Real-World comprehensive genomic profiling data for diagnostic clarity in pulmonary Large-Cell neuroendocrine carcinoma

BACKGROUND

Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is an uncommon subtype of lung cancer believed to represent a spectrum of tumors sharing characteristics of both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Other groups have proposed genomic LCNEC subtypes, including small cell-like, non-small cell-like, and carcinoid-like subtypes. The primary goal of this study was to better define the NSCLC-like subtype with comprehensive genomic profiling (CGP).

METHODS

An institutional database was queried to identify tissue specimens (TBx, N = 1,426) and liquid biopsies (LBx, N = 39) submitted for CGP during routine clinical care (8/2014 - 7/2023) with a disease ontology of LCNEC. TBx were profiled with FoundationOne® (F1) or F1CDx, using hybrid-capture technology to detect genomic alterations (GAs).

RESULTS

1,426 LCNEC samples were genomically profiled. The presence of RB1 and TP53 genomic alterations (GAs) were used to define a SCLC-like subtype (n = 557). A carcinoid-like group was defined by the presence of MEN1 mutation in the absence of TP53 GAs (n = 25). The remaining 844 samples were compared to the SCLC-like group and GAs enriched relative to the SCLC-like samples with a false discovery rate (FDR) < 0.0001 were used to define a NSCLC-like group. These NSCLC-like subtype-defining GAs included SMARCA4, KRAS, FGF3/4/19, STK11, CDKN2A/B, MTAP, and CCND1. Under this schema, 530 samples were classified as NSCLC-like and 314 remained unclassified.

CONCLUSIONS

Large-scale CGP can better characterize biologically distinct molecular subtypes in LCNEC. Further studies to define how these molecular subtypes may help inform treatment decisions in this complex and challenging malignancy are warranted.

Black Race Remains Associated with Lower Eligibility for Screening Using 2021 US Preventive Services Task Force Recommendations Among Lung Cancer Patients at an Urban Safety Net Hospital

OBJECTIVE

To evaluate whether the revised US Preventive Services Task Force (USPSTF) criteria reduced inequities in lung cancer screening (LCS) eligibility among a racially diverse sample of patients with lung cancer.

METHODS

This is a retrospective analysis of adults diagnosed with primary lung malignancies at an urban safety net hospital. For all patients and exclusively ever-smokers, χ2 tests were used to evaluate differences in LCS eligibility among socio-demographic variables using the 2013 and 2021 USPSTF criteria. Patients who were ineligible for LCS were categorized by reason for exclusion.

RESULTS

Among 678 lung cancer patients (46% female, mean age 66 ± 10 years), 51% were White, and 39% were Black. Using the 2013 guidelines, White patients (57%) would have been more likely to be eligible than Black (37%) and other-race patients (35%) (P < 0.0001) at time of cancer diagnosis. Under the 2021 guidelines, White patients (68%) remained more likely to be eligible for LCS than Black (54%) and other-race patients (48%) (P = 0.0002). Among exclusively ever-smoking patients, we did not observe a significant difference in eligibility by race under the 2021 USPSTF guidelines (White [73%], Black [65%], and other-race [65%]; [P = 0.48]). Sex, ethnicity, education level, and insurance type were not associated with differential screening eligibility under either the 2013 or 2021 guidelines.

CONCLUSION

The revised 2021 USPSTF LCS guidelines may not be sufficient to eliminate racial inequities in LCS eligibility among patients who go on to be diagnosed with primary lung cancer. Differential rates of lung cancer among never-smokers may contribute to this inequity.

Disparities in outcomes between Black and White patients in North America with thoracic malignancies and COVID-19 infection (TERAVOLT)

BACKGROUND

Patients with thoracic malignancies who develop COVID-19 infection have a higher hospitalization rate compared to the general population and to those with other cancer types, but how this outcome differs by race and ethnicity is relatively understudied.

METHODS

The TERAVOLT database is an international, multi-center repository of cross-sectional and longitudinal data studying the impact of COVID-19 on individuals with thoracic malignancies. Patients from North America with thoracic malignancies and confirmed COVID-19 infection were included for this analysis of racial and ethnic disparities. Patients with missing race data or races and ethnicities with fewer than 50 patients were excluded from analysis. Multivariable analyses for endpoints of hospitalization and death were performed on these 471 patients.

RESULTS

Of the 471 patients, 73% were White and 27% were Black. The majority (90%) were non-Hispanic ethnicity, 5% were Hispanic, and 4% were missing ethnicity data. Black patients were more likely to have an Eastern Cooperative Oncology Group (ECOG) Performance Status ≥ 2 (p-value = 0.04). On multivariable analysis, Black patients were more likely than White patients to require hospitalization (Odds Ratio (OR): 1.69, 95% CI: 1.01-2.83, p-value = 0.044). These differences remained across different waves of the pandemic. However, no statistically significant difference in mortality was found between Black and White patients (OR 1.29, 95% CI: 0.69-2.40, p-value = 0.408).

CONCLUSIONS

Black patients with thoracic malignancies who acquire COVID-19 infection are at a significantly higher risk of hospitalization compared to White patients, but there is no significant difference in mortality. The underlying drivers of racial disparity among patients with thoracic malignancies and COVID-19 infection require ongoing investigation.

Disparities in US Lung Cancer Clinical Trial Enrollment

BACKGROUND

Disparities within clinical trial enrollment are well-documented, reducing the generalizability of results. Although nearly 30 years have passed since Congress passed the NIH Revitalization Act to encourage the participation of minoritized populations in clinical trials, these patients continue to be underrepresented. This study aimed to investigate lung cancer clinical trial enrollment disparities for race/ethnicity, sex, and age.

