[Features of cognitive function in patients with laryngeal carcinoma]

Objective:To study the differences in cognitive function between patients with laryngeal carcinoma and healthy volunteers. Method:Patients with laryngeal carcinoma who have been first diagnosed with laryngeal carcinoma, but not received treatment at the Department of Otolaryngology in two hospitals in Shanxi Province and healthy volunteers of the same age, gender-matched and similar education were studied for the purpose to evaluate the cognitive status by using the Wechsler memory scale.Result:No significant difference of age, gender and educational level was found between both groups（P>0.05）.The score of Memory Quotient was significantly lower in the laryngeal carcinoma group than that in healthy control group (P<0.05). There were significant differences in the results of Wechsler memory scale except for Experience, Orientation and Association test (P<0.05).Conclusion:The memory, attention and computing power of patients in the laryngeal carcinoma group were not as good as those of patients in the healthy control group. Patients with laryngeal carcinoma have cognitive impairment or lower ability , so we need to pay more attention to the patients during their rehabilitation. The early detection of cancer-related cognitive impairments can help patients improve their cognitive function early, reduce the burden on their families and society, and promote better return of patients to society.

Clinical, pathological, and demographic factors associated with development of recurrences after surgical resection in elderly patients with neuroendocrine tumors

Background

Incidence of locoregional neuroendocrine tumors (NETs) is rising. However, after curative resection, the patterns and risk factors associated with recurrence remain unknown. Consensus guidelines recommend surveillance every 6-12 months for up to 10 years after surgery for resected, well-differentiated NETs irrespective of patient demographics, site, grade or stage of tumor with few exceptions.

Patients and methods

From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified localized and regional stage NET patients who underwent surgical resection between January 2002 and December 2011. Development of recurrence was identified by capturing at least two claims indicative of metastatic disease until 31 December 2013.

Results

Of the 2366 identified patients (median age 73 years), 369 (16%) developed metastatic disease within 5 years and only an additional 1% developed metastases between years 5 and 10 with the majority dying due to unrelated causes. The 5-year risk of developing metastases (hazard ratio, HR) varied significantly (log-rank P < 0.001) by grade: 9.9% versus 25.9% (2.2) versus 48.1% (4.4) for grades 1, 2, and  ≥ 3, respectively; stage: 10.3% versus 31.1% (2.8) for localized versus regional; primary tumor size: 7.6% versus 15% (1.3) versus 26.6% (1.5) for <1, 1-2, and > 2 cm, respectively; and site: ranging from 11.3% for colon to 23.9% for pancreas.

Conclusions

Contrary to current guidelines, our study suggests that surveillance recommendations should be tailored according to patient and tumor characteristics. Surveillance past 5 years may be avoided in elderly patients with competing morbidities or low risk of recurrence. Pancreatic, lung, higher grade, and regional NETs have a higher risk of recurrence and may be considered for future adjuvant trials.

Efficacy of everolimus plus octreotide LAR in patients with advanced neuroendocrine tumor and carcinoid syndrome: final overall survival from the randomized, placebo-controlled phase 3 RADIANT-2 study

Background

In the phase 3 RADIANT-2 study, everolimus plus octreotide long-acting repeatable (LAR) showed improvement of 5.1 months in median progression-free survival versus placebo plus octreotide LAR among patients with advanced neuroendocrine tumors associated with carcinoid syndrome. The progression-free survival P-value was marginally above the prespecified threshold for statistical significance. Here, we report final overall survival (OS) and key safety update from RADIANT-2.

Patients and methods

The RADIANT-2 trial compared everolimus (10 mg/day, orally; n = 216) versus placebo (n = 213), both in conjunction with octreotide LAR (30 mg, intramuscularly, every 28 days). Patients, unblinded at the time of progression or after end of double-blind core phase following primary analysis, were offered open-label everolimus with octreotide LAR (open-label phase). In the open-label phase, patients had similar safety and efficacy assessments as those in the core phase. For OS, hazard ratios (HRs) with 95% CIs using unadjusted Cox model and a Cox model adjusted for prespecified baseline covariates were calculated.

Results

A total of 170 patients received open-label everolimus (143 crossed over from the placebo arm; 27 in the everolimus arm continued to receive the same treatment after unblinding). The median OS (95% CI) after 271 events was 29.2 months (23.8-35.9) for the everolimus arm and 35.2 months (30.0-44.7) for the placebo arm (HR, 1.17; 95% CI, 0.92-1.49). HR adjusted for baseline covariates was 1.08 (95% CI, 0.84-1.38). The most frequent drug-related grade 3 or 4 AEs reported during the open-label phase were diarrhea (5.3%), fatigue (4.7%), and stomatitis (4.1%). Deaths related to pulmonary or cardiac failure were observed more frequently in the everolimus arm.

Conclusion

No significant difference in OS was observed for the everolimus plus octreotide LAR and placebo plus octreotide LAR arms of the RADIANT-2 study, even after adjusting for imbalances in the baseline covariates.

Clinical Trial Number

NCT00412061, www.clinicaltrials.gov.

