolic responses, assessed by fluorodeoxyglucose positron emission tomography, were observed at ⩾40 mg BID (n=8 at day 35).

Conclusion:

The maximum tolerated dose for AZD8055 is 90 mg BID. Apart from elevated transaminases, which occurred at most dose levels, the drug had an acceptable toxicity profile; however, no RECIST responses were seen.

Erlotinib 'dosing-to-rash': a phase II intrapatient dose escalation and pharmacologic study of erlotinib in previously treated advanced non-small cell lung cancer

BACKGROUND

To evaluate the anticancer activity of erlotinib in patients with previously treated, advanced non-small cell lung cancer (NSCLC) whose dose is increased to that associated with a maximal level of tolerable skin toxicity (i.e., target rash (TR)); to characterise the pharmacokinetics (PK) and pharmacodynamics (PD) of higher doses of erlotinib.

METHODS

Patients initially received erlotinib 150 mg per day. The dose was successively increased in each patient to that associated with a TR. Anticancer activity was evaluated. Plasma, skin, and hair were sampled for PK and PD studies.

RESULTS

Erlotinib dose escalation to 200-475 mg per day was feasible in 38 (90%) of 42 patients. Twenty-four (57%) patients developed a TR, but 19 (79%) did so at 150 mg per day. Five (12%) patients, all of whom developed a TR, had a partial response. Median progression-free survival (PFS) was 2.3 months (95% CI: 1.61, 4.14); median PFS was 3.5 months and 1.9 months, respectively, for patients who did and did not experience a TR (hazard ratio, 0.51; P=0.051). Neither rash severity nor response correlated with erlotinib exposure.

CONCLUSION

Intrapatient dose escalation of erlotinib does not appreciably increase the propensity to experience a maximal level of tolerable skin toxicity, or appear to increase the anticancer activity of erlotinib in NSCLC.

Abstract P1-15-02: Impact of Retinoblastoma (RB) Tumor Suppressor Pathway on Ductal Carcinoma In Situ (DCIS) Recurrence

The retinoblastoma (RB) tumor suppressor is functionally inactivated at high frequency in human malignancies including breast cancer. By immunohistochemistry loss of RB function is associated with p16ink4a overexpression and high Ki67 proliferation index.We have previously shown that loss of RB results in dramatic upregulation of genes associated with tumorigenesis and is a key determinant of therapeutic response in invasive breast carcinoma. Recently publish data indicate that RB pathway dysregulation plays an important role in DCIS progression to invasive carcinoma. The aim of this study was to evaluate the expression p16ink4a and Ki67 (indicative of RB loss) in a large cohort of DCIS patients treated at one institution with wide-excision and close follow-up. Material and Methods

149 DCIS patients were included in the study. Expression of p16ink4a and Ki67 was assessed by employing a standard immunoperoxidase method with ani-p16ink4a (MTM Laboratories Westborough, MA) and anti-Ki67 (AbCam Cambridge, MA) antibodies. The p16ink4a staining in DCIS epithelium was scored semi-quantitatively as negative (0; no staining), weak (1;staining in less than 25% of cells), moderate (2; defined as staining in 25-75% of cells) and strong (3; &gt;75% of cells staining). For statistical analysis, the original p16ink4a scores (0, 1, 2, 3) were dichotomized as low (0,1) vs. high (2-3) and original ki67 scores were dichotomized as low (&lt;= 10%) vs. high (&gt; 10%). Stromal p16 staining was scored as absent or present.

Association between p16ink4a and Ki67 and nuclear grade, necrosis, hormone receptor and Her2 expression as well as recurrence was assessed using Fisher's exact test. The Cox proportional hazard model was used for analyses of time to recurrence. Results

There was a statistically significant association between high p16ink4a and Ki67 expression in DCIS epithelium and triple negative as well as Her2 positive DCIS subtypes. Significant association was detected between high expression of p16 and Ki67 in DCIS epithelium and DCIS recurrence (p=0.005). Stromal expression of p16 was the strongest predictor of DCIS recurrence (p &lt; 0.0001). In multivariate Cox model DCIS cases with high expression of p16 and Ki67 in epithelium and stromal p16 expression had the shortest time to recurrence.

Conclusion

RB pathway dysregulation in DCIS epithelium as well as stromal expression of p16ink4a indicative of senescence are associated with DCIS recurrence.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-15-02.