METHODS

We queried the National Institutes of Health: US National Library of Medicine database of clinical trials for all US-based lung cancer clinical trials completed between 2004 and 2021 and collected data on race and ethnicity, gender, and age breakdown. This data was compared to Surveillance, Epidemiology, and End Results (SEER) database data. Independent sample t-tests and Kruskal-Wallis's approach were used to analyze the data.

RESULTS

Of 311 eligible trials with exclusive US enrollment, 136 (44%) reported race and ethnicity breakdown for the patient cohort representing 9869 patients. Hispanic, Non-Hispanic American Indian/Alaska Native, Non-Hispanic Black, and Non-Hispanic Unreported participants were underrepresented (p = 0.001, p = 0.005, p = 0.014, p = 0.002, respectively). Non-Hispanic White participants were overrepresented (p = 0.018). Disparities worsened from 2017 to 2021 for Hispanic patients (p = 0.03). No significant differences were found for sex or age.

CONCLUSIONS

Disparities for clinical lung cancer trial enrollment have not shown statistically significant improvement since 2004, and representation remains unequal, especially for racial and ethnic minorities.

Association between hospital safety-net burden and receipt of trimodality therapy and survival for patients with esophageal cancer

BACKGROUND

To examine the relationship between hospital safety-net burden and (1) receipt of surgery after chemoradiation (trimodality therapy) and (2) survival in esophageal cancer patients.

METHODS

The National Cancer Database was queried to identify 22,842 clinical stage II to IVa esophageal cancer patients diagnosed in 2004 to 2015. The treatment facilities were categorized by proportion of uninsured/Medicaid-insured patients into percentiles. No safety-net burden hospitals (0-37th percentile) treated no uninsured/Medicaid-insured patients, whereas low (38-75th percentile) and high (76-100th percentile) safety-net burden hospitals treated a median (range) of 8.8% (0.87%-16.7%) and 23.6% (16.8%-100%), respectively. Adjusted odds ratios and hazard ratios with 95% confidence intervals were computed, adjusting for patient, tumor, and treatment characteristics.

RESULTS

Compared to no safety-net burden hospital patients, high safety-net burden hospital patients were significantly more likely to be young, Black, and low-income. Age, female sex, Black race, Hispanic ethnicity, nonprivate insurance, lower income, higher comorbidity score, upper esophageal location, squamous cell histology, higher stage, time to treatment, and treatment at a community program or a low-volume facility were associated with lower odds of receiving trimodality therapy. Adjusting for these factors, high safety-net burden hospital patients were less likely to receive surgery after chemoradiation versus no safety-net burden hospital patients (adjusted odds ratio 0.77 [95% confidence interval 0.68-0.86], P < .0001); no difference was detected comparing low safety-net burden hospitals versus no safety-net burden hospitals (adjusted odds ratio 1.01 [0.92-1.11], P = .874). No significant survival difference was noted by safety-net burden (low safety-net burden hospitals versus no safety-net burden hospitals: adjusted hazard ratio 1.01 [0.96-1.06], P = .704; high safety-net burden hospital versus no safety-net burden hospitals: adjusted hazard ratio 0.99 [0.93-1.06], P = .859).

CONCLUSION

Adjusting for patient, tumor, and treatment factors, high safety-net burden hospital patients were less likely to undergo surgery after chemoradiation but without significant survival differences.

Implementation Challenges and Disparities in Molecular Testing for Patients With Stage IV NSCLC: Perspectives from an Urban Safety-Net Hospital

The advent of next-generation sequencing (NGS), including both tissue assays and circulating tumor DNA (ct-DNA), has been pivotal in improving outcomes for patients with non-small cell lung cancer (NSCLC). Although molecular testing is standard of care for advanced NSCLC, challenges still exist in its implementation. This Perspective examines barriers to the widespread implementation of NGS from the vantage point of a single urban safety-net institution, with a particular focus on examining racial disparities in NGS completion. We conducted a review of patients at our institution from January 2015 through January 2022 and examined molecular testing patterns before and after the publication of updated molecular testing guidelines from the International Association for the Study of Lung Cancer (IASLC), Association for Molecular Pathology (AMP), and College of American Pathologists (CAP) in March of 2018. While NGS increased over time, we found that 43% of patients in the March 2018 through January 2022 group still did not receive NGS, and the most common reasons for the absence of testing included a lack of physician ordering and insufficient tissue on biopsy. We did not note any racial disparities in completion or time-to-adoption of NGS. Patients with squamous cell carcinoma (SCC) histology were noted to receive liquid NGS markedly less often than patients with non-squamous histology in the March 2018 through January 2022 period. Based on our own data and a review of findings from colleagues in the field, we advocate for additional physician educational programming, increased use of ct-DNA biopsy, automated (reflexive) NGS tissue testing on receipt of biopsy, and consideration for the broader molecular profiling of patients with SCC histology.

Timeliness of Lung Cancer Care From the Point of Suspicious Image at an Urban Safety Net Hospital

BACKGROUND

Timeliness of care is an important metric for lung cancer patients, and care delays in the safety-net setting have been described. Timeliness from the point of the suspicious image is not well-studied. Herein, we evaluate time intervals in the workup of lung cancer at an urban, safety net hospital and assess for disparities by demographic and clinical factors.