A randomized, open-label, phase 2 study of everolimus in combination with pasireotide LAR or everolimus alone in advanced, well-differentiated, progressive pancreatic neuroendocrine tumors: COOPERATE-2 trial

Background

Several studies have demonstrated the antitumor activity of first-generation somatostatin analogs (SSAs), primarily targeting somatostatin receptor (sstr) subtypes 2 and 5, in neuroendocrine tumors (NET). Pasireotide, a second-generation SSA, targets multiple sstr subtypes. We compared the efficacy and safety of pasireotide plus everolimus to everolimus alone in patients with advanced, well-differentiated, progressive pancreatic NET.

Patients and methods

Patients were randomized 1 : 1 to receive a combination of everolimus (10 mg/day, orally) and pasireotide long-acting release (60 mg/28 days, intramuscularly) or everolimus alone (10 mg/day, orally); stratified by prior SSA use, and baseline serum chromogranin A and neuron-specific enolase. The primary end point was progression-free survival (PFS). Secondary end points included overall survival, objective response rate, disease control rate, and safety. Biomarker response was evaluated in an exploratory analysis.

Results

Of 160 patients enrolled, 79 were randomized to the combination arm and 81 to the everolimus arm. Baseline demographics and disease characteristics were similar between the treatment arms. No significant difference was observed in PFS: 16.8 months in combination arm versus 16.6 months in everolimus arm (hazard ratio, 0.99; 95% confidence interval, 0.64-1.54). Partial responses were observed in 20.3% versus 6.2% of patients in combination arm versus everolimus arm; however, overall disease control rate was similar (77.2% versus 82.7%, respectively). No significant improvement was observed in median overall survival. Adverse events were consistent with the known safety profile of both the drugs; grade 3 or 4 fasting hyperglycemia was seen in 37% versus 11% of patients, respectively.

Conclusions

The addition of pasireotide to everolimus was not associated with the improvement in PFS compared with everolimus alone in this study. Further studies to delineate mechanisms by which SSAs slow tumor growth in NET are warranted.

[Cervical pains in Pott's disease: Epidemiological, clinical and radiological aspects concerning 26 cases in Abidjan]

In this study, we report the results of the experience of the Rheumatology Department of Cocody University Hospital in the management of the cervical spinal tuberculosis in Abidjan area. This was a retrospective study of 26 cases collected over a 7 year period (January 2006 to December 2013). The objective of this work was to illustrate the epidemiological, clinical and radiological profile of the cervical localization of tuberculosis in our practice. The prevalence of cervical disease was 4.87%. The average age of our patients was 48.27 years, with a slight male predominance (60.7%). The duration of disease progression was long (8 months on average); symptomatology was dominated by pain associated with stiffness in all patients (100%). One third of patients had already consulted at the stage of neurological complications (1 case of Brown Sequard syndrome, 2 cases of tetraparesis, 5 cases of paraplegia). Computer tomography was performed in all patients, followed by an MRI scan for 6 patients, which revealed the predominance of damage to the C3-C4 floor (34.62%) and 3 cases of sub occipital localization. Spondylodiscitis was the main radiological anatomical lesion (88.46%), lesions were multi-stage in 61.54% of cases, the prevalence of retropharyngeal abscess was high (84.61% of cases), that of the epiduritis was 76.92% and radiological spinal cord compression was recorded in a third of cases. All patients benefited from an antituberculous treatment associated with cervical immobilization.

[Ocular manifestations in rheumatoid arthritis: 24 cases in Abidjan]

OBJECTIVE

Determine the prevalence and the main ocular manifestations in rheumatoid arthritis in Abidjan.

PATIENTS AND METHODS

Prospective and descriptive study of 24 patients with rheumatoid arthritis fulfilling the criteria of the American College of Rheumatology, views from September 2003 to August 2004 in department of rheumatology at the University Hospital of Cocody. The patients performed an eye examination including: visual acuity examination at the slit lamp, ocular fundus, color vision and visual field.

RESULTS

Ocular manifestations were observed in 9 of 24 patients representing a prevalence of 37.5%. There were 03 cases of decreased visual acuity, 03 cataract, 02 keratitis cases and 01 cases of anterior uveitis. No fundus abnormality in color vision and visual field was highlighted. These manifestations were found between 5 and 10 years (04 cases) and after 10 years (05 cases) of evolution of the disease. The term rheumatoid arthritis influenced the occurrence of ocular manifestations (P = 0.00).

CONCLUSION

Ocular manifestations in rheumatoid arthritis are rare in our practice and were mainly affected by visual acuity, annexes and anterior segment of the eye.

Quality of life, resource utilisation and health economics assessment in advanced neuroendocrine tumours: a systematic review

Neuroendocrine tumours (NET) are often diagnosed at an advanced stage when the prognosis is poor for patients, who often experience diminished quality of life (QoL). As new treatments for NET become available, it is important to characterise the associated outcomes, costs and QoL. A comprehensive search was performed to systematically review available data in advanced NET regarding cost of illness/resource utilisation, economic studies/health technology assessment and QoL. Four rounds of sequential review narrowed the search results to 22 relevant studies. Most focused on surgical procedures and diagnostic tools and contained limited information on the costs and consequences of medical therapies. Multiple tools are used to assess health-related QoL in NET, but few analyses have been conducted to assess the comparative impact of available treatment alternatives on QoL. Limitations include English language and the focus on advanced NET; ongoing terminology and classification changes prevented pooled statistical analyses. This systematic review suggests a lack of comparative economic and outcomes data associated with NET treatments. Further research on disease costs, resource utilisation and QoL for patients with advanced NET is warranted.