Gastrointestinal and Cardiovascular Safety Profiles of Neratinib Monotherapy in Patients with Advanced ErbB2-Positive Breast Cancer

Background: In a phase 2 study, oral neratinib was administered to patients (pts) with advanced breast cancer in 2 cohorts, those with prior trastuzumab treatment (prior T, n=66) and those with no prior trastuzumab treatment (no prior T, n=70). Neratinib demonstrated robust antitumor activity with objective response rates of 26% and 51%, respectively, and was generally tolerable (Burstein et al. Cancer Res 2009;69:72S). Diarrhea, all grades, occurred in 89% of total pts. Characteristics of the diarrhea and left ventricular ejection fraction (LVEF) measurements are described. Methods: Pts were required to have ErbB2 gene amplification in tumor tissue as measured by fluorescence in situ hybridization by independent assessment. Serial LVEF measurements were made with a multigated acquisition scan or echocardiogram. Pts were ineligible if baseline LVEF was &lt;50%. Adverse events were graded based on the NCI Common Terminology Criteria, v 3.0. Pts received oral neratinib 240 mg daily. Results: Data collected by 18 Mar 2009 are reported; the median (range) duration of neratinib treatment was 4.5 (0.2-23.5) months for pts with prior T and 7.8 (0.5-24.2) months for pts with no prior T. Diarrhea, all grades occurred in 93% of the total population (prior T: 97%, no prior T: 89%); grade 3-4 diarrhea occurred in 21% of the total population (prior T: 30%, no prior T: 13%). Median times of onset were 2 and 3 days after first dose of neratinib, respectively, and median durations of diarrhea were 7 and 5 days. In study week 1, 86% and 73% of pts with prior T and no prior T, respectively, had diarrhea; this decreased to 12-14% in months 3 and 4 (Table). Diarrhea was the cause of dose interruptions in 36% of pts with prior T and 11% of pts with no prior T and of dose reductions in 30% of pts with prior T and 5% of pts with no prior T; only 1 pt (prior T) discontinued treatment due to diarrhea. Pts used anti-diarrheal medications for supportive therapy (prior T: 91%, no prior T: 67%). For LVEF measurements, there was little variation from baseline in most pts during the study. Four pts had at least 1 LVEF measurement &lt;50% (2 of these pts had measurements within the institutional range of normal). None had congestive heart failure. One of these pts had grade 3 atrioventricular block and grade 3 bradycardia, which were considered unrelated to neratinib. Discussion: Neratinib treatment was not associated with clinically significant cardiotoxicity. Pts who developed diarrhea with neratinib monotherapy had early onset, but frequency and severity decreased with time on study. Despite the high frequency of diarrhea with neratinib treatment, it was readily managed with supportive therapy and dose interruptions and/or reductions.Time Course of Diarrhea in ErbB2-Positive Breast Cancer Patients Treated With NeratinibStudy PeriodPrior T: No. on StudyPrior T: % With Diarrhea, All Grades*Prior T: % With Diarrhea, Gr 3-4*No Prior T: No. on StudyNo Prior T: % With Diarrhea, All Grades*No Prior T: % With Diarrhea, Gr 3-4*Week 166861770737Week 2-466611170436Month 260331066152Month 34713060120Month 44312058140*For pts with multiple toxicity grades in a period, the maximum grade was reported.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5096.

Lapatinib Restores Endocrine Sensitivity in Selected Patients with Estrogen Receptor (ER) Positive Metastatic Breast Cancer

Background:Breast cancer cell lines achieve a state of resistance to antiestrogens and to estrogen withdrawal or aromatase inhibitors by utilizing other growth factor pathways to transactivate ERα and undergo estrogen-independent growth. Breast cancer cell lines consistently overexpress the epidermal growth factor family of receptors (ErbB) and/or the epidermal growth factor (EGF) ligands when they achieve endocrine-independent growth. Our hypothesis is that the ErbB family of receptors is the dominant pathway utilized by breast cancers in our patients with endocrine-resistant tumors. Because ErbB2 is the dominant partner in ErbB heterodimerization, a tyrosine kinase inhibitor with ErbB2 activity such as lapatinib would be the preferred agent to block transactivation of ERα. Lapatinib has minimal activity as a single agent against ErbB2 unamplified cancers, and any clinical benefit from the combination of lapatinib and endocrine therapy indicates evidence of an interaction between the ER and ErbB pathways.Materials and Methods:Patients with hormone receptor positive, metastatic breast carcinoma with an initial clinical benefit from any line of endocrine therapy, were enrolled within six weeks of documentation of clinical progression on endocrine therapy. Subjects had an ECOG performance status of 0-2, adequate organ function, and recovery from prior cancer treatment. They were continued on the same endocrine therapy, with the addition of lapatinib at 1500 mg once daily. Patients were restaged at 14 and 26 weeks, and those with stable disease or better at 26 weeks were eligible to continue the combination of lapatinib and endocrine therapy until disease progression.Results:Twenty one patients have been enrolled to date. The median age is 60 (range 39-77), one patient has ErbB2 amplified disease, one patient has borderline amplification, and 19 patients are unamplified for ErbB2. Fifteen patients were treated with aromatase inhibitors, while six patients used antiestrogens. Ten patients had bone only metastatic disease, and only three patients had visceral metastases at enrollment. The treatment was well-tolerated; four patients had Grade 3 diarrhea, there were five episodes of diarrhea-related Grade 3 electrolyte abnormalities, and one patient went off study due to a reversible Grade 3 elevation in ALT. Seven of sixteen evaluable patients had stable disease at 26 weeks. The median time to disease progression is 179 days (range 94-513 days), and four patients remain on study free of disease progression. The use of, or duration of prior tamoxifen treatment was not predictive of progression-free survival on study.Conclusions:In a highly selected group of patients with metastatic breast cancer, the addition of lapatinib to the endocrine agent on which the cancer had just progressed maintained the duration of response by an average of six months. This demonstrates a favorable interaction between lapatinib and both aromatase inhibitors and antiestrogens in patients with newly acquired endocrine resistance. Accrual to this study is continuing.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3089.

