Development of leptomeningeal carcinomatosis (LC) in advanced prostate cancer patients: Characteristics of six cases in a single institution

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Background: In the past months, we have noticed an increasing number of leptomeningeal carcinomatosis (LC) in patients known for advanced prostate cancer (PC). This complication has only been reported in a few patients.

Methods: We identified and reviewed the charts of all patients known for advanced PC who later developed LC. We report their characteristics as well as survival.

Results: Between March 2009 and April 2010, we identified 6 patients known for advanced PC that showed evidence of LC (median time from diagnosis of prostate cancer to development of LC, 55.8 months). Disease was already metastatic to other sites in all of them, and all had previously showed evidence of castrate refractory prostate cancer (CRPC). All patients maintained LHRH agonist therapy and were treated with prednisone once they showed evidence of CRPC. Most had also been treated with docetaxel (n=5), zoledronic acid (n=4; the remaining 2 patients received either zoledronic acid or denosumab as part of a protocol) and/or other (dasatinib/placebo as part of a protocol, n=1; sunitinib as part of a protocol, n=1). LC was diagnosed a median of 21.2 months after evidence of CRPC, based on clinical findings (cranial nerve[s] involvement [n=6] and nausea and/or ataxia [n=2]) and magnetic resonance imaging (MRI). 2 patients underwent lumbar puncture (negative results). Treatment administered for LC included dexamethasone (n=1), radiation therapy (n=1), or both (n=2). Two patients with poor performance status did not receive any treatment. All patients assessable for response (n=3) showed a partial improvement in their symptoms, but not complete resolution. Median overall survival from development of CRPC and from diagnosis of LC is 23.9 months and 2.7 months, respectively.

Conclusions: LC is a newly described site of metastasis in patients with advanced CRPC. It is associated with a late onset and a very poor prognosis.

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Negative impact of bone metastasis on outcome in clear-cell renal cell carcinoma treated with sunitinib

BACKGROUND

The aim of our study was to determine whether the presence of bone metastases affects outcomes in patients with metastatic clear-cell renal cell carcinoma (m-ccRCC) receiving sunitinib.

PATIENTS AND METHODS

We reviewed the charts of all patients in four academic centers in Belgium and France who started first-line sunitinib (50 mg/day; 4 weeks on and 2 weeks off) between January 2005 and December 2008. Data were collected on known prognostic factors for metastatic renal cell carcinoma and metastatic sites. Response and progression were evaluated by computed tomography scan (according to RECIST).

RESULTS

Two hundred twenty-three patients were identified. With a median follow-up of 40 months, median progression-free survival (PFS) and median overall survival (OS) were significantly shorter in patients with bone metastases than in those without: respectively, 8.2 versus 19.1 months (P<0.0001) and 19.5 versus 38.5 months (P<0.0001). On multivariate analysis, taking on account platelet count, Eastern Cooperative Oncology Group performance status, number of metastatic sites, neutrophil count, corrected serum calcium, time from diagnosis to systemic treatment, and the presence of bone metastases, bone metastasis was the independent variable most significantly associated with poor PFS (P<0.0001) and OS (P=0.001).

CONCLUSION

The presence of bone metastases in m-ccRCC patients has a significant and clinically relevant negative impact on outcome on sunitinib.

Bone markers in prostate cancer (PC) patients: Biologic criteria to identify patients at risk of developing distant metastases

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Background: Currently, there are no specific serum and/or urinary bone markers able to accurately identify PC patients with hormone-refractory disease and/or those with distant metastases. Methods: Four categories of PC patients were defined as follows: A. hormone-sensitive without distant metastases; B. hormone-sensitive with metastases; C. hormone-refractory without metastases; D. hormone-refractory with metastases. The serum bone markers investigated were osteogenesis-related [Osteocalcin (OC), procollagen type 1 amino-terminal propeptide (P1NP), bone alkaline phosphatase (BALP)], osteolysis-related [beta collagen 1 carboxyterminal peptide (βCTX), carboxyterminal telopeptide type 1 collagen (1CTP), tartrate resistant acid phosphatase (TRAP)] or osteoclastogenesis-related [osteoprotegerin (OPG)]. Receiver Operating Characteristic (ROC) curves and the Area Under these curves were used to estimate the overall accuracy of each marker in discriminating between the four categories (A vs. BCD; B vs. ACD; C vs. ABD and D vs. ABC) with no adjustment for multiplicity. Parametric (Student's t-test) and non-parametric (Kruskal- Wallis) tests were conducted too. All statistical analyses were performed by means of SPSS v 16 (SPSS Inc). Results: Data were from 40 consecutive PC patients treated at the Georges Pompidou European Hospital in Paris, France and who were equally distributed between categories. Hormone-refractory patients with distant metastases were accurately identified by P1NP, 1CTP and TRAP. The respective areas under the ROC values were 0.76, 0.84 and 0.79 (all Pvalues less than 0.01). None of the markers identified category B of patients. Conclusions: Some bone-related serum markers may be associated with the onset of hormone-refractory status and distant metastases. They should be prospectively validated in a larger cohort of patients.