A phase II randomized trial of induction chemotherapy versus no induction chemotherapy followed by preoperative chemoradiation in patients with esophageal cancer

BACKGROUND

The contribution of induction chemotherapy (IC) before preoperative chemoradiation for esophageal cancer (EC) is not known. We hypothesized that IC would increase the rate of pathologic complete response (pathCR).

METHODS

Trimodality-eligibile patients were randomized to receive no IC (Arm A) or IC (oxaliplatin/FU; Arm B) before oxaliplatin/FU/radiation. Surgery was attempted ∼5-6 weeks after chemoradiation. The pathCR rate, post-surgery 30-day mortality, overall survival (OS), and toxic effects were assessed. Bayesian methods and Fisher's exact test were used.

RESULTS

One hundred twenty-six patients were randomized dynamically to balance the two arms for histology, baseline stage, gender, race, and age. Fifty-five patients in Arm A and 54 in Arm B underwent surgery. The median actuarial OS for all patients (54 deaths) was 45.62 months [95% confidence interval (CI), 27.63-NA], with median OS 45.62 months (95% CI 25.56-NA) in Arm A and 43.68 months (95% CI 27.63-NA) in Arm B (P = 0.69). The pathCR rate in Arm A was 13% (7 of 55) and 26% (14 of 54) in Arm B (two-sided Fisher's exact test, P = 0.094). Safety was similar in both arms.

CONCLUSIONS

These data suggest that IC produces non-significant increase in the pathCR rate and does not prolong OS. Further development of IC before chemoradiation may not be beneficial. Clinical trial no.: NCT 00525915 (www.clinicaltrials.gov).

Everolimus plus octreotide LAR (E+O) versus placebo plus octreotide LAR (P+O) in patients with advanced neuroendocrine tumors (NET): Updated results of a randomized, double-blind, placebo-controlled, multicenter phase III trial (RADIANT-2)

159

Background: Octreotide LAR has been the foundation of NET therapy; however, additional treatment options are needed. Everolimus, an oral inhibitor of mTOR, demonstrated promising antitumor activity in patients with NET as a single agent and in combination with octreotide LAR in two phase II studies.

Methods: Patients (n = 429) with well or moderately differentiated advanced NET and history of carcinoid symptoms received oral everolimus 10 mg/d + octreotide LAR 30 mg IM q 28 days (n = 216) or placebo + octreotide LAR (n = 213). Common primary sites included the small intestine, lung, and colon. The primary endpoint was progression-free survival (PFS) per central review by RECIST. Crossover from P+O to open-label E+O was allowed at disease progression.

Results: Median PFS (95% CI) with E+O was 16.4 months (13.67-21.19) vs. 11.3 months (8.44-14.59) for P+O. E+O was associated with a 23% reduction in risk of progression: HR = 0.77; 95% CI: 0.59-1.00; one-sided p-value = .026 (pre-specified significance boundary is p ≤ .0246). A high rate of informative censoring resulted in loss of power in central review results. Correcting for the informative censoring bias, the pre-specified marginal Cox model using inverse probability of censoring weights (IPCW) analysis showed a significant 5.5-month improvement in median PFS with E+O; HR = 0.60; 95% CI: 0.44-0.84, with one-sided p-value = .0014. The benefit of E+O was seen across all patient subgroups. Updated analyses of the impact of pre-study and post-progression octreotide LAR therapy will be reported. Most frequent drug-related adverse events (AEs) with E+O were stomatitis, rash, fatigue, and diarrhea; mostly grade 1-2. Grade 3-4 AEs reported in >5% were stomatitis, fatigue, diarrhea, infections, and hyperglycemia.

Conclusions: In this large phase III trial, E+O provided a 5.1-month clinically meaningful increase in median PFS compared with P+O in the central adjudicated review. Correcting for the informative censoring bias, a significant PFS improvement of 5.5 months was seen, with a p value = .0014. The safety profile of E+O was acceptable.

[Table: see text]

Everolimus in patients with advanced pancreatic neuroendocrine tumors (pNET): Updated results of a randomized, double-blind, placebo-controlled, multicenter phase III trial (RADIANT-3)

158

Background: There is an unmet medical need for effective treatments for patients with advanced pNET. Systemic therapies for advanced pNET are limited both by toxicity and efficacy. Everolimus, an oral mTOR inhibitor, has shown promising antitumor activity in 2 phase II studies, leading to further investigation in the largest phase III randomized controlled trial completed in pNET patients.

Methods: Patients with advanced low- or intermediate-grade pNET were randomly assigned to everolimus 10 mg/d orally + best supportive care (BSC; n = 207) or placebo + BSC (n = 203). Long-acting somatostatin analogs (SSAs) were permitted as BSC during the study. The primary endpoint was progression free survival (PFS). At progression (RECIST), patients could be unblinded and those randomly assigned to placebo were offered open-label everolimus.

