Randomized, Double-Blind Phase III Study of Pazopanib Versus Placebo in Patients With Metastatic Renal Cell Carcinoma Who Have No Evidence of Disease After Metastasectomy: ECOG-ACRIN E2810

PURPOSE

Patients with no evidence of disease (NED) after metastasectomy for renal cell carcinoma are at high risk of recurrence. Pazopanib is an inhibitor of vascular endothelial growth factor receptor and other kinases that improves progression-free survival in patients with metastatic RCC (mRCC). We conducted a randomized, double-blind, placebo-controlled multicenter study to test whether pazopanib would improve disease-free survival (DFS) in patients with mRCC rendered NED after metastasectomy.

PATIENTS AND METHODS

Patients with NED after metastasectomy were randomly assigned 1:1 to receive pazopanib 800 mg once daily versus placebo for 52 weeks. The study was designed to observe an improvement in DFS from 25% to 45% with pazopanib at 3 years, corresponding to 42% reduction in the DFS event rate.

RESULTS

From August 2012 to July 2017, 129 patients were enrolled. The study was unblinded after 83 DFS events (92% information). The study did not meet its primary end point. An updated analysis at 60.5-month median follow-up from random assignment (95% CI, 59.3 to 71.0) showed that the 3-year DFS was 27.4% (95% CI, 17.9 to 41.7) for pazopanib and 21.9% (95% CI, 13.3 to 36.2) for placebo. Hazard ratio (HR) for DFS was 0.90 ([95% CI, 0.60 to 1.34]; Pone-sided = .29) in favor of pazopanib. Three-year overall survival (OS) was 81.9% (95% CI, 72.7 to 92.2) for pazopanib and 91.4% (95% CI, 84.4 to 98.9) for placebo. The HR for OS was 2.55 (95% CI, 1.23 to 5.27) in favor of placebo (Ptwo-sided = .012). Health-related quality-of-life measures deteriorated in the pazopanib group during the treatment period.

CONCLUSION

Pazopanib did not improve DFS as the primary end point compared with blinded placebo in patients with mRCC with NED after metastasectomy. In addition, there was a concerning trend favoring placebo in OS.

Combination Immune Checkpoint Blockade Regimens for Previously Untreated Metastatic Renal Cell Carcinoma: The Winship Cancer Institute of Emory University Experience

Introduction

There are three combination immune checkpoint inhibitor (ICI)-based regimens in the first-line setting for metastatic renal cell carcinoma (mRCC). Currently, there is limited real-world data for clinical outcomes and toxicity in mRCC patients treated with first-line ICI-based regimens.

Methods

We performed a retrospective review of 49 mRCC patients treated with ICI-based combination regimens in the standard of care setting at the Winship Cancer Institute of Emory University from 2015-2020. We collected baseline data from the electronic medical record including demographic information and disease characteristics. Immune-related adverse events (irAEs) were collected from clinic notes and laboratory values. The primary clinical outcomes measured were overall survival (OS), progression-free survival (PFS), and objective response rate (ORR).

Results

The median age was 65 years, and most patients (80%) were males. The majority were White (86%) and had clear cell RCC (83%). Most patients had an Eastern Cooperative Oncology Group (ECOG) performance status score of 0 (43%) or 1 (45%). Approximately one-half (49%) had at least three sites of distant metastatic disease. Most patients (88%) received nivolumab and ipilimumab. More than one-half (53%) of patients experienced an irAE, with 13 (27%) patients having treatment delayed and 18% discontinuing treatment for toxicity. The median OS was not reached, and the median PFS was 8.0 months per a Kaplan-Meier estimation. More than half of patients (53%) had a PFS > 6 months, and 22% had PFS > 1 year. The ORR was 33% for the entire cohort, and 7% of patients had a complete response.

Conclusion

We presented real-world efficacy and toxicity data for front-line ICI combination treatment regimens. The ORR and median PFS were lower in our cohort of patients compared to the available data in the clinical trial setting. This was likely because of more advanced disease in this study. Future studies should provide additional data that will allow comparisons between different ICI combination regimens for untreated mRCC.

Analysis of Toxicity and Clinical Outcomes in Full Versus Reduced Starting Dose Cabozantinib in Metastatic Renal Cell Carcinoma Patients

BACKGROUND

Full dose cabozantinib for metastatic renal cell carcinoma (mRCC) is 60 mg, but adverse events (AEs) may require dose reductions. Limited data exist comparing efficacy among cabozantinib doses. We compared AEs and clinical outcomes in mRCC patients treated with full vs. reduced starting cabozantinib dose.

