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Dubash S, Barwick TD, Kozlowski K, Rockall AG, Khan S, Khan S, Yusuf S, Lamarca A, Valle JW, Hubner RA, McNamara MG, Frilling A, Tan T, Wernig F, Todd J, Meeran K, Pratap B, Azeem S, Huiban M, Keat N, Lozano-Kuehne JP, Aboagye EO, Sharma R. Somatostatin Receptor Imaging with [ 18F]FET-βAG-TOCA PET/CT and [ 68Ga]Ga-DOTA-Peptide PET/CT in Patients with Neuroendocrine Tumors: A Prospective, Phase 2 Comparative Study. J Nucl Med 2024; 65:jnumed.123.266601. [PMID: 38331457 PMCID: PMC10924162 DOI: 10.2967/jnumed.123.266601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 02/10/2024] Open
Abstract
There is a clinical need for 18F-labeled somatostatin analogs for the imaging of neuroendocrine tumors (NET), given the limitations of using [68Ga]Ga-DOTA-peptides, particularly with regard to widespread accessibility. We have shown that [18F]fluoroethyl-triazole-[Tyr3]-octreotate ([18F]FET-βAG-TOCA) has favorable dosimetry and biodistribution. As a step toward clinical implementation, we conducted a prospective, noninferiority study of [18F]FET-βAG-TOCA PET/CT compared with [68Ga]Ga-DOTA- peptide PET/CT in patients with NET. Methods: Forty-five patients with histologically confirmed NET, grades 1 and 2, underwent PET/CT imaging with both [18F]FET-βAG-TOCA and [68Ga]Ga-peptide performed within a 6-mo window (median, 77 d; range, 6-180 d). Whole-body PET/CT was conducted 50 min after injection of 165 MBq of [18F]FET-βAG-TOCA. Tracer uptake was evaluated by comparing SUVmax and tumor-to-background ratios at both lesion and regional levels by 2 unblinded, experienced readers. A randomized, blinded reading of both scans was also then undertaken by 3 experienced readers, and consensus was assessed at a regional level. The ability of both tracers to visualize liver metastases was also assessed. Results: A total of 285 lesions were detected on both imaging modalities. An additional 13 tumor deposits were seen in 8 patients on [18F]FET-βAG-TOCA PET/CT, and [68Ga]Ga-DOTA-peptide PET/CT detected an additional 7 lesions in 5 patients. Excellent correlation in SUVmax was observed between both tracers (r = 0.91; P < 0.001). No difference was observed between median SUVmax across regions, except in the liver, where the median tumor-to-background ratio of [18F]FET-βAG-TOCA was significantly lower than that of [68Ga]Ga-DOTA-peptide (2.5 ± 1.9 vs. 3.5 ± 2.3; P < 0.001). Conclusion: [18F]FET-βAG-TOCA was not inferior to [68Ga]Ga-DOTA-peptide in visualizing NET and may be considered in routine clinical practice given the longer half-life and availability of the cyclotron-produced fluorine radioisotope.
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Affiliation(s)
- Suraiya Dubash
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Tara D Barwick
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Imaging, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kasia Kozlowski
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Andrea G Rockall
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sairah Khan
- Department of Imaging, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sameer Khan
- Department of Imaging, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Siraj Yusuf
- Radiology and Nuclear Medicine Department, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Tricia Tan
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Florian Wernig
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jeannie Todd
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Bhavesh Pratap
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Saleem Azeem
- Invicro-London, Imperial College London, London, United Kingdom; and
| | - Michael Huiban
- Invicro-London, Imperial College London, London, United Kingdom; and
| | - Nicholas Keat
- Invicro-London, Imperial College London, London, United Kingdom; and
| | - Jingky P Lozano-Kuehne
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Population Health Sciences Institute, Faculty of Medical Sciences, University of Newcastle, Newcastle, United Kingdom
| | - Eric O Aboagye
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Rohini Sharma
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom;
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Lamarca A, Ostios L, McNamara MG, Garzon C, Gleeson JP, Edeline J, Herrero A, Hubner RA, Moreno V, Valle JW. Resistance mechanism to fibroblast growth factor receptor (FGFR) inhibitors in cholangiocarcinoma. Cancer Treat Rev 2023; 121:102627. [PMID: 37925878 DOI: 10.1016/j.ctrv.2023.102627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 11/07/2023]
Abstract
Precision medicine is a major achievement that has impacted on management of patients diagnosed with advanced cholangiocarcinoma (CCA) over the last decade. Molecular profiling of CCA has identified targetable alterations, such as fibroblast growth factor receptor-2 (FGFR-2) fusions, and has thus led to the development of a wide spectrum of compounds. Despite favourable response rates, especially with the latest generation FGFRi, there are still a proportion of patients who will not achieve a radiological response to treatment, or who will have disease progression as the best response. In addition, for patients who do respond to treatment, secondary resistance frequently develops and mechanisms of such resistance are not fully understood. This review will summarise the current state of development of FGFR inhibitors in CCA, their mechanism of action, activity, and the hypothesised mechanisms of resistance.
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Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology - OncoHealth Institute - Instituto de Investigaciones Sanitarias FJD, Fundación Jiménez Díaz University Hospital, Madrid, Spain; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom.
| | - Lorena Ostios
- START-FJD Phase I Unit, Department of Medical Oncology, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Carlos Garzon
- Department of Medical Oncology, Infanta Elena University Hospital, Madrid, Spain
| | - Jack P Gleeson
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom; Cancer Res @UCC, University College Cork, Cork, Ireland
| | - Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Ana Herrero
- Department of Medical Oncology, Villalba University Hospital, Madrid, Spain
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Victor Moreno
- START-FJD Phase I Unit, Department of Medical Oncology, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
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d'Abrigeon C, McNamara MG, Le Sourd S, Lamarca A, Lièvre A, Bourien H, Peinoit A, Uguen T, Hubner RA, Valle JW, Edeline J. Influence of cirrhosis on outcomes of patients with advanced intrahepatic cholangiocarcinoma receiving chemotherapy. Br J Cancer 2023; 129:1766-1772. [PMID: 37813958 PMCID: PMC10667219 DOI: 10.1038/s41416-023-02460-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 09/18/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Cirrhosis is a risk factor for intrahepatic cholangiocarcinoma (iCC). However, its exact prevalence is uncertain and its impact on the management of advanced disease is not established. METHODS Retrospective analysis of patients treated with systemic chemotherapy for advanced iCC in the 1st-line setting at 2 tertiary cancer referral centres. Cirrhosis was diagnosed based on at least one element prior to any treatment: pathological diagnosis, baseline platelets <150 × 109/L, portal hypertension and/or dysmorphic liver on imaging. RESULTS In the cohort of patients (n = 287), 82 (28.6%) had cirrhosis (45 based on pathological diagnosis). Patients with cirrhosis experienced more grade 3/4 haematologic toxicity (44% vs 22%, respectively, P = 0.001), and more grade 3/4 non-haematologic toxicity (34% vs 14%, respectively, P = 0.001) than those without. The overall survival (OS) was significantly shorter in patients with cirrhosis: median 9.1 vs 13.1 months for those without (HR = 1.56 [95% CI: 1.19-2.05]); P = 0.002), confirmed on multivariable analysis (HR = 1.48 [95% CI: 1.04-2.60]; P = 0.028). CONCLUSION Cirrhosis was relatively common in patients with advanced iCC and was associated with increased chemotherapy-induced toxicity and shorter OS. Formal assessment and consideration of cirrhosis in therapeutic management is recommended.
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Affiliation(s)
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, The Christie NHS Foundation, Manchester, UK
| | - Samuel Le Sourd
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation, Manchester/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Astrid Lièvre
- Department of Gastroenterology, CHU Pontchaillou, Inserm U1242, COSS (Chemistry Oncogenesis Stress Signaling), Rennes 1 University, Rennes, France
| | - Héloïse Bourien
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Alexandre Peinoit
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Thomas Uguen
- Department of Hepatology, CHU Pontchaillou, Rennes, France
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation, Manchester/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, The Christie NHS Foundation, Manchester, UK
| | - Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France.
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Clelland S, Nuttall CL, Stott HE, Cope J, Barratt NL, Farrell K, Eyong MV, Gleeson JP, Lamarca A, Hubner RA, Valle JW, McNamara MG. Prognosis Discussion and Referral to Community Palliative Care Services in Patients with Advanced Pancreatic Cancer Treated in a Tertiary Cancer Centre. Healthcare (Basel) 2023; 11:2802. [PMID: 37893876 PMCID: PMC10606359 DOI: 10.3390/healthcare11202802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/10/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Advanced pancreatic cancer is associated with a poor prognosis, often less than 1 year. Honest prognosis discussions guide early community palliative care services input, facilitating timely advance care planning and improving quality of life. The aims were to assess if patients were offered prognosis discussions and community palliative care services referral. A retrospective analysis of consecutive case-notes of new advanced pancreatic cancer patients was conducted. Chi-squared test assessed the association with prognosis discussion and community palliative care services referral. In total, 365 cases (60%) had a documented prognosis discussion at any time-point in the treatment pathway; 54.4% during the first appointment. The frequency of prognosis discussion was greater with nurse clinician review at first appointment (p < 0.001). In total, 171 patients (28.1%) were known to community palliative care services at the first appointment. Of those not known, 171 (39.1%) and 143 (32.7%) were referred at this initial time-point or later, respectively. There was a significant association between the referral to community palliative care services at first appointment and the reviewing professional (this was greatest for nurse clinicians (frequency 65.2%)) (p < 0.001), and also if reviewed by clinical nurse specialist at first visit or not (47.8% vs. 35.6%) (p < 0.01). Prognosis discussions were documented in approximately two-thirds of cases, highlighting missed opportunities. Prognosis discussion was associated with clinician review and was most frequent for nurse clinician, as was referral to community palliative care services. Clinical nurse specialist review increased referral to community palliative care services if seen at the initial visit. Multi-disciplinary review, specifically nursing, therefore, during the first consultation is imperative and additive. It should be considered best practice to offer and negotiate the content and timing of prognosis discussions with cancer patients, and revisit this offer throughout their treatment pathway. Greater attention to prognosis discussion documentation is recommended.
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Affiliation(s)
- Sarah Clelland
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | | | - Helen E. Stott
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Joseph Cope
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | | | - Kelly Farrell
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Manyi V. Eyong
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | | | - Angela Lamarca
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Richard A. Hubner
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Juan W. Valle
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Mairéad G. McNamara
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
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Weaver JMJ, Hubner RA, Valle JW, McNamara MG. Selection of Chemotherapy in Advanced Poorly Differentiated Extra-Pulmonary Neuroendocrine Carcinoma. Cancers (Basel) 2023; 15:4951. [PMID: 37894318 PMCID: PMC10604995 DOI: 10.3390/cancers15204951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/09/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
Extra-pulmonary poorly differentiated neuroendocrine carcinoma is rare, and evidence for treatment has been limited. In this article, the evidence behind the cytotoxic chemotherapy choices used for metastatic or unresectable EP-PD-NEC is reviewed. In the first-line setting, etoposide and platinum chemotherapy or irinotecan and platinum have been demonstrated to be equivalent in a large phase III trial. Questions remain regarding the optimal number of cycles, mode of delivery, and the precise definition of platinum resistance in this setting. In the second-line setting, FOLFIRI has emerged as an option, with randomized phase 2 trials demonstrating modest, but significant, response rates. Beyond this, data are extremely limited, and several regimens have been used. Heterogeneity in biological behaviour is a major barrier to optimal EP-PD-NEC management. Available data support the potential role of the Ki-67 index as a predictive biomarker for chemotherapy response. A more personalised approach to management in future studies will be essential, and comprehensive multi-omic approaches are required to understand tumour somatic genetic changes in relation to their effects on the surrounding microenvironment.
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Affiliation(s)
- Jamie M. J. Weaver
- The Christie NHS Foundation Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK; (J.M.J.W.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Richard A. Hubner
- The Christie NHS Foundation Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK; (J.M.J.W.); (R.A.H.); (J.W.V.)
| | - Juan W. Valle
- The Christie NHS Foundation Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK; (J.M.J.W.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Mairead G. McNamara
- The Christie NHS Foundation Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK; (J.M.J.W.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, Manchester M20 4BX, UK
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Wainberg ZA, Melisi D, Macarulla T, Pazo Cid R, Chandana SR, De La Fouchardière C, Dean A, Kiss I, Lee WJ, Goetze TO, Van Cutsem E, Paulson AS, Bekaii-Saab T, Pant S, Hubner RA, Xiao Z, Chen H, Benzaghou F, O'Reilly EM. NALIRIFOX versus nab-paclitaxel and gemcitabine in treatment-naive patients with metastatic pancreatic ductal adenocarcinoma (NAPOLI 3): a randomised, open-label, phase 3 trial. Lancet 2023; 402:1272-1281. [PMID: 37708904 DOI: 10.1016/s0140-6736(23)01366-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/09/2023] [Accepted: 06/28/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma remains one of the most lethal malignancies, with few treatment options. NAPOLI 3 aimed to compare the efficacy and safety of NALIRIFOX versus nab-paclitaxel and gemcitabine as first-line therapy for metastatic pancreatic ductal adenocarcinoma (mPDAC). METHODS NAPOLI 3 was a randomised, open-label, phase 3 study conducted at 187 community and academic sites in 18 countries worldwide across Europe, North America, South America, Asia, and Australia. Patients with mPDAC and Eastern Cooperative Oncology Group performance status score 0 or 1 were randomly assigned (1:1) to receive NALIRIFOX (liposomal irinotecan 50 mg/m2, oxaliplatin 60 mg/m2, leucovorin 400 mg/m2, and fluorouracil 2400 mg/m2, administered sequentially as a continuous intravenous infusion over 46 h) on days 1 and 15 of a 28-day cycle or nab-paclitaxel 125 mg/m2 and gemcitabine 1000 mg/m2, administered intravenously, on days 1, 8, and 15 of a 28-day cycle. Balanced block randomisation was stratified by geographical region, performance status, and liver metastases, managed through an interactive web response system. The primary endpoint was overall survival in the intention-to-treat population, evaluated when at least 543 events were observed across the two treatment groups. Safety was evaluated in all patients who received at least one dose of study treatment. This completed trial is registered with ClinicalTrials.gov, NCT04083235. FINDINGS Between Feb 19, 2020 and Aug 17, 2021, 770 patients were randomly assigned (NALIRIFOX, 383; nab-paclitaxel-gemcitabine, 387; median follow-up 16·1 months [IQR 13·4-19·1]). Median overall survival was 11·1 months (95% CI 10·0-12·1) with NALIRIFOX versus 9·2 months (8·3-10·6) with nab-paclitaxel-gemcitabine (hazard ratio 0·83; 95% CI 0·70-0·99; p=0·036). Grade 3 or higher treatment-emergent adverse events occurred in 322 (87%) of 370 patients receiving NALIRIFOX and 326 (86%) of 379 patients receiving nab-paclitaxel-gemcitabine; treatment-related deaths occurred in six (2%) patients in the NALIRIFOX group and eight (2%) patients in the nab-paclitaxel-gemcitabine group. INTERPRETATION Our findings support use of the NALIRIFOX regimen as a possible reference regimen for first-line treatment of mPDAC. FUNDING Ipsen. TRANSLATION For the plain language summary see Supplementary Materials section.
