Newly Diagnosed Multifocal GBM: A Monocentric Experience and Literature Review

Simple Summary

Glioblastoma is an aggressive brain tumor with a dismal prognosis. In a minority of cases, it presents with multiple lesions already at the time of diagnosis, affecting patients’ survival and treatment. Our retrospective study aims to increase the current understanding and define a treatment for this sub-entity, to improve patient survival. Chemoradiotherapy is a also safe and efficacy treatment in patients with multiple lesions. Survival advantages from extensive resection remain unclear.

Abstract

Glioblastomas with multiple foci at presentation (mGBMs) account for 2–35% of all GBMs. mGBMs have limited existing data and no standardized treatment. This study aims to determine their incidence, demographic and clinical features, outcome, and prognostic factors in terms of overall survival. We performed a monocentric retrospective study, reviewing patients treated at the Istituto Oncologico Veneto. Inclusion criteria were: new diagnosis of GBM and presence of multiple lesions on pre-treatment MRI. ECOG PS was used to evaluate clinical condition, RANO criteria for radiological assessment, and CTCAE v5.0 for treatment-related adverse events. The incidence of newly diagnosed mGBM was 7.2% and the study population consisted of 98 patients. Median age was 63 years, M:F ratio of 1.8:1, and a surgical approach was undertaken in 73 patients (mostly partial resection). MGMT was methylated in 47.5%, and 82 patients received active oncological treatment (65.9% radiotherapy plus temozolomide (RT + TMZ)). The disease control rate with RT + TMZ was 63%. Median OS of the entire study population was 10.2 months (95% CI 6.6–13.8), and median PFS was 4.2 months (95% CI 3.2–5.2). The ECOG PS, the extent of resection, and the RT + TMZ were significant prognostic factors in the univariate analysis for OS, but only the RT + TMZ was a significant independent OS predictor in the multivariate analysis (HR = 3.1, 95% IC 1.3–7.7, p = 0.014). The incidence of mGBM is not rare. RT + TMZ is confirmed to be an independent prognostic factor for survival and a safe and effective treatment. When feasible, RT + TMZ should be considered as a possible first-line treatment. The role of the extent of resection is still unclear.

Prognostic Role of Circulating Tumor Cells in Metastatic Renal Cell Carcinoma: A Large, Multicenter, Prospective Trial

BACKGROUND

Circulating tumor cells (CTCs) correlate with adverse prognosis in patients with breast, colorectal, lung, and prostate cancer. Little data are available for renal cell carcinoma (RCC).

MATERIALS AND METHODS

We designed a multicenter prospective observational study to assess the correlation between CTC counts and progression-free survival (PFS) in patients with metastatic RCC treated with an antiangiogenic tyrosine kinase inhibitor as a first-line regimen; overall survival (OS) and response were secondary objectives. CTC counts were enumerated by the CellSearch system at four time points: day 0 of treatment, day 28, day 56 and then at progression, or at 12 months in the absence of progression.

RESULTS

One hundred ninety-five eligible patients with a median age of 69 years were treated with sunitinib (77.5%) or pazopanib (21%). At baseline, 46.7% of patients had one or more CTCs per milliliter (range, 1 to 263). Thirty patients had at least three CTCs, with a median PFS of 5.8 versus 15 months in the remaining patients (p = .002; hazard ratio [HR], 1.99), independently of the International Metastatic RCC Database Consortium score at multivariate analysis (HR, 1.91; 95% confidence interval [CI], 1.16-3.14). Patients with at least three CTCs had a shorter estimated OS of 13.8 months versus 52.8 months in those with fewer than three CTCs (p = .003; HR, 1.99; multivariate analysis HR, 1.67; 95% CI, 0.95-2.93). Baseline CTC counts did not correlate with response; neither did having CTC sequencing counts greater than or equal to one, two, three, four, or five.

CONCLUSION

We provide prospective evidence that the presence of three or more CTCs at baseline is associated with a significantly shorter PFS and OS in patients with metastatic RCC.

IMPLICATIONS FOR PRACTICE

This prospective study evaluated whether the presence of circulating tumor cells (CTCs) in the peripheral blood correlates with activity of first-line tyrosine kinase inhibitors in metastatic renal cell carcinoma (RCC). This study demonstrated that almost half of patients with metastatic RCC have at least one CTC in their blood and that those patients with at least three CTCs are at increased risk of early progressive disease and early death due to RCC. Studies incorporating CTC counts in the prognostic algorithms of metastatic RCC are warranted.

A fully automated assay to detect the expression of pan-cytokeratins and of EML4-ALK fusion protein in circulating tumour cells (CTCs) predicts outcome of non-small cell lung cancer (NSCLC) patients

Background

In advanced non-small cell lung cancer (NSCLC) a recent meta-analysis confirms circulating tumour cells (CTCs) as an independent prognostic indicator of progression-free survival (PFS) and overall survival (OS). However, further investigations are necessary to predict and dynamically monitor the therapy in NSCLC patients using CTCs. To this aim, we combined the classical standard assay (SA) with an expanded cytokeratins profile (EA) and quantified the expression of EML4-ALK fusion protein in CTCs.

Methods

The CellSearch (CS) platform—first marked in vitro diagnostic use (IVD) from Food and Drug Administration (FDA), and “gold standard” for quantifying CTCs - detects EpCAM and cytokeratins (CKs) 8, 18, and 19. Since NSCLC shows different CKs profile, we customized the SA, to recognize CK 4, 5, 6, 7, 8, 10, 13, 14, 18, and 19 (EA). Using both assays we designed a prospective, multi-center study, primarily aimed to enumerate CTCs in advanced NSCLC. Secondarily, we developed an integration of the EA to quantify the expression of EML4-ALK fusion protein in CTCs, and correlated them with PFS and OS.

Results

EA identified a significantly much more number of CTC-positive patients (115 out of 180) than SA (103 out of 192; Chi-square =4.0179, with 1 degrees of freedom, P=0.04502). Similar to SA, EA levels were still associated with patient’ outcomes. Furthermore, the expression of EML4-ALK on CTCs allowed stratifying NSCLC patients according to a statistically significant difference in PFS.

