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Roxburgh CSD, Strombom P, Lynn P, Cercek A, Gonen M, Smith JJ, Temple LKF, Nash GM, Guillem JG, Paty PB, Shia J, Vakiani E, Yaeger R, Stadler ZK, Segal NH, Reidy D, Varghese A, Wu AJ, Crane CH, Gollub MJ, Saltz LB, Garcia-Aguilar J, Weiser MR. Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short-term outcomes. Colorectal Dis 2019; 21:1140-1150. [PMID: 31108012 PMCID: PMC6773478 DOI: 10.1111/codi.14713] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
AIM Significant recent changes in management of locally advanced rectal cancer (LARC) include preoperative staging, use of extended neoadjuvant therapies and minimally invasive surgery (MIS). This study was aimed at characterizing these changes and associated short-term outcomes. METHOD We retrospectively analysed treatment and outcome data from patients with T3/4 or N+ LARC ≤ 15 cm from the anal verge who were evaluated at a comprehensive cancer centre in 2009-2015. RESULTS In total, 798 patients were identified and grouped into five cohorts based on treatment year: 2009-2010, 2011, 2012, 2013 and 2014-2015. Temporal changes included increased reliance on MRI staging, from 57% in 2009-2010 to 98% in 2014-2015 (P < 0.001); increased use of total neoadjuvant therapy, from 17% to 76% (P < 0.001); and increased use of MIS, from 33% to 70% (P < 0.001). Concurrently, median hospital stay decreased (from 7 to 5 days; P < 0.001), as did the rates of Grade III-V complications (from 13% to 7%; P < 0.05), surgical site infections (from 24% to 8%; P < 0.001), anastomotic leak (from 11% to 3%; P < 0.05) and positive circumferential resection margin (from 9% to 4%; P < 0.05). TNM downstaging increased from 62% to 74% (P = 0.002). CONCLUSION Shifts toward MRI-based staging, total neoadjuvant therapy and MIS occurred between 2009 and 2015. Over the same period, treatment responses improved, and lengths of stay and the incidence of complications decreased.
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Affiliation(s)
- C S D Roxburgh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - P Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - P Lynn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - A Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - M Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J J Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - L K F Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - G M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - P B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - E Vakiani
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - R Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Z K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - N H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - D Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - A Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - A J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - C H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - M J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - L B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - M R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
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Belum VR, Benhuri B, Postow MA, Hellmann MD, Lesokhin AM, Segal NH, Motzer RJ, Wu S, Busam KJ, Wolchok JD, Lacouture ME. Characterisation and management of dermatologic adverse events to agents targeting the PD-1 receptor. Eur J Cancer 2016; 60:12-25. [PMID: 27043866 DOI: 10.1016/j.ejca.2016.02.010] [Citation(s) in RCA: 273] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/12/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Dermatologic adverse events (AEs) are some of the most frequently observed toxicities of immune-checkpoint inhibitor therapy, but they have received little attention. The drugs, pembrolizumab and nivolumab are recently approved inhibitors of the programmed death (PD)-1 receptor that have overlapping AE profiles however, the incidence, relative risk (RR), and clinico-morphological pattern of the associated dermatologic AEs are not known. METHODS We conducted a systematic review of the literature, and performed a meta-analysis of dermatologic AEs observed with the use of pembrolizumab and nivolumab in cancer patients. An electronic search was conducted using the PubMed, and Web of Science, and on the American Society of Clinical Oncology and European Society for Medical Oncology meeting abstracts' libraries for potentially relevant oncology trials, that employed the drugs at Food and Drug Administration-approved doses and reported dermatologic AEs. The incidence, RR and 95% confidence intervals were calculated using either random- or fixed-effects models based on the heterogeneity of included studies. The clinical presentation, histology of affected skin areas, and management strategies (based on institutional experience), are also presented. RESULTS Rash, pruritus and vitiligo were found to be the most frequently reported dermatologic AEs. The calculated incidence of all-grade rash with pembrolizumab and nivolumab was 16.7% (RR = 2.6) and 14.3% (RR = 2.5), respectively. Other significant all-grade AEs included pruritus (pembrolizumab: incidence, 20.2% [RR = 49.9]; nivolumab: incidence, 13.2% [RR = 34.5]) and vitiligo (pembrolizumab: incidence, 8.3% [RR = 17.5]; nivolumab: 7.5% [RR = 14.6]). Interestingly, all the vitiligo events were reported in trials investigating melanoma. The RR for developing dermatologic AEs in general, was 2.95 with pembrolizumab, and 2.3 with nivolumab. CONCLUSION We found that pembrolizumab and nivolumab are both associated with dermatologic AEs, primarily low-grade rash, pruritus, and vitiligo, which are reminiscent of those seen with ipilimumab. Knowledge of these findings is critical for optimal care, maintaining dose intensity, and health-related quality of life in cancer patients receiving PD-1 inhibitors.