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Affiliation(s)
- Zev A Wainberg
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Davide Melisi
- Università degli studi di Verona and Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Teresa Macarulla
- Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | | | | | - Andrew Dean
- St John of God Subiaco Hospital, Subiaco, WA, Australia
| | - Igor Kiss
- Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | | | | | - Eric Van Cutsem
- University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven, Belgium
| | - A Scott Paulson
- Texas Oncology-Baylor Charles A Sammons Cancer Center, Dallas, TX, USA
| | | | | | - Richard A Hubner
- The Christie NHS Foundation Trust, and Division of Cancer Sciences, University of Manchester, Manchester, UK
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Foy V, McNamara MG, Valle JW, Lamarca A, Edeline J, Hubner RA. Current Evidence for Immune Checkpoint Inhibition in Advanced Hepatocellular Carcinoma. Curr Oncol 2023; 30:8665-8685. [PMID: 37754543 PMCID: PMC10529518 DOI: 10.3390/curroncol30090628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/02/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023] Open
Abstract
The treatment of advanced unresectable HCC (aHCC) remains a clinical challenge, with limited therapeutic options and poor prognosis. The results of IMbrave150 and HIMALAYA have changed the treatment paradigm for HCC and established immune checkpoint inhibition (ICI), either combined with anti-angiogenic therapy or dual ICI, as preferred first-line therapy for eligible patients with aHCC. Numerous other combination regimens involving ICI are under investigation with the aim of improving the tumour response and survival of patients with all stages of HCC. This review will explore the current evidence for ICI in patients with advanced HCC and discuss future directions, including the unmet clinical need for predictive biomarkers to facilitate patient selection, the effects of cirrhosis aetiology on response to ICI, and the safety of its use in patients with impaired liver function.
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Affiliation(s)
- Victoria Foy
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
| | - Mairéad G. McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Juan W. Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
- Department of Oncology, OncoHealth Institute, Fundación Jiménez Díaz University Hospital, Avenida de los Reyes Catolicos 2, 28040 Madrid, Spain
| | - Julien Edeline
- Centre Eugène Marquis, Av. de la Bataille Flandres Dunkerque-CS 44229, CEDEX, 35042 Rennes, France;
| | - Richard A. Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
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Joharatnam-Hogan N, Hatem D, Cafferty FH, Petrucci G, Cameron DA, Ring A, Kynaston HG, Gilbert DC, Wilson RH, Hubner RA, Swinson DEB, Cleary S, Robbins A, MacKenzie M, Scott-Brown MWG, Sothi S, Dawson LK, Capaldi LM, Churn M, Cunningham D, Khoo V, Armstrong AC, Ainsworth NL, Horan G, Wheatley DA, Mullen R, Lofts FJ, Walther A, Herbertson RA, Eaton JD, O'Callaghan A, Eichholz A, Kagzi MM, Patterson DM, Narahari K, Bradbury J, Stokes Z, Rizvi AJ, Walker GA, Kunene VL, Srihari N, Gentry-Maharaj A, Meade A, Patrono C, Rocca B, Langley RE. Thromboxane biosynthesis in cancer patients and its inhibition by aspirin: a sub-study of the Add-Aspirin trial. Br J Cancer 2023; 129:706-720. [PMID: 37420000 PMCID: PMC10421951 DOI: 10.1038/s41416-023-02310-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Pre-clinical models demonstrate that platelet activation is involved in the spread of malignancy. Ongoing clinical trials are assessing whether aspirin, which inhibits platelet activation, can prevent or delay metastases. METHODS Urinary 11-dehydro-thromboxane B2 (U-TXM), a biomarker of in vivo platelet activation, was measured after radical cancer therapy and correlated with patient demographics, tumour type, recent treatment, and aspirin use (100 mg, 300 mg or placebo daily) using multivariable linear regression models with log-transformed values. RESULTS In total, 716 patients (breast 260, colorectal 192, gastro-oesophageal 53, prostate 211) median age 61 years, 50% male were studied. Baseline median U-TXM were breast 782; colorectal 1060; gastro-oesophageal 1675 and prostate 826 pg/mg creatinine; higher than healthy individuals (~500 pg/mg creatinine). Higher levels were associated with raised body mass index, inflammatory markers, and in the colorectal and gastro-oesophageal participants compared to breast participants (P < 0.001) independent of other baseline characteristics. Aspirin 100 mg daily decreased U-TXM similarly across all tumour types (median reductions: 77-82%). Aspirin 300 mg daily provided no additional suppression of U-TXM compared with 100 mg. CONCLUSIONS Persistently increased thromboxane biosynthesis was detected after radical cancer therapy, particularly in colorectal and gastro-oesophageal patients. Thromboxane biosynthesis should be explored further as a biomarker of active malignancy and may identify patients likely to benefit from aspirin.
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Affiliation(s)
| | - Duaa Hatem
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Fay H Cafferty
- MRC Clinical Trials Unit, UCL, London, UK
- The Institute of Cancer Research, London, UK
| | - Giovanna Petrucci
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - David A Cameron
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, The University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Alistair Ring
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Howard G Kynaston
- Department of Urology, Cardiff University School of Medicine, Cardiff, UK
| | - Duncan C Gilbert
- MRC Clinical Trials Unit, UCL, London, UK
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Richard H Wilson
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Richard A Hubner
- The Christie NHS Foundation Trust, Department of Medical Oncology, Manchester, UK
- University of Manchester, Division of Cancer Sciences, Manchester, UK
| | | | | | | | | | | | - Sharmila Sothi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Lesley K Dawson
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | | | - Mark Churn
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | | | - Vincent Khoo
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Anne C Armstrong
- The Christie NHS Foundation Trust, Department of Medical Oncology, Manchester, UK
| | - Nicola L Ainsworth
- The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Gail Horan
- The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | | | - Russell Mullen
- The Highland Breast Centre, Raigmore Hospital, Inverness, UK
| | - Fiona J Lofts
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Axel Walther
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - John D Eaton
- University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, UK
| | | | | | | | | | - Krishna Narahari
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
- Division of Cancer and Genetics, Cardiff University, Cardiff, UK
| | | | - Zuzana Stokes
- United Lincolnshire Hospitals NHS Trust, Lincoln City, UK
| | - Azhar J Rizvi
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | | | - Victoria L Kunene
- Walsall Manor Hospital and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | - Carlo Patrono
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Bianca Rocca
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
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9
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Passhak M, McNamara MG, Hubner RA, Ben-Aharon I, Valle JW. Choosing the best systemic treatment sequence for control of tumour growth in gastro-enteropancreatic neuroendocrine tumours (GEP-NETs): What is the recent evidence? Best Pract Res Clin Endocrinol Metab 2023; 37:101836. [PMID: 37914565 DOI: 10.1016/j.beem.2023.101836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Gastro-enteropancreatic neuroendocrine tumours (GEP-NETs) represent a rare and highly heterogeneous entity with increasing incidence. Based on the results obtained from several trials performed in the last decade, various therapeutic options have been established for the treatment of patients with GEP-NETs. The options include somatostatin analogues, targeted therapies (sunitinib and everolimus), chemotherapy (with temozolomide or streptozocin-based regimens), and peptide receptor radionuclide therapy. The treatment choice is influenced by various clinico-pathological factors including tumour grade and morphology, the primary mass location, hormone secretion, the volume of the disease and the rate of tumour growth, as well as patient comorbidities and performance status. In this review, the efficacy and safety of treatment options for patients with GEP-NETs is discussed and the evidence to inform the best sequence of available therapies to control tumour growth, prolong patient survival, and to lower potential toxicity, while maintaining patient quality of life is explored.
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Affiliation(s)
- Maria Passhak
- Fishman Oncology Center, Rambam Health Care Campus, Haifa, Israel
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Richard A Hubner
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Irit Ben-Aharon
- Fishman Oncology Center, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK.
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10
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Robinson MD, McNamara MG, Clouston HW, Sutton PA, Hubner RA, Valle JW. Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know. Cancers (Basel) 2023; 15:3781. [PMID: 37568597 PMCID: PMC10417541 DOI: 10.3390/cancers15153781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/13/2023] [Revised: 07/15/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.
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Affiliation(s)
- Matthew D. Robinson
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
| | - Mairéad G. McNamara
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Hamish W. Clouston
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Paul A. Sutton
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Richard A. Hubner
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Juan W. Valle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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11
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Gray S, Letissier O, d'Abrigeon C, Shah D, Wardell S, Faluyi O, Lamarca A, Hubner RA, Edeline J, Valle JW, McNamara MG. Third-Line Palliative Systemic Therapy for Advanced Biliary Tract Cancer: Multicentre Review of Patterns of Care and Outcomes. Cancers (Basel) 2023; 15:cancers15113047. [PMID: 37297009 DOI: 10.3390/cancers15113047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/17/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
Phase 3 trials have established standard first-line (1L) and 2L systemic therapy options for patients with advanced biliary cancer (ABC). However, a standard 3L treatment remains undefined. Clinical practice and outcomes for 3L systemic therapy in patients with ABC were therefore evaluated from three academic centres. Included patients were identified using institutional registries; demographics, staging, treatment history, and clinical outcomes were collected. Kaplan-Meier methods were used to assess progression-free survival (PFS) and overall survival (OS). Ninety-seven patients, treated between 2006 and 2022, were included; 61.9% had intrahepatic cholangiocarcinoma. At the time of analysis, there had been 91 deaths. Median PFS from initiating 3L palliative systemic therapy (mPFS3) was 3.1 months (95%CI 2.0-4.1), while mOS3 was 6.4 months (95%CI 5.5-7.3); mOS1 was 26.9 months (95%CI 23.6-30.2). Among patients with a therapy-targeted molecular aberration (10.3%; n = 10; all received in 3L), mOS3 was significantly improved versus all other included patients (12.5 vs. 5.9 months; p = 0.02). No differences in OS1 were demonstrated between anatomical subtypes. Fourth-line systemic therapy was received by 19.6% of patients (n = 19). This international multicentre analysis documents systemic therapy use in this select patient group, and provides a benchmark of outcomes for future trial design.
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Affiliation(s)
- Simon Gray
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Department of Molecular and Clinical Cancer Medicine, Faculty of Health and Life Sciences, University of Liverpool, Ashton St., Liverpool L69 3GB, UK
- Department of Medical Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Pembroke Pl, Liverpool L7 8YA, UK
| | - Octave Letissier
- Centre Eugène Marquis, Av. De la Bataille Flandres Dunkerque-CS 44229, CEDEX, 35042 Rennes, France
| | - Constance d'Abrigeon
- Centre Eugène Marquis, Av. De la Bataille Flandres Dunkerque-CS 44229, CEDEX, 35042 Rennes, France
| | - Dinakshi Shah
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
| | - Stephen Wardell
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
| | - Olusola Faluyi
- Department of Medical Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Pembroke Pl, Liverpool L7 8YA, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Department of Oncology, Oncohealth Institute, Jimémez Díaz University Hospital, Av. de los Reyes Catolicos 2, 28040 Madrid, Spain
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Julien Edeline
- Centre Eugène Marquis, Av. De la Bataille Flandres Dunkerque-CS 44229, CEDEX, 35042 Rennes, France
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd., Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
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12
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McNamara MG, Swain J, Craig Z, Sharma R, Faluyi O, Wadsley J, Morgan C, Wall LR, Chau I, Reed N, Sarker D, Margetts J, Krell D, Cave J, Sothi S, Anthoney A, Bell C, Patel A, Oughton JB, Cairns DA, Mansoor W, Lamarca A, Hubner RA, Valle JW. NET-02: a randomised, non-comparative, phase II trial of nal-IRI/5-FU or docetaxel as second-line therapy in patients with progressive poorly differentiated extra-pulmonary neuroendocrine carcinoma. EClinicalMedicine 2023; 60:102015. [PMID: 37287870 PMCID: PMC10242623 DOI: 10.1016/j.eclinm.2023.102015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 06/09/2023] Open
Abstract
Background The prognosis for patients with poorly-differentiated extra-pulmonary neuroendocrine carcinoma (PD-EP-NEC) is poor. A recognised first-line (1L) treatment for advanced disease is etoposide/platinum-based chemotherapy with no standard second-line (2L) treatment. Methods Patients with histologically-confirmed PD-EP-NEC (Ki-67 > 20%; Grade 3) received IV liposomal irinotecan (nal-IRI) (70 mg/m2 free base)/5-FU (2400 mg/m2)/folinic acid, Q14 days (ARM A), or IV docetaxel (75 mg/m2), Q21 days (ARM B), as 2L therapy. Primary endpoint was 6-month progression-free survival (PFS) rate (80% power to demonstrate one-sided 95% lower confidence interval excluded 15% (target level of efficacy: 30%)). Secondary endpoints: objective response rate (ORR), median PFS, overall survival (OS), toxicity and patient-reported quality-of-life (QoL) (ClinicalTrials.gov: NCT03837977). Findings Of 58 patients (29 each arm); 57% male, 90% ECOG PS 0/1, 10% PS 2, 89.7% Ki-67 ≥ 55%, primary site: 70.7%-gastrointestinal, 18.9%-other, 10.3%-unknown, 91.4%/6.9%/1.7% were resistant/sensitive/intolerant to 1L platinum-based treatment, respectively. The primary end-point of 6-month PFS rate was met by ARM A: 29.6% (lower 95% Confidence-Limit (CL) 15.7), but not by ARM B: 13.8% (lower 95%CL:4.9). ORR, median PFS and OS were 11.1% (95%CI:2.4-29.2) and 10.3% (95%CI:2.2-27.4%); 3 months (95%CI:2-6) and 2 months (95%CI:2-2); and 6 months (95%CI:3-10) and 6 months (95%CI:3-9) in ARMS A and B, respectively. Adverse events ≥ grade 3 occurred in 51.7% and 55.2% (1 and 6 discontinuations due to toxicity in ARMS A and B), respectively. QoL was maintained in ARM A, but not ARM B. Interpretation nal-IRI/5-FU/folinic acid, but not docetaxel, met the primary endpoint, with manageable toxicity and maintained QoL, with no difference in OS. ORR and median PFS were similar in both arms. This study provides prospective efficacy, toxicity and QoL data in the 2L setting in a disease group of unmet need, and represents some of the strongest evidence available to recommend systemic treatment to these patients. Funding Servier.