Conclusions

We proposed here two novel automated tests, to characterize the expression of specific molecules on CTCs. We demonstrated that these integrated assays are robust and actionable in prospective clinical studies, and in the future could allow clinicians to improve both choice and length of treatment in individual NSCLC patient.

Role of the oncological-multidimensional prognostic index in older patients with metastatic colorectal cancer treated in a real-world setting

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Background: About 50% of diagnoses of colorectal cancer (CRC) occur in patients (pts) older than 70 years. Though a comprehensive geriatric assessment (CGA) is recommended for proper management of older cancer pts, there is still no consensus on the best form of geriatric assessment. We investigated possible prognostic factors in elderly metastatic (m)CRC pts in a real-world setting, focusing on the role of the oncological-multidimensional prognostic index (onco-MPI). Methods: Pts aged ≥ 70 years with mCRC referred to the Medical Oncology 1 Unit from May 2010 to May 2017 were assessed by a multidisciplinary team and received a basal CGA. Onco-MPI was calculated by a validated algorithm as a weighted linear combination of the CGA domains, as previously described. The following 3 different prognostic groups were identified: low (scores 0.0-0.46), medium (scores 0.47-0.63) and high risk (scores 0.64-1.0). Results: A total of 206 mCRC pts were included, 123 males. Mean age was 76.1 years (69.2-90.8). ECOG PS was < 2 in 90% and mini-mental state examination was ≥ 24 in 85% of pts. Primary tumor was located in rectum, left and right side in 18%, 42% and 40% of pts, respectively. RAS and BRAF mutations were detected in 44% and 9% of pts, respectively. According to onco-MPI score, 32%, 39% and 28% of cases were low, medium and high risk, respectively. According to CGA as per Balducci’s criteria, 56% of pts were classified as fit, 31% vulnerable and 13% frail. Median overall survival (OS) was 26 months (95% CI 19.7-32.4). The following factors were significantly associated with OS: ECOG PS (0-1 vs > 1, 31% vs 15%, p = 0.004); onco-MPI score (low vs medium vs high risk, 29% vs 38% vs 19%, p = 0.005), treatment (monotherapy vs doublet vs triplet, 20% vs 31% vs 30%, p = 0.01). No significant difference in OS was observed in CGA-based groups (p = 0.15). In high onco-MPI score, doublet-regimen correlated with higher OS compared to monotherapy (79% vs 51%, p = 0,03). Conclusions: Onco-MPI emerged as a significant prognosticator in mCRC elderly pts. It may be useful in daily clinical practice for driving decision-making in this age group. Thanks to its marked standardization it may be also applied in clinical trials.

Genetic, Epigenetic, and Immunologic Profiling of MMR-Deficient Relapsed Glioblastoma

PURPOSE

In-depth characterization of recurrent glioblastoma (rGBM) might contribute to a better understanding of the mechanisms behind tumor progression and enable rGBM treatment with targeted drugs.Experimental Design: In this study, GBM samples were collected at diagnosis and recurrence from adult patients treated with Stupp protocol. Expression of mismatch repair (MMR) proteins was evaluated by IHC, followed by whole exome sequencing (WES) of tumor samples showing loss of MSH6 reactivity. Established genetic, epigenetic, and immunologic markers were assessed by standard methods and correlated with loss of MMR proteins and patient survival.

RESULTS

Expression of MMR proteins was partially or completely lost in 25.9% rGBM samples. Specifically, 12 samples showed partial or total MSH6 expression reduction. Conversely, 96.4% of GBM samples at diagnosis expressed MMR markers. WES disclosed lack of variants in MMR genes in primary samples, whereas two MSH6-negative rGBM samples shared a c.3438+1G>A* splicing MSH6 variant with a potential loss of function effect. MSH6-negative rGBM specimens had high tumor mutational burden (TMB), but no microsatellite instability. In contrast, GBM samples with partial loss of MMR proteins disclosed low TMB. MMR-deficient rGBM showed significant telomere shortening and MGMT methylation and are characterized by highly heterogeneous MHC class I expression.

CONCLUSIONS

Multilevel profiling of MMR-deficient rGBM uncovered hypermutated genotype uncoupled from enriched expression of immune-related markers. Assessment of MHC class I expression and TMB should be included in protocols aiming to identify rGBM patients potentially eligible for treatment with drugs targeting immune-checkpoint inhibitors.

Phytosome complex of curcumin as complementary therapy of advanced pancreatic cancer improves safety and efficacy of gemcitabine: Results of a prospective phase II trial

A large body of biomedical evidence indicates that activation of Nrf2 by curcumin increases the nucleophilic tone and damps inflammation cumulatively supporting the malignant phenotype. Conversely, genetic analyses suggest a possible oncogenic nature of constitutive Nrf2 activation since an increased nucleophilic tone is alleged increasing chemoresistance of cancer cells. Aiming to contribute to solve this paradox, this study addressed the issue of safety and efficacy of curcumin as complementary therapy of gemcitabine on pancreatic cancer. This was a single centre, single arm prospective phase II trial. Patients received gemcitabine and Meriva^®, a patented preparation of curcumin complexed with phospholipids. Primary endpoint was response rate, secondary endpoints were progression free survival, overall survival, tolerability and quality of life. Analysis of inflammatory biomarkers was also carried out. Fifty-two consecutive patients were enrolled. Forty-four (13 locally advanced and 31 metastatic) were suitable for primary endpoint evaluation. Median age was 66 years (range 42-87); 42 patients had Eastern Cooperative Oncology Group performance status 0-1. The median number of treatment cycle was 4.5 (range 2-14). We observed 27.3% of response rate and 34.1% of cases with stable disease, totalizing a disease control rate of 61.4%. The median progression free survival and overall survival were 8.4 and 10.2 months, respectively. Higher IL-6 and sCD40L levels before treatment were associated to a worse overall survival (p < 0.01). Increases in sCD40L levels after 1 cycle of chemotherapy were associated with a reduced response to the therapy. Grade 3/4 toxicity was observed (neutropenia, 38.6%; anemia, 6.8%). There were no significant changes in quality of life during therapy. In conclusion, the complementary therapy to gemcitabine with phytosome complex of curcumin is not only safe but also efficiently translate in a good response rate in first line therapy of advanced pancreatic cancer.