PATIENTS AND METHODS

We performed a retrospective analysis of lung cancer patients receiving some portion of their care at Boston Medical Center between 2015 and 2020. A total of 687 patients were included in the final analysis. Median times from suspicious image to first treatment (SIT), suspicious image to diagnosis (SID), and diagnosis to treatment (DT) were calculated. Nonparametric tests were applied to assess for intergroup differences in time intervals.

RESULTS

SIT, SID, and DT for the entire cohort was 78, 34, and 32 days, respectively. SIT intervals were 87 days for females and 72 days for males (p < .01). SIT intervals were 106, 110, 81, and 41 days for stages I, II, III, and IV, respectively (p < .01). SID intervals differed between black (40.5) and Hispanic (45) patients compared to white (28) and Asian (23) patients (p < .05).

CONCLUSION

Advanced stage at presentation and male gender were associated with more timely treatment from the point of suspicious imaging while white and Asian were associated with more timely lung cancer diagnosis. Future analyses should seek to elucidate drivers of timeliness differences and assess for the impact of timeliness disparities on patient outcomes in the safety net setting.

The impact of substance use on health care utilization, treatment, and outcomes in patients with non-small cell lung cancer

BACKGROUND

Mortality from non-small cell lung cancer (NSCLC) has improved with screening and novel treatments. The substance use epidemic has threatened health outcomes in a variety of diseases, but little is known about how it is associated with NSCLC outcomes.

METHODS

We performed a retrospective cohort study of 211 patients with NSCLC treated at a safety-net hospital. Sociodemographic data and clinical outcomes were extracted via review of electronic medical records. Patients were stratified based on substance use status. Comparative and multivariable analyses were performed to evaluate baseline characteristics and lung cancer outcomes including survival.

RESULTS

Among 193 patients (91.5%) with information available on substance use, 24.9% reported substance use; specifically, alcohol, marijuana, and illicit substances. Patients with substance use were more likely to have increased health care utilization and poor social determinants of health, including safe housing, stable employment, and social support. There were no significant differences in treatment adherence. Only 6.3% of patients with substance use did not receive guideline concordant care (GCC) compared to 24.8% of patients without substance use; due to poor performance status, increased comorbidities, or loss to follow up. On univariable analysis, patients with substance use experienced inferior median overall survival (OS) if they had metastatic disease (0.40 vs. 1.03 years, P=0.01). However, in the multivariable analysis, substance use did not predict for survival. Independent predictors of mortality were sex (male HR, 1.67; 95% CI: 1.04-2.68; P=0.04), smoking status (current smoking HR, 2.63; 95% CI: 1.14-6.08; P=0.02), and stage (stage IV HR, 14.96; 95% CI: 6.28-35.63; P=0.008).

CONCLUSIONS

Substance use is associated with poor social determinants of health and increased health care utilization. On multivariable analysis, substance use was not independently associated with OS once guideline-concordant care was used. Future studies should focus on improving our understanding of these associations, delineating potential mechanisms, and developing evidence-based strategies to reduce health care utilization and overcome challenges related to poor social determinants of health.

Small cell lung cancer in young patients: trends in sociodemographic factors, diagnosis, treatment, and survival

Background

Small cell lung cancer (SCLC) in patients <50 years old has unique socioeconomic and clinical implications. We aimed to examine the demographics, treatment patterns, and survival of young patients with SCLC and compared them to older adults.

Methods

The National Cancer Database (NCDB) was queried to identify SCLC cases diagnosed from 2004 to 2016. Patients were divided into three age groups: ≥18–<50, ≥50–<70, and ≥70 years. Patient characteristics were evaluated for survival within each age group. Kaplan-Meier and Cox regression analyses were used to assess survival.

Results

Of the 172,453 evaluated SCLC patients (median age 66 years), 8,792 were ≥18–<50 years old. Compared to the older groups, patients under 50 were more likely to be Black, uninsured or on Medicaid, have household income <$30,000, and present with stage III or IV disease (P<0.0001 for all). While young patients were more likely to receive guideline-concordant care (GCC), the hazard of death increased to 1.96 (95% CI: 1.80–2.14; P<0.0001) with receipt of nonstandard therapy. Private insurance, female gender, non-White race, Hispanic ethnicity, and higher income were associated with better survival. The youngest cohort had significantly better survival overall when compared to the older patients (P<0.0001), but the survival advantage was reduced with the advancing stage.

Conclusions

SCLC patients under 50 years old represent a socioeconomically disadvantaged group with advanced disease at presentation. Despite having fewer comorbidities and being offered guideline-concordant treatment, younger patients with SCLC have only marginally better survival than older patients in advanced stages.

Trends of HIV-Related Cancer Mortality between 2001 and 2018: An Observational Analysis

The burden of AIDS-defining cancers has remained relatively steady for the past two decades, whilst the burden of non-AIDS-defining cancer has increased. Here, we conduct a study to describe mortality trends attributed to HIV-associated cancers in 31 countries. We extracted HIV-related cancer mortality data from 2001 to 2018 from the World Health Organization Mortality Database. We computed age-standardized death rates (ASDRs) per 100,000 population using the World Standard Population. Data were visualized using Locally Weighted Scatterplot Smoothing (LOWESS). Data for females were available for 25 countries. Overall, there has been a decrease in mortality attributed to HIV-associated cancers among most of the countries. In total, 18 out of 31 countries (58.0%) and 14 out of 25 countries (56.0%) showed decreases in male and female mortality, respectively. An increasing mortality trend was observed in many developing countries, such as Malaysia and Thailand, and some developed countries, such as the United Kingdom. Malaysia had the greatest increase in male mortality (+495.0%), and Canada had the greatest decrease (−88.5%). Thailand had the greatest increase in female mortality (+540.0%), and Germany had the greatest decrease (−86.0%). At the endpoint year, South Africa had the highest ASDRs for both males (16.8/100,000) and females (19.2/100,000). The lowest was in Japan for males (0.07/100,000) and Egypt for females (0.028/100,000).