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Affiliation(s)
- Mairéad G. McNamara
- Division of Cancer Sciences, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Jayne Swain
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, UK
| | - Zoe Craig
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, UK
| | | | | | | | | | | | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Nick Reed
- Beatson Oncology Centre, Glasgow, UK
| | | | - Jane Margetts
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Judith Cave
- Southampton University Hospitals NHS Trust, Southampton, UK
| | | | | | | | - Alkesh Patel
- The Christie NHS Foundation Trust, Manchester, UK
| | - Jamie B. Oughton
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, UK
| | - David A. Cairns
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, UK
| | | | - Angela Lamarca
- Division of Cancer Sciences, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A. Hubner
- Division of Cancer Sciences, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W. Valle
- Division of Cancer Sciences, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
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13
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Xu J, Kato K, Raymond E, Hubner RA, Shu Y, Pan Y, Park SR, Ping L, Jiang Y, Zhang J, Wu X, Yao Y, Shen L, Kojima T, Gotovkin E, Ishihara R, Wyrwicz L, Van Cutsem E, Jimenez-Fonseca P, Lin CY, Wang L, Shi J, Li L, Yoon HH. Tislelizumab plus chemotherapy versus placebo plus chemotherapy as first-line treatment for advanced or metastatic oesophageal squamous cell carcinoma (RATIONALE-306): a global, randomised, placebo-controlled, phase 3 study. Lancet Oncol 2023; 24:483-495. [PMID: 37080222 DOI: 10.1016/s1470-2045(23)00108-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The options for first-line treatment of advanced oesophageal squamous cell carcinoma are scarce, and the outcomes remain poor. The anti-PD-1 antibody, tislelizumab, has shown antitumour activity in previously treated patients with advanced oesophageal squamous cell carcinoma. We report interim analysis results from the RATIONALE-306 study, which aimed to assess tislelizumab plus chemotherapy versus placebo plus chemotherapy as first-line treatment for advanced or metastatic oesophageal squamous cell carcinoma. METHODS This global, randomised, double-blind, parallel-arm, placebo-controlled, phase 3 study was conducted at 162 medical centres across Asia, Europe, Oceania, and North America. Patients (aged ≥18 years) with unresectable, locally advanced, recurrent or metastatic oesophageal squamous cell carcinoma (regardless of PD-L1 expression), Eastern Cooperative Oncology Group performance status of 0-1, and measurable or evaluable disease per Response Evaluation Criteria in Solid Tumours (version 1.1) were recruited. Patients were randomly assigned (1:1), using permuted block randomisation (block size of four) and stratified by investigator-chosen chemotherapy, region, and previous definitive therapy, to tislelizumab 200 mg or placebo intravenously every 3 weeks on day 1, together with an investigator-chosen chemotherapy doublet, comprising a platinum agent (cisplatin 60-80 mg/m2 intravenously on day 1 or oxaliplatin 130 mg/m2 intravenously on day 1) plus a fluoropyrimidine (fluorouracil [750-800 mg/m2 intravenously on days 1-5] or capecitabine [1000 mg/m2 orally twice daily on days 1-14]) or paclitaxel (175 mg/m2 intravenously on day 1). Treatment was continued until disease progression or unacceptable toxicity. Investigators, patients, and sponsor staff or designees were masked to treatment. The primary endpoint was overall survival. The efficacy analysis was done in the intention-to-treat population (ie, all randomly assigned patients) and safety was assessed in all patients who received at least one dose of study treatment. The trial is registered with ClinicalTrials.gov, NCT03783442. FINDINGS Between Dec 12, 2018, and Nov 24, 2020, 869 patients were screened, of whom 649 were randomly assigned to tislelizumab plus chemotherapy (n=326) or placebo plus chemotherapy (n=323). Median age was 64·0 years (IQR 59·0-69·0), 563 (87%) of 649 participants were male, 86 (13%) were female, 486 (75%) were Asian, and 155 (24%) were White. 324 (99%) of 326 patients in the tislelizumab group and 321 (99%) of 323 in the placebo group received at least one dose of the study drug. As of data cutoff (Feb 28, 2022), median follow-up was 16·3 months (IQR 8·6-21·8) in the tislelizumab group and 9·8 months (IQR 5·8-19·0) in the placebo group, and 196 (60%) of 326 patients in the tislelizumab group versus 226 (70%) of 323 in the placebo group had died. Median overall survival in the tislelizumab group was 17·2 months (95% CI 15·8-20·1) and in the placebo group was 10·6 months (9·3-12·1; stratified hazard ratio 0·66 [95% CI 0·54-0·80]; one-sided p<0·0001). 313 (97%) of 324 patients in the tislelizumab group and 309 (96%) of 321 in the placebo group had treatment-related treatment-emergent adverse events. The most common grade 3 or 4 treatment-related treatment-emergent adverse events were decreased neutrophil count (99 [31%] in the tislelizumab group vs 105 [33%] in the placebo group), decreased white blood cell count (35 [11%] vs 50 [16%]), and anaemia (47 [15%] vs 41 [13%]). Six deaths in the tislelizumab group (gastrointestinal and upper gastrointestinal haemorrhage [n=2], myocarditis [n=1], pulmonary tuberculosis [n=1], electrolyte imbalance [n=1], and respiratory failure [n=1]) and four deaths in the placebo group (pneumonia [n=1], septic shock [n=1], and unspecified death [n=2]) were determined to be treatment-related. INTERPRETATION Tislelizumab plus chemotherapy as a first-line treatment for advanced or metastatic oesophageal squamous cell carcinoma provided superior overall survival with a manageable safety profile versus placebo plus chemotherapy. Given that the interim analysis met its superiority boundary for the primary endpoint, as confirmed by the independent data monitoring committee, this Article represents the primary study analysis. FUNDING BeiGene.
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Affiliation(s)
- Jianming Xu
- Fifth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ken Kato
- National Cancer Center Hospital, Tokyo, Japan
| | - Eric Raymond
- Centre Hospitalier Paris Saint-Joseph, Paris, France
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Yongqian Shu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | | | - Sook Ryun Park
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Lu Ping
- The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
| | - Yi Jiang
- Cancer Hospital of Shantou University Medical College, Shantou, China
| | | | | | - Yuanhu Yao
- The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Lin Shen
- Beijing Cancer Hospital, Beijing, China
| | | | | | - Ryu Ishihara
- Osaka International Cancer Institute, Osaka, Japan
| | - Lucjan Wyrwicz
- Maria Sklodowska-Curie National Cancer Research Institute, Warsaw, Poland
| | - Eric Van Cutsem
- University Hospitals Gasthuisberg, Leuven, and KU Leuven, Leuven, Belgium
| | | | - Chen-Yuan Lin
- China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - Lei Wang
- Clinical Development, BeiGene (Beijing), Beijing, China
| | - Jingwen Shi
- Clinical Biomarker, BeiGene (Beijing), Beijing, China
| | - Liyun Li
- Clinical Development, BeiGene (Beijing), Beijing, China
| | - Harry H Yoon
- Department of Oncology, Mayo Clinic, Rochester, MN, USA.
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14
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Carnie LE, Shah D, Vaughan K, Kapacee ZA, McCallum L, Abraham M, Backen A, McNamara MG, Hubner RA, Barriuso J, Gillespie L, Lamarca A, Valle JW. Prospective Observational Study of Prevalence, Assessment and Treatment of Pancreatic Exocrine Insufficiency in Patients with Inoperable Pancreatic Malignancy (PANcreatic Cancer Dietary Assessment-PanDA). Cancers (Basel) 2023; 15:cancers15082277. [PMID: 37190204 DOI: 10.3390/cancers15082277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency (PEI) in patients with advanced pancreatic cancer (aPC) is well documented, but there is no consensus regarding optimal screening. METHODS AND ANALYSIS Patients diagnosed with aPC referred for palliative therapy were prospectively recruited. A full dietetic assessment (including Mid-Upper Arm Circumference (MUAC), handgrip and stair-climb test), nutritional blood panel, faecal elastase (FE-1) and 13C-mixed triglyceride breath tests were performed. PRIMARY OBJECTIVE prevalence of dietitian-assessed PEI (demographic cohort (De-ch)); design (diagnostic cohort (Di-ch)) and validation (follow-up cohort (Fol-ch)) of a PEI screening tool. Logistic and Cox regressions were used for statistical analysis. RESULTS Between 1 July 2018 and 30 October 2020, 112 patients were recruited (50 (De-ch), 25 (Di-ch) and 37 (Fol-ch)). Prevalence of PEI (De-ch) was 64.0% (flatus (84.0%), weight loss (84.0%), abdominal discomfort (50.0%) and steatorrhea (48.0%)). The derived PEI screening panel (Di-ch) included FE-1 (normal/missing (0 points); low (1 point)) and MUAC (normal/missing (>percentile 25) (0 points); low (2 points)) and identified patients at high-risk (2-3 total points) of PEI [vs. low-medium risk (0-1 total points)]. When patients from the De-ch and Di-ch were analysed together, those classified by the screening panel as "high-risk" had shorter overall survival (multivariable Hazard Ratio (mHR) 1.86 (95% CI 1.03-3.36); p-value 0.040). The screening panel was tested in the Fol-ch; 78.4% patients classified as "high-risk", of whom 89.6% had dietitian-confirmed PEI. The panel was feasible for use in clinical practice (64.8% patients completed all assessments), with high acceptability (87.5% would repeat it). Most patients (91.3%) recommended dietetic input for all patients with aPC. CONCLUSIONS PEI is present in most patients with aPC; early dietetic input provides a holistic nutritional overview, including, but not limited to, PEI. This proposed screening panel may help to prioritise those at higher risk of PEI, requiring urgent dietitian input. Its prognostic role needs further validation.
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Affiliation(s)
- Lindsay E Carnie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Dinakshi Shah
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Kate Vaughan
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Zainul Abedin Kapacee
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | | | - Marc Abraham
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Alison Backen
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Jorge Barriuso
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Loraine Gillespie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK
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15
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Mahmood RD, Graham K, Gleeson J, Hubner RA, Valle JW, McNamara MG. Targeting PD-1/PD-L1 in biliary tract cancer: role and available data. Immunotherapy 2023; 15:517-530. [PMID: 37009698 DOI: 10.2217/imt-2022-0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
There is a critical need for novel therapies to treat patients with advanced biliary tract cancer (BTC). This systematic review summarizes the evidence-based knowledge for the potential role of PD-1 and PD-L1 monoclonal antibodies in the treatment of patients with early-stage and advanced BTC. An Embase database search was conducted, identifying 15 eligible phase II/III clinical trials for review. Results from recent phase III trials show a statistically significant overall survival (OS) benefit from the addition of PD-1/PD-L1 inhibitors to chemotherapy in the first-line management of advanced BTC. Future research should concentrate on the discovery of biomarkers to identify patients who would benefit most from these therapies.
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Affiliation(s)
- Reem D Mahmood
- Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Kathryn Graham
- The Library, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Jack Gleeson
- Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Richard A Hubner
- Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Juan W Valle
- Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, M20 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester, M13 9PL, UK
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Robinson MD, Livesey D, Hubner RA, Valle JW, McNamara MG. Future therapeutic strategies in the treatment of extrapulmonary neuroendocrine carcinoma: a review. Ther Adv Med Oncol 2023; 15:17588359231156870. [PMID: 36872945 PMCID: PMC9983111 DOI: 10.1177/17588359231156870] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/27/2023] [Indexed: 03/06/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) are rare malignancies arising most commonly in the gastrointestinal and bronchopulmonary systems. Neuroendocrine carcinomas (NECs) are a subgroup of NENs characterised by aggressive tumour biology, poor differentiation and dismal prognosis. Most NEC primary lesions arise in the pulmonary system. However, a small proportion arise outside of the lung and are termed extrapulmonary (EP)-, poorly differentiated (PD)-NECs. Patients with local or locoregional disease may benefit from surgical excision; however, this is often not an option, due to late presentation. To date, treatment has mirrored that of small-cell lung cancer, with platinum-etoposide forming the basis of first-line treatment. There is a lack of consensus in relation to the most effective second-line treatment option. Low incidence, an absence of representative preclinical models and a lack of understanding of the tumour microenvironment all present challenges to drug development in this disease group. However, progress made in elucidating the mutational landscape of EP-PD-NEC and the observations made in several clinical trials are paving the way towards improving outcomes for these patients. The optimisation and strategic delivery of chemotherapeutic interventions according to tumour characteristics and the utilisation of targeted and immune therapies in clinical studies have yielded mixed results. Targeted therapies that complement specific genetic aberrations are under investigation, including AURKA inhibitors in those with MYCN amplifications, BRAF inhibitors in those with BRAFV600E mutations and EGFR suppression, and Ataxia Telangiectasia and Rad3-related inhibitors in patients with ATM mutations. Immune checkpoint inhibitors (ICIs) have conferred promising results in several clinical trials, particularly with dual ICIs and in combination with targeted therapy or chemotherapy. However, further prospective investigations are required to elucidate the impact of programmed cell death ligand 1 expression, tumour mutational burden and microsatellite instability on response. This review aims to explore the most recent developments in the treatment of EP-PD-NEC and contribute towards the requirement for clinical guidance founded on prospective evidence.
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Affiliation(s)
- Matthew D Robinson
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Daniel Livesey
- The Christie Library, School of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M20 4BX, UK.,Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK
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Craig Z, Swain J, Sharma R, Faluyi OO, Wadsley J, Morgan C, Wall LR, Chau I, Reed NS, Sarker D, Margetts J, Krell D, Cave J, Sharmila S, Anthoney A, Patel A, Lamarca A, Hubner RA, Valle JW, McNamara MG. Health-related quality of life (HRQoL) in patients (pts) with progressive, poorly differentiated, extra-pulmonary neuroendocrine carcinoma (PD-EP-NEC) enrolled in NET-02: A phase II trial of liposomal irinotecan (nal-IRI)/5-fluorouracil (5-FU)/folinic acid or docetaxel as second-line therapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
293 Background: NET-02 was a multi-centre, randomised (1:1), non-comparative phase II trial of nal-IRI/5-FU/folinic acid (ARM A) or docetaxel (ARM B) in pts with progressive PD-EP-NEC, aimed at selecting a treatment for evaluation in a phase III trial. Primary analysis (N = 58) showed ARM A, but not ARM B, achieved the target 6-month progression-free survival rate primary endpoint (McNamara et al. ASCO 2022). HRQoL was a secondary endpoint in NET-02. Methods: HRQoL was assessed using the EORTC QLQ-C30 and GINET21 (at baseline (BL), 6-weekly intervals and at disease progression). The mean change from BL was estimated for each scale by timepoint and treatment arm. Results are presented where there were ≥4 responses per time point. Scores were considered stable if they did not change by > 10 points from BL. The mean BL C30 scores for all pts were compared to United Kingdom (UK) population normative C30 data using a 2-sample t-test. Results: Fifty-four of 58 pts (93%) completed a BL questionnaire; of these, 39 (72%) completed ≥1 post-BL questionnaire, with 21 (51%) completing questionnaires at progression. Global health status (GHS) and all functional scales in ARM A remained stable from BL to intervals pre-progression, with a sustained improvement in role functioning observed post-BL. In ARM B, GHS and all C30 functional scales decreased by > 10 points between BL and week 18 (worsening of QoL). Both arms had a > 10-point increase from BL in constipation and diarrhoea in ≥1 post-BL time point. In ARM A, pain, insomnia and financial problems decreased from BL. No C30 symptom scales in ARM B were consistently lower post-BL. Patterns of change in GINET21 mean score were similar in both arms: body image, disease-related worries, information/communication, sexual function and social function all had a > 10-point reduction in score from BL (indicating improvement in symptoms/problems); endocrine and gastrointestinal symptoms remained stable; muscle/bone pain varied across time points, initially showing a reduction in pain followed by an increase, compared to BL. In comparison to the UK C30 norms (BL all pts), 11 of 15 C30 scales did not significantly differ (P > 0.05). Mean scores for fatigue and appetite loss were significantly higher than UK C30 norms (worse symptoms in pts from NET-02) (P = 0.03, P = 0.0003 respectively). However, emotional functioning and GHS were significantly better in pts from NET-02 (P = 0.001, P = 0.03 respectively). Role and social functioning were lower in pts from NET-02 (both P = 0.06) (poorer level of functioning). Conclusions: HRQoL was maintained and potentially improved with nal-IRI/5-FU/folinic acid, but not docetaxel. Compared to the UK general population, BL QoL did not substantially differ in pts from NET-02. Clinical trial information: NCT03837977.
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Affiliation(s)
- Zoe Craig
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Jayne Swain
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | | | | | | | - Lucy R. Wall
- Western General Hospital, Edinburgh, United Kingdom
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Debashis Sarker
- King's College Hospital, Institute of Liver Studies, London, United Kingdom
| | - Jane Margetts
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Daniel Krell
- Mount Vernon Cancer Center, Middlesex, United Kingdom
| | - Judith Cave
- Southampton University Hospital NHS Foundation Trust, Brockenhurst, United Kingdom
| | | | - Alan Anthoney
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Alkesh Patel
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Lamarca
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W. Valle
- University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
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18
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Shah D, Kapacee ZA, Lamarca A, Hubner RA, Valle JW, McNamara MG. Use of the Rockwood Clinical Frailty Scale in patients with advanced hepatopancreaticobiliary malignancies. Expert Rev Anticancer Ther 2022; 22:1009-1015. [PMID: 35768183 DOI: 10.1080/14737140.2022.2096594] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Co-existing frailty in older patients with hepatopancreaticobiliary (HPB) malignancies is common. This study assessed the relationship between the Rockwood Clinical Frailty scale (CFS) and systemic anti-cancer therapy dose intensity (SACT-DI) and overall survival (OS) in patients with advanced HPB malignancies. RESEARCH DESIGN AND METHODS CFS was assessed prospectively for consecutive patients with newly diagnosed advanced HPB malignancy (The Christie; Sep-2019 to June-2020). Mann-Whitney U test assessed association between CFS, ECOG Performance Status (ECOG PS), and SACT-DI and Spearman's rank assessed the association between ECOG PS, age, and frailty. Survival analysis was performed using Kaplan-Meier and Cox regression. RESULTS Two hundred patients met inclusion criteria. SACT-DI was higher in Group-1 (not frail) (CFS 1-3)(median = 61%) than Group-2 (vulnerable/mildly frail) (CFS 4-5)(median = 25.1%), p < 0.001. Median OS was shorter in frail and pre-frail patients (HR 2.3(95%CI 1.8-2.9),p < 0.001. On multivariable analysis, both CFS (HR 1.5-(95%CI 1.2-1.9), p = 0.002) and ECOG PS (HR 1.9 (95%CI 1.6-2.3), p < 0.001) were independent prognostic factors for OS. CONCLUSION Frailty assessments, in addition to ECOG PS, may identify patients that will benefit from systemic therapy and are both independent prognostic factors for OS.