Influence of genetic polymorphisms in the apolipoprotein (APOE) and the butyrylcholinesterase (BCHE) gene on stress markers in older adults: a 3-year study

The present study examined the influence of genetic polymorphisms in the apolipoprotein (APOE) and the butyrylcholinesterase (BCHE) gene on GC secretion, cognition and personality in 66 healthy older adults. These particular variables were chosen given that they have been shown to be associated with human stress (i.e.stress markers). Measures included basal serum GC levels and cognitive scores on declarative memory obtained annually over 3 years. Also, self-esteem, neuroticism and depression were evaluated. Results showed that participants with the APOE E4-BCHE K variant (E4-K group) present increased basal levels of GCs and poorer cognitive performance when compared to non-carriers of these variants. In addition, the E4-K group reported lower self-esteem and higher levels of depression. These findings may indicate a genotype effect on markers of stress and cognitive integrity years before symptoms of dementia are apparent.

Evaluation of the feasibility of expression microarray analysis in endoscopically obtained biopsies of gastric carcinoma and their clinical applicability

21164

Background: The feasibility of extracting high quality RNA for expression microarray analysis from endoscopic biopsy in gastric carcinoma has not been previously established. Methods: Patients with histologically confirmed locally advanced gastric or gastroesophageal junction adenocarcinoma were screened for enrollment in an NCI-sponsored trial of neoadjuvant irinotecan and cisplatin chemotherapy (NC1–5917). All patients underwent a repeat endoscopic biopsy for the procurement of fresh tumor tissue. Gross microdissection was performed to enrich the sample to at least 80% malignancy. RNA was isolated from the tumor specimens using RNeasy columns (Qiagen) and its quality verified by RNA 6000 NanoAssay and Bioanalyzer 2100 (Agilent). Gene expression profiling was performed on Human Genome U133A GeneChip (Affymetrix) which contained 22,215 oligonucleotide-base probe-sets. Differential gene expression profiles for Lauren's classification were assessed using empirical Bayes t test, a threshold p < 0.001 was considered statistically significant. Results: Of 36 patients with previous biopsy confirmed gastric cancer, repeat endoscopic biopsy identified carcinoma in 28 patients (78%, 95%CI 61–90%). Adequate RNA for microarray analysis was obtained from 21 patients-representing 58% of those who presented for the procedure and 75% in whom endoscopic biopsies confirmed malignancy. This yield improved with increasing number of samples taken. Lauren's classification was available on 26 patients who underwent resection. From the total 54,613 gene probe-sets on the arrays, comparison of the expression profiles of diffuse-type and intestinal-type identified 167 genes that were differentially expressed. Diffuse gastric cancer demonstrated altered expression of genes related to cell-matrix interaction whereas intestinal gastric cancer expression analysis showed enhancement of cell growth. Conclusions: Endoscopic biopsy for expression analysis of gastric cancer is feasible with increasing yield with each core taken. Expression analysis at the time of endoscopic biopsy can differentiate Lauren's histology, a characteristic not routinely evaluable by pathologic review.

No significant financial relationships to disclose.