Role of dose exposure and inflammatory status in a single center, real-world analysis of sunitinib in patients with metastatic renal cell carcinoma

AIM, PATIENTS & METHODS: To evaluate the real-world setting use of sunitinib, we reviewed data of our patients from January 2007 to December 2014.

RESULTS

In 114 patients, sunitinib was used as first-line TKI. Out of 110 evaluable patients, 5 complete responses, 37 partial responses, 42 stabilizations were reported. Median progression-free survival and overall survival (OS) were 14.3 and 28.4 months. Patients who received ≥ 4 full-dose cycles had a better OS (p = 0.02). A neutrophil-lymphocyte ratio <3 was associated both with OS and progression-free survival (50.4 vs 8.4 and 20.0 vs 3.3 months).

CONCLUSION

Sunitinib is active and feasible. Patients receiving <4 full-dose cycles or having increased neutrophil-lymphocyte ratio achieved worse outcomes: therefore, these are present potential predictive factors.

Metastatic colorectal cancer (mCRC) treatment: A high-volume, single-center, real-life experience

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Background: Few data are available on outcome of clinical practice unselected patients (pts) with mCRC. Methods: We retrospectively collected data of pts with mCRC followed at our Institution from January 2010 to December 2013 evaluating the clinical characteristics, treatments and survival outcomes. Results: A total of 584 pts were evaluated, 461 were followed at our Center while 123 were seen for a second opinion. Median age was 66 ys (25-94), 59% were male, 63% had an ECOG PS = 0 while 11% ≥2. 33% had right colon primary, 68% synchronous metastatic (mts) disease and 70% a single mts site. 81% underwent surgery on primary and 41% on metastases. 51% were RAS mutated (mut) and 5% BRAF mut. 57 pts didn't receive any systemic treatment, 33 due to frail clinical conditions and 24 due to radical surgical approach (R0). Among 404 treated pts, 239 received all 3 available cytotoxic agents (oxaliplatin, irinotecan, 5FU), 324 bevacizumab and 98 anti-EGFR; 153 (38%) were enrolled in clinical trials. Median overall survival (OS) was 27.6 months (mo) for the entire mCRC population, 3.7 mo for untreated frail pts, 28.7 mo for treated pts while it is still not reached for untreated R0 pts. OS was significantly longer for pts receiving first line combination therapy (29 vs 17 mo, p < 0.01) while a poor prognosis was confirmed for BRAF mut pts (p < 0.001). In a multivariate analysis age < 70, PS 0 and R0 surgery on mts disease showed a positive prognostic impact on OS while a right site of primary was a negative predictor of outcome. At logistic regression older age, low PS and peritoneal disease negatively affected the possibility to receive all 3 active drugs. Conclusions: Despite being an unselected population our outcomes are comparable with results of clinical trials in the corresponding period. We feel that such positive evidence derives from a personalization of treatment and a multidisciplinary approach to mts disease.

Development of an oncological-multidimensional prognostic index (Onco-MPI) for mortality prediction in older cancer patients

Purpose

A multidimensional prognostic index (MPI) based on a comprehensive geriatric assessment (CGA) has been developed and validated in independent cohorts of older patients demonstrating good accuracy in predicting one-year mortality. The aim of this study was to develop a cancer-specific modified MPI (Onco-MPI) for mortality prediction in older cancer patients.

Methods

We enrolled 658 new cancer subjects ≥70 years (mean age 77.1 years, 433 females, 65.8 %) attending oncological outpatient services from September 2004 to June 2011. The Onco-MPI was calculated according to a validated algorithm as a weighted linear combination of the following CGA domains: age, sex, basal and instrumental activities of daily living, Eastern Cooperative Oncology Group performance status, mini-mental state examination, body mass index, Cumulative Illness Rating Scale, number of drugs and the presence of caregiver. Cancer sites (breast 46.5 %, colorectal 21.3 %, lung 6.4 %, prostate 5.5 %, urinary tract 5.0 %, other 15.3 %) and cancer stages (I 37 %, II 22 %, III 19 %, IV 22 %) were also included in the model. All-cause mortality was recorded. Three grades of severity of the Onco-MPI score (low risk: 0.0–0.46, medium risk: 0.47–0.63, high risk: 0.64–1.0) were calculated using RECPAM method. Discriminatory power and calibration were assessed by estimating survival C-indices, along with 95 % confidence interval (CI) and the survival-based Hosmer–Lemeshow (HL) measures.

Results

One-year mortality incidence rate was 17.4 %. A significant difference in mortality rates was observed in Onco-MPI low risk compared to medium- and high-risk patients (2.1 vs. 17.7 vs. 80.8 %, p < 0.0001). The discriminatory power of one-year mortality prediction of the Onco-MPI was very good (survival C-index 0.87, 95 % CI 0.84–0.90) with an excellent calibration (HL p value 0.854).

Conclusion

Onco-MPI appears to be a highly accurate and well-calibrated predictive tool for one-year mortality in older cancer patients that can be useful for clinical decision making in this age group.

Do pathological parameters of primary tumor correlate with overall survival (OS) of metastatic clear-cell renal cell carcinoma (ccRCC)?