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Affiliation(s)
- Dinakshi Shah
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, Department of Medical Oncology, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, Department of Medical Oncology, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
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19
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McNamara MG, Swain J, Craig Z, Sharma R, Faluyi OO, Wadsley J, Morgan C, Wall LR, Chau I, Reed N, Sarker D, Margetts J, Krell D, Cave J, Sharmila S, Anthoney A, Patel A, Lamarca A, Hubner RA, Valle JW. NET-02: A multicenter, randomized, phase II trial of liposomal irinotecan (nal-IRI) and 5-fluorouracil (5-FU)/folinic acid or docetaxel as second-line therapy in patients (pts) with progressive poorly differentiated extra-pulmonary neuroendocrine carcinoma (PD-EP-NEC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.4005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
4005 Background: The prognosis for pts with PD-EP-NEC is poor. A recognised first-line (1L) treatment for advanced disease is etoposide/platinum-based chemotherapy; there is no standard second-line (2L) treatment (area of unmet need). Methods: This was a multi-centre, randomised (1:1), phase II trial of IV nal-IRI (70mg/m2 free base)/5-FU (2400 mg/m2)/folinic acid, Q14 days (ARM A), or IV docetaxel (75mg/m2), Q21 days (ARM B), as 2L therapy in a planned 102 pts with progressive PD-EP-NEC, aimed at selecting a treatment for continuation to a phase III trial. Pts with histologically-confirmed PD-EP-NEC (Ki-67>20%; Grade 3, WHO 2019), who had prior 1L platinum-based chemotherapy and radiological disease progression or discontinuation of 1L therapy due to intolerance, with an ECOG performance status ≤2 were eligible. Randomisation was stratified by Ki-67, ECOG PS, presence of liver metastases, and response to previous platinum-based therapy. Primary endpoint was 6 month (mo) progression-free survival (PFS) rate; 80% power to demonstrate the one-sided 95% confidence interval (CI) of the 6 mo PFS rate excluded 15%, if the true rate was at least 30%, where 30% was the required level of efficacy; a rate of <15% would give grounds for rejection. Intention was to show that the regimens were sufficiently active, but not to assess superiority of one regimen over the other. Secondary endpoints included objective response rate (ORR), PFS, overall survival (OS), and toxicity. Based on futility analysis, the DSMB recommended closure of recruitment in Dec 21. Results: Of 58 patients in 15 UK centres (Nov 18-Dec 21), 29 in ARM A, 29 in ARM B, 57% were male, median age (range): 63.5 years (22-85), 90% ECOG PS 0/1, 10% PS 2, 90% Ki-67≥55%, 33%/38%/29% small/large cell/unknown morphology, primary site: 69% gastrointestinal, 12% unknown, 9% genitourinary, 5% head & neck, 3% gynae, 2% breast, 60% had liver mets, 91%/7%/2% were resistant/sensitive/intolerant to 1L platinum-based treatment. At a median follow up of 6.6 mo, the primary end-point of 6-mo PFS rate was met in ARM A; ORR, median PFS and OS are also presented (Table). Adverse events ≥ grade 3 occurred in 51.7% and 55.2% in ARM A and B and there were 1 and 6 discontinuations due to toxicity in ARM A and B, respectively. Data cleaning is on-going. Conclusions: nal-IRI/5-FU, but not docetaxel, met the primary endpoint (exceeding the threshold for efficacy), with manageable toxicity, and warrants evaluation in a phase III trial. Clinical trial information: 03837977. [Table: see text]
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Affiliation(s)
| | | | - Zoe Craig
- University of Leeds, Leeds, United Kingdom
| | | | | | | | | | - Lucy R. Wall
- Western General Hospital, Edinburgh, United Kingdom
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Debashis Sarker
- King's College Hospital, Institute of Liver Studies, London, United Kingdom
| | - Jane Margetts
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Daniel Krell
- Mount Vernon Cancer Centre, Middlesex, United Kingdom
| | - Judith Cave
- Southampton University Hospitals NHS Trust, Brockenhurst, United Kingdom
| | | | - Alan Anthoney
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Alkesh Patel
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Lamarca
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Medical Oncology Department, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Juan W. Valle
- University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
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20
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Gray S, de Liguori Carino N, Radhakrishna G, Lamarca A, Hubner RA, Valle JW, McNamara MG. Clinical challenges associated with utility of neoadjuvant treatment in patients with pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2022; 48:1198-1208. [PMID: 35264307 DOI: 10.1016/j.ejso.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an increasingly common cancer with a persistently poor prognosis, and only approximately 20% of patients are clearly anatomically resectable at diagnosis. Historically, a paucity of effective therapy made it inappropriate to forego the traditional gold standard of upfront surgery in favour of neoadjuvant treatment; however, modern combination chemotherapy regimens have made neoadjuvant therapy increasingly viable. As its use has expanded, the rationale for neoadjuvant therapy has evolved from one of 'downstaging' to one of early treatment of micro-metastases and selection of patients with favourable tumour biology for resection. Defining resectability in PDAC is problematic; multiple differing definitions exist. Multidisciplinary input, both in initial assessment of resectability and in supervision of multimodality therapy, is therefore advised. European and North American guidelines recommend the use of neoadjuvant chemotherapy in borderline resectable (BR)-PDAC. Similar regimens may be applied in locally advanced (LA)-PDAC with the aim of improving potential access to curative-intent resection, but appropriate patient selection is key due to significant rates of recurrence after excision of LA disease. Upfront surgery and adjuvant chemotherapy remain standard-of-care in clearly resectable PDAC, but multiple trials evaluating the use of neoadjuvant therapy in this and other localised settings are ongoing.
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Affiliation(s)
- Simon Gray
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, United Kingdom
| | - Ganesh Radhakrishna
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom; Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom; Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom.
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21
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Frizziero M, Kilgour E, Simpson KL, Rothwell DG, Moore DA, Frese KK, Galvin M, Lamarca A, Hubner RA, Valle JW, McNamara MG, Dive C. Expanding Therapeutic Opportunities for Extrapulmonary Neuroendocrine Carcinoma. Clin Cancer Res 2022; 28:1999-2019. [PMID: 35091446 PMCID: PMC7612728 DOI: 10.1158/1078-0432.ccr-21-3058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/08/2021] [Accepted: 01/13/2022] [Indexed: 11/16/2022]
Abstract
Poorly differentiated neuroendocrine carcinomas (PD-NEC) are rare cancers garnering interest as they become more commonly encountered in the clinic. This is due to improved diagnostic methods and the increasingly observed phenomenon of "NE lineage plasticity," whereby nonneuroendocrine (non-NE) epithelial cancers transition to aggressive NE phenotypes after targeted treatment. Effective treatment options for patients with PD-NEC are challenging for several reasons. This includes a lack of targetable, recurrent molecular drivers, a paucity of patient-relevant preclinical models to study biology and test novel therapeutics, and the absence of validated biomarkers to guide clinical management. Although advances have been made pertaining to molecular subtyping of small cell lung cancer (SCLC), a PD-NEC of lung origin, extrapulmonary (EP)-PD-NECs remain understudied. This review will address emerging SCLC-like, same-organ non-NE cancer-like and tumor-type-agnostic biological vulnerabilities of EP-PD-NECs, with the potential for therapeutic exploitation. The hypotheses surrounding the origin of these cancers and how "NE lineage plasticity" can be leveraged for therapeutic purposes are discussed. SCLC is herein proposed as a paradigm for supporting progress toward precision medicine in EP-PD-NECs. The aim of this review is to provide a thorough portrait of the current knowledge of EP-PD-NEC biology, with a view to informing new avenues for research and future therapeutic opportunities in these cancers of unmet need.
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Affiliation(s)
- Melissa Frizziero
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester M13 9PL, United Kingdom
- Manchester European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust, 550 Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Elaine Kilgour
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
| | - Kathryn L. Simpson
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
| | - Dominic G. Rothwell
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
| | - David A. Moore
- Cancer Research UK Lung Cancer Centre of Excellence, University College London Cancer Institute, 72 Huntley St, London WC1E 6DD, United Kingdom
- Department of Cellular Pathology, University College London Hospital NHS Foundation Trust, 235 Euston Rd, London NW1 2BU, United Kingdom
| | - Kristopher K. Frese
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
| | - Melanie Galvin
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester M13 9PL, United Kingdom
- Manchester European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust, 550 Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Richard A. Hubner
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester M13 9PL, United Kingdom
- Manchester European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust, 550 Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Juan W. Valle
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester M13 9PL, United Kingdom
- Manchester European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust, 550 Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Mairéad G. McNamara
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester M13 9PL, United Kingdom
- Manchester European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust, 550 Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Caroline Dive
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Alderley Park, SK10 4TG, United Kingdom
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22
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Kamposioras K, Papaxoinis G, Dawood M, Appleyard J, Collinson F, Lamarca A, Ahmad U, Hubner RA, Wright F, Pihlak R, Damyanova I, Razzaq B, Valle JW, McNamara MG, Anthoney A. Markers of tumor inflammation as prognostic factors for overall survival in patients with advanced pancreatic cancer receiving first-line FOLFIRINOX chemotherapy. Acta Oncol 2022; 61:583-590. [PMID: 35392758 DOI: 10.1080/0284186x.2022.2053198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/08/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Identifying pretreatment blood markers that distinguish prognostic groups of patients with advanced pancreatic ductal adenocarcinoma (PDAC) under first-line FOLFIRINOX chemotherapy has the potential to improve management of this condition. Aim of this study was to determine the prognostic utility of a range of pretreatment, inflammation-related, blood cell markers in this group of patients. MATERIAL AND METHODS Data from a training cohort were analyzed to identify potential pretreatment blood markers correlating to survival outcomes. The most informative markers were further analyzed in a validation cohort comprised patients from a geographically separate cancer center undergoing the same treatment. RESULTS A total of 138 consecutive patients receiving FOLFIRINOX chemotherapy between 2010 and 2019, constituted the training cohort. Neutrophil/lymphocyte (NLR), monocyte/lymphocyte (MLR), and platelet/lymphocyte ratio (PLR) as well as the systemic inflammatory response index (SIRI) and CA19.9 showed prognostic significance in addition to tumor stage. A pretreatment SIRI score cutoff of 2.35 differentiated between a poor prognostic group with median overall survival (mOS) 5.1 months and a better prognostic group, mOS 12.5 months. SIRI ≤/> 2.35 was predictive of mOS in patients with locally advanced and metastatic PDAC. SIRI was confirmed as a prognostic marker in a validation cohort of 67 patients with mOS of 13.4 months and 6.3 months for those with SIRI ≤ 2.35 and >2.35, respectively. Additional analysis revealed baseline SIRI as being prognostic within additional subgroups of patients in both cohorts. CONCLUSIONS This large, retrospective, analysis of real-world patients receiving first-line FOLFIRINOX chemotherapy for advanced PDAC has identified the pretreatment blood SIRI as a strong prognostic marker for survival. This will allow better counseling of patients with regards to the benefits of treatment, improved stratification within clinical trials, and potentially identify groups of patients for novel therapy trials as first-line treatment.
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Affiliation(s)
| | - George Papaxoinis
- Second Department of Oncology, Agios Savvas Anticancer Hospital, Athens, Greece
| | - Mohamed Dawood
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jordan Appleyard
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Fiona Collinson
- Department of Medical Oncology, Leeds Institute for Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Usman Ahmad
- Department of Medical Oncology, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Francesca Wright
- Department of Medical Oncology, Leeds Institute for Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, UK
| | - Rille Pihlak
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Iva Damyanova
- Department of Medical Oncology, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Bilal Razzaq
- Department of Medical Oncology, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - Alan Anthoney
- Department of Medical Oncology, Leeds Institute for Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, UK
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23
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Conway AM, Morris GC, Smith S, Vekeria M, Manoharan P, Mitchell C, Backen A, Oliveira P, Hubner RA, Lamarca A, McNamara MG, Valle JW, Cook N. Intrahepatic cholangiocarcinoma hidden within cancer of unknown primary. Br J Cancer 2022; 127:531-540. [PMID: 35484217 PMCID: PMC9345855 DOI: 10.1038/s41416-022-01824-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 12/08/2021] [Revised: 03/29/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Many patients referred with a provisional diagnosis of cancer of unknown primary (pCUP) present with presumed metastatic disease to the liver. Due to the lack of definitive histological markers, intrahepatic cholangiocarcinoma (iCCA) may be overlooked. This study assessed the frequency of iCCA within a pCUP cohort. Methods A single UK cancer-center study of sequential patients referred with pCUP from January 2017 to April 2020. Baseline diagnostic imaging was reviewed independently by a radiologist and oncologist; those with radiological features of iCCA (dominant liver lesion, capsular retraction) were identified. Results Of 228 patients referred with pCUP, 72 (32%) had malignancy involving the liver. 24/72 patients had radiological features consistent with iCCA; they were predominantly female (75%) with an average age of 63 years and 63% had an ECOG PS ≤ 2. The median overall survival (OS) of the iCCA group and the remaining liver-involved CUP group were similar (OS 4.1 vs 4.4 months, p-value = 0.805). Patients, where a primary diagnosis was subsequently determined, had better OS (10.2 months, p-values: iCCA = 0.0279: cCUP = 0.0230). Conclusions In this study, 34% of patients with liver-involved pCUP, fulfilled the radiological criteria for an iCCA diagnosis. Consideration of an iCCA diagnosis in patients with CUP could improve timely diagnosis, molecular characterisation and treatment.
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Affiliation(s)
- Alicia-Marie Conway
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Manchester, UK.,Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Georgina C Morris
- School of Medical Sciences, University of Manchester, Manchester, UK
| | - Sarah Smith
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Monique Vekeria
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Prakash Manoharan
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Claire Mitchell
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Alison Backen
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Pedro Oliveira
- Department of Pathology, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK. .,Division of Cancer Sciences, University of Manchester, Manchester, UK.
| | - Natalie Cook
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK. .,Division of Cancer Sciences, University of Manchester, Manchester, UK.
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24
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Gray S, Lamarca A, Edeline J, Klümpen HJ, Hubner RA, McNamara MG, Valle JW. Targeted Therapies for Perihilar Cholangiocarcinoma. Cancers (Basel) 2022; 14:1789. [PMID: 35406560 PMCID: PMC8997784 DOI: 10.3390/cancers14071789] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/16/2022] Open
Abstract
Perihilar cholangiocarcinoma (pCCA) is the anatomical sub-group of biliary tract cancer (BTC) arising between the second-order intrahepatic bile ducts and the cystic duct. Together with distal and intrahepatic cholangiocarcinoma (dCCA and iCCA; originating distal to, and proximal to this, respectively), gallbladder cancer (GBC) and ampulla of Vater carcinoma (AVC), these clinicopathologically and molecularly distinct entities comprise biliary tract cancer (BTC). Most pCCAs are unresectable at diagnosis, and for those with resectable disease, surgery is extensive, and recurrence is common. Therefore, the majority of patients with pCCA will require systemic treatment for advanced disease. The prognosis with cytotoxic chemotherapy remains poor, driving interest in therapies targeted to the molecular nature of a given patient's cancer. In recent years, the search for efficacious targeted therapies has been fuelled both by whole-genome and epigenomic studies, looking to uncover the molecular landscape of CCA, and by specifically testing for aberrations where established therapies exist in other indications. This review aims to provide a focus on the current molecular characterisation of pCCA, targeted therapies applicable to pCCA, and future directions in applying personalised medicine to this difficult-to-treat malignancy.