METHODS

We performed a retrospective analysis of 87 mRCC patients treated with cabozantinib at Winship Cancer Institute from 2016 to 2019. Overall survival (OS), progression-free survival (PFS), and objective response (OR) rate measured clinical outcomes. AEs were collected from clinic notes and the most common were hypertension, mucositis/hand-foot skin reaction (HFSR), or gastrointestinal toxicity. Univariate analysis (UVA) between starting doses and AEs with clinical outcomes was performed using logistic regression model. Multivariable analysis was also performed using Cox proportional hazard model.

RESULTS

Most patients were men (71%) with clear-cell RCC (72%). The majority were IMDC intermediate (58%) or poor (35%) risk. One third received first-line cabozantinib and 64% had ≥3 baseline metastatic sites. Most patients (68%) required dose reduction from 60 mg or started at reduced dose without escalation. Reduced dose patients were more likely to have ≥3 distant metastatic sites (70% vs. 58%) and ≥2 prior lines of systemic therapy (50% vs. 40%) compared to full dose patients. UVA revealed a trend towards shorter OS (HR: 1.78, P = .095), PFS (HR: 1.50, P = .107), and lower chance of OR (HR:0.42, P = .149) among reduced dose patients. This trend did not hold in Multivariable analysis (OS HR: 1.20, P = .636; PFS HR: 1.23, P = .4662). Mucositis/HFSR and hypertension were significantly associated with improved outcomes in UVA.

CONCLUSIONS

Although we found a trend favoring full dose cabozantinib, this is likely due to worse baseline disease characteristics among patients starting on a reduced dose. Hypertension and mucositis/HFSR may be associated with improved outcomes. Larger studies are warranted to validate these findings.

Body Composition as an Independent Predictive and Prognostic Biomarker in Advanced Urothelial Carcinoma Patients Treated with Immune Checkpoint Inhibitors

BACKGROUND

Several immune checkpoint inhibitors (ICIs) are approved for the treatment of advanced urothelial carcinoma (UC). There are limited biomarkers for ICI-treated patients with UC. We investigated the association between body composition and clinical outcomes in ICI-treated UC patients.

MATERIALS AND METHODS

We conducted a retrospective analysis of 70 ICI-treated patients with advanced UC at Winship Cancer Institute from 2015 to 2020. Baseline computed tomography images within 2 months of ICI initiation were collected at mid-L3 and muscle and fat compartments (subcutaneous, intermuscular, and visceral) were segmented using SliceOMatic v5.0 (TomoVision, Magog, Canada). A prognostic body composition risk score (high: 0-1, intermediate: 2-3, or low-risk: 4) was created based on the β coefficient from the multivariate Cox model (MVA) following best-subset variable selection. Our body composition risk score was skeletal muscle index (SMI) + 2 × attenuated skeletal muscle (SM) mean + visceral fat index (VFI). Concordance statistics (C-statistics) were used to quantify the discriminatory magnitude of the predictive model.

RESULTS

Most patients (70%) were men and the majority received ICIs in the second- (46%) or third-line (21%) setting. High-risk patients had significantly shorter overall survival (OS; hazard ratio [HR], 6.72; p < .001), progression-free survival (HR, 5.82; p < .001), and lower chance of clinical benefit (odds ratio [OR], 0.02; p = .003) compared with the low-risk group in MVA. The C-statistics for our body composition risk group and myosteatosis analyses were higher than body mass index for all clinical outcomes.

CONCLUSION

Body composition variables such as SMI, SM mean, and VFI may be prognostic and predictive of clinical outcomes in ICI-treated patients with UC. Larger, prospective studies are warranted to validate this hypothesis-generating data.

IMPLICATIONS FOR PRACTICE

This study developed a prognostic body composition risk scoring system using radiographic biomarkers for patients with bladder cancer treated with immunotherapy. The study found that the high-risk patients had significantly worse clinical outcomes. Notably, the study's model was better at predicting outcomes than body mass index. Importantly, these results suggest that radiographic measures of body composition should be considered for inclusion in updated prognostic models for patients with urothelial carcinoma treated with immunotherapy. These findings are useful for practicing oncologists in the academic or community setting, particularly given that baseline imaging is routine for patients starting on treatment with immunotherapy.

Modified Glasgow Prognostic Score associated with survival in metastatic renal cell carcinoma treated with immune checkpoint inhibitors

BACKGROUND

The modified Glasgow Prognostic Score (mGPS) is a composite biomarker that uses albumin and C reactive protein (CRP). There are multiple immune checkpoint inhibitor (ICI)-based combinations approved for metastatic renal cell carcinoma (mRCC). We investigated the ability of mGPS to predict outcomes in patients with mRCC receiving ICI.