Results: Compared with placebo, everolimus reduced the risk of progression by 65% and increased median PFS by more than 6 months, from 4.6 to 11.0 months (HR = 0.35; 95% CI: 0.27-0.45; p < 0.0001), by investigator review (primary endpoint). Median PFS by central review was consistent (HR = 0.34; 95% CI: 0.26 to 0.44; p < 0.001] in favor of everolimus. Eighteen-month PFS estimates were 34% for everolimus (95% CI: 26-43) vs 9% (95% CI: 4-16) for placebo. Everolimus demonstrated a significant PFS benefit across all patient subgroups according to baseline characteristics and prior SSA use. Prior SSA use was 49% in the everolimus arm and 50% in the placebo arm. Updated analyses of the impact of concomitant SSA will be reported. The most common drug-related adverse events were stomatitis, rash, diarrhea, fatigue, and infections (primarily upper respiratory); most were grade 1 or 2. Stomatitis (6.9% vs 0%), anemia (6% vs 0%), and hyperglycemia (5% vs 2%) were the most common grade 3-4 events.

Conclusions: Everolimus significantly prolonged PFS compared with placebo in patients with advanced pNET in this large phase III clinical trial. This benefit was seen across all patient subgroups. Treatment resulted in a significant 6.4-month prolongation in median PFS. Everolimus had an acceptable and predictable safety profile.

[Table: see text]

Risk factors for low-grade neuroendocrine carcinoma (LGNET): Hospital-based case-control study in US

4641

Background: There has been an increase in the diagnosed incidence of LGNET in US over the last 2 decades. Little is known about the etiology of LGNET. In this hospital-based, case-control study we evaluated the association of cigarette smoking, alcohol consumption, diabetes mellitus (DM) and family history of cancers with LGNET of different sites. Method: Cases were patients with LGNET referred to The University of Texas M.D. Anderson Cancer Center between 12/1999 and 9/2005. Controls were selected from healthy individuals who accompanied patients with other cancers. Logistic regression was applied to estimate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for potential risk factors and demographic characteristics. Result: We identified 951 LGNET patients with primary sites including appendix (n=102, 10.7%), small bowel (n=234, 24.6%), lung (n=149, 15.7%), pancreas (n=166, 17.5%), stomach (n=55, 5.8%), rectum (n=56, 5.9%), and others (n=189, 19.2%). Cases were compared to 924 controls. Majority of subjects were white-race (cases, 79.7%; controls, 89.5%). Gender distribution was similar in LGNET patients with 1:1 ratio. DM was associated with pancreatic and gastric primary sites; AOR and 95% CI were 2.5 (1.6–3.9) and 4.5 (2.2–9.3) respectively. Ever cigarette smoking was associated with lung carcinoid (OR=1.3; 95%CI, 1.01–1.9) especially among heavy smokers (20 cigarettes per day), (OR=1.7; 95%CI, 1.01–2.9). Ever or heavy alcohol consumption (= 60 ml ethanol/day) was not significantly related to LGNET of any site. The significantly elevated risk for carcinoid tumors extended to participants with a family history of breast, colon, esophageal, pancreas, prostate, and renal cancers after adjustment for demographic and environmental risk factors (P<.05). Conclusion: Smoking, DM, and family history may increase the risk of LGNET of various sites. Determining environmental and genetic factors related to LGNET may lead to development of surveillance and prevention strategies for high-risk individuals.

No significant financial relationships to disclose.

Phase II study of RAD001 (everolimus) and depot octreotide (sandostatin LAR) in advanced low grade neuroendocrine carcinoma (LGNET)

4503

Background: Effective systemic therapy for advanced LGNET is lacking. Mutations involving the mTOR pathway including TSC2, NF-1, and vHL are associated with development of LGNET. mTOR also mediate signaling downstream of IGF1 and VEGF. RAD001 is a novel oral mTOR inhibitor. Octreotide has been described to inhibit VEGF and IGF1 production in solid tumors. Methods: Patients (pts) received depot octreotide 30 mg q28 days, and RAD001 5 (pts 1–30) or 10 mg (pts 31–60) po daily. Response was evaluated every 12 weeks (wks). Results: 30 carcinoid (C) and 30 islet cell (I) patients (pts) were enrolled between 2/05–7/06. 38 pts (23 C, 15 I) had prior octreotide. By RECIST criteria, there were 10 PR (17%), 45 SD (75%) (15 pts had > 15% reduction), 5 PD (8%). The response rates within C, and I groups were 13% and 20%. The response rates within the 5 mg and 10 mg groups were 13% and 20% respectively. Of 39 pts with PD prior to study entry, there were 7 (18%) PR, 27 (69%) SD (9 pts had > 15% reduction), 5 (13%) PD. PFS rate at 24 wks was 86%. The median PFS duration is 59 wks. The median PFS duration among the C and I groups were 69 and 39 wks. Among the 39 pts with progression at study entry, the median PFS duration was 38 wks. Of 24 pts with elevated chromogranin A at entry, 19 (56%) had > 50% reduction. Treatment was well tolerated. The most common toxicity was mild aphthous ulceration. CTC G3/4 toxicities included: thrombocytopenia (3), neutropenia (3), hypophosphatemia (5), hyperglycemia (4), hypoglycemia (2), hypokalemia (2), fatigue (6), diarrhea (6), aphthous ulcer (5), rash (3), and 1 each of anemia, hypertriglyceridemia, bilirubin, AST/ALT, pain, nausea, nail, dysgeusia, pneumonitis. Conclusions: RAD001 at 5 or 10 mg daily was well tolerated in combination with octreotide. Promising anti-tumor activity has been observed. The RADIANT (RAD001 In Advanced Neuroendocrine Tumors) trials are underway to evaluate RAD001 in larger patient groups.