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Affiliation(s)
- Simon Gray
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester M20 4BX, UK; (S.G.); (A.L.); (R.A.H.); (M.G.M.)
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester M20 4BX, UK; (S.G.); (A.L.); (R.A.H.); (M.G.M.)
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester M13 9PL, UK
| | - Julien Edeline
- Centre Eugène Marquis, Av. de la Bataille Flandres Dunkerque-CS 44229, CEDEX, 35042 Rennes, France;
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Amsterdam University Medical Center, P.O. Box 7057, 1081 HV Amsterdam, The Netherlands;
| | - Richard A. Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester M20 4BX, UK; (S.G.); (A.L.); (R.A.H.); (M.G.M.)
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester M13 9PL, UK
| | - Mairéad G. McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester M20 4BX, UK; (S.G.); (A.L.); (R.A.H.); (M.G.M.)
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester M13 9PL, UK
| | - Juan W. Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester M20 4BX, UK; (S.G.); (A.L.); (R.A.H.); (M.G.M.)
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester M13 9PL, UK
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25
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Wheatley RC, Kilgour E, Jacobs T, Lamarca A, Hubner RA, Valle JW, McNamara MG. Potential influence of the microbiome environment in patients with biliary tract cancer and implications for therapy. Br J Cancer 2022; 126:693-705. [PMID: 34663949 PMCID: PMC8888758 DOI: 10.1038/s41416-021-01583-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/16/2021] [Accepted: 10/04/2021] [Indexed: 12/25/2022] Open
Abstract
Biliary tract cancers, including intra- and extra-hepatic cholangiocarcinoma as well as gallbladder cancer, are associated with poor prognosis and the majority of patients present with advanced-stage, non-resectable disease at diagnosis. Biliary tract cancer may develop through an accumulation of genetic and epigenetic alterations and can be influenced by microbial exposure. Furthermore, the liver and biliary tract are exposed to the gastrointestinal microbiome through the gut-liver axis. The availability of next-generation sequencing technology has led to an increase in studies investigating the relationship between microbiota and human disease. In particular, the interplay between the microbiome, the tumour micro-environment and response to systemic therapy is a prospering area of interest. Given the poor outcomes for patients with biliary tract cancer, this emerging field of research, through which new biomarkers may be identified, offers potential as a tool for early diagnosis, prognostication or even as a future therapeutic target. This review summarises the available evidence on the microbiome environment in patients with biliary tract cancer, including a discussion around confounding factors, implications for therapy and proposed future directions.
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Affiliation(s)
- Roseanna C Wheatley
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Elaine Kilgour
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, University of Manchester, Alderley Park, UK
| | - Timothy Jacobs
- The Library, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.
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26
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Lamarca A, Frizziero M, Barriuso J, Kapacee Z, Mansoor W, McNamara MG, Hubner RA, Valle JW. Molecular Profiling of Well-Differentiated Neuroendocrine Tumours: The Role of ctDNA in Real-World Practice. Cancers (Basel) 2022; 14:cancers14041017. [PMID: 35205766 PMCID: PMC8870317 DOI: 10.3390/cancers14041017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/13/2021] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 12/18/2022] Open
Abstract
Simple Summary The analysis of circulating tumour DNA (ctDNA) can help to identify genetic alterations present in cancer cells without the need to access tumour tissue, which can be an invasive approach. This study explored the feasibility of analysing ctDNA in patients with advanced well-differentiated neuroendocrine tumours (WdNETs). A total of 45 patients (15 with WdNETs) were included. Although feasible (with a non-evaluable sample rate of 27.8%), mutation-based ctDNA analysis was of limited clinical utility for patients with advanced WdNETs. While patients with WdNETs could still be offered genomic profiling (if available and reimbursed), it is important to manage patients’ expectations regarding the likelihood of the results impacting their treatment. Abstract Background: The role of tumour genomic profiling in the clinical management of well-differentiated neuroendocrine tumours (WdNETs) is unclear. Circulating tumour DNA (ctDNA) may be a useful surrogate for tumour tissue when the latter is insufficient for analysis. Methods: Patients diagnosed with WdNETs underwent ctDNA genomic profiling (FoundationLiquid®); non-WdNETs (paraganglioma, goblet cell or poorly-differentiated neuroendocrine carcinoma) were used for comparison. The aim was to determine the rate of: test failure (primary end-point), “pathological alterations” (PAs) (secondary end-point) and patients for whom ctDNA analysis impacted management (secondary end-point). Results: Forty-five patients were included. A total of 15 patients with WdNETs (18 ctDNA samples) were eligible: 8 females (53.3%), median age 63.2 years (range 23.5–86.8). Primary: small bowel (8; 53.3%), pancreas (5; 33.3%), gastric (1; 6.7%) and unknown primary (1; 6.7%); grade (G)1 (n = 5; 33.3%), G2 (9; 60.0%) and G3 (1; 6.7%); median Ki-67: 5% (range 1–30). A total of 30 patients with non-WdNETs (34 ctDNA samples) were included. Five WdNETs samples (27.78%) failed analysis (vs. 17.65% in non-WdNETs; p-value 0.395). Of the 13 WdNET samples with successful ctDNA analyses, PAs were detected in 6 (46.15%) (vs. 82.14% in non-WdNETs; p-value 0.018). In WdNETs, the PA rate was independent of concomitant administration anti-cancer systemic therapies (2/7; 28.57% vs. 4/6; 66.67%; p-value 0.286) at the time of the ctDNA analysis: four, one and one samples had one, two and three PAs, respectively. These were: CDKN2A mutation (mut) (one sample), CHEK2mut (one), TP53mut (one), FGFR2 amplification (one), IDH2mut (one), CTNNB1mut (one), NF1mut (one) and PALB2mut (one). None were targetable (0%) or impacted clinical management (0%). There was a lower maximum mutant allele frequency (mMAF) in WdNETs (mean 0.33) vs. non-WdNETs (mean 26.99), even though differences did not reach statistical significance (p-value 0.0584). Conclusions: Although feasible, mutation-based ctDNA analysis was of limited clinical utility for patients with advanced WdNETs. The rates of PAs and mMAFs were higher in non-WdNETs. While patients with WdNETs could still be offered genomic profiling (if available and reimbursed), it is important to manage patients’ expectations regarding the likelihood of the results impacting their treatment.
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Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Correspondence:
| | - Melissa Frizziero
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Jorge Barriuso
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Zainul Kapacee
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Wasat Mansoor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Mairéad G. McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Richard A. Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Juan W. Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK; (M.F.); (J.B.); (Z.K.); (W.M.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
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27
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Taboada RG, Riechelmann RP, Mauro C, Barros M, Hubner RA, McNamara MG, Lamarca A, Valle JW. Everolimus-Induced Pneumonitis in Patients with Neuroendocrine Neoplasms: Real-World Study on Risk Factors and Outcomes. Oncologist 2022; 27:97-103. [PMID: 35641203 PMCID: PMC8895743 DOI: 10.1093/oncolo/oyab024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/29/2021] [Accepted: 09/29/2021] [Indexed: 12/27/2022] Open
Abstract
Abstract
Background
Everolimus-induced pneumonitis (EiP) has been poorly studied in patients with neuroendocrine neoplasms (NEN) outside clinical trials. The aim of this study was to evaluate the incidence, risk factors, and outcomes of EiP in patients with NENs using real-world data.
Methods
Retrospective study of everolimus-treated patients with advanced NENs. Imaging reports were systematically reviewed for the presence of pneumonitis. Clinical features and treatment profiles for EiP were summarized. Overall survival (OS) was calculated from the initiation of everolimus to the date of death or last follow-up using the Kaplan-Meier method.
Results
A total of 122 patients were included. Median age at start of everolimus was 62 (19-86) years, 62% (76/122) were male, and half were from pancreatic origin (62, 51%). Twenty-eight patients (23%) developed EiP: 82% grade (G)1 or G2, 14% G3 and 4% G4. The median time to EiP was 3.6 (0.8-51) months. Primary tumor site, concurrent lung disease, smoking history, and prior therapies were not associated with the onset of EiP. Patients who developed EiP had longer time on everolimus treatment (median 18 months vs 6 months; P = .0018) and OS (77 months vs 52 months; P = .093). Everolimus-induced pneumonitis was a predictor of improved OS by multivariable analysis (HR 0.39, 95% CI 0.19-0.82; P = .013).
Conclusion
Everolimus-induced pneumonitis in the real-world clinical setting is present in one quarter of patients with NENs receiving everolimus and often occurs early. While risk factors for EiP were not identified, patients with EiP had improved survival.
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Affiliation(s)
- Rodrigo G Taboada
- Department of Medical Oncology, A.C.Camargo Cancer Center, São Paulo, Brazil
| | | | - Carine Mauro
- Department of Medical Oncology, A.C.Camargo Cancer Center, São Paulo, Brazil
| | - Milton Barros
- Department of Medical Oncology, A.C.Camargo Cancer Center, São Paulo, Brazil
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
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28
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D'abrigeon C, McNamara MG, Le Sourd S, Lamarca A, Lièvre A, Hubner RA, Valle JW, Edeline J. Influence of cirrhosis on outcomes of patients with advanced intrahepatic cholangiocarcinoma receiving chemotherapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
475 Background: Cirrhosis is a risk factor for intrahepatic cholangiocarcinoma (iCC). However, its impact on the management of advanced disease is not established. Methods: Retrospective analysis of patients (pts) treated with systemic chemotherapy for advanced iCC in the first-line setting at 2 tertiary cancer referral centers, the second center used to validate findings from the first. Cirrhosis was diagnosed based on at least one element among pathological diagnosis, baseline platelet < 150 G/L, portal hypertension and/or dysmorphic liver at imaging. Results: In the first center (n=185), 55 pts (29.7%) had cirrhosis (74.5 % based on pathological diagnosis). Main aetiology of cirrhosis was alcohol for 17 pts (31%), non-alcoolic steato-hepatitis (NASH) for 10 pts (18.2%), and mixed alcohol and NASH for 9 pts (16.4%). 102 (57.0%) pts received gemcitabine-cisplatin, 55 (30.7%) pts received gemcitabine-oxaliplatin, and 11 (6%) pts received gemcitabine, with no difference between cirrhotic and non-cirrhotic pts (p=0.38). Second-line treatment was less frequent in cirrhotic pts (21.8% vs. 50.0%, p=0.001). Cirrhotic pts experienced more grade 3/4 hematologic toxicity than non-cirrhotic pts (38% vs. 20%, respectively, p=0,014), and more grade 3/4 non-hematologic toxicity (28% vs. 15%, respectively, p=0.048). The overall survival (OS) was significantly shorter in cirrhotic pts; median: 9.0 vs. 13.8 months for non-cirrhotic pts (HR = 1.54 [95%CI: 1.09-2.16]; p = 0.014); confirmed on multivariable analysis, adjusted on ALBI-score, ECOG PS, extension of the disease (liver only disease and bilobar) (HR = 1.53 [95% CI: 1.01-2.33]; p=0.046). However, PFS was not significantly shorter in cirrhotic pts: median 9,9 months vs. 11.7 for non-cirrhotics (p = 0.35). In the second center (n=102), similar results were seen: 27 (26.5%) pts had cirrhosis. The cirrhotic pts experienced more grade 3/4 hematologic toxicities than non-cirrhotic pts (55.6% vs. 25.4%, respectively, p=0.005), and more grade 3/4 non-hematologic toxicity (44.4% vs. 12.7%, respectively, p = 0.001). OS was shorter in cirrhotic pts; median 9.1 months vs. 11.7 months for non-cirrhotic pts (HR = 1.81 [95%CI: 1.14-2.87]; p = 0.011). PFS was not significantly shorter in cirrhotic pts: 7.5 months for patients without cirrhosis, and 4.2 months for pts with cirrhosis (p=0.221). Conclusions: Cirrhosis was frequent in pts with advanced iCC, and had a negative impact on patients’ outcomes, with increased chemotherapy-induced toxicity and shorter OS. Formal assessment and consideration of cirrhosis in the therapeutic management should be recommended and could lead to a dose adjustment.
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Affiliation(s)
| | | | | | - Angela Lamarca
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Astrid Lièvre
- Department of Gastroenterology, CHU Pontchaillou, INSERM U1242, "Chemistry, Oncogenesis Stress Signaling", Rennes 1 University, Rennes, France
| | - Richard A Hubner
- Medical Oncology Department, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Juan W. Valle
- University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
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29
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Childs A, Zakeri N, Ma YT, O’Rourke J, Ross P, Hashem E, Hubner RA, Hockenhull K, Iwuji C, Khan S, Palmer DH, Connor J, Swinson D, Darby S, Braconi C, Roques T, Yu D, Luong TV, Meyer T. Biopsy for advanced hepatocellular carcinoma: results of a multicentre UK audit. Br J Cancer 2021; 125:1350-1355. [PMID: 34526664 PMCID: PMC8575957 DOI: 10.1038/s41416-021-01535-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/04/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Advanced hepatocellular carcinoma (HCC) is commonly diagnosed using non-invasive radiological criteria (NIRC) defined by the European Association for the Study of the Liver or the American Association for the Study of Liver Diseases. In 2017, The National Institute for Clinical Excellence mandated histological confirmation of disease to authorise the use of sorafenib in the UK. METHODS This was a prospective multicentre audit in which patients suitable for sorafenib were identified at multidisciplinary meetings. The primary analysis cohort (PAC) was defined by the presence of Child-Pugh class A liver disease and performance status 0-2. Clinical, radiological and histological data were reported locally and collected on a standardised case report form. RESULTS Eleven centres reported 418 cases, of which 361 comprised the PAC. Overall, 76% had chronic liver disease and 66% were cirrhotic. The diagnostic imaging was computed tomography in 71%, magnetic resonance imaging in 27% and 2% had both. Pre-existing histology was available in 45 patients and 270 underwent a new biopsy, which confirmed HCC in 93.4%. Alternative histological diagnoses included cholangiocarcinoma (CC) and combined HCC-CC. In cirrhotic patients, NIRC criteria had a sensitivity of 65.4% and a positive predictive value of 91.4% to detect HCC. Two patients (0.7%) experienced mild post-biopsy bleeding. CONCLUSION The diagnostic biopsy is safe and feasible for most patients eligible for systemic therapy.