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Affiliation(s)
- V R Belum
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - B Benhuri
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; College of Medicine and Life Sciences, University of Toledo, Health Science Campus, 3000 Arlington Avenue, Toledo, OH, USA
| | - M A Postow
- Melanoma and Immunotherapeutics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - M D Hellmann
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - A M Lesokhin
- Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - N H Segal
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - R J Motzer
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - S Wu
- Division of Medical Oncology, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA; Division of Hematology and Oncology, Department of Medicine, Northport VA Medical Center, Northport, NY, USA
| | - K J Busam
- Pathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - J D Wolchok
- Melanoma and Immunotherapeutics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - M E Lacouture
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA.
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Lee JK, Capanu M, O'Reilly EM, Ma J, Chou JF, Shia J, Katz SS, Gansukh B, Reidy-Lagunes D, Segal NH, Yu KH, Chung KY, Saltz LB, Abou-Alfa GK. A phase II study of gemcitabine and cisplatin plus sorafenib in patients with advanced biliary adenocarcinomas. Br J Cancer 2013; 109:915-9. [PMID: 23900219 PMCID: PMC3749586 DOI: 10.1038/bjc.2013.432] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 06/20/2013] [Accepted: 07/01/2013] [Indexed: 01/07/2023] Open
Abstract
Background: This study evaluated the addition of sorafenib to gemcitabine and cisplatin in biliary adenocarcinoma first-line therapy. Methods: Patients with advanced biliary adenocarcinomas received gemcitabine 1000 mg m−2 and cisplatin 25 mg m−2 on a 2 weeks on/1 week off cycle and sorafenib 400 mg twice daily. After the initial 16 patients were enrolled, the chemotherapy doses were amended in view of grade 3 and 4 hand–foot skin reaction and haematologic toxicity. Subsequently, 21 patients received gemcitabine 800 mg m−2, cisplatin 20 mg m−2 and sorafenib 400 mg. The primary end point was an improvement in 6-month progression-free survival (PFS6) from historical 57–77% (90% power, type I error of 10%). Pretreatment pERK, evaluated by immunostaining, was correlated with clinical outcome. Results: A total of 39 patients were accrued. The most common grade 3–4 toxicities noted in >10% of patients were fatigue, elevated liver function tests and haematologic toxicities including thromboemboli, hyponatraemia and hypophosphataemia. Six-month progression-free survival was 51% (95% confidence interval (CI) 34–66%). Median PFS and overall survival were 6.5 (95% CI: 3.5–8.3) and 14.4 months (95% CI: 11.6–19.2 months), respectively. No correlation was observed between pERK and outcomes. Conclusion: The addition of sorafenib to gemcitabine and cisplatin in biliary adenocarcinomas did not improve efficacy over historical data, and toxicity was increased.
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Affiliation(s)
- J K Lee
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA
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Ding P, Weiser MR, Hajj C, Saltz L, Segal NH, Goodman KA. Induction chemotherapy followed by chemoradiotherapy and TME for high-risk locally advanced rectal cancer. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e14059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gava VG, Reidy DL, Paty P, Saltz L, Chung KY, Weiser MR, Temple LK, Segal NH, Moreira LF, Nash G. Surgical cytoreduction in patients with colorectal peritoneal carcinomatosis treated with contemporary chemotherapy. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.3546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wesa KM, Jacobs G, Woo D, Cronin A, Segal NH, Coleton M, Saltz L, Cassileth BR. Vitamin D levels and survival in colorectal cancer (CRC). J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.3615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Segal NH, Reidy-Lagunes D, Capanu M, Kemeny N, Chung K, Kelsen D, Hollywood E, Goodman-Davis N, Saltz LB. Phase II study of bevacizumab in combination with cetuximab plus irinotecan in irinotecan-refractory colorectal cancer (CRC) patients who have progressed on a bevacizumab-containing regimen (The BOND 2.5 Study). J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.4087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4087 Background: We previously showed that adding bevacizumab (bev) to cetuximab (cetux) plus irinotecan (IRI) in bev-naïve, IRI-refractory CRC patients is feasible, and yielded a favorable response rate and time to tumor progression (TTP) compared with historical controls (Saltz: JCO, 2007). Since most CRC patients now receive a bev-containing regimen prior to cetux, we evaluated the addition of bev to cetux plus IRI (CBI) in patients with metastatic CRC who had previously progressed on chemo + bev. Methods: All patients were naïve to cetux. The importance of KRAS mutation was not appreciated when the trial was designed and this has not yet been evaluated. Patients received IRI at the same dose and schedule as last received prior