METHODS

We retrospectively reviewed patients with mRCC treated with ICI as monotherapy or in combination at Winship Cancer Institute between 2015 and 2020. Overall survival (OS) and progression-free survival (PFS) were measured from the start date of ICI until death or clinical/radiographical progression, respectively. The baseline mGPS was defined as a summary score based on pre-ICI values with one point given for CRP>10 mg/L and/or albumin<3.5 g/dL, resulting in possible scores of 0, 1 and 2. If only albumin was low with a normal CRP, no points were awarded. Univariate analysis (UVA) and multivariate analysis (MVA) were carried out using Cox proportional hazard model. Outcomes were also assessed by Kaplan-Meier analysis.

RESULTS

156 patients were included with a median follow-up 24.2 months. The median age was 64 years and 78% had clear cell histology. Baseline mGPS was 0 in 36%, 1 in 40% and 2 in 24% of patients. In UVA, a baseline mGPS of 2 was associated with shorter OS (HR 4.29, 95% CI 2.24 to 8.24, p<0.001) and PFS (HR 1.90, 95% CI 1.20 to 3.01, p=0.006) relative to a score of 0; this disparity in outcome based on baseline mGPS persisted in MVA. The respective median OS of patients with baseline mGPS of 0, 1 and 2 was 44.5 (95% CI 27.3 to not evaluable), 15.3 (95% CI 11.0 to 24.2) and 10 (95% CI 4.6 to 17.5) months (p<0.0001). The median PFS of these three cohorts was 6.7 (95% CI 3.6 to 13.1), 4.2 (95% CI 2.9 to 6.2) and 2.6 (95% CI 2.0 to 5.6), respectively (p=0.0216). The discrimination power of baseline mGPS to predict survival outcomes was comparable to the IMDC risk score based on Uno's c-statistic (OS: 0.6312 vs 0.6102, PFS: 0.5752 vs 0.5533).

CONCLUSION

The mGPS is prognostic in this cohort of patients with mRCC treated with ICI as monotherapy or in combination. These results warrant external and prospective validation.

Body Composition Variables as Radiographic Biomarkers of Clinical Outcomes in Metastatic Renal Cell Carcinoma Patients Receiving Immune Checkpoint Inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICI) have revolutionized the treatment of metastatic renal cell carcinoma (mRCC). Biomarkers for mRCC patients treated with ICI are limited, and body composition is underutilized in mRCC. We investigated the association between body composition and clinical outcomes in ICI-treated mRCC patients.

METHODS

We performed a retrospective analysis of 79 ICI-treated mRCC patients at Winship Cancer Institute from 2015-2020. Baseline CT images were collected at mid-L3 and segmented using SliceOMatic v5.0 (TomoVision). Density of skeletal muscle (SM), subcutaneous fat, inter-muscular fat, and visceral fat were measured and converted to indices by dividing by height(m)2 (SMI, SFI, IFI, and VFI, respectively). Total fat index (TFI) was defined as the sum of SFI, IFI, and VFI. Patients were characterized as high versus low for each variable at gender-specific optimal cuts using overall survival (OS) as the primary outcome. A prognostic risk score was created based on the beta coefficient from the multivariable Cox model after best subset variable selection. Body composition risk score was calculated as IFI + 2*SM mean + SFI and patients were classified as poor (0-1), intermediate (2), or favorable risk (3-4). Kaplan-Meier method and Log-rank test were used to estimate OS and PFS and compare the risk groups. Concordance statistics (C-statistics) were used to measure the discriminatory magnitude of the model.

RESULTS

Most patients were male (73%) and most received ICI as first (35%) or second-line (51%) therapy. The body composition poor-risk patients had significantly shorter OS (HR: 6.37, p<0.001), PFS (HR: 4.19, p<0.001), and lower chance of CB (OR: 0.23, p=0.044) compared to favorable risk patients in multivariable analysis. Patients with low TFI had significantly shorter OS (HR: 2.72, p=0.002), PFS (HR: 1.91, p=0.025), and lower chance of CB (OR: 0.25, p=0.008) compared to high TFI patients in multivariable analysis. The C-statistics were higher for body composition risk groups and TFI (all C-statistics ≥ 0.598) compared to IMDC and BMI.