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Affiliation(s)
- Alexa Childs
- grid.437485.90000 0001 0439 3380Department of Oncology, Royal Free London NHS Foundation Trust, London, UK
| | - Nekisa Zakeri
- grid.437485.90000 0001 0439 3380Department of Oncology, Royal Free London NHS Foundation Trust, London, UK
| | - Yuk Ting Ma
- grid.412563.70000 0004 0376 6589University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanne O’Rourke
- grid.412563.70000 0004 0376 6589University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Ross
- grid.429705.d0000 0004 0489 4320King’s College Hospital NHS Foundation Trust, London, UK
| | - Essam Hashem
- grid.429705.d0000 0004 0489 4320King’s College Hospital NHS Foundation Trust, London, UK
| | - Richard A. Hubner
- grid.412917.80000 0004 0430 9259Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Kimberley Hockenhull
- grid.412917.80000 0004 0430 9259Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Chinenye Iwuji
- grid.269014.80000 0001 0435 9078Oncology Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sam Khan
- grid.269014.80000 0001 0435 9078Oncology Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel H. Palmer
- grid.418624.d0000 0004 0614 6369University of Liverpool and The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Joanna Connor
- grid.418624.d0000 0004 0614 6369University of Liverpool and The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Daniel Swinson
- grid.415967.80000 0000 9965 1030Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Suzanne Darby
- grid.31410.370000 0000 9422 8284Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Chiara Braconi
- grid.5072.00000 0001 0304 893XThe Royal Marsden NHS Foundation Trust, London, UK
| | - Tom Roques
- grid.240367.40000 0004 0445 7876Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Dominic Yu
- grid.437485.90000 0001 0439 3380Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Tu Vinh Luong
- grid.437485.90000 0001 0439 3380Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Tim Meyer
- grid.437485.90000 0001 0439 3380Department of Oncology, Royal Free London NHS Foundation Trust, London, UK ,grid.83440.3b0000000121901201UCL Cancer Institute, University College London, London, UK
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Broadbent R, Wheatley R, Stajer S, Jacobs T, Lamarca A, Hubner RA, Valle JW, Amir E, McNamara MG. Prognostic factors for relapse in resected gastroenteropancreatic neuroendocrine neoplasms: A systematic review and meta-analysis. Cancer Treat Rev 2021; 101:102299. [PMID: 34662810 DOI: 10.1016/j.ctrv.2021.102299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/02/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gastroenteropancreatic neoplasms (GEP-NENs)can potentially be cured through surgical resection, but only 42-57% achieve 5-year disease-free survival.There is a lack of consensus regarding the factorsassociated withrelapse followingresection ofGEP-NENs. METHODS Asystematic review identified studies reporting factors associated with relapse in patients with GEP-NENs following resection of a primary tumour. Meta-analysis was performed to identify the factors prognostic for relapse-free survival (RFS)oroverall survival (OS). RESULTS 63 studies comprising 13,715 patients were included; 56 studies reported on pancreatic NENs (12,418 patients), 24 reported on patients with grade 1-2 tumours (4,735 patients). Median follow-up was 44.2 months, median RFS was 32 months. Pooling of multivariable analyses of GEP-NENs (all sites and grades) found the following factors predicted worse RFS (all p values < 0.05): vascular resection performed, metastatic disease resected, grade 2 disease, grade 3 disease, tumour size > 20 mm, R1 resection, microvascular invasion, perineural invasion, Ki-67 > 5% and any lymph node positivity. In a subgroup of studies comprising exclusively of grade 1-2 GEP-NENs, R1 resection, perineural invasion, grade 2 disease, any lymph node positivity and tumour size > 20 mm predicted worse RFS (all p values < 0.05). Few OSdata were available for pooling; in univariableanalysis(entire cohort), grade 2 predicted worse OS (p = 0.007), whileR1 resectiondid not (p = 0.14). CONCLUSIONS The factors prognostic for worse RFS following resection of a GEP-NEN identified in this meta-analysis could be included in post-curative treatment surveillance clinical guidelines and inform the stratification and inclusion criteria of future adjuvant trials.
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Affiliation(s)
- Rachel Broadbent
- University of Manchester, Division of Cancer Sciences, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Roseanna Wheatley
- University of Manchester, Division of Cancer Sciences, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Sabrina Stajer
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Timothy Jacobs
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Angela Lamarca
- University of Manchester, Division of Cancer Sciences, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Richard A Hubner
- University of Manchester, Division of Cancer Sciences, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Juan W Valle
- University of Manchester, Division of Cancer Sciences, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mairéad G McNamara
- University of Manchester, Division of Cancer Sciences, Manchester M20 4BX, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK.
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Carnie LE, Farrell K, Barratt N, Abraham M, Gillespie L, Satyadas T, McNamara MG, Hubner RA, Geraghty J, Bibby N, Valle JW, Lamarca A. Pancreatic Enzyme Replacement Therapy for Patients Diagnosed With Pancreaticobiliary Cancer: Validation of an Algorithm for Dose Escalation and Management. Pancreas 2021; 50:1254-1259. [PMID: 34860808 DOI: 10.1097/mpa.0000000000001906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE An algorithm was designed aiming to provide consistency of pancreatic enzyme replacement therapy (PERT) dosing/titration across healthcare professionals in pancreaticobiliary cancers (PBCs). This prospective observational study aimed to validate this algorithm. METHODS Consecutive patients with inoperable or postoperative PBC with pancreatic exocrine insufficiency (PEI) symptoms, not taking PERT, or taking below the algorithm "starting dose," were eligible. A dietitian or clinical nurse specialist reviewed patients for up to 3 weeks, titrating PERT as per the algorithm. Feasibility of algorithm deliverability was assessed by the percentage of patients with successful completion (primary objective). RESULTS Twenty-five patients were eligible (N = 25): at baseline, 22 took PERT (100% on suboptimal doses, 54.5% taking incorrectly) and 3 initiated PERT because of PEI symptoms. Algorithm completion (20 of 25, 80%) confirming deliverability by dietitians (11 of 12, 92%) and clinical nurse specialists (9 of 13, 69%). Symptom resolution occurred in 8 of 19 (42%), 3 of 7 (43%), and 1 of 3 (33%) patients at first, second, and third reviews, respectively; advice compliance was between 63% and 86%. CONCLUSIONS This algorithm provides a structured method to titrate PERT. At diagnosis, all patients with PBC should be assessed for PEI and adequate PERT initiated. Regular reviews are required for timely symptom resolution and adequate escalation, facilitating differential diagnosis if refractory symptoms exist.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Neil Bibby
- Dietetics, Manchester Royal Infirmary, Manchester, United Kingdom
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Lamarca A, Carnie L, Shah D, Vaughan K, Kapacee ZA, McCallum L, Abraham M, Backen A, McNamara MG, Hubner RA, Barriuso J, Gillespie L, Valle JW. Prospective observational study of prevalence, assessment and treatment of pancreatic exocrine insufficiency (PEI) in patients with advanced pancreatic cancer (aPC): PanDA. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
196 Background: PEI in patients with advanced pancreatic cancer is well documented, but there is a lack of consensus regarding optimal screening. Methods: Eligible patients for this observational study (NCT03616431) were those diagnosed with aPC referred for consideration of palliative therapy who consented to evaluation by a research dietitian. In addition to symptom and full dietetic assessment (including Mid-Upper Arm Circumference (MUAC), handgrip and stair climb test), full nutritional blood panel, faecal elastase (FE) and 13C mixed triglyceride breath test (for diagnostic cohort (DiC)) were performed. Primary objectives: prospective assessment of PEI prevalence (dietitian-assessed; demographic cohort (DeC)), and to design (using breath test as gold standard; DiC) and validate (follow-up cohort (FuC)) the most suitable screening tool for PEI in patients with aPC. Logistic and Cox regression were used for statistical analysis (Stat v.12). Results: Between 1st July 2018 and 30th October 2020, 112 eligible patients [50 (DeC), 25 (DiC), 37 (FuC)]. Prevalence of PEI in the DeC was 64.0% (PEI-related symptoms were flatus (84.0%), weight loss (84.0%), abdominal discomfort (50.0%) and steatorrhea (48.0%)); 70.0% of patients required pancreatic enzyme replacement therapy and 74.0% had anorexia (low appetite); 44.0% and 18.0% had low vitamin D and vitamin A levels, respectively. Designed PEI screening panel (DiC; 19 patients with breath test completed) included FE [normal/missing (0 points); low (1 point)] and MUAC [normal/missing ( > percentile 25 for age/gender) (0 points); low (2 points)] and identified patients at high-risk (2-3 total points) of PEI [vs. low-medium risk (0-1 total points)]. When patients from DeC and DiC) were analysed together, those classified as “high-risk of PEI” according to the screening panel had shorter overall survival (multivariable Hazard Ratio (mHR) 1.86 (95% CI 1.03-3.36); p-value 0.040) when adjusted for other prognostic factors, including presence of PEI symptoms (mHR 2.28 (95% CI 1.19-4.35); p-value 0.013). The screening panel was tested in the FuC; 78.38% were classified as patients at “high-risk of PEI”; of these, 89.6% were confirmed to have PEI by the dietitian. The panel was feasible for use in clinical practice, (64.8% of patients completed fully the assessments required) and acceptability was high (87.5% of patients would do it again). The majority of patients (91.3%) recommended that all future patients with aPC should have dietitian input. Conclusions: PEI is present in the majority of patients with aPC, and early dietetic input is important to provide a holistic nutritional overview, including, but not limited to, PEI. This proposed screening panel could be used to prioritise patients at higher risk of PEI requiring urgent dietitian input. Its prognostic role needs further validation. Clinical trial information: NCT03616431.
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Affiliation(s)
- Angela Lamarca
- The Christie NHS Foundation Trust/Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Lindsay Carnie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Dinakshi Shah
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Kate Vaughan
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Zainul Abedin Kapacee
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Marc Abraham
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Alison Backen
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Richard A Hubner
- Medical Oncology Department, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Jorge Barriuso
- Division of Cancer Sciences, University of Manchester, Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Loraine Gillespie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W. Valle
- University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Edeline J, Lamarca A, McNamara MG, Jacobs T, Hubner RA, Palmer D, Groot Koerkamp B, Johnson P, Guiu B, Valle JW. Locoregional therapies in patients with intrahepatic cholangiocarcinoma: A systematic review and pooled analysis. Cancer Treat Rev 2021; 99:102258. [PMID: 34252720 DOI: 10.1016/j.ctrv.2021.102258] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/02/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Locoregional treatments (LRT) including radioembolisation (SIRT), transarterial chemo-embolisation (TACE), hepatic arterial infusion (HAI) of chemotherapy, external beam radiotherapy (EBRT) and ablation have been studied for the management of intrahepatic cholangiocarcinoma (iCC). The aim of this systematic review was to provide outcome benchmarks for clinical trial design. METHODS Identification of studies reporting outcomes of patients treated with LRT for iCC was performed using PubMed and Embase. Pooled weighted means were calculated for progression-free survival (PFS) and overall survival (OS); meta-analysis of proportions was used for estimation of pooled response rate. RESULTS 6325 entries were reviewed; 93 studies were eligible, representing 101 cohorts and 3990 patients: 15 cohorts (645 patients) for ablation, 18 cohorts (541 patients) for EBRT, 27 cohorts (1232 patients) for SIRT, 22 cohorts (1145 patients) for TACE, 16 cohorts (331 patients) for HAI and 3 cohorts (96 patients) not pooled. 74% of the studies were retrospective, 99% non-randomised. The pooled mean weighted OS was 30.2 months (95% confidence interval (CI): 21.8-38.6) for ablation, 18.9 (14.2-23.5) for EBRT, 14.1 (12.1-16.0) for SIRT, 15.9 (12.9-19.0) for TACE and 21.3 (15.4-27.1) for HAI. The pooled complete response rate was 93.9% for ablation. When analysed together, SIRT, TACE and HAI had a pooled mean weighted OS of 15.7 months, and 25.2 months for patients treated in first-line with concomitant systemic chemotherapy. CONCLUSIONS Available literature on LRT for iCC was heterogeneous and of insufficient quality to make strong recommendations. Ablation achieved satisfactory outcomes, and may be recommended when surgery is not feasible.
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Affiliation(s)
- Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France.
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation, Manchester/Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, Manchester, United Kingdom
| | - Timothy Jacobs
- The Library, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation, Manchester/Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Dan Palmer
- University of Liverpool, Liverpool, United Kingdom
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Boris Guiu
- Departement of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, Manchester, United Kingdom
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Bourien H, Lamarca A, McNamara MG, Hubner RA, Valle JW, Edeline J. Druggable molecular alterations in bile duct cancer: potential and current therapeutic applications in clinical trials. Expert Opin Investig Drugs 2021; 30:975-983. [PMID: 34420429 DOI: 10.1080/13543784.2021.1964470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction: Cholangiocarcinomas (CCA) are rare tumors that are associated with a variety of molecular alterations. Many of these alterations are now actionable using drugs currently in development, and CCA may be a perfect example of application of a precision oncology approach. However, development of drugs in CCA faces the challenge of targeting rare alterations in a rare disease.Areas covered: In this review, we present the current data on targeted therapies in development for CCA, focusing on IDH1, FGFR2, BRAF, and HER2 alterations. We also discuss rationale for targeting other alterations, currently without specific development in CCA. We searched PubMed and google scholar in February 2021 for relevant articles and presentation in recent congress regarding the literature on molecular alterations, drugs in cholangiocarcinomas and biliary tract cancers.Expert opinion: Despite a strong rationale and promising early results, applying a precision oncology approach in CCA for everyday patients is still exposed to significant challenges: obtaining the molecular portrait of these tumors due to difficulties with biopsy access, complexities of drug development in subgroups of these relatively rare tumors, and sub-optimal access to drugs outside clinical trials.
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Affiliation(s)
- Héloïse Bourien
- Department Of Medical Oncology, Centre Eugène Marquis, Rennes, France, France
| | - Angela Lamarca
- Department Of Medical Oncology, The Christie Nhs Foundation Trust/Division Of Cancer Sciences, University Of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Division Of Cancer Sciences, University Of Manchester/Department Of Medical Oncology, The Christie Nhs Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Department Of Medical Oncology, The Christie Nhs Foundation Trust/Division Of Cancer Sciences, University Of Manchester, Manchester, UK
| | - Juan W Valle
- Division Of Cancer Sciences, University Of Manchester/Department Of Medical Oncology, The Christie Nhs Foundation Trust, Manchester, UK
| | - Julien Edeline
- Department Of Medical Oncology, Centre Eugène Marquis, Rennes, France, France
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Frizziero M, Durand A, Taboada RG, Zaninotto E, Luchini C, Chakrabarty B, Hervieu V, Claro LCL, Zhou C, Cingarlini S, Milella M, Walter T, Riechelmann RS, Lamarca A, Hubner RA, Mansoor W, Valle JW, McNamara MG. Is the Morphological Subtype of Extra-Pulmonary Neuroendocrine Carcinoma Clinically Relevant? Cancers (Basel) 2021; 13:4152. [PMID: 34439308 PMCID: PMC8392018 DOI: 10.3390/cancers13164152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/13/2021] [Indexed: 12/20/2022] Open
Abstract
Extra-pulmonary neuroendocrine carcinomas (EP-NECs) are lethal cancers with limited treatment options. Identification of contributing factors to the observed heterogeneity of clinical outcomes within the EP-NEC family is warranted, to enable identification of effective treatments. A multicentre retrospective study investigated potential differences in "real-world" treatment/survival outcomes between small-cell (SC) versus (vs.) non-SC EP-NECs. One-hundred and seventy patients were included: 77 (45.3%) had SC EP-NECs and 93 (54.7%) had non-SC EP-NECs. Compared to the SC subgroup, the non-SC subgroup had the following features: (1) a lower mean Ki-67 index (69.3% vs. 78.7%; p = 0.002); (2) a lower proportion of cases with a Ki-67 index of ≥55% (73.9% vs. 88.7%; p = 0.025); (3) reduced sensitivity to first-line platinum/etoposide (objective response rate: 31.6% vs. 55.1%, p = 0.015; and disease control rate; 59.7% vs. 79.6%, p = 0.027); (4) worse progression-free survival (PFS) (adjusted-HR = 1.615, p = 0.016) and overall survival (OS) (adjusted-HR = 1.640, p = 0.015) in the advanced setting. Within the advanced EP-NEC cohort, subgroups according to morphological subtype and Ki-67 index (<55% vs. ≥55%) had significantly different PFS (adjusted-p = 0.021) and OS (adjusted-p = 0.051), with the non-SC subgroup with a Ki-67 index of <55% and non-SC subgroup with a Ki-67 index of ≥55% showing the best and worst outcomes, respectively. To conclude, the morphological subtype of EP-NEC provides complementary information to the Ki-67 index and may aid identification of patients who could benefit from alternative first-line treatment strategies to platinum/etoposide.
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Affiliation(s)
- Melissa Frizziero
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (M.F.); (A.L.); (R.A.H.); (J.W.V.)
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Alice Durand
- Department of Gastroenterology and Medical Oncology, Edouard Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France; (A.D.); (T.W.)
| | - Rodrigo G. Taboada
- Department of Clinical Oncology, A. C. Camargo Cancer Center, São Paulo 01509-010, Brazil; (R.G.T.); (R.S.R.)
| | - Elisa Zaninotto
- Department of Medical Oncology, University Hospital of Verona, 37134 Verona, Italy; (E.Z.); (S.C.); (M.M.)