The Impact of Residential Racial Segregation on Non-Small Cell Lung Cancer Treatment and Outcomes

BACKGROUND

Despite decreases in lung cancer incidence, racial disparities in diagnosis and treatment persist. Residential segregation and structural racism have effects on socioeconomic status for black people, affecting healthcare access. This study aims to determine the impact of residential segregation on racial disparities in non-small cell lung cancer (NSCLC) treatment and mortality.

METHODS

Patient data were obtained from Surveillance, Epidemiology, and End Results Program (SEER) database for black and white patients diagnosed with NSCLC from 2004-2016 in the 100 most populous counties. Regression models were built to assess outcomes of interest - stage at diagnosis and surgical resection of disease. Predicted margins assessed impact of index of dissimilarity (IoD) on these disparities. Competing risk regressions for black and white patients in highest and lowest quartiles of IoD were used to assess cancer-specific mortality.

RESULTS

Our cohort had 193,369 white and 35,649 black patients. Black patients were more likely to be diagnosed at advanced stage than white patients with increasing IoD. With increasing IoD, black patients were less likely to undergo surgical resection than white. Disparities were eliminated at low IoD. Black patients at high IoD had lower cancer-specific survival.

CONCLUSIONS

Black patients were more likely to present at advanced disease, were less likely to receive surgery for early stage, and had higher cancer-specific mortality at higher IoD. Our findings highlight the impact of structural racism and residential segregation on NSCLC outcomes. Solutions to these disparities must come from policy reforms to reverse residential segregation and deleterious socioeconomic effects of discriminatory policies.

Reducing delays to lung cancer treatment through systematic consult scheduling: A multidisciplinary quality improvement initiative at a safety-net hospital

e18640

Background: Delays in diagnosis and treatment have been identified as practice gaps in lung cancer management. At our large safety-net hospital, 2016-2018 data provided by the Commission on Cancer (CoC) indicated that 58-66% of lung cancer patients began treatment > 30 days after their diagnosis, compared to a median of 30 days for CoC-accredited hospitals. A quality improvement (QI) project was performed to identify causes for treatment delays, and to implement changes to reduce the median time from diagnosis to treatment to < 30 days. Methods: Root cause analysis was performed on a cohort of lung cancer patients identified and abstracted by the CoC Registry with diagnosis in October 2018-September 2019, to provide more recent data on treatment delays and to identify actionable interventions. Subsequently, a multidisciplinary QI initiative through Thoracic Surgery, Hematology Oncology, and Radiation Oncology was implemented using the Plan-Do-Study-Act (PDSA) tool. The initiative was tracked for 6 months starting in August 2020, with time from referral to consult and time from diagnosis to treatment calculated via chart review. Results: For the root cause analysis, 36 patients were identified. Eleven cases were excluded as they did not receive treatment at our institution. For the remaining 25 patients, the median time from referral to consult across all three oncology specialties was 13 days. The most common barriers to initiating treatment were appointment scheduling delays (37.5%), patient factors including synchronous malignancies or insurance, geographic or cultural barriers (31.3%), and multiple factors including appointment scheduling delays (25%). Median time from diagnosis to treatment was 31 days, with 36% (N = 9) starting treatment in < 30 days. While appointment scheduling delays included both work-up (imaging, procedures) and consults as well as follow-ups, multidisciplinary discussions identified time from referral to consult as the most actionable QI initiative. With support from Patient Navigation, the three oncology specialties jointly implemented a system whereby suspected or confirmed new lung cancer patients were scheduled for consult ideally in < 7 days, and no more than 14 days from the referral date. Of 28 new lung cancer patients who started treatment after the QI intervention, median time from referral to consult decreased to 7 days. Median time from diagnosis to treatment decreased to 26.5 days, with 53.6% (N = 15) of patients starting treatment in < 30 days. Conclusions: By decreasing time from referral to consult, this multidisciplinary QI intervention facilitated earlier initiation of treatment for lung cancer patients. Similar actions to decrease other scheduling delays and mitigate the impact of social determinants of health could further promote improvements in timely patient care.

Phase II two-arm study of tepotinib plus osimertinib in patients with EGFR-mutant NSCLC and acquired resistance to first-line osimertinib due to MET amplification: INSIGHT 2