No significant financial relationships to disclose.

Population based study of islet cell carcinoma

15103

Background: Little is known about the epidemiology and natural history of islet cell carcinoma. In this study, we examine the epidemiology, natural history, and prognostic factors impacting survival duration for islet cell carcinoma using population based registries. Methods: The Surveillance, Epidemiology, and End Results (SEER) Program database (1973 - 2003 release April 2006) was used to identify cases of islet cell carcinoma using histology codes and tumor site. Results: 1,310 (619 women and 691 men) cases were identified. Median age at diagnosis was 59 years. The annual age-adjusted incidence in the periods covered by SEER 9 (1973–1991), SEER 13 (1992–1999), and SEER 17 (2000–2003) were 0.16, 0.14, and 0.12 per 100,000 respectively. The estimated 28-year limited duration prevalence on January 1, 2003 in the United States was 2,705 cases. Insulinomas (57%), glucagonomas (53%), and VIPomas (64%) were more likely to be located in the tail of the pancreas while gastrinomas were more likely to be located in the head of the pancreas (63%). Classified by SEER stage, localized, regional, and distant stages corresponded to 14%, 23% and 54% of cases. The median survival was 38 months. By stage, median survival for patients with localized, regional, and distant disease were 124 (95% CI, 80–168) months, 70 (95% CI, 54 - 86) months, and 23 (95% CI, 20 - 26) months respectively. By multivariate Cox proportional modeling, stage (P < 0.001), primary tumor location (P = .04), and age at diagnosis (P < 0.001) were found to be significant predictors of survival. Conclusion: Islet cell carcinomas account for approximately 1.3% of cancers arising in the pancreas. Most patients have advanced disease at the time of diagnosis. Despite its reputation of being indolent, survival of patients with advanced disease remains in the range of 2 years. Development of novel therapeutic approaches is needed.

No significant financial relationships to disclose.

Treatment with bevacizumab (BEV) upregulates expression of the transcription factor Sp1 and its downstream target genes in human carcinoid cells: Molecular basis of the synergistic antiangiogenic activity of bevacizumab and mithramycin A (MIT)

15031

Background: Our previous studies show that human carcinoid cells overexpress pro-angiogenic factors, vascular endothelial growth factor A (VEGF), and transcription factor Sp1 plays a critical role in VEGF inducible and constitutive expression. However, the impact of antiangiogenic therapy on the Sp1/VEGF pathway remains unclear. Method: Groups of 10 athymic BALB/c nude mice were implanted with 1.5 million human H727 carcinoid cells. Treatment with VEGF neutralizing monoclonal antibody, BEV, MIT, or BEV + MIT was initiated once implanted tumor reached 4 mm in size. Result: Treatment with BEV, suppressed human carcinoid growth in nude mice (tumor size at week 5 1280 mm3 vs 480 mm3; p < 0.001). Gene expression analyses revealed that this treatment substantially upregulated the expression of Sp1 (7 folds) and its downstream target genes, including VEGF (5 folds) and epidermal growth factor receptor (4 folds), in tumor tissues, whereas it did not have this effect on carcinoid cells in culture. Treatment with mithramycin A, an Sp1 inhibitor, suppressed the expression of Sp1 and its downstream target genes in both cell culture and tumors growing in nude mice. Median survival of mice treated with PBS, BEV, MIT, and BEV + MIT groups were 88, 112, 121, and >160 days respectively (p < 0.001). Combined treatment with bevacizumab and mithramycin A produced synergistic tumor suppression, which was consistent with suppression of the expression of Sp1 and its downstream target genes. Conclusion: Treatment with bevacizumab may block VEGF function but activate the pathway of its expression via positive feedback. Given the fact that Sp1 is an important regulator of the expression of multiple angiogenic factors, bevacizumab-initiated upregulation of Sp1 and subsequent overexpression of its downstream target genes may affect the potential angiogenic phenotype and effectiveness of antiangiogenic strategies for human carcinoid.

No significant financial relationships to disclose.