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134 Verona, Italy;
| | - Bipasha Chakrabarty
- Department of Pathology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Valérie Hervieu
- Department of Pathology, Edouard Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France;
| | - Laura C. L. Claro
- Department of Pathology, A. C. Camargo Cancer Center, São Paulo 01509-010, Brazil;
| | - Cong Zhou
- Cancer Biomarker Centre, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park SK10 4TG, UK;
| | - Sara Cingarlini
- Department of Medical Oncology, University Hospital of Verona, 37134 Verona, Italy; (E.Z.); (S.C.); (M.M.)
| | - Michele Milella
- Department of Medical Oncology, University Hospital of Verona, 37134 Verona, Italy; (E.Z.); (S.C.); (M.M.)
| | - Thomas Walter
- Department of Gastroenterology and Medical Oncology, Edouard Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France; (A.D.); (T.W.)
| | - Rachel S. Riechelmann
- Department of Clinical Oncology, A. C. Camargo Cancer Center, São Paulo 01509-010, Brazil; (R.G.T.); (R.S.R.)
| | - Angela Lamarca
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (M.F.); (A.L.); (R.A.H.); (J.W.V.)
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Richard A. Hubner
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (M.F.); (A.L.); (R.A.H.); (J.W.V.)
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Wasat Mansoor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Juan W. Valle
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (M.F.); (A.L.); (R.A.H.); (J.W.V.)
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Mairéad G. McNamara
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (M.F.); (A.L.); (R.A.H.); (J.W.V.)
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
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Abdul Rahman R, Lamarca A, Hubner RA, Valle JW, McNamara MG. The Microbiome as a Potential Target for Therapeutic Manipulation in Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13153779. [PMID: 34359684 PMCID: PMC8345056 DOI: 10.3390/cancers13153779] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Pancreatic cancer is one of the most lethal cancers. It is a difficult cancer to treat, and the complexity surrounding the pancreatic tumour is one of the contributing factors. The microbiome is the collection of microorganisms within an environment and its genetic material. They reside on body surfaces and most abundantly within the human gut in symbiotic balance with their human host. Disturbance in the balance can lead to many diseases, including cancers. Significant advances have been made in cancer treatment since the introduction of immunotherapy, and the microbiome may play a part in the outcome and survival of patients with cancer, especially those treated with immunotherapy. Immunotherapy use in pancreatic cancer remains challenging. This review will focus on the potential interaction of the microbiome with pancreas cancer and how this could be manipulated. Abstract Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers and is projected to be the second most common cause of cancer-related death by 2030, with an overall 5-year survival rate between 7% and 9%. Despite recent advances in surgical, chemotherapy, and radiotherapy techniques, the outcome for patients with PDAC remains poor. Poor prognosis is multifactorial, including the likelihood of sub-clinical metastatic disease at presentation, late-stage at presentation, absence of early and reliable diagnostic biomarkers, and complex biology surrounding the extensive desmoplastic PDAC tumour micro-environment. Microbiota refers to all the microorganisms found in an environment, whereas microbiome is the collection of microbiota and their genome within an environment. These organisms reside on body surfaces and within mucosal layers, but are most abundantly found within the gut. The commensal microbiome resides in symbiosis in healthy individuals and contributes to nutritive, metabolic and immune-modulation to maintain normal health. Dysbiosis is the perturbation of the microbiome that can lead to a diseased state, including inflammatory bowel conditions and aetiology of cancer, such as colorectal and PDAC. Microbes have been linked to approximately 10% to 20% of human cancers, and they can induce carcinogenesis by affecting a number of the cancer hallmarks, such as promoting inflammation, avoiding immune destruction, and microbial metabolites can deregulate host genome stability preceding cancer development. Significant advances have been made in cancer treatment since the advent of immunotherapy. The microbiome signature has been linked to response to immunotherapy and survival in many solid tumours. However, progress with immunotherapy in PDAC has been challenging. Therefore, this review will focus on the available published evidence of the microbiome association with PDAC and explore its potential as a target for therapeutic manipulation.
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Affiliation(s)
- Rozana Abdul Rahman
- Experimental Cancer Medicine Team, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK; (A.L.); (R.A.H.)
| | - Richard A. Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester M20 4BX, UK; (A.L.); (R.A.H.)
| | - Juan W. Valle
- Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Mairéad G. McNamara
- Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
- Correspondence:
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37
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Affiliation(s)
- Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Helen L Reeves
- Newcastle University Translational and Clinical Research Institute, Newcastle University and The Liver Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
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Carnie LE, Lamarca A, Vaughan K, Kapacee ZA, McCallum L, Backen A, Barriuso J, McNamara MG, Hubner RA, Abraham M, Valle JW. Prospective observational study of prevalence, assessment and treatment of pancreatic exocrine insufficiency in patients with inoperable pancreatic malignancy (PANcreatic cancer Dietary Assessment (PanDA): a study protocol. BMJ Open 2021; 11:e042067. [PMID: 33986039 PMCID: PMC8126274 DOI: 10.1136/bmjopen-2020-042067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/11/2020] [Accepted: 03/12/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency (PEI) in patients with pancreatic malignancy is well documented in the literature and is known to negatively impact on overall survival and quality of life. A lack of consensus opinion remains on the optimal diagnostic test that can be adapted for use in a clinical setting for this cohort of patients. This study aims to better understand the prevalence of PEI and the most suitable diagnostic techniques in patients with advanced pancreatic malignancy. METHODS AND ANALYSIS This prospective observational study will be carried out in patients with pancreatic malignancy (including adenocarcinoma and neuroendocrine neoplasms). Consecutive patients with inoperable pancreatic malignancy referred for consideration of first-line chemotherapy will be considered for eligibility. The study comprises three cohorts: demographic cohort (primary objective to prospectively investigate the prevalence of PEI in patients with inoperable pancreatic malignancy); sample size 50, diagnostic cohort (primary objective to design and evaluate an optimal diagnostic panel to detect PEI in patients with inoperable pancreatic malignancy); sample size 25 and follow-up cohort (primary objective to prospectively evaluate the proposed PEI diagnostic panel in a cohort of patients with inoperable pancreatic malignancy); sample size 50. The following is a summary of the protocol and methodology. ETHICS AND DISSEMINATION Full ethical approval has been granted by the North West Greater Manchester East Research and Ethics Committee, reference: 17/NW/0597. This manuscript reflects the latest protocol V.8 approved 21 April 2020. Findings will be disseminated by presentation at national/international conferences, publication in peer-review journals and distribution via patient advocate groups. TRIAL REGISTRATION NUMBER 194255, NCT0361643.
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Affiliation(s)
- Lindsay E Carnie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Kate Vaughan
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | | | | | - Alison Backen
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Jorge Barriuso
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Richard A Hubner
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Marc Abraham
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
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Kapacee ZA, McNamara MG, de Liguori Carino N, Lamarca A, Valle JW, Hubner RA. Systemic therapies in elderly patients with advanced hepatocellular carcinoma: do not forget metronomic capecitabine. Eur J Surg Oncol 2021; 47:2209-2210. [PMID: 33965291 DOI: 10.1016/j.ejso.2021.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Zainul Abedin Kapacee
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom.
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, United Kingdom
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester/Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Curigliano G, Martin M, Jhaveri K, Beck JT, Tortora G, Fazio N, Maur M, Hubner RA, Lahner H, Donnet V, Ajipa O, Li Z, Blumenstein L, Andre F. Alpelisib in combination with everolimus ± exemestane in solid tumours: Phase Ib randomised, open-label, multicentre study. Eur J Cancer 2021; 151:49-62. [PMID: 33964572 DOI: 10.1016/j.ejca.2021.03.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/17/2020] [Revised: 02/18/2021] [Accepted: 03/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Combined mTORC1 inhibition with everolimus (EVE) and phosphatidylinositol 3-kinase catalytic subunit p110α blockade with alpelisib (ALP) has demonstrated synergistic efficacy in preclinical models and supports testing the combination of ALP and EVE in the clinical setting. The primary objective was to determine the maximum tolerated dose (MTD)/recommended dose for expansion (RDE) of ALP in combination with EVE and in combination with EVE and exemestane (EXE) and subsequently assess safety, preliminary efficacy and effect of ALP on the pharmacokinetics of EVE and determine the magnitude of the drug-drug interaction. PATIENTS AND METHODS Dose escalation phases were conducted in patients with advanced solid tumours and in postmenopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (ABC). The dose expansion phase was conducted in patients with pancreatic neuroendocrine tumour and renal cell carcinoma (RCC) (both mechanistic target of rapamycin inhibitor [mTORi]-naive), in patients with mTORi-pretreated solid tumours and in postmenopausal women with HR+, HER2- ABC. RESULTS During the doublet escalation phase, dose-limiting toxicities (DLTs) were reported in 5 of 10 (50%) patients: one patient had grade (Gr) 2 hyperglycemia and one patient had Gr 3 diarrhoea in the 300 mg dose group, one patient had Gr 2 hyperglycemia and one patient had Gr 4 hypocalcaemia in the 250 mg dose group, and one patient in the 200 mg dose group had Gr 3 diarrhoea and Gr 3 stomatitis. The combination of ALP 250 mg + EVE 2.5 mg was declared as the MTD/RDE in subjects with advanced solid tumours. In the triplet escalation phase, one patient who received ALP 200 mg + EVE 2.5 mg + EXE 25 mg had a DLT of Gr 3 acute kidney injury. This dose combination was declared as the MTD and RDE in subjects with advanced HR-positive HER2-negative BC. The common adverse events (≥30% patients), occurring across all phases, were hyperglycaemia, stomatitis, diarrhoea, nausea, asthenia, decreased appetite and fatigue. The sixteen-week progression-free survival rate was 52.4% (90% confidence interval [CI]: 32.8, 71.4) in the RCC cohort, 35.3% (90% CI: 16.6, 58.0) in the prior pNET cohort and 30.0% (90% CI: 8.7, 60.7) in the prior mTORi cohort. The pharmacokinetics of 2.5 mg of EVE was largely unchanged in the presence of ALP, independent of the dose (250 mg or 300 mg). There were no clinically relevant drug-drug interactions observed between ALP and EVE. CONCLUSION The overall safety profile of ALP with EVE and EXE is manageable and reversible; no unexpected safety signals were noted compared with the individual safety profiles. Pharmacokinetics of ALP, EVE and EXE was largely unchanged in combination with each other.
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Affiliation(s)
- Giuseppe Curigliano
- Department of Oncology and Hematology, University of Milano, Milan, Italy; European Intitute of Oncology, IEO, IRCCS, Milan, Italy.
| | - Miguel Martin
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - J T Beck
- Highlands Oncology Group, AR, USA
| | | | - Nicola Fazio
- European Intitute of Oncology, IEO, IRCCS, Milan, Italy
| | | | | | | | | | | | - Zheng Li
- Novartis Pharmaceuticals, NJ, USA
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Angelakas A, Lamarca A, Hubner RA, McNamara MG, Valle JW. Ivosidenib: an investigational drug for the treatment of biliary tract cancers. Expert Opin Investig Drugs 2021; 30:301-307. [PMID: 33683991 DOI: 10.1080/13543784.2021.1900115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction: Biliary tract cancers (BTCs) [including cholangiocarcinoma and gallbladder cancer] are rare cancers associated with poor survival; most patients have advanced disease at diagnosis. Current chemotherapy reference regimens include cisplatin and gemcitabine as first-line; and oxaliplatin and 5-fluorouracil (FOLFOX) in second-line. Molecular profiling has identified several actionable therapeutic targets including isocitrate dehydrogenase (IDH)1 mutations. Ivosidenib is a reversible inhibitor of mutant IDH1; it is currently approved for the treatment of acute myeloid leukemia and has been studied in patients with advanced cholangiocarcinoma.Areas covered: This article introduces current treatments for BTC and sheds light on the mechanism of action, pharmacodynamics, pharmacokinetics, clinical efficacy, and safety of ivosidenib in advanced cholangiocarcinoma. The authors conclude with insights on the changing treatment paradigm created by emerging drugs and precision approaches.Expert opinion: Ivosidenib is well tolerated, with good oral exposure and long half-life as shown by phase I data. In a phase III study, ivosidenib has demonstrated improved progression-free survival compared to placebo (median 2.7 vs 1.4 months; hazard ratio 0.37; 95% confidence interval 0.25-0.54; one-sided p < 0.0001); it has also demonstrated a trend toward increased overall survival in patients with cholangiocarcinoma and disease progression on prior chemotherapy. Final survival data from this study are pending presentation. Increased use of molecular profiling will continue to identify potential therapeutic targets and improve the prognosis of patients with these cancers.
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Affiliation(s)
- Angelos Angelakas
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Department of Medical Oncology, the Christie NHS Foundation Trust/Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, the Christie NHS Foundation Trust/Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester/Department of Medical Oncology, the Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester/Department of Medical Oncology, the Christie NHS Foundation Trust, Manchester, UK
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Kapacee ZA, McNamara MG, de Liguori Carino N, Lamarca A, Valle JW, Hubner RA. Systemic therapies in advanced hepatocellular carcinoma: How do older patients fare? Eur J Surg Oncol 2021; 47:583-590. [DOI: 10.1016/j.ejso.2020.03.210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 01/15/2023] Open
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Garcia-Torralba E, Spada F, Lim KHJ, Jacobs T, Barriuso J, Mansoor W, McNamara MG, Hubner RA, Manoharan P, Fazio N, Valle JW, Lamarca A. Knowns and unknowns of bone metastases in patients with neuroendocrine neoplasms: A systematic review and meta-analysis. Cancer Treat Rev 2021; 94:102168. [PMID: 33730627 DOI: 10.1016/j.ctrv.2021.102168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/05/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to develop an evidence-based summary of current knowledge of bone metastases (BMs) in neuroendocrine neoplasms (NENs), inform diagnosis and treatment and standardise management between institutions. METHODS PubMed, Medline, EMBASE and meeting proceedings were searched for eligible studies reporting data on patients with BMs and NENs of any grade of differentiation and site; poorly-differentiated large/small cell lung cancer were excluded. Data were extracted and analysed using STATA v.12. Meta-analysis of proportions for calculation of estimated pooled prevalence of BM and calculation of weighted pooled frequency and weighted pooled mean for other variables of interest was performed . RESULTS A total of 149 studies met the eligibility criteria. Pooled prevalence of BMs was 18.4% (95% CI 15.4-21.5). BMs were mainly metachronous with initial diagnosis of NEN (61.2%) and predominantly osteoblastic; around 61% were multifocal, with a predisposition in axial skeleton. PET/CT seemed to provide (together with MRI) the highest sensitivity and specificity for BM detection. Almost half of patients (46.4%) reported BM-related symptoms: pain (66%) and skeletal-related events (SREs, fracture/spinal cord compression) (26.2%; weightedweighted mean time-to-SRE 9.9 months). Management of BMs was multimodal [bisphosphonates and bone-modifying agents (45.2%), external beam radiotherapy (34.9%), surgery (14.8%)] and supported by little evidence. Overall survival (OS) from the time of diagnosis of BMs was long [weighted mean 50.9 months (95% CI 40.0-61.9)]. Patients with BMs had shorter OS [48.8 months (95% CI 37.9-59.6)] compared to patients without BMs [87.4 months (95% CI 74.9-100.0); p = 0.001]. Poor performance status and BM-related symptoms were also associated with worse OS. CONCLUSIONS BMs in patients with NENs remain underdiagnosed and undertreated. Recommendations for management of BMs derived from current knowledge are provided. Prospective studies to inform management are required.
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Affiliation(s)
- Esmeralda Garcia-Torralba
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, United Kingdom; Department of Haematology and Medical Oncology, Hospital Morales Meseguer, Murcia, Spain
| | - Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IEO, IRCCS, Milan, Italy
| | - Kok Haw Jonathan Lim
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, United Kingdom; Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Timothy Jacobs
- Medical Library, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jorge Barriuso
- Division of Cancer Sciences, University of Manchester, Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Was Mansoor
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Prakash Manoharan
- Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IEO, IRCCS, Milan, Italy
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Lamarca
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom.