TPS9136

Background: METamp is a mechanism of acquired resistance to EGFR tyrosine kinase inhibitors (TKIs). METamp occurs in ̃30% of patients who progress on EGFR TKI therapy as measured using fluorescence in situ hybridization (FISH). There is an unmet need for targeted treatment options in these patients. Combination treatment with a MET TKI may overcome MET-related osimertinib resistance. Tepotinib is an oral, once daily (QD), highly selective, potent MET TKI. In the INSIGHT study (NCT01982955), the combination of tepotinib and the EGFR TKI gefitinib improved outcomes in patients with EGFR-mutant METamp NSCLC and EGFR TKI resistance compared to chemotherapy (INSIGHT). Median progression-free survival (PFS) was 16.6 vs 4.2 months (hazard ratio [HR] = 0.13; 90% confidence interval [CI]: 0.04, 0.43) and median overall survival (OS) was 37.3 vs 13.1 months (HR = 0.08; 90% CI: 0.01, 0.51). Methods: INSIGHT 2 is a global, open-label, Phase II trial of tepotinib + osimertinib in patients with advanced EGFR-mutant NSCLC. Following a protocol amendment in Apr 2020, the study is enrolling patients with acquired resistance to 1L osimertinib (radiological documentation of disease progression following previous objective clinical benefit) due to METamp by FISH (GCN ≥5 or MET/CEP7 ratio ≥2). Patients must be ≥18 years old, have an Eastern Cooperative Oncology Group performance status of 0/1, and normal organ function. Both tissue and liquid biopsy, obtained at the time of progression to osimertinib, will be sent for central confirmation of METamp. Liquid biopsy samples will also be used for exploratory biomarker evaluation. Enrollment is allowed based on local FISH testing while awaiting central confirmation of METamp. Patients will receive 500 mg QD (450 mg active moiety) tepotinib + 80 mg QD osimertinib until disease progression, unacceptable toxicity, or consent withdrawal. The study is anticipated to enroll 120 patients. The primary endpoint is objective response rate (ORR) by independent review (RECIST v1.1) in patients with METamp, centrally confirmed by FISH. Secondary endpoints include ORR by investigator assessment, duration of response, disease control, PFS, OS, pharmacokinetics, health-related quality of life, tolerability, and safety. An exploratory tepotinib monotherapy arm will enroll 12 patients to assess the contribution of tepotinib to the activity of the combination. At progression (determined by independent review committee), monotherapy patients can switch to combination treatment. These patients will be analyzed separately. Recruitment is ongoing, with > 300 patients prescreened. Approximately 100 sites in 17 countries in Europe, Asia, and North America are expected to participate. Approximately 15 sites will recruit patients in the US. Clinical trial information: NCT03940703.

Racial and Other Healthcare Disparities in Patients With Extensive-Stage SCLC

INTRODUCTION

Systemic treatment with chemotherapy is warranted for patients with extensive-stage SCLC (ES-SCLC). The objective of this study was to determine whether racial and other healthcare disparities exist in receipt of chemotherapy for ES-SCLC.

METHODS

Utilizing the National Cancer Database, 148,961 patients diagnosed to have stage IV SCLC from 2004 to 2016 were identified. Adjusted ORs with 95% confidence intervals (95% CIs) were computed for receipt of chemotherapy using multivariate logistic regression modeling. Cox regression modeling was used to perform overall survival analysis, and adjusted hazard ratios were calculated.

RESULTS

A total of 82,592 patients were included, among which chemotherapy was not administered to 6557 (7.9%). Higher education, recent year of diagnosis, and treatment at more than one facility were associated with increased odds of receiving chemotherapy. Factors associated with a decreased likelihood of receiving chemotherapy were increasing age, race, nonprivate insurance, and comorbidities. On multivariate analysis, black patients had lower odds of receiving chemotherapy compared with white patients (adjusted OR, 0.85; 95% CI: 0.77-0.93, p = 0.0004). Furthermore, black patients had better survival compared with white patients (adjusted hazard ratio, 0.91; 95% CI: 0.89-0.94, p = 0.91). The 1-year survival (median survival) for black and white patients was 31.7% (8.3 mo) and 28.6% (8 mo), respectively.

CONCLUSIONS

Black patients with ES-SCLC were less likely to receive chemotherapy, as were elderly, uninsured, and those with nonprivate insurance. Further studies are required to address underlying reasons for lack of chemotherapy receipt in black patients with ES-SCLC and guide appropriate interventions to mitigate disparities.

c-Cbl Expression Correlates with Human Colorectal Cancer Survival and Its Wnt/β-Catenin Suppressor Function Is Regulated by Tyr371 Phosphorylation

The proto-oncogene β-catenin drives colorectal cancer (CRC) tumorigenesis. Casitas B-lineage lymphoma (c-Cbl) inhibits CRC tumor growth through targeting nuclear β-catenin by a poorly understood mechanism. In addition, the role of c-Cbl in human CRC remains largely underexplored. Using a novel quantitative histopathologic technique, we demonstrate that patients with high c-Cbl-expressing tumors had significantly better median survival (3.7 years) compared with low c-Cbl-expressing tumors (1.8 years; P = 0.0026) and were more than twice as likely to be alive at 3 years compared with low c-Cbl tumors (P = 0.0171). Our data further demonstrate that c-Cbl regulation of nuclear β-catenin requires phosphorylation of c-Cbl Tyr371 because its mutation compromises its ability to target β-catenin. The tyrosine 371 (Y371H) mutant interacted with but failed to ubiquitinate nuclear β-catenin. The nuclear localization of the c-Cbl-Y371H mutant contributed to its dominant negative effect on nuclear β-catenin. The biological importance of c-Cbl-Y371H was demonstrated in various systems, including a transgenic Wnt-8 zebrafish model. c-Cbl-Y371H mutant showed augmented Wnt/β-catenin signaling, increased Wnt target genes, angiogenesis, and CRC tumor growth. This study demonstrates a strong link between c-Cbl and overall survival of patients with CRC and provides new insights into a possible role of Tyr371 phosphorylation in Wnt/β-catenin regulation, which has important implications in tumor growth and angiogenesis in CRC.

Racial differences in colorectal cancer survival at a safety net hospital

BACKGROUND

While racial disparity in colorectal cancer survival have previously been studied, whether this disparity exists in patients with metastatic colorectal cancer receiving care at safety net hospitals (and therefore of similar socioeconomic status) is poorly understood.