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Background: T and N stage, Fuhrman grade, necrosis and sarcomatoid features in the primary tumor are key prognostic factors for relapse of ccRCC, but they are not part of Heng's algorithm applied to predict OS in the metastatic setting, which instead is based on 6 clinical/laboratory items. Methods: Retrospective analysis on correlation between pathological parameters and OS (from start of first-line targeted therapy) and Heng's prognostic factors in a multicenter cohort of pts with advanced ccRCC, all of whom had undergone surgery on the kidney. Results: From 2006 to 2012, data of 903 eligible metastatic pts were collected from 33 Italian Oncology Institutions, median age 66 years, 72.6% males, 36.4 metastatic at diagnosis. After a median observation of 42 mo, 70,5% of pts died, estimated OS is 28.5 mo. Heng good prognosis pts were 14.45%, intermediate 69.1% and poor 16.45%. Univariate analysis showed that all pathological parameters significantly correlated with OS: T stage 3-4 vs 1-2 (HR 1.3), N1 vs N0 (1.3), Fuhrman grade 3-4 vs 1-2 (1.7) presence of necrosis (1.5) and sarcomatoid features (1,6). All pathological parameters had a strong correlation with a time to metastases < 1 year, while only weak correlations were found with the other clinical prognostic items of Heng's model. At multivariate analysis only N stage showed an independent impact on OS (table). Conclusions: T3-4 stage, N1, Fuhrman grade 3-4, presence of necrosis and sarcomatoid features negatively affect OS of metastatic ccRCC, but clinical items of Heng's model confirm to have a more robust prognostic significance at multivariate analysis. [Table: see text]

Adjuvant chemotherapy for soft tissue sarcomas: a 10-year mono-institutional experience

Purpose

The role of adjuvant chemotherapy (ACT) for soft tissue sarcomas (STS) is not standard practice. We investigated effectiveness and tolerability of ACT in patients (pts) with operated high-risk STS in clinical practice.

Methods

Medical records of pts with localized STS referred to Istituto Oncologico Veneto, Padova, from January 1, 2003 to July 07, 2012 were reviewed. Data were collected for pts with high-risk STS (size ≥5 cm, high grade and stage III). For those who received ACT, regimens used, drug doses, number of cycles, toxicity, and reasons for dose reduction or treatment interruption were recorded. Disease-free survival (DFS) and overall survival (OS) were calculated with the Kaplan–Meier method.

Results

Out of 96 eligible pts, median age 62 years, 36 received ACT after loco-regional treatment. Median DFS was 29.6 months (95 % CI 13.2–46.0) in pts receiving ACT and 7.8 months (95 % CI 3.9–11.7) in untreated pts (p < 0.0001); median OS was 67.0 months (95 % CI 25.4–108.6) in treated and 33.7 months (95 % CI 23.3–44.2) in untreated pts (p = 0.005). Among pts receiving ACT, a significant difference in DFS was observed between pts with limb/girdle disease (median DFS 82.4 months; 95 % CI 0.0–184.7) and pts with other primary sites (median DFS 18.3 months; 95 % CI 8.0–28.5) (p = 0.052). Grade ≥3 toxicities occurred in 20 pts (20.8 %), leading to dose reductions, delays, and treatment discontinuation in five cases. There was no treatment-related death.

Conclusion

Our data confirm benefit of ACT with regard to DFS and OS in pts with high-risk STS, greatest for limb/girdle STS.

Estimating the risk of chemotherapy toxicity in older patients with cancer: The role of the Vulnerable Elders Survey-13 (VES-13)

OBJECTIVE

Some parameters of the Comprehensive Geriatric Assessment (CGA) are predictive of chemotherapy toxicity. The Vulnerable Elders Survey-13 (VES-13) is a short instrument that has been tested as a means of identifying patients who need a full CGA, but its ability to predict chemotherapy toxicity is still unclear. We performed a pooled analysis of four published clinical trials studying VES-13 as a means of diagnosing vulnerability, in order to evaluate its accuracy in predicting the risk of grade 3/4 toxicity in older patients undergoing chemotherapy.

MATERIALS AND METHODS

The study involved patients aged ≥ 66 years with a diagnosis of solid or hematological cancer, all of whom were administered VES-13. The number of medications taken by each patient, their comorbidities, their Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score and index, the type of chemotherapy and treatment line, and their Mini Mental State Evaluation (MMSE), and Mini Nutritional Assessment (MNA) scores were recorded. Information was available concerning the grades 3-4 hematological and non-hematological toxicities experienced by each patient.

RESULTS

The study involved 648 patients aged ≥ 66 years (mean age 76.2±4.5, range 66-90) of whom 336 (51.9%) were female. VES-13 identified 287 patients (44.3%) as vulnerable. Grades 3-4 hematological and non-hematological toxicities were more prevalent in the vulnerable subjects (35.2% vs 20.8%, p<0.0001, and 18.5% vs 10.8%, p=0.0055), who were also at higher risk of both (adjusted ORs 2.15, 95% CI 1.46-3.17, p<0.001); and 1.66 (95% CI 1.02-2.72, p=0.043).

CONCLUSIONS

VES-13 could be considered to be a good candidate for future prospective studies to assess older patients with cancer at risk of toxicity.

Diagnostic value of plasma and urinary 2-hydroxyglutarate to identify patients with isocitrate dehydrogenase-mutated glioma

BACKGROUND

Mutant isocitrate dehydrogenase (IDH) 1/2 enzymes can convert α-ketoglutarate into 2-hydroxyglutarate (2HG). The aim of the present study was to explore whether 2HG in plasma and urine could predict the presence of IDH1/2 mutations in patients with glioma.

MATERIALS AND METHODS

All patients had histological confirmation of glioma and a recent brain magnetic resonance imaging scan showing the neoplastic lesion. Plasma and urine samples were taken from all patients, and the 2HG concentrations were determined using liquid chromatography tandem mass spectrometry.

RESULTS

A total of 84 patients were enrolled: 38 with R132H-IDH1 mutated and 46 with wild type. Among the 38 patients with mutant IDH1, 21 had high-grade glioma and 17 had low-grade glioma. Among the 46 patients with IDH1 wild-type glioma, 35 and 11 had high- and low-grade glioma, respectively. In all patients, we analyzed the mean 2HG concentration in the plasma, urine, and plasma/urine ratio (Ratio_2HG). We found a significant difference in the Ratio_2HG between patients with and without an IDH1 mutation (22.2 ± 8.7 vs. 15.6 ± 6.8; p < .0001). The optimal cutoff value for Ratio_2HG to identify IDH1 mutation was 19 (sensitivity, 63%; specificity, 76%; accuracy, 70%). In the patients with high-grade glioma only, the optimal cutoff value was 20 (sensitivity, 76%; specificity, 89%; accuracy, 84%; positive predictive value, 80%; negative predictive value, 86%). In 7 of 7 patients with high-grade glioma, we found a correlation between the Ratio_2HG value and the response to treatment.