Analysis of toxicity in a phase II study of sorafenib in soft tissue sarcoma (STS)

10061

Background: Sorafenib (BAY 43–9006) is an oral multi-targeted kinase inhibitor. Sorafenib causes dermatologic toxicity and hypertension, although the mechanisms are poorly understood. We observed significant toxicity requiring dose reductions in our phase II study of sorafenib in STS. Methods: 120 patients (40 M, 80 F; median age, 55 years) were treated between 10/05 and 12/06; accrual continues. All patients initially received sorafenib 400 mg BID. 118/120 registered patients were evaluable for toxicity. Clinical and laboratory variables were analyzed for association with dose reduction, using Kruskal-Wallis rank sum test for continuous variables and Fisher exact test for categorical variables. Variables significant at the p=0.05 level were further analyzed with a multivariate logistic regression model for their effects on dose reduction. Results: 53% of patients (63/118) required dose reductions, 53/63 for grade 2 or greater skin toxicity. Most common grade 3–4 drug-related toxicities included lymphopenia (14%), rash (12%), and hand-foot skin reaction (10%). Sex, height, weight, BSA and serum creatinine (Cr) were significantly associated with dose reduction by univariate analysis. Adjusting for sex and/or low serum Cr, BSA was not significantly associated with dose reduction. Sex and low serum Cr were borderline statistically significant predictors of dose reductions when both variables were included in a multivariate model. Only female sex remained a significant predictor when eliminating one outlier with BSA 2.83 (p=0.04). Conclusions: Female gender appears associated with skin toxicity, requiring dose reductions. Based on this multivariate analysis, a starting dose of 400 mg oral daily in women may limit side effects. Correlation with trough serum sorafenib levels is pending. This study is funded in part by NCI Grant P01-CA47179.

No significant financial relationships to disclose.

Peak bone mass in patients with phenylketonuria

OBJECTIVE

Several studies have suggested a compromised bone mass in phenylketonuria patients but most reported on heterogeneous or small patient groups. Our aim was to evaluate peak bone mass in adult PKU patients and to relate BMD to nutritional parameters.

PATIENTS AND METHODS

BMD was measured by dual-energy x-ray absorptiometry in 31 adult PKU patients (18 female), mean age 25 +/- 5.3 years. Nutritional intake was calculated based on food diaries. Diet adherence was determined based on patients' report.

RESULTS

Mean blood phenylalanine (Phe) concentration was 968 +/- 526 micromol/L (16 +/- 8.7 mg/dl). Eight patients (32.2%) met the recommended blood Phe concentration of <726 micromol/L (<12 mg/dl), and there was no significant difference in Phe concentrations between diet-adherent and non-adherent patients. Osteopenia was detected in 11 patients (38.7%), while osteoporosis was detected in 2 patients (6.5%). No correlation was found between BMD and age, blood minerals, Phe, vitamin D and alkaline phosphatase levels, calcium and protein intake, body mass index, and body fat percentage.

CONCLUSIONS

Peak bone mass is decreased in PKU patients. Possible explanations include long-standing dietary deficiency in protein, calcium, vitamin D or trace elements, or a primary defect in bone turnover inherent to the disease itself. Our data do not favour any of these hypotheses. Further studies are needed to elucidate the cause of low bone density in PKU patients.

Selective Use of Expanded Criteria Donors for Renal Transplantation With Good Results

Increasing demand for renal transplants has stimulated expanded criteria for the use of deceased donors. Recently an official category of "Expanded Criteria Donors" (ECD) was designated by UNOS. This category included any deceased donor (1) greater than age 60 years or (2) age 50 to 59 years with any two of: (a) creatinine greater than 1.5 mg/dL (b) cerebrovascular accident cause of death, or (c) hypertension history. It has been anticipated that at 3 years, 70% of ECD kidneys with serum creatinine greater than 1.5 would be lost. We reviewed our experience with the use of this type of kidney prior to the era of officially designated ECD. Survival rates and serum creatinines were compared to standard criteria donor recipients for the same time period whose donor was greater than 50 years of age and correlated with biopsies. From 1996 to 2003, 341 deceased donor kidneys were transplanted at our center. Of these, 37 were ECD kidneys and 46 were standard criteria donors kidneys. Four pretransplant biopsies had greater than 20% sclerosed glomeruli. Four donors had 0% to 25% arteriosclerosis pretransplant; on postperfusion biopsy, eight had 0% to 25% arteriosclerosis, while three had 25% to 50%. The mean donor age was 61 years; mean recipient age was 54 years; recipient sex was 57% male, and 54% of the recipients were African-American. At 1, 2, and 3 years posttransplant, there was no significant difference between the two groups in serum creatinine, graft survival, or patient survival. Despite using ECD donors, good long-term function can be obtained, particularly if selectivity is exercised.