to study, Cetux 400 mg/m2 loading dose, then weekly at 250 mg/m2, plus Bev 5 mg/kg given every two weeks or 7.5 mg/kg given every three weeks. Results: 33 received treatment. Median age was 58 (range 29–85). Median number of prior regimens was 2 (range 1–2). Median performance status was ECOG 1 (range 0–1). Patients received a median of 2 cycles (range 1–15). Grade 3/4 Toxicities: Acneiform Rash 18%, hypomagnesemia 6%, hypophosphatemia 6%, Neutropenia 15%, Diarrhea 6%. One patient developed neutropenic fever and one patient had a hypersensitivity reaction to cetux. At a median follow up of 32 months (range 21–32 months) in 33 evaluable patients, we observed 3 (9%) partial responses and 11 (33%) patients with stable disease for > 4 months. Median TTP was 3.9 months (95% CI: 1.3 - 6.8). Median survival was 10.6 months (95% CI: 6.6 - 13.8). Conclusions: The toxicity profile was similar to what would have been expected from the individual agents alone. Recognizing the limitations of cross-study comparisons, the response rates and TTP seen with CBI in patients who have previously progressed on bev do not appear to be as encouraging as the 37% response rate and 7.3 months TTP seen in the BOND 2 trial of bev-naïve CRC patients. Ongoing randomized trials, including SWOG 0600, will be needed to definitively determine the contribution of continued use of bev after progression on a bev-containing regimen. Supported by Genentech. [Table: see text]
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Affiliation(s)
- N. H. Segal
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - M. Capanu
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - N. Kemeny
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - K. Chung
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - D. Kelsen
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - E. Hollywood
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - L. B. Saltz
- Memorial Sloan-Kettering Cancer Center, New York, NY
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Yoon SS, Segal NH, Olshen AB, Brennan MF, Singer S. Circulating angiogenic factor levels correlate with extent of disease and risk of recurrence in patients with soft tissue sarcoma. Ann Oncol 2004; 15:1261-6. [PMID: 15277268 DOI: 10.1093/annonc/mdh309] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Tumor angiogenesis, or new blood vessel formation, is regulated by a balance between pro-angiogenic factors such as vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), and anti-angiogenic factors such as endostatin. PATIENTS AND METHODS To investigate this angiogenic balance in soft tissue sarcomas (STS), blood samples were collected from 76 STS patients and 15 healthy controls, and analyzed for VEGF, bFGF and endostatin using quantitative enzyme-linked immunosorbent assays (ELISA). RESULTS Forty-one patients (54%) had primary tumors, 20 (26%) had local recurrences and 15 (20%) had metastatic disease with or without local disease. Levels of all three angiogenic factors were highly variable in STS patients. Mean levels of VEGF and bFGF were 12 and 14 times higher, respectively, in patients compared with controls (P<0.0001). VEGF levels correlated with size of tumor, with the highest levels found in tumors >10 cm in size. Patients with metastases had endostatin levels 45% lower than patients without metastases (P=0.047). In 54 patients who underwent resection of primary disease or local recurrence, low pre-operative bFGF level was associated with a higher risk of subsequent recurrence (P=0.044). CONCLUSIONS STS secrete widely variable levels of angiogenic factors, and levels of specific factors may correlate with extent of disease, predict risk of recurrence and possibly guide the use of anti-angiogenic agents.
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Affiliation(s)
- S S Yoon
- Sarcoma Disease Management Team, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Segal NH, Cohen RJ, Haffejee Z, Savage N. BCL-2 proto-oncogene expression in prostate cancer and its relationship to the prostatic neuroendocrine cell. Arch Pathol Lab Med 1994; 118:616-8. [PMID: 8204007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Prostatic adenocarcinoma has a divergent response to androgen ablation and a varied long-term prognosis. BCL-2 is a proto-oncogene that prevents programmed cell death. Since androgen withdrawal induces apoptosis, it has been postulated that BCL-2 may play a role in androgen resistance. Neuroendocrine cells have been demonstrated in prostate cancer and have an adverse influence on long-term prognosis. This study demonstrates a proportional relationship between the tissue levels of BCL-2 and the neuroendocrine marker, neuron-specific enolase in 11 of 13 cases of primary prostate cancer. This relationship does not appear to exist in metastatic prostate cancer or in most nonprostate cancers. Direct immunohistochemical staining confirmed BCL-2 in six of the primary tumors, and these BCL-2-containing cells appeared to be intimately associated with tumor neuroendocrine cells.
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Affiliation(s)
- N H Segal
- Department of Anatomical Pathology, School of Pathology, South African Institute for Medical Research, Parktown
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