CONCLUSION

Ratio_2HG might be a predictor of the presence of IDH1 mutation. The measurement of 2HG could be useful for disease monitoring and also to assess the treatment effects in these patients.

Are circulating tumor cells (CTCs) a feasible tool for predicting disease recurrence and survival in nonmetastatic (M0) colorectal cancer (CRC)?

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Background: Based on the correlation between CTCs and clinical outcome of metastatic breast, prostatic and CRC cancer, CTCs might be an ideal model to investigate the individual risk to develop metastasis. On the other way, data on their significance in M0 CRC are still limited. In a previous study we investigated CRC cell death in the circulating compartment, finding high value of apoptotic CTCs (M30-positive) independently from the disease stage. Our aim was to evaluate the prognostic role of total and M30-positive CTCs in M0 CRC patients (pts). Methods: From January 2009 to December 2011, we prospectively enrolled 192 stage 0-III CRC pts (stage 0 identified rectal cancer pts with Tis or complete pathological response after neoadjuvant therapy). We used CellSearch assay to quantify total and M30-positive CTCs in peripheral blood of CRC pts candidate to curative resection at diagnosis, time of surgery and four months later. Multivariate survival analyses were conducted using a Cox-regression. Results: At baseline 81 out of 192 pts (43.3%) had at least 1 CTC/7.5 mL of peripheral blood, 40 pts (22.2%) had >2 cells and 20 pts (11.6%) had >3 cells. We found a weak association between OS and total CTCs number (p=0.069), a significant association with M30-positive CTCs (p=0.022) and no association between RFS and CTC status. Limiting the analysis to stage I-III (n=151), we found a strong association between OS and both CTCs number (p=0.021) and M30-positive cells (p=0.007). The multivariate analyses demonstrated a significant improvement of survival prediction adding baseline CTCs count to clinical and pathological characteristics (HR=1.51, 95% CI 1.16-1.96). Conclusions: We first demonstrated a significant association between OS and CTCs status in stage I-III CRC pts. This result is consistent with previous report in metastatic CRC. It highlights a potential advantage of CTCs count in stratifying CRC pts and identifying a subset of pts with a high metastatic risk that could benefit from an adjuvant therapy. Further studies are needed to explore this aspect, which might be particularly significant in stage II CRC where the indication for adjuvant therapy is still under debate.

Immune senescence and cancer in elderly patients: results from an exploratory study

BACKGROUND

The challenge of immune senescence has never been addressed in elderly cancer patients. This study compares the thymic output and peripheral blood telomere length in ≥70year old cancer patients.

PATIENTS AND METHODS

Fifty-two elderly cancer patients and 39 age-matched controls without personal history of cancer were enrolled. All patients underwent a Comprehensive Geriatric Assessment (CGA), from which a multidimensional prognostic index (MPI) score was calculated. Peripheral blood samples were studied for naïve and recent thymic emigrant (RTE) CD4(+) and CD8(+) cells by flow cytometry. T-cell receptor rearrangement excision circle (TREC) levels, telomere length and telomerase activity in peripheral blood cells were quantified by real-time PCR.

RESULTS

The percentages of CD8(+) naïve and CD8(+) RTE cells and TREC levels were significantly lower in cancer patients than in controls (p=0.003, p=0.004, p=0.031, respectively). Telomere lengths in peripheral blood cells were significantly shorter in cancer patients than in controls (p=0.046) and did not correlate with age in patients, whereas it did in controls (r=-0.354, p=0.031). Short telomere (≤median)/low TREC (≤median) profile was associated with higher risk of cancer (OR=3.68 [95% CI 1.22-11.11]; p=0.021). Neither unfitness on CGA nor MPI score were significantly related to thymic output or telomere length in either group.

CONCLUSIONS

Immune senescence is significantly worse in elderly cancer patients than in age-matched controls. The low thymic output and the shorter telomeres in peripheral blood cells of cancer patients may reflect a pre-existing condition which facilitates the onset of malignancies in elderly people.

Bevacizumab as front-line treatment of brain metastases from solid tumors: a case series

BACKGROUND

Despite the large use of bevabizumab in the treatment of primary tumors of the brain, there is only limited experience with brain metastases (BM) and no experience in the treatment of previously untreated secondary brain lesions.

PATIENTS AND METHODS

We treated patients with BM, not suitable for local treatment, with a bevacizumab-based therapy associated with chemotherapy or interferon-α, as indicated for the primary cancer type.

RESULTS

We studied 18 patients with BM mostly from lung and renal adenocarcinoma, and the majority of patients had a treatment-naïve brain disease. Bevacizumab was found to be effective: the response rate was 60% partial responses with 40% disease stabilizations. The progression-free survival was 14 months and the overall survival was 15 months. Moreover, bevacizumab has a high capability of providing a long-lasting clinical benefit and reducing edema.

CONCLUSION

Bevacizumab for treatment of BM is feasible and the efficacy data are very encouraging.

Bi-weekly liposomal doxorubicin for advanced breast cancer in elderly women (≥ 70 years)

BACKGROUND

We conducted a multicenter prospective trial to assess tolerability and activity of pegylated liposomal doxorubicin (PLD) in women ≥ 70 years with locally-advanced or metastatic breast cancer.

PATIENTS AND METHODS

All patients underwent Multidimensional Geriatric Assessment (MGA). Frail patients were excluded. Normal cardiac function was required for inclusion. A bi-weekly schedule of PLD at 20mg/mq was adopted.