A phase I, pharmacokinetic (PK) and pharmacodynamic (PD) study of the combination of an oral antimicrotubular agent, DJ-927 (D), and capecitabine (C) in patients (Pts) with advanced cancers

2016

Background: DJ-927, an oral microtubule stabilizer, has impressive cytotoxic activity in taxane-resistant tumors and an acceptable toxicity profile. C and Taxane combinations are active in solid tumors such as breast cancer. Non-overlapping mechanism of action and toxicity profiles and the convenience of an orally administered therapy have prompted a phase I evaluation of the combination. D was given orally once on day 1 and C for 14-days (D1–14), every three weeks. Methods: Eligible pts had evaluable cancer, minimal prior therapy and PS 0 - 2 ECOG. D was started at 18 mg/m2 on day 1 along with 1,250 mg/m2 of C orally B.I.D for 14 days, of a 21-day cycle. Incremental doses of both drugs were explored until the maximum tolerated dose (MTD) was reached. PK samples were collected during cycles 1 and 2, for assays of C and for D when given concurrently with C during cycle 1 and D given alone during cycle 2. Results: Twenty-seven pts [18 Male/ 9 Female; median age (range)- 58 yrs (33–70); PS 0 (n=8) ; PS 1 (n=19)] received 81 cycles [median (range)- 3 (1–8)] in 5 cohorts, with D and C 18/ 1250 mg/m2 (n = 3), 27/ 1250 mg/m2 (n = 7), 27/ 1900 mg/m2 (n = 7), 35/ 1900 mg/m2 (n = 3),and 27/ 2500 mg/m2 (n = 7). Dose-limiting toxicity (DLT) was grade 4 neutropenia in 2 of 3 pts at 35/ 1900 mg/m2 dose. Other common drug-related toxicities were leukopenia, nausea & vomiting (12 pts each, 44.4%), neutropenia, diarrhea and hand-foot syndrome (11 pts each, 40.7%), and fatigue (7 pts, 25.9%). A pt with hepatocellular carcinoma had an unconfirmed partial response at cycle 2 and 10 pts experienced disease stabilization lasting ≥ 12 weeks. The median elimination half-life (t½) of D was 182 hrs for cycle 1 (with C) and 204 hrs for cycle 2 (without C). Median tmax values for D with and without C occurred at 2 hours. Median clearance values (CL/F) for D in plasma were similar with and without C at 18.4 L/h/m2 and 19.8 L/h/m2, respectively. Conclusions: The combination of D and C is feasible and safe at the MTD of 27 mg/m2 and 2500 mg/m2, respectively. Co-administering C with D did not alter the PK of either drug. Preliminary evidence of antitumor activity suggests that further studies of this combination are warranted.

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A putative tumor suppressor role for Wnt-signaling in sarcomagenesis

9507

Background: We sought to elucidate the relationship between the human adult mesenchymal stem cell (hMSC), Wnt signaling and sarcomagenesis. Methods: In vitro hMSC differentiation, microarray gene expression analysis, distance correlation analysis, and standard molecular biology techniques were used to explore the role of Wnt in controlling the differentiation of both hMSCs and high grade undifferentiated sarcoma (HGUS; MFH, malignant fibrous histiocytoma), a common form of adult soft tissue sarcoma. Results: We determined that 1) hMSCs appear to be the progenitor cells of HGUS/MFH; 2) Dickkopf-1 (Dkk1), a specific inhibitor of Wnt signaling, is overexpressed in MFH as compared to other sarcoma subtypes and is involved in the proliferation of hMSCs; 3) in hMSCs, Dkk1 levels decline and nuclear β-catenin accumulates as hMSCs reach confluence, a prerequisite for initiation of in vitro differentiation, while in an MFH cell line Dkk1 levels do not decline and there is no nuclear β-catenin accumulation; 3) MFH cells appear to be primed for differentiation and express early markers of mesenchymal differentiation, then undergo apoptosis, if nuclear β-catenin is manipulated to enter the nucleus; 4) Wnt2 signals via the canonical β-catenin pathway and is responsible for “commitment” of hMSC and an MFH cell line to various differentiation pathways, while Wnt5a signals via the non-canonical JNK pathway in preventing apoptosis upon appropriate commitment toward differentiation. Conclusions: We identified the contribution of canonical and non-canonical Wnt signaling in the differentiation of hMSCs and showed that enhancing signaling via these pathways could be exploited as a potential target for therapy for high grade undifferentiated sarcomas. These data implicate Wnt-signaling as a mechanism of tumor suppression in early sarcomagenesis.

No significant financial relationships to disclose.