METHODS

We examined racial differences in survival in a cohort of patients with stage IV colorectal cancer treated at the largest safety net hospital in the New England region, which serves a population with a majority (65%) of non-Caucasian patients. Data was extracted from the hospital's electronic medical record. Survival differences among different racial and ethnic groups were examined graphically using Kaplan-Meier analysis. A univariate cox proportional hazards model and a multivariable adjusted model were generated.

RESULTS

Black patients had significantly lower overall survival compared to White patients, with median overall survival of 1.9 years and 2.5 years respectively. In a multivariate analysis, Black race posed a significant hazard (HR 1.70, CI 1.01-2.90, p=0.0467) for death. Though response to therapy emerged as a strong predictor of survival (HR=0.4, CI=0.2-0.7, p=0.0021), it was comparable between Blacks and Whites.

CONCLUSIONS

Despite presumed equal access to healthcare and socioeconomic status within a safety-net hospital system, our results reinforce findings from previous studies showing lower colorectal cancer survival in Black patients, and also point to the importance of investigating other factors such as genetic and pathologic differences.

c-Cbl expression as a novel predictive marker of survival in patients with metastatic colorectal cancer

e15090

Background: Aberrant hyperactive Wnt/ß-catenin signaling is critical in colorectal cancer (CRC) tumorigenesis. Casitas B-lineage Lymphoma (c-Cbl) is a negative regulator of Wnt signaling, and functions as a tumor suppressor. The objective of this study was to evaluate c-Cbl expression as a predictive marker of survival in patients with metastatic CRC (mCRC). Methods: Patients with mCRC treated at Boston University Medical Center between 2004 and 2014 were analyzed. c-Cbl and nuclear ß-catenin expression was quantified in explanted biopsies using a customized color-based image segmentation pipeline. Quantification was normalized to the total tumor area in an image, and deemed ‘low’ or ‘high’ according to the mean normalized values of the cohort. A supervised machine-learning model based on bootstrap aggregating was constructed with c-Cbl expression as the input feature and 3-year survival as output. Results: Of the 72 subjects with mCRC, 52.78% had high and 47.22% had low c-Cbl expression. Patients with high c-Cbl had significantly better median overall survival than those with low c-Cbl expression (3.7 years vs. 1.8 years; p = 0.0026), and experienced superior 3-year survival (47.37% vs 20.59%; p = 0.017). Intriguingly, nuclear ß-catenin expression did not correlate with survival. No significant differences were detected between high and low c-Cbl groups in baseline characteristics (demographics, comorbidities), tumor-related parameters (primary tumor location, number of metastasis, molecular features) or therapy received (surgery, chemotherapy regimen). A 5-fold cross-validated machine-learning model associated with 3-year survival demonstrated an area under the curve of 0.729, supporting c-Cbl expression as a predictor of mCRC survival. Conclusions: Our results show that c-Cbl expression is associated with and predicts mCRC survival. Demonstration of these findings despite the small cohort size underscores the power of quantitative histology and machine-learning application. While further work is needed to validate c-Cbl as a novel biomarker of mCRC survival, this study supports c-Cbl as a regulator of Wnt/ß-catenin signaling and a suppressor of other oncogenes in CRC tumorigenesis.

MRI in local staging of rectal cancer: an update

Preoperative imaging for staging of rectal cancer has become an important aspect of current approach to rectal cancer management, because it helps to select suitable patients for neoadjuvant chemoradiotherapy and determine the appropriate surgical technique. Imaging modalities such as endoscopic ultrasonography, computed tomography, and magnetic resonance imaging (MRI) play an important role in assessing the depth of tumor penetration, lymph node involvement, mesorectal fascia and anal sphincter invasion, and presence of distant metastatic diseases. Currently, there is no consensus on a preferred imaging technique for preoperative staging of rectal cancer. However, high-resolution phased-array MRI is recommended as a standard imaging modality for preoperative local staging of rectal cancer, with excellent soft tissue contrast, multiplanar capability, and absence of ionizing radiation. This review will mainly focus on the role of MRI in preoperative local staging of rectal cancer and discuss recent advancements in MRI technique such as diffusion-weighted imaging and dynamic contrast-enhanced MRI.

Effect of DNA-PK dependent phosphorylation of topo-I-S10 on its rate of proteasomal degradation and CPT response

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Background: Topoisomerase I (topo-I) degradation by ubiquitin proteasomal pathway (UPP), in response to camptothecins (CPTs) is linked to the CPT response. But the mechanism is not understood. Methods: Improvised GST pull down experiments were performed to isolate topo-I interacting proteins which were analyzed by SDS-PAGE and identified by mass spectrometry. DNA-PKcs mediated phosphorylation of GST-topo-I was analyzed by SDS-PAGE and autoradiography. Immunoblot analysis of anti-BRCA1 precipitates from HCT15 cell lines was performed. GST-topo-I phosphorylated by DNA-PKcs, was incubated with the BRCA1/BARD1 heterodimer in the presence of E1, UbCH5c and ATP in ubiquitination buffer. Four triple negative breast cancer cell lines were selected to compare the degree of topo-I degradation. Colorectal cancer (CRC) tissues were immunostained with 1C1.H5.H7 to determine topo-I-pS10 level and identify a correlation between the topo-I-pS10 level and CPT response. Results: We isolated a topo-I interacting protein complex and determined that Ku70/Ku80/DNA-PKcs complex associates with topo-I, and DNA-PKcs phosphorylates topo-I at Serine10. We showed that cells with higher topo-I-pS10 level rapidly degrade topo-I and are CPT resistant. The cells with non-detectable level of topo-I-pS10 fail to degrade topo-I and are CPT sensitive. Retrospective study with 48 CRC tissues immuno-stained with anti-topo-I-pS10 supported our cell line data. Percent DAB positive nuclei demonstrated statistically significant differential staining between CPT responders and non-responders, and ROC analysis confirmed that nearly all non-responders exhibit >35% positive nuclei, indicating that topo-I-pS10 level determines topo-I degradation and a potential predictive biomarker for CPT response. Conclusions: Colorectal cancers are treated with topo-I inhibitors, but the response rate is low. We have shown that topo-I degradation rate is linked to CPT response. We have determined that high topo-I-pS10 level is indicative of rapid topoI degradation and can serve as a biomarker for CPT resistance.