RESULTS

Thirty-two patients were enrolled with a median age of 78 years, 78.1% with visceral involvement, and 37.6% previously treated with chemotherapy for advanced disease. A mean of 7.8 cycles were delivered (range 1 to 20), with a median cumulative dose intensity of 8.9 mg/m(2)/week. Grade 3-4 toxicities were anemia (6.3%), palmar-plantar erythrodysesthesia (6.3%), mucositis (6.3%), infection (3.1%), and pulmonary embolism (3.1%). No cardiac events were registered. Causes of treatment interruption were maximal response (15.6%), progression (40.6%), refusal/loss to follow-up (28.1%), toxicities (9.4%), or other (6.3%). Response was obtained in 33.3% of 27 evaluable patients; median time to progression (TTP) was 10.3 months. MGA status (vulnerable vs. fit) did not have an impact on response, progression, and toxicity.

CONCLUSIONS

Bi-weekly PLD is well tolerated in both fit and vulnerable patients, with an apparently fairly good response rate and TTP (possibly biased by subsequent endocrine therapy and loss to follow-up). Close observation of patients is recommended in order to avoid early refusal/loss to follow-up.

Validation of a cancer-specific Oncological-Multidimensional Prognostic Index (Onco-MPI) for mortality prediction in older cancer patients

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Background: Recently, a Multidimensional Prognostic Index (MPI) based on a Comprehensive Geriatric Assessment (CGA) was developed and validated in independent cohorts of older patients (pts) demonstrating good accuracy in predicting 1-year mortality. Aim of the study was to validate a cancer-specific modified MPI (Onco-MPI) for mortality prediction in older cancer pts. Methods: 658 consecutive new cancer pts aged ≥70 years (mean age 77,1 years, 433 females, 65.8%) referred to the Geriatric Oncology Program from Sep 2004 to June 2011 were included. MPI was calculated according to a previously validated algorithm (derived from multivariate Cox regressions) as a weighted linear combination of the CGA domains: age, sex, basal and instrumental activities of daily living (ADL, IADL), Performance Status, Mini Mental State Examination, Body Mass Index, comorbidity by Cumulative Illness Rating Scale, number of drugs and presence of caregiver. To develop the Onco-MPI, cancer sites (breast 46.5%, colorectal 21.3%, lung 6.4%, prostate 5.5%, urinary tract 5.0%, other 15.3%) and cancer stages (I 37%, II 22%, III 19%, IV 22%) were also included in the model. Pts were followed for a median of 2,5 years and mortality was recorded. Three grades of severity of the onco-MPI (low 0.0-0.46, medium 0.47-0.63, high-risk 0.64-1.0 score) were calculated on the basis of estimated recursive partition and amalgamation method (RECPAM) cut-offs. Discriminatory power and calibration were further assessed. Results: Overall 1-year mortality incidence rate (events/person-years) was 17.4%. A significant difference in mortality rates was observed for Onco-MPI low-risk compared to medium- and high- risk pts (2.1% vs 17.7% vs 80.8%, p<0.0001). The discriminatory power of 1-year mortality prediction of the Onco-MPI was very good (survival C index 0.86, 95%CI 0.83-0.89). The Onco-MPI was well calibrated showing < 10% differences between predicted and observed mortality. Conclusions: The Onco-MPI is an accurate and well-calibrated predictive tool for 1-year mortality in older cancer pts and can be useful for clinical decision making in geriatric oncology.

Analysis of clinical features of ovarian cancer (OC) and breast cancer (BC) among BRCA-mutated (BRCA+) and sporadic (NH) double tumours

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Background: The clinical outcome of double OC and BC is specifically unknown either BRCA+ and in double tumours NH patients. Methods: The present databases made of 106 patients, 67 cases of NH (negative, no-tested or ongoing test for BRCA1/2 mutations) and 39 of BRCA+, were constituted to identify the clinical and pathological features of BC and OC. The primary endpoint was to evaluate biological characteristics of both cancers and clinical outcome of OC in coexistence with BC. Patients were censored at last follow-up or death (any cause) for determination of overall survival (OS). OS were determined using the Kaplan-Meier method and log-rank test to compared the different levels of a variable. Pearson Chi-Square or Fisher’s exact test were used to compare relationship between variables in to groups and Mann-Whitney U test to compare the medians. Results: 32/39 (82 %) BRCA+ and 44/67 (66 %) NH had BC as their first malignancy. As regards the genetic test on NH patients, 28 were BRCA negative, 22 have not been tested and in 10 patients the test is still in progress. All BRCA2 patients had BC as first malignancy, while 20/22 of BRCA1. Bilateral BC was more frequent in BRCA+ than in NH (33 % vs 9 %), resulted in a fivefold higher risk (p = 0.002). III-IV stage OC at diagnosis was 79% in BRCA+ vs 55 % in NH (p = 0.013); indeed BRCA+ patients have a threefold higher risk (however moderate) to develop an advanced stage OC. Death for progression of ovarian cancer involved both groups, and third neoplasm was involved in death cause in 1/1 of BRCA and 5/6 of NH. Two BRCA1 with OC as first neoplasm are alive. Conclusions: III-IV stage OC is more frequent in BRCA+ than in NH, and the main cause of disease progression and death is due to OC. Eventually the most relevant conclusive assessment is the suggestion of a more conserving management for BC and an intensive follow-up for OC in patients with double tumours, irrespective of their pathological or genetic features. Prospective trials are also indicated.