Preferential inhibition of Sp1 expression in growing tumors by mithramycin-A (MIT) directly correlates with its potent antiangiogenic effects in human carcinoid xenograft model

15041

Background: MIT, also known as aureolic acid and plicamycin (Mithracin), is an aureolic acid-type polyketide produced by various soil bacteria of the genus Streptomyces. Previous studies have shown that MIT exhibits antitumor activity. In the present study, we examine the antiangiogenic effect of MIT and its underlying mechanisms. Methods: Cohorts of 10 athymic BALB/c nude mice were implanted with 1.5 million human H727 carcinoid cells. Mice were treated with subcutaneous or intraperitoneal 0.2 mg/kg of mithramycin twice weekly once implanted tumor reached 4 mm in size. Results: Both subcutaneous and intraperitoneal MIT significantly suppressed the growth of carcinoid cells in nude mouse models (median tumor weight in PBS, s.c., i.p. groups 790 mm3 vs 280 mm3, 480 mm3; P < 0.01). We also evaluated the Sp1 expression in growing tumors and various organs. We found that the liver expressed the highest level of Sp1 among normal organs (including liver, stomach, large intestine, and small intestine, spleen, kidney, brain and lymph node). However, Sp1 expression in the growing tumors was more than 10 times higher than that in a normal liver. Treatment with MIT reduced the Sp1 expression in the tumors, while no discernible effect on Sp1 expression in normal tissues was observed. This is the first demonstration that MIT selectively inhibited the Sp1 expression in the growing tumors. Consistent with the expression of Sp1, a substantial suppression of VEGF, PDGF, EGFR, and IGFR expression was evident. Finally, treatment with MIT reduced the microvessel formation in tumors by 80% (MVD count; P < 0.01). This antiangiogenic activity was confirmed by in vitro tubulogenesis assay and in vivo Matrigel plug assay. Conclusions: Collectively, our studies strongly indicate that MIT is a potent antiangiogenic agent and its mechanism of action involved suppression of Sp1 expression and its consequent downregulation of its downstream targets including VEGF, PDGF, EGFR, and IGFR that are key to tumor angiogenesis.

No significant financial relationships to disclose.

First-in-human phase-I pharmacokinetic trial of NS-9, a liposomal poly(I):poly(C), in patients with liver metastases from various primary cancers

13016

Background: NS-9 is a complex of poly-inosinate [poly(I)] and poly-cytidylate [poly(C)] in a cationic liposome and is active in vitro and in vivo. Objectives: to determine the tolerability, safety, and maximal tolerated dose (MTD), and pharmacokinetics of NS-9 by 1 hr IV infusion, given daily x5 q 28 days. Methods: A phase I dose escalation study was undertaken in patients with liver metastases from solid tumors. Eligible patients were adults with ECOG PS 0–1 and no recent chemotherapy (≥ 4 wks prior). Dose cohorts studied were 0.1, 0.15, 0.2, 0.3 and 0.4mg/m2. Results: 18 patients were enrolled (13M:5F) median age 58 (range 21 to 77 yrs). Tumor types included neuroendocrine (8), and ocular melanoma (1), gastric (1), GE junction (1), esophageal (2), and colorectal (5) carcinomas. Two of three patients treated at the first dose level (0.4 mg/m2) had grade 3/4 reversible lipase elevation with or without acute pancreatitis, a dose limiting toxicity (DLT). De-escalation to doses ranging from 0.1 to 0.2 mg/m2/day was with no DLT. At 0.3 mg/m2 two of three patients treated had a DLT (neutropenia and thrombocytopenia). The MTD was determined at 0.2 mg/m2. Common toxicities included pyrexia, chills, nausea, fatigue, abdominal pain, myalgia, anorexia, sweating, neutropenia, thrombocytopenia, and elevated glucose, amylase, and LFTs. Pharmacokinetics showed rapid elimination (T1/2 ranged from 2.4 to 5.0 hours) without accumulation after multiple doses. 1 patient (esophageal Ca) had a PR in the target lesions in the liver. Conclusions: The MTD is 0.2 mg/m2/day with a hint of antitumor activity. NS-9 should be pursued in phase-II studies.

No significant financial relationships to disclose.

Phase II study of RAD001 (everolimus) and depot octreotide (Sandostatin LAR) in patients with advanced low grade neuroendocrine carcinoma (LGNET)

4042

Background: Effective systemic therapy for advanced LGNET is lacking. Patients with mutation in TSC2, an endogenous inhibitor of mTOR develop LGNET. mTOR also mediate signaling downstream of IGF1 and VEGF, pathways important in LGNET. RAD001 inhibits the serine-threonine kinase activity of mTOR. Octreotide may have cytostatic activity and has been described to inhibit VEGF and IGF1 production in solid tumors. Methods: Treatment consisted of depot octreotide 30 mg IM q28 days, and RAD001 5 or 10 mg po daily. Response evaluation is performed every 12 weeks. Results: 32 patients (18 carcinoids, 13 islet cell) were enrolled between 2/05 - 1/06. 20 had prior octreotide. 27 patients have completed 12 weeks of therapy at the 5 mg dose level and undergone response evaluation. By RECIST criteria, response rate was 15%. There were 4 PR, 19 SD (including 4 patients having 18–28% reduction), 4 PD. PR occurred in 2 carcinoids, and 2 islet cell. PFS rate at week 24 was 71%. Of 21 patients with radiological progression prior to study entry, 17 have completed 12 weeks of therapy. Among these, there were 3 PR, 10 SD, 4 PD. Of 18 patients with elevated chromogranin A at baseline, 9 (50%) patients had > 50% reduction. Treatment is generally well tolerated. The most common toxicity is mild aphthous ulceration. CTC G3/4 toxicity include: anemia (1), thrombocytopenia (1), leukopenia (1), fatigue (3), aphthous ulcer (2), diarrhea (2), hypoglycemia (2), pain (2), rash (2), hyperglycemia (1), edema (1), nausea (1). Conclusions: RAD001 5 mg po daily is well tolerated in combination with Depot Octreotide. Anti-tumor activity has been observed. An additional cohort will be treated at RAD001 10 mg daily dose. Optional blood draws and tumor biopsies will be performed to help assess biomarkers that may predict benefit.