No significant financial relationships to disclose.

What is the place of clinical variables in advanced non-small cell lung cancer (NSCLC) patients treated with chemotherapy?

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Background: Chemotherapy (CT) has shown its effectiveness in symptom control and quality of life improvement in advanced NSCLC patients. The therapeutic strategy and some clinical variables could have a major impact on outcome. Methods: Our retrospective analysis evaluated the impact on overall survival (OS) of the clinical benefit (CB), ECOG performance status (PS) and toxicity, function of treatment. CB was defined as disease-related symptoms improvement according to hospitalization report. Only grade III-IV CTC-NCI version 2 toxicities have been considered. OS was calculated between start of CT and death or last follow-up. Multivariate Cox regression analysis including CB, PS, toxicity and age, stratified by AJCC initial stage was used. Results: Data of 68 consecutive stage IIIB-IV patients treated in a single French centre were analyzed. Chemotherapy was platinum-salt based in 88, 45 and 25% of pts for the first, second and third-line, respectively. Median age was 61 years, 37% were women. More than half (66%) were metastatic and 14% were previously irradiated. Median survival was 14 months (95% CI, 6.1–21.8), 53 % of patients are dead. The risk of death PS-related was multiplied by 2.3, 2.4 and 5.3 for the first, second and third-line of CT, respectively. PS and CB were initially associated with OS (first and second-line CT), but after the third-line of CT only PS was significantly related with OS. The risk of death reduction induced by a CB was 59, 82 and 29%, respectively. Less toxicities during CT were associated with a better OS (an unsignificant 20- 30% risk of death reduction), independently of the chronology of CT. Older pts >70 years have a higher risk of death (HR=1.87), independently of the CB and treatment-related toxicities in the multivariate analysis (P=0.18), sex-adjusted. Conclusions: No matter how many lines of CT are used for a specified patient, the ECOG PS was a patient-related variable with a dominant impact on the outcome. CT must be less toxic in order to achieve a CB and ameliorate the PS.

No significant financial relationships to disclose.

Early placenta insuline-like peptide (pro-EPIL): A novel biomarker in advanced and metastatic non-small cell lung cancer (NSCLC) patients treated by chemotherapy

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Background: Some studies suggest a causal relationship between the early placenta insuline-like peptide encoded by the insulin-like 4 gene and cancer invasiveness. Methods: Serum concentrations of pro-EPIL were measured by ELISA using a novel two-site “sandwitch” assay, based on two monoclonal antibodies (mAb) raised against synthetic peptides analogous to two distinct regions of the pro-Epil polypeptide: mAb EPIL15, and biotinylated mAb EPIL02, used as the labelled indicator. The first mAb EPIL15 was purified and bound to a solid phase. Pro-EPIL was allowed to bind, and unbound proteins were removed by washing. The sensitivity limit of the assay was 3 ng/mL of synthetic peptide, and detection was linear over a range of at 3 pg to 200 ng of the synthetic peptide. As primary endpoint, we studied the Pro-EPIL distribution according to some clinico-biological prognostic factors. Results: Between July 2001 and April 2005, nineteen chemonaive NSCLC pts were treated by chemotherapy in our center and serum determinations of pro-EPIL were performed. Ten pts (63%) overexpressed pro-EPIL before start of chemotherapy with a median value of 1.06 ng/mL (range 0.01–6.75). Median age was 60 years (range 38–80), more than 90% of pts were men with an advanced or metastatic disease. Forty-two percent of pts had a large cell carcinoma subtype, with 25% of adenocarcinoma and 25% of epidermoid type. Immunologic evaluations were performed with a median value of the CD3+ lymphocites of 1290/mm3 (range 610–2138). Significant correlations were observed between age, serum alcaline phosphatase and CD3+ number. A border-line positive correlation was observed between pro-EPIL and CD3+ levels (P = 0.09, R2 = 0.5). Median OS for entire cohort was 7.5 months (95% CI, 5.5–9.4), with 67% deaths. Because our sample size was very low, no survival analysis were performed according to the baseline pro-EPIL value and other prognostic factors. A bootstrapping procedure is planned on our data. Conclusions: This results showed that pro-EPIL was overexpressed in the majority of advanced NSCLC pts. Interactions between this biomarker and immune system are possible. Furthemore, pro-EPIL as a therapeutic target might be tested in prospective studies.

No significant financial relationships to disclose.