Long-term outcome of sunitinib in metastatic renal cell carcinoma: Single center experience

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Background: The multi-target tyrosine-kinase inhibitor sunitinib has been widely used in first or subsequent lines of treatment for metastatic renal cell carcinoma (mRCC). Since results of registrative clinical trials may be overestimated due to patient selection, outcome data of sunitinib in the routine clinical practice are warranted. Methods: We retrospectively reviewed clinical data of all consecutive mRCC patients starting sunitinib from March 2006 to September 2012 at our Institution. Results: Eligible were 106 pts, median age 63 years (range 27-89), 70% males, 89% clear cell histology, 87% prior nephrectomy. Sunitinib was prescribed either as first (70%) or second or further line of treatment after cytokines or targeted therapies. Patients received a median of 8 sunitinib cycles (1-49). Median PFS and OS in the first line were 15.0 mo (95% CI= 9.8-20) and 35 mo. PFS and OS in the second or further line were 15 mo (11.7-18.2) and 25 mo. Motzer risk score retained its prognostic relevance both in the first and in the second of further line. Patients who received at least 4 cycles at standard dose (50 mg/d 4 wks on/2wks off) had a significantly better PFS and OS compared to patients who did not (PFS 23.0 vs 12.0 mo p=0.012, OS 49.0 vs 16.0 mo p=0.006). First line pts progressing within three months from starting sunitinib were 18.9% (primary refractory), while 25.7% pts were treated for more than 24 mo (long term responders). Grade 3 or 4 toxicities have been recorded in 35% of pts but only 7 pts (6.6%) discontinued the treatment due to unacceptable toxicities. Conclusions: Sunitinib is active and feasible in a broader population of mRCC pts, with apparently superior PFS and OS results compared to pivotal trials. Better management of drug toxicities, less strict criteria for radiological progression, and availability of further sequential treatments may explain such results. Pts receiving at least 4 full dose cycles achieved statistically significant better outcomes.

Abstract 4841: GSTM1 and GSTT1 polymorphisms in population-based study of colorectal cancer risk

Introduction: Colorectal cancer (CRC) remains a significant cause of mortality accounting for 10% of all deaths of malignancies in European Caucasians. Glutathione S-transferases (GSTs) participate in the detoxification of chemotherapeutic agents used in therapy of CRC. Genetic polymorphisms in GST genes (copy-number variants of GSTM1 and GSTT1) that lead to diminished enzyme activity have been associated with CRC risk and survival increased chemotherapeutic treatment benefit in patients in most of the studies.

Aims: In this study we examined associations of GSTM1 and GSTT1 genotypes and clinical factors (age, gender, stage, localization of the tumor) with risk and we assessed the effect of genetic polymorphisms in GST genes on survival in CRC patients treated with adjuvant/palliative chemotherapy.

Materials & methods: We followed 1106 CRC patients treated with chemotherapy based on fluoropyrimidines and 1343 unrelated controls. Polymorphisms were genotyped by a relative quantification method (copy-number variants of GSTM1 and GSTT1), and PCR followed by gel electrophoresis (null/non-null genotypes for GSTM1 and GSTT1). Statistical evaluations of risk were evaluated using the Pearson Chi-Square Test. Associations between genotypes and overall survival were assessed using Kaplan-Meier curves and Cox proportional hazards regression.

Results: GSTT1 null was associated with a small but significant increase in risk (p = 0.013, OR = 1.393, 95% CI = 1.007-1.818). Copy-number variants of GSTM1 was associated with a reduction of risk (pDominant model &lt; 0.001, OR = 0.673, 95% CI = 0.552-0.820). The same associations were founded in male cases after gender stratification.

There were no significant associations between GSTT1 and GSTM1 genotypes with other clinical factors (localization, stage and tumor node metastasis classification) in the total case group. However, following stratification by age (&lt;70 vs ≥70 years at diagnosis), in young patients, GSTT1 null was associated with an increased risk (p &lt; 0.001, OR = 1.942, 95% CI = 1.523-3.440).

Furthermore, GSTM1 null and GSTT1 copy number variation were associated with low survival rates in younger patients (p = 0.047, HR = 3.937; p = 0.039, HR = 4.246). However, survival increase is observed in young patients with GSTM1 copy number variant (pDominant model &lt; 0.001, HR = 13.246).

Conclusions: This study confirms the association with the risk and the effect of GSTT1 and GSTM1 polymorphisms on survival in CRC patients who received chemotherapy.

We also suggest a specific risk association with GST null genotype in younger patients, particularly in those with presentation of tumor under the age of 70 years. The null GST genotype could be related to an improved immune response in younger patients, but less detoxification and increased rates of DNA damage in older patients.

Citation Format: Silvia Boffo, Erika Cecchin, Flavio Rizzolio, Sara Lonardi, Vittorina Zagonel, Pasquale Fiduccia, Giuseppe Toffoli. GSTM1 and GSTT1 polymorphisms in population-based study of colorectal cancer risk. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4841. doi:10.1158/1538-7445.AM2013-4841

Predictive role of MGMT status in recurrent glioblastoma (GBM) patients (PTS) treated with antiangiogenic drug (AD) plus temozolomide (TMZ) or CPT-11

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Background: Methylation and silencing of MGMT promoter is a favourable predictive factor in PTS with GBM treated with single alkylating agent such as TMZ. Yet, MGMT is an important resistance determinant to CPT-11 activity. AD can be administered in second line treatment as single agent or in combination to cytotoxic drugs. We analyzed the predictive role of MGMT status in PTS treated with AD plus TMZ or CPT-11 as second line treatment. Methods: Retrospectively, 55 PTS were analyzed: 36 (65%) with unmethlyated MGMT, 19 (35%) with methylated MGMT; 3 (5%) PTS with IDH1 mutations. 17 (31%) PTS performed a reoperation before the second line treatment and MGMT status was changed in 2 (18%) PTS, IDH1 status was unchanged in all PTS. 32 PTS were treated with sorafenib 800mg/die plus TMZ 40mg/m2/die, 23 with bevacizumab 10mg/Kg plus irinotecan every two weeks. Tumor response was evaluated by clinician assessment and by MRI according to RANO criteria every two months or when clinically indicated. Results: Among all PTS, median PFS was 2.7 months (95%CI 1.5-3.5), median OS from start of AD was 7.3 months (95%CI 6.02-8.5), 6-month PFS was 32%; no significant differences were observed and MGMT status was balanced between the two AD groups (p>0.05). Analyzing MGMT status at first surgery, according to univariate analyses there were no significant differences in terms of PFS (3.5ms vs 2.1ms; p=0.2), OS (6.5ms vs 7.2ms; p=0.1) and 6-PFS (HR=0.2, CI95% 0.05-1.07) between PTS with unmethylated and methylated MGMT, respectively. On multivariate analysis, adjusted for performance status, age and cytotoxic drug, MGMT status was not statistically significant in terms of PFS (p=0.8) and OS (p=0.1). Yet, no significant differences emerged with MGMT status at second surgery as well as analyzing the two AD groups, separately. Conclusions: MGMT status might not be a predictive factor in recurrent GBM patients treated with AD plus TMZ or CPT-11 as second line treatment, although MGMT status may change in some PTS between first and second surgery. In conclusion, the outcome of patients with recurrent GBM receiving AD plus TMZ or CPT-11 is not significantly influenced by MGMT methylation status.