No significant financial relationships to disclose.

Association of VEGF expression with poor prognosis among patients with low-grade neuroendocrine carcinoma

4091

Background: Low-grade neuroendocrine carcinomas (LGNET) can arise from neuroendocrine cells throughout the body and have a wide range of aggressiveness. Reliable predictive and prognostic markers of outcome are lacking. Angiogenesis is critical for metastasis and tumor growth beyond a small tumor size and VEGF is a powerful mediator of tumor angiogenesis. Methods: LGNET tissue from 50 patients (24 with local-regional disease, 26 with metastasis) who underwent tumor resection at the University of Texas M.D. Anderson Cancer Center was evaluated for expression VEGF by immunohistochemistry. Chi-square and Fisher’s exact test were used to test the association between study parameters. Kaplan-Meier analysis was used to assess the affect of study parameters on progression free survival (PFS). Results: Strong, weak, and negative VEGF expression was observed in 32%, 54%, and 14% of cases respectively. Larger tumor size was observed among patients with strong VEGF expression. Mean tumor sizes in patients with strong, weak and negative VEGF were 4.8, 2.8, and 2.9 cm. Compared to the group with negative VEGF expression, VEGF (weak/strong) expression was associated with metastasis (14% v 58%; P = .045). The median PFS durations of patients with strong and weak VEGF expression were 29 months and 81 months respectively. With a median follow-up duration of 50 months, the median PFS duration for the group with negative VEGF expression has not been reached. Compared by log rank test VEGF expression was associated with poor PFS (P = .022). Conclusions: This study suggests that tissue VEGF expression is associated with aggressive tumor growth and metastasis among patients with LGNET. VEGF expression may serve as a useful prognostic marker following tumor resection.

No significant financial relationships to disclose.

Extended safety and efficacy data on S-1 plus cisplatin in patients with advanced gastric carcinoma in a multi-center phase II study

4083

Background: We obtained additional phase II safety and efficacy data in a multi-center setting on an active regimen of S-1 plus cisplatin; the experimental arm of the global phase III First-Line Advanced Gastric cancer Study (FLAGS). Methods: Eligible patients had untreated advanced gastric cancer (AGC), histologic proof, KPS ≥70%, adequate organ function, and gave written consent. Patients received S-1 (25mg/m2 p.o. bid on days 1–21) plus cisplatin (75mg/m2 i.v. on day 1) every 28 days. All reported confirmed overall response rate (C-ORR), response durations, and time-to-progression (TTP) are externally reviewed. Results: All 72 patients were assessed for safety and 64 for efficacy. The median age was 56 years and median KPS was 90%. Median no. of cycles was 4. C-ORR was 50% (95% CI, 37%-63%). Median duration of response is >6 months. At 6 months, only 35% of patients have had cancer progression. Median survival (n=72) is 10.5 months (95% CI, 9.3 to NR). At least one SAE occurred in 43% of patients. The frequent grade 3 or 4 adverse events (occurring in >10% of patients) included: fatigue/asthenia (26%), vomiting (21%), nausea (18%), diarrhea (17%), neutropenia (18%), anorexia (11%), and dehydration (11%). Febrile neutropenia (1.4%) and grade 4 diarrhea (1.4%) were rare. Conclusions: These extended data confirm that S-1 plus cisplatin has a very desirable safety profile and impressive efficacy data in AGC. FLAGS will complete accrual of >700 patients by March of 2007. (Supported by Taiho Pharma-USA).

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Paclitaxel-based chemoradiotherapy in localized gastric carcinoma: degree of pathologic response and not clinical parameters dictated patient outcome

PURPOSE

Preoperative chemoradiotherapy may increase the R0 (curative) resection rate, overall survival (OS) duration, and disease-free survival (DFS) duration. We evaluated paclitaxel-based induction chemotherapy and chemoradiotherapy in patients with localized gastric or gastroesophageal adenocarcinoma to determine its feasibility, impact on the R0 resection rate, type of pathologic response, OS, and DFS.

PATIENTS AND METHODS

Patients with operable, localized gastric, or gastroesophageal adenocarcinoma were eligible. Staging included endoscopic ultrasonography (EUS) and laparoscopy. Patients received two 28-day cycles of induction chemotherapy of fluorouracil, paclitaxel, and cisplatin followed by 45 Gy of radiation and concurrent fluorouracil plus paclitaxel. The cancer was restaged and surgery was attempted. Postsurgery pathologic findings and R0 resection were correlated with OS and DFS.