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Kanabar R, Barriuso J, McNamara MG, Mansoor W, Hubner RA, Valle JW, Lamarca A. Liver Embolisation for Patients with Neuroendocrine Neoplasms: Systematic Review. Neuroendocrinology 2021; 111:354-369. [PMID: 32172229 DOI: 10.1159/000507194] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/12/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Liver embolisation is one of the treatment options available for patients diagnosed with neuro-endocrine neoplasms (NEN). It is still uncertain whether the benefits of the various types of embolisation treatments truly outweigh the complications in NENs. This systematic review assesses the available data relating to liver embolisation in patients with NENs. METHODS Eligible studies (identified using MEDLINE-PubMed) were those reporting data on NEN patients who had undergone any type of liver embolisation. The primary end points were best radiological response and symptomatic response; secondary end-points included progression-free survival (PFS), overall survival (OS) and toxicity. RESULTS Of 598 studies screened, 101 were eligible: 16 were prospective (15.8%). The eligible studies included a total of 5,545 NEN patients, with a median of 39 patients per study (range 5-214). Pooled rate of partial response was 36.6% (38.9% achieved stable disease) and 55.2% of patients had a symptomatic response to therapy when pooled data were analysed. The median PFS and OS were 18.4 months (95% CI 15.5-21.2) and 40.7 months (95% CI 35.2-46.2) respectively. The most common toxicities were found to be abdominal pain (48.8%) and nausea (48.1%). Outcome did not significantly vary depending on the type of embolisation performed. CONCLUSION Liver embolisation provides adequate symptom relief for patients with carcinoid syndrome and is also able to reach partial response in a significant proportion of patients and a reasonable PFS. Quality of studies was limited, highlighting the need of further prospective studies to confirm the most suitable form of liver embolisation in NENs.
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Affiliation(s)
- Rahul Kanabar
- Manchester Medical School, The University of Manchester, Manchester, United Kingdom,
| | - Jorge Barriuso
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Was Mansoor
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Backen A, Lamarca A, Hubner RA, McNamara MG, Valle JW. HPB cancers in older patients | inclusion of older/senior patients in clinical trials. Eur J Surg Oncol 2020. [PMID: 33298342 DOI: 10.1016/j.ejso.2020.11.002.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Liver, biliary tract and pancreatic cancers are increasingly diseases of older people and the global population is aging. 'Older/senior' patients are a heterogeneous group who vary widely in their general health, physical reserve and degree of dependence on others. Cancer is not the only disease that becomes more prevalent in old age, which means older/senior patients may also have comorbidities and lower resilience. The use of chemotherapy decreases as age increases. Chemotherapy treatment regimens may require modification to reduce toxicity, which is more common in older/senior patients. The effect this has on treatment efficacy is not fully understood. Older/senior patients are not represented well in clinical trials which makes estimating benefit for these patients challenging. Medicine demands that new drugs are rigorously tested and evaluated before use, yet clinicians are treating older/senior patients on the basis of extrapolating from randomised controlled trials which actively exclude comorbidities and older patients. This review considers the current situation and the value of retrospective analyses and real-world evidence to plug the older/senior patient 'data gaps'. Moving forwards it is essential to broaden clinical trial inclusion criteria to include more older/senior people. The use of appropriate geriatric assessments may help selection of older patients who are fit enough for more rigorous treatment regimens, alongside effective methods of predicting and managing treatment toxicities. The ability to see past the numerical age of a person and offer appropriate therapeutic choices to individual patients in clinic, is an important skill for younger (and not so young) Medical Oncologists to learn.
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Affiliation(s)
- Alison Backen
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.
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Backen A, Lamarca A, Hubner RA, McNamara MG, Valle JW. HPB cancers in older patients | inclusion of older/senior patients in clinical trials. Eur J Surg Oncol 2020; 47:597-602. [PMID: 33298342 DOI: 10.1016/j.ejso.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 01/17/2023] Open
Abstract
Liver, biliary tract and pancreatic cancers are increasingly diseases of older people and the global population is aging. 'Older/senior' patients are a heterogeneous group who vary widely in their general health, physical reserve and degree of dependence on others. Cancer is not the only disease that becomes more prevalent in old age, which means older/senior patients may also have comorbidities and lower resilience. The use of chemotherapy decreases as age increases. Chemotherapy treatment regimens may require modification to reduce toxicity, which is more common in older/senior patients. The effect this has on treatment efficacy is not fully understood. Older/senior patients are not represented well in clinical trials which makes estimating benefit for these patients challenging. Medicine demands that new drugs are rigorously tested and evaluated before use, yet clinicians are treating older/senior patients on the basis of extrapolating from randomised controlled trials which actively exclude comorbidities and older patients. This review considers the current situation and the value of retrospective analyses and real-world evidence to plug the older/senior patient 'data gaps'. Moving forwards it is essential to broaden clinical trial inclusion criteria to include more older/senior people. The use of appropriate geriatric assessments may help selection of older patients who are fit enough for more rigorous treatment regimens, alongside effective methods of predicting and managing treatment toxicities. The ability to see past the numerical age of a person and offer appropriate therapeutic choices to individual patients in clinic, is an important skill for younger (and not so young) Medical Oncologists to learn.
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Affiliation(s)
- Alison Backen
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.
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Carnie L, Abraham M, McNamara MG, Hubner RA, Valle JW, Lamarca A. Impact on prognosis of early weight loss during palliative chemotherapy in patients diagnosed with advanced pancreatic cancer. Pancreatology 2020; 20:1682-1688. [PMID: 33046391 DOI: 10.1016/j.pan.2020.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 06/24/2020] [Revised: 08/28/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
AIM Weight loss at diagnosis is common in pancreatic cancer (PC) and can adversely affect overall survival (OS). Little is known about the impact of weight loss occurring during palliative treatment. This study aimed to investigate if early weight loss during chemotherapy for inoperable PC affects OS. METHOD This retrospective study included patients newly-diagnosed with inoperable PC. Consecutive patients initiating first-line palliative chemotherapy between Jan'15 - Jan'19 with data on percentage weight loss at week 4 of treatment (%WLWeek4) were eligible. %WLWeek4 was dichotomised using 5% cut-off. OS was measured from chemotherapy initiation. Survival analysis was performed using Cox regression. RESULTS Eligible patients (n = 255); 59.2% with head/neck PC; 52.6% metastatic; received triplet (32.2%), doublet (42.7%) or single-agent (25.1%) palliative chemotherapy. Median %WLWeek4 was -2.05% (95% confidence interval (CI) -2.58 to -1.56); %WLWeek4 was ≥5% in 23.1% patients. Patients on triplet chemotherapy were more likely to develop %WLWeek4 of ≥5% [35.4% (triplet) vs. 19.3% (doublet) vs 14.1% (monotherapy); multivariable Odds Ratio (triplet vs monotherapy) =3.25; 95% CI 1.40-7.56; p-value 0.006]. Median OS was 9.7 months (95% CI 8.54-10.41). Multivariable Cox regression demonstrated shorter OS if %WLWeek4 ≥5% (median OS 7.4 months (95% CI 6.27-10.01) vs. 9.9 months (95% CI 9.20-12.05); HR 2.37 (95% CI 1.64-3.42), P < 0.001); this was independent from other factors (stage, age, number of chemotherapy drugs, ECOG-PS), including response to therapy (supporting that %WLWeek4 impacted on OS regardless of response to therapy). CONCLUSION In advanced PC treated with palliative chemotherapy, a %WLWeek4 ≥5% was more prevalent in patients undergoing triplet chemotherapy, and was associated with shorter OS, regardless of response/progression to therapy. Early identification and intervention of weight loss seems to be key to improve patient outcomes.
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Affiliation(s)
- Lindsay Carnie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Marc Abraham
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Mairéad G McNamara
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK
| | - Richard A Hubner
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK
| | - Juan W Valle
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK
| | - Angela Lamarca
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK.
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Frizziero M, McNamara MG, Lamarca A, Pihlak R, Kurup R, Hubner RA. Current Translational and Clinical Challenges in Advanced Hepatocellular Carcinoma. Curr Med Chem 2020; 27:4789-4805. [PMID: 32321391 DOI: 10.2174/0929867327666200422143847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/30/2019] [Revised: 03/16/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is a frequent and increasing cause of cancerrelated deaths worldwide. Reversing this trend is complicated by the varied aetiological factors leading to liver cirrhosis resulting in molecular genetic and clinical heterogeneity, combined with frequent presentation at advanced stage. Large-scale genomic studies have identified alterations in key signalling pathways for HCC development and progression, but these findings have not yet directly influenced patient management in the clinical setting. Despite these translational challenges, a small number of anti-angiogenic systemic therapy agents have succeeded in recent randomized trials enriching the repertoire of available treatments for advanced HCC. In addition, the early promise of immune checkpoint inhibition is now on the cusp of delivering changes to standard systemic therapy algorithms. This review focuses on recent translational and clinical developments that have advanced. current practice and explores the challenges encountered in attempting to improve the outcomes and experience of patients diagnosed with advanced HCC.
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Affiliation(s)
- Melissa Frizziero
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
| | - Rille Pihlak
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
| | - Roopa Kurup
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, United Kingdom
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Manas D, Bell JK, Mealing S, Davies H, Baker H, Holmes H, Hubner RA. The cost-effectiveness of TheraSphere in patients with hepatocellular carcinoma who are eligible for transarterial embolization. Eur J Surg Oncol 2020; 47:401-408. [PMID: 32958370 DOI: 10.1016/j.ejso.2020.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 06/17/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The aim of the study is to estimate the cost-effectiveness of TheraSphere against other embolic treatments in a population with early to intermediate stage hepatocellular carcinoma (HCC) who are unresectable at presentation and are eligible for transarterial embolization (TAE), conventional transarterial chemoembolization (cTACE) or drug-eluting bead TACE (DEB-TACE). MATERIALS AND METHODS A Markov model was constructed using a UK National Health Service (NHS) perspective, a 20-year time horizon, and four-week cycles. The eight health states included 'watch and wait', 'transplantation' (pre-, post and post (No HCC)), 'resection', 'no HCC other', 'pharmacological management' and 'death'. Clinical data were sourced from literature and expert opinion. Resource use and costs were reflective of the NHS, and benefits were quantified using Quality-Adjusted Life Years (QALYs), with utility weights sourced from literature. Comparators were TAE, cTACE and DEB-TACE. The primary output was the Incremental Cost-Effectiveness Ratio (ICER) expressed as cost per QALY gained. An ICER of under £20,000/QALY gained for an intervention is cost-effective and represents efficient use of healthcare resources. Extensive deterministic and probabilistic sensitivity analyses were undertaken. RESULTS TheraSphere patients were predicted to gain 0.7 additional QALYs compared to all other treatments. The base case ICERs for TheraSphere were £17,300, £17,279 and £23,020 per QALY gained compared to TAE, cTACE and DEB-TACE, respectively. In the TheraSphere cohort, 87% more patients were predicted to achieve downstaging compared to all other treatment options. CONCLUSIONS This study indicates that treatment with TheraSphere is a potentially cost-effective option for patients with early to intermediate stage HCC.
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Affiliation(s)
- Derek Manas
- Newcastle upon Tyne NHS Trust, Freeman Hospital Freeman Road High Heaton Newcastle upon Tyne, NE7 7DN, UK.
| | - Jon K Bell
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, UK.
| | - Stuart Mealing
- York Health Economics Consortium, Enterprise House, University of York, York, YO10 5NQ, UK.
| | - Heather Davies
- York Health Economics Consortium, Enterprise House, University of York, York, YO10 5NQ, UK.
| | - Hannah Baker
- York Health Economics Consortium, Enterprise House, University of York, York, YO10 5NQ, UK.
| | - Hayden Holmes
- York Health Economics Consortium, Enterprise House, University of York, York, YO10 5NQ, UK.
| | - Richard A Hubner
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, UK.
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Lamarca A, Kapacee Z, Breeze M, Bell C, Belcher D, Staiger H, Taylor C, McNamara MG, Hubner RA, Valle JW. Molecular Profiling in Daily Clinical Practice: Practicalities in Advanced Cholangiocarcinoma and Other Biliary Tract Cancers. J Clin Med 2020; 9:E2854. [PMID: 32899345 PMCID: PMC7563385 DOI: 10.3390/jcm9092854] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Molecular profiling is becoming increasingly relevant in the management of patients with advanced cancer; to identify targetable aberrations and prognostic markers to enable a precision medicine strategy. METHODS Eligible patients were those diagnosed with advanced biliary tract cancer (BTC) including intrahepatic (iCCA) and extrahepatic cholangiocarcinoma (eCCA), gallbladder cancer (GBC), and ampullary carcinoma (Amp) who underwent molecular profiling between April 2017 and June 2020 based on analysis of either tumour samples (FoundationOne CDx®/Oncomine® platforms) or ctDNA (FoundationOne Liquid® platform (Foundation Medicine, Cambridge, MA, USA)). Baseline patient characteristics and molecular profiling outcomes were extracted. The primary aim was to describe sample failure rate. Secondary aims included description of reason for sample failure, summary of findings derived from molecular profiling, and assessment of concordance between paired tissue and ctDNA samples. RESULTS A total of 149 samples from 104 individual patients diagnosed with advanced BTC were identified and eligible for this analysis: 68.2% iCCA, 100% advanced stage; 94.2% received palliative therapy. The rate of sample failure was 26.8% for tissue and 15.4% for ctDNA; p-value 0.220, predominantly due to insufficient (defined as <20%) tumour content in the sample (the reason for 91.2% of tissue sample failure). Of the 112 samples successfully analysed, pathological molecular findings were identified in the majority of samples (88.4%) and identification of pathological findings using ctDNA, was possible regardless of whether the patient was on active treatment at time of blood acquisition or not (p-value 1.0). The rate of targetable alterations identified was 40.2% across all successfully-analysed samples (39 iCCA; 6 non-iCCA): IDH1 mutations (19.1% of individual patients), FGFR2 alterations (10.1% and 5.6% of individual patients had FGFR2 fusions and mutations, respectively); 10.6% of all patients (12.4% of patients with successfully analysed samples) entered trials with matched targeted therapies as a consequence. Concordance of findings for paired tissue and paired tissue-ctDNA was high (3/3; 100% and 6/6; 100%, respectively). Twelve ctDNA samples were taken prior to palliative treatment initiation, median maximum mutant allele frequency (MAF) was 0.47 (range 0.21-19.8); no significant association between reported maximum MAF and progression-free survival (PFS) or overall survival (OS) (all Cox regression p-values > 0.273). A total of 15 patients (16.6%) harboured alterations in DNA damage repair (DDR) genes; when treated with platinum-based chemotherapy, there was a trend towards increased partial response rate (21.4% vs. 15.9%; p-value 0.653), radiological benefit rate (64.3% vs. 36.2%; p-value 0.071), and longer OS (median OS 20.4 months (95% CI 7.9-26.7) vs. 13.3 (95 CI 11.0-16.4); Cox Regression HR 0.79 (95% CI 0.39-1.61), p-value 0.527). CONCLUSIONS Molecular profiling is of use for identification of novel therapeutic strategies for patients with advanced BTC (mainly iCCA). One in four archived tissue samples may have insufficient tumour content for molecular profiling; ctDNA-based approaches may overcome these obstacles.
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Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, University of Manchester, Manchester M204BX, UK
| | - Zainul Kapacee
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Michael Breeze
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Christopher Bell
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Dean Belcher
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Helen Staiger
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Claire Taylor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
| | - Mairéad G. McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, University of Manchester, Manchester M204BX, UK
| | - Richard A. Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, University of Manchester, Manchester M204BX, UK
| | - Juan W. Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M204BX, UK; (Z.K.); (M.B.); (C.B.); (D.B.); (H.S.); (C.T.); (M.G.M.); (R.A.H.); (J.W.V.)
- Division of Cancer Sciences, University of Manchester, Manchester M204BX, UK
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