PET/CT imaging in gynecologic malignancies: a critical overview of its clinical impact and our retrospective single center analysis

Gynecologic cancers represent a major global healthcare problem since they are associated with a significant mortality and morbidity. Over the last decade, considerable efforts have been spent in the development and optimization of novel diagnostic modalities to achieve an early diagnosis, aid in choosing appropriate treatment, improving long term surveillance, with the ultimate goal of increasing survival of gynecologic cancer patients. A growing body of evidence defines PET/CT as one of the most powerful tools for tumor, nodal and metastasis (TNM) cancer staging both in pre-treatment and in post treatment follow-up settings. At any phase of cancer evaluation, detection of metastasis represents one of the most critical impediments to the cure of tumor; traditional diagnostic imaging modalities, such as computed tomography (CT), are frequently found to inadequately stage the tumor, based on subsequent outcomes. As a consequence, patients may undergo pointless surgery for disease that could be treated with local medical therapies. In the setting of restaging, the ability to describe primary lesion, lymph nodes, possible metastases to peritoneum, bone, liver, lungs and brain renders PET/CT a potential alternative for a series of tests, including bone scanning, MRI or ultrasound, diagnostic CT, lymph node surgical sampling, that need to be used in combination in order to obtain a level of clinical confidence. In this review, we describe, the theoretical advantage and prognostic implications of PET/CT in the management of gynecologic cancer patients.

Intrapleural paclitaxel for malignant pleural effusion from ovarian and breast cancer: a phase II study with pharmacokinetic analysis

INTRODUCTION

Malignant pleural effusion (MPE) is a frequent complication in many types of tumors diminishing the patient's ability to perform activities. Despite various studies on talc treatment, some doubts about its safety and effectiveness remain, so the search for a more ideal intrapleural agent continues. We analyzed the effectiveness and safety of intrapleural paclitaxel in ovarian and breast cancer patients.

PATIENTS AND METHODS

The primary endpoint was overall response rate (ORR); secondary objectives included time to progression (TTP), overall survival (OS) and safety of intrapleural paclitaxel. Pharmacokinetics of the drug was also analyzed. After drainage of pleural effusion and lung re-expansion, paclitaxel 120 mg/m(2) diluted in normal saline was infused through a preinserted catheter which was immediately closed and reopened 24 h later. Blood and pleural fluid samples were collected 1, 4 and 24 h after the end of paclitaxel instillation. When MPE was less than 200 ml/24 h the catheter was removed. Chest radiographs were performed at the beginning of intrapleural paclitaxel, at 1 and 2 months later or with clinical deterioration.

RESULTS

We enrolled 18 patients with recurrent MPE: 11 with ovarian cancer and 7 with breast cancer. ORR was 77.8% at 1 month and 88.8%. at 2 months. Median TTP was 5.5 months (CI 95% 0.9-10.1) and median OS was 8.9 months (CI 95% 0.1-17.6). Patients achieving a complete response obtained a statistically significant longer survival than did patients with partial response or progressive disease. Chest pain, fever, and dyspnea were the most frequent side effects. Intrapleural paclitaxel concentrations were very high (mean ± SD = 478 ± 187 mg/l) and declined slowly (mean 24 h reduction ~30%). Detectable but low taxol plasma levels were found in most patients (mean ± SD = 0.045 ± 0.073 mg/l).

CONCLUSION

Intrapleural paclitaxel is a safe and effective palliative treatment for MPE from breast and ovarian cancers and may be integrated with systemic chemotherapy.

Positive experience of intraperitoneal chemotherapy followed by intravenous chemotherapy in heavily pretreated patients with suboptimal residual ovarian cancer and primary peritoneal cancer

AIMS AND BACKGROUND

To assess feasibility and toxicity of intraperitoneal administration of cisplatin and paclitaxel, followed by intravenous chemotherapy in pretreated patients with suboptimal ovarian cancer (residuum >1 cm) or primary peritoneal tumor, and suffering from ascites and/or intestinal obstruction.

METHODS

Fourteen relapsed ovarian cancer patients, 5 of whom were platinum sensitive (platinum-free interval >6 mo), 7 platinum-resistant (platinum-free interval <6 mo), and 2 platinum-refractory, received one cycle of intraperitoneal cisplatin, 100 mg/m2 on day 1, and two cycles of intraperitoneal paclitaxel, 120 mg/m2 on days 8 and 14. Intravenous chemotherapy was administrated 4 weeks following the last intraperitoneal paclitaxel instillation. Blood and peritoneal fluid samples were harvested at 0, 1, 4 and 24 h after ending paclitaxel delivery to guarantee proper tumor exposure and patient safety.

RESULTS

Intraperitoneal cisplatin determined 6 cases of vomiting grade 1-2 (40% of the morbidity). Intraperitoneal paclitaxel was associated with 6 events of grade 1-2 abdominal pain; the only grade 4 toxicity was one case of neutropenia and one of mucositis. Ascites decreased in 11 patients: the median time to first need for paracentesis was 5 months, compared to a median baseline paracentesis of 4 weeks. Three intestinal normalizations were obtained. The median overall survival was 10 months for our cohort of patients. Intraperitoneal paclitaxel clearance was significantly higher in patients with suboptimal tumor and symptomatic disease than in patients with smaller residual masses and without ascites (P = 0.004).

CONCLUSIONS

Intraperitoneal treatment was feasible, and enhanced response to the following intravenous chemotherapy was seen in these patients.