RESULTS

Forty-one patients were enrolled. Most carcinomas were proximal (83%) and pretreatment stage EUST3 (85%). Forty patients (98%) underwent surgery, and 78% had an R0 resection. We observed a pathologic complete response (pathCR) rate of 20% and a pathologic partial response (pathPR) rate of 15% (< 10% residual cancer cells in the resected specimen). No pretreatment parameter (sex, cancer location, baseline T stage, or baseline N stage) predicted the type of postsurgery pathologic response, OS, or DFS. However, pathCR (P = .02), pathCR + pathPR (P = .006), R0 resection (P < .001), and postsurgery T and N stages (P = .01 and P < .001, respectively) were associated with OS. Same parameters were significantly correlated with DFS. Toxicity was manageable.

CONCLUSION

The type of pathologic response but not pretreatment parameters was associated with OS and DFS. Efforts to increase the rate of pathologic response and better systemic cancer control are warranted.

Significance of post-chemoradiation biopsy in predicting residual esophageal carcinoma in the surgical specimen

Pathologic complete response in the resected esophagus can be achieved in approximately 30% of patients with locally advanced esophageal or gastroesophageal junction carcinoma after preoperative chemoradiation therapy. These patients tend to have a longer survival than those who have less than pathologic complete response. Post-chemoradiation esophageal biopsy (PCEB) is used to check for the presence of residual tumor before a definitive resection is performed, but the clinical significance of PCEB findings is not clear due to the possibility of sampling bias and the superficial nature of the specimen obtained. We evaluated the use of PCEB (defined as biopsy taken within 30 days before esophagectomy) in predicting residual cancer in post-treatment esophagectomy specimens. PCEB was performed in 65 of 183 (36%) patients with locally advanced esophageal or gastroesophageal junction carcinoma, who received preoperative chemoradiation therapy. The cancer status in PCEB was correlated with the residual cancer in the esophagectomy specimens. PCEB had no cancer in 80% (52 of 65) of patients (Bx-negative) and cancer in 20% (13 of 65) of patients (Bx-positive). There was no difference in the presence of residual cancer (either in esophagus or lymph node) in esophagectomy specimens between Bx-negative patients (77%, 40 of 52) or Bx-positive patients (92%, 12 of 13), P = 0.44. The positive predictive value of biopsy was 92% (12 of 13), negative predictive value 23% (12 of 52), sensitivity 23% (12 of 52) and specificity 92% (12 of 13). There was no difference in the residual cancer staging in the esophagectomy specimen between Bx-positive and Bx-negative patients. In contrast, residual metastatic carcinoma in lymph nodes was more frequent in Bx-positive patients (69.2%, 9 of 13) than in Bx-negative patients (28.8%, 15 of 52), P = 0.01. Our data suggest that PCEB is a specific but not a sensitive predictor of residual cancer following esophagectomy. Bx-positive patients tend to have more frequent residual tumor in lymph nodes. The utility of PCEB in predicting residual cancer in the lymph nodes needs to be explored further along with molecular predictors of response to preoperative therapy.

First Report of Sclerotium rolfsii on Island Ash Seedlings in Taiwan

Island ash (Fraxinus formosana Hay.) is a large, semideciduous tree in Taiwan. It is used for forestation, a shade tree, and producing wood for furniture. During the summer of 2001, a sudden wilt of 1-year-old plants was observed in a nursery in northern Taiwan. Initial symptoms included stem necrosis at the soil line and yellowing and tan discoloration of the leaves. As stem necrosis progressed, infected plants wilted and died. Necrotic tissues were covered with white mycelium that differentiated into reddish brown, spherical (1 to 2 mm in diameter) sclerotia. Sclerotium rolfsii was consistently recovered from the surface of symptomatic stem sections that were disinfected for 1 min in 0.5% NaOCl and then plated on potato dextrose agar (PDA) amended with 100 ppm of ampicillin. Pathogenicity of two S. rolfsii isolates was confirmed on 1-year-old island ash seedlings grown in 12.7 cm- (5-in) plastic pots in a sterilized mixture of peat moss and vermiculite (3:1). Seedlings were inoculated with mycelia and sclerotia of the pathogen grown on PDA. Three plants each were inoculated with four disks (5 mm) of agar with mycelium and three were inoculated with 10 sclerotia that were placed on the soil surface around the base of each plant. Noninoculated plants served as controls. All plants were kept in a growth chamber at 25 to 35°C and >95% relative humidity. The test was repeated once. All inoculated plants developed symptoms within 14 days, while control plants remained symptomless. Sclerotia developed on infected tissues, and S. rolfsii was reisolated from symptomatic tissues. This disease has been observed on many species of plants (1), but to our knowledge, this is the first report of Southern blight of Island ash seedlings caused by S. rolfsii in Taiwan. Reference: (1) Y. P. Tsai ed. List of Plant Diseases in Taiwan. The Plant Protection Society of the Republic of China and The Phytopathological Society of the Republic of China, 1991.