Possible predictive clinical factors for chemotherapy holiday in metastatic colorectal cancer: A single institution–based retrospective data analysis

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Background: During the last decade, numerous new agents were introduced into the therapy of metastatic colorectal cancer. For those patients who are not curable by resection, life can be extended with chemotherapy. However, it is not possible to predict who can safely take breaks without compromising survival. We sought to evaluate the relationship between various possible predictive factors and the duration of break from chemotherapy in patients with metastatic colorectal cancer. Methods: The hospital’s cancer registry was used to identify metastatic colon cancer cases diagnosed from January 2008 to December 2012. To be included in the study, the patient must have been diagnosed with colorectal adenocarcinoma, treated with a fluoropyrimidine based chemotherapy regimen and had planned treatment breaks. Retrospective chart review of electronic medical records was used to collect patient characteristics, including age, performance status (ECOG), comorbidities, disease burden (number of metastasis), and response to the initial treatment. Multivariate regression analysis was performed to observe impact of various variables on the duration of break from chemotherapy. Results: A total of 110 patients were diagnosed with metastatic colorectal cancer between 2008 to 2012 and 27 (24.5%) subjects in the initial analysis met the inclusion criteria, with a mean age of 56 years. The percentage of male and female patients was 37% and 63%, respectively. Patients who had a complete response to the initial chemotherapy (n=6) had 69±23 week breaks which was significantly longer (p<0.01) than the 17±2 and 13±5 week breaks of those with partial response or stable disease. In multivariate regression analysis, degree of response was a significant predictor for chemotherapy breaks (CI 0.36 – 1.77, p=0.005). No statistical difference was noted in other variables. Conclusions: These preliminary findings suggest that complete response to initial chemotherapy may be a strong predictor of patients who can safely undergo chemotherapy breaks. This study also raises the possibility that various factors could influence break from chemotherapy.

Gastrointestinal symptoms are closely associated with depression in iron deficiency anemia: a comparative study

BACKGROUND AND OBJECTIVES

Until now, very few studies evaluated the association between gastrointestinal and psychiatric symptoms in iron deficiency anemia (IDA). The study investigated the frequency of functional dyspepsia (FD) in IDA patients and determined its association with depression and somatization.

DESIGN AND SETTINGS

The study was conducted at the Hematology Department of Trakya University Medical Faculty, which is a tertiary referral center in northwestern Turkey. It was a case-control study.

MATERIALS AND METHODS

A total of 125 consecutive IDA patients and 57 healthy control subjects were included. Patients and controls were questioned about the severity of their gastrointestinal system (GIS)-related symptoms and the presence of constipation and associated symptoms using a visual analog scale. In addition, IDA patients were administered a validated depression scale (Beck Depression Inventory, BDI) and somatization symptoms checklist.

RESULTS

IDA patients had more frequent self-reported constipation compared with controls (56% vs 22.8%, P < .001). The mean scores of bloating, dyspepsia, and constipation-related quality of life (QoL) disturbance were significantly higher in the IDA group than in the control group (all P values.

Potassium abnormalities in current clinical practice: frequency, causes, severity and management

OBJECTIVE

We aimed to investigate the prevalence and etiology of potassium abnormalities (hypokalemia and hyperkalemia) and management approaches for hospitalized patients.

SUBJECTS AND METHODS

Over a 4-month period, all hospitalized patients at Hacettepe University Medical Faculty Hospitals who underwent at least one measurement of serum potassium during hospitalization were included. Data on serum levels of electrolytes, demographic characteristics, cause(s) of hospitalization, medications, etiology of potassium abnormality and treatment approaches were obtained from the hospital records.

RESULTS

Of the 9,045 hospitalized patients, 1,265 (14.0%) had a serum potassium abnormality; 604 (6.7%) patients had hypokalemia and 661 (7.30%) had hyperkalemia. In the hypokalemic patients, the most important reasons were gastrointestinal losses in 555 (91.8%) patients and renal losses in 252 (41.7%) patients. The most frequent treatment strategies were correcting the underlying cause and replacing the potassium deficit. Of the 604 hypokalemic patients, 319 (52.8%) were normokalemic at hospital discharge. The most common reason for hyperkalemia was treatment with renin-angiotensin-aldosterone system blockers in 228 (34.4%) patients, followed by renal failure in 191 (28.8%). Two hundred and ninety-eight (45.0%) patients were followed without any specific treatment. Of the 661 hyperkalemic patients, 324 (49.0%) were normokalemic at hospital discharge.

CONCLUSION

This study showed a high prevalence of potassium imbalance among hospitalized patients. Although most of the potassium abnormalities were mild/moderate, approximately half of the patients treated for hypokalemia or hyperkalemia were discharged from the hospital with ongoing dyskalemia.

Decreased dickkopf-1 levels in chronic lymphocytic leukemia and increased osteopontin levels in non-Hodgkin's lymphoma at initial diagnosis: Could they be playing roles in pathogenesis?

Aims We determined plasma levels of dickkopf-1 (DKK-1) and osteopontin (OPN) which have roles in the Wnt pathway in chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL) patients and in healthy controls. We also tested whether DKK-1 and OPN levels could be of clinical or prognostic significance in CLL and NHL. Methods We included 36 CLL, 24 NHL patients, and 21 healthy controls. Patients' clinical and demographic features, treatment modalities, and response to treatment were recorded. DKK-1 and OPN levels in plasma obtained at initial diagnosis were determined with enzyme-linked immunosorbent assay. Results CLL patients had significantly lower DKK-1 levels than NHL and control groups (P levels, respectively, 0.048 and 0.017). OPN level was significantly higher in NHL group than in CLL and control groups (P values, 0.017 and <0.001). CLL patients with early and late Rai stages of disease had similar DKK-1 and OPN levels. After a median follow-up of 48 months, 13 CLL patients died. Univariate analysis showed that advanced Rai stages and older age were significantly poor prognostic factors. DKK-1 level in CLL patients who have died was significantly lower than those who were alive (P = 0.035). NHL patients with extranodal involvement had significantly higher OPN levels than those with no involvement (P = 0.04). Conclusions Our results demonstrated that the Wnt pathway inhibitor DKK-1 was decreased in CLL. OPN was increased in NHL and associated with extranodal involvement. In order to reveal the pathogenic and clinical roles of DKK-1 and OPN in CLL and NHL, larger studies need to be conducted.

An adult patient with common B-cell acute lymphoblastic leukaemia who presented with pancreatic involvement, description of the second adult case and review of paediatric cases

Pancreatic involvement in acute lymphoblastic leukaemia (ALL) may go unrecognised. There are only a few paediatric cases; nevertheless, presentation with pancreatic involvement in an adult patient with ALL has been reported rarely. Our 52-year-old male patient came to us with abdominal pain, nausea and vomiting; he had pancreatic enlargement on CT. He was diagnosed with common B-cell ALL with pancreatic involvement. The patient obtained haematological remission and the pancreatic enlargement regressed after chemotherapy, but later he had central nervous system and liver relapses. He died 6 months after diagnosis because of progressive pneumonia and chemotherapy-resistant ALL with multiple extramedullary relapses.

Radiofrequency ablation: technique and clinical applications

Radiofrequency ablation is the most commonly used percutaneous ablation technique and well-documented in the literature on focal therapies. It has become the image-guided ablation method of choice because of its efficacy, safety, and ease of use. Radiofrequency ablation has shown promise in treating selected solid tumors, particularly those involving the liver, kidneys, lungs, and the musculoskeletal system. It is a minimally invasive technique often used in inoperable patients with other comorbidities. Radiofrequency ablation requires a minimal hospital stay or can be performed on an outpatient basis. The aim of this article is to review radiofrequency ablation techniques and their clinical applications.

Multimodality treatment in the management of anorectal melanoma: a case report and review of the literature

Anorectal melanoma represents approximately 0.2-1% of all malignant melanomas and has a poor prognosis, with a median survival of 8 to 23 months after the time of diagnosis. The typical treatment modalities include surgery, radiotherapy and chemotherapy. The particular approach taken depends on the patient's status and disease stage. Although there are different treatment options for this rare condition, there are not enough studies on multimodality treatment. Here, we present the case of a 54-year-old female with anorectal melanoma that had metastasized to an inguinal lymph node. She underwent local excision of the rectal mass and inguinal lymph-node dissection. Temozolomide treatment was started after radiotherapy and was given for 24 months. Follow-up revealed that the patient has been doing well with no signs of recurrence three years after the completion of treatment. We aim to discuss combined treatment modalities for ARM in light of the pertinent literature.

Primary thyroid marginal zone B-cell lymphoma MALT-type in a patient with rheumatoid arthritis

Autoimmune diseases are defined as specific, adapted immune reactions against self antigens. Immune mechanism deficiency is a causal factor for B-cell lymphoma in primary Sjögren's syndrome and autoimmune thyroid disease. Thyroid mucosa-associated lymphoid tissue (MALT) lymphoma is a 67-fold and parotid lymphoma is a 44-fold increased risk in Sjögren's syndrome and thyroiditis. MALT lymphoma was not reported in rheumatoid arthritis. We herein report the case of a 56-year-old woman with maltoma of thyroid in rheumatoid arthritis patient.

Liver dysfunction after chemotherapy in lymphoma patients infected with hepatitis C

Reactivation of hepatitis B virus (HBV) infection in asymptomatic hepatitis B surface antigen carriers undergoing chemotherapy or immunosuppressive therapy is a well-documented complication. However, data on the consequence of chemotherapy on the course of hepatitis C virus (HCV) infection in HCV+ patients have been controversial. Here, we review the current knowledge about the complications related to HCV in lymphoma patients receiving chemotherapy/immunosuppressive therapy. Although less frequent than HBV, these complications occur in a subset of patients with mortality rates up to 45%. Therefore, baseline screening for HBV and HCV before initiation of chemotherapy is crucial. High-risk patients having chronic active hepatitis, high baseline HCV viral load, HBV co-infection and receiving cytotoxic drugs, corticosteroids and rituximab (particularly if combined) should be closely monitored for serum transaminase, bilirubin and HCV RNA levels.