CONCLUSIONS

Risk stratification using the body composition variables IFI, SM mean, SFI, and TFI may be prognostic and predictive of clinical outcomes in mRCC patients treated with ICI. Larger, prospective studies are warranted to validate this hypothesis-generating data.

Immune-Related Adverse Events as Clinical Biomarkers in Patients with Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICIs) are an important treatment for metastatic renal cell carcinoma (mRCC). These agents may cause immune-related adverse events (irAEs), and the relationship between irAEs and outcomes is poorly understood. We investigated the association between irAEs and clinical outcomes in patients with mRCC treated with ICIs.

METHODS

We performed a retrospective study of 200 patients with mRCC treated with ICIs at Winship Cancer Institute from 2015 to 2020. Data on irAEs were collected from clinic notes and laboratory values and grades were determined using Common Terminology Criteria in Adverse Events version 5.0. The association with overall survival (OS) and progression-free survival (PFS) was modeled by Cox proportional hazards model. Logistic regression models were used to define odds ratios (ORs) for clinical benefit (CB). Landmark analysis and extended Cox models were used to mitigate lead-time bias by treating irAEs as a time-varying covariate.

RESULTS

Most patients (71.0%) were male, and one-third of patients (33.0%) experienced at least one irAE, most commonly involving the endocrine glands (13.0%), gastrointestinal tract (10.5%), or skin (10.0%). Patients who experienced irAEs had significantly longer OS (hazard ratio [HR], 0.52; p = .013), higher chance of CB (OR, 2.10; p = .023) and showed a trend toward longer PFS (HR, 0.71; p = .065) in multivariate analysis. Patients who had endocrine irAEs, particularly thyroid irAEs, had significantly longer OS and PFS and higher chance of CB. In a 14-week landmark analysis, irAEs were significantly associated with prolonged OS (p = .045). Patients who experienced irAEs had significantly longer median OS (44.5 vs. 18.2 months, p = .005) and PFS (7.5 vs. 3.6 months, p = .003) without landmark compared with patients who did not.

CONCLUSION

We found that patients with mRCC treated with ICIs who experienced irAEs, particularly thyroid irAEs, had significantly improved clinical outcomes compared with patients who did not have irAEs. This suggests that irAEs may be effective clinical biomarkers in patients with mRCC treated with ICIs. Future prospective studies are warranted to validate these findings.

IMPLICATIONS FOR PRACTICE

This study found that early onset immune-related adverse events (irAEs) are associated with significantly improved clinical outcomes in patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitors (ICIs). In this site-specific irAE analysis, endocrine irAEs, particularly thyroid irAEs, were significantly associated with improved clinical outcomes. These results have implications for practicing medical oncologists given the increasing use of ICIs for the treatment of mRCC. Importantly, these results suggest that early irAEs and thyroid irAEs at any time on treatment with ICIs may be clinical biomarkers of clinical outcomes in patients with mRCC treated with ICIs.

Racial Differences in Clinical Outcomes for Metastatic Renal Cell Carcinoma Patients Treated With Immune-Checkpoint Blockade

BACKGROUND

Immune-checkpoint-inhibitors (ICIs) have become the cornerstone of metastatic renal-cell-carcinoma (mRCC) therapy. However, data are limited regarding clinical outcomes by race. In this study, we compared the real-world outcomes between African American (AA) and Caucasian mRCC patients treated with ICIs.

METHODS

We performed a retrospective study of 198 patients with mRCC who received ICI at the Emory Winship Cancer Institute from 2015-2020. Clinical outcomes were measured by overall survival (OS), progression-free survival (PFS), and overall response rate (ORR) defined as a complete or partial response maintained for at least 6 months per response evaluation criteria in solid tumors version 1.1. Univariate and multivariable analyses were carried out for OS and PFS by Cox proportional-hazard model and ORR by logistical-regression model. Descriptive statistics compared rates of immune-related adverse events (irAEs) and non-clear-cell-RCC (nccRCC) histology were assessed using Chi-square test.

RESULTS

Our cohort was comprised of 38 AA and 160 Caucasian patients. Most were diagnosed with clear-cell-RCC (ccRCC) (78%) and more than half received (57%) PD-1/PD-L1 monotherapy. Most patients were intermediate or poor-risk groups (83%). Comparing to Caucasians, our AA cohort contained more females and nccRCC cases. Kaplan-Meier method showed AAs had no statistically different median OS (17 vs 25 months, p=0.368) and PFS (3.1 vs 4.4 months, p=0.068) relative to Caucasian patients. On multivariable analysis, AA patients had significantly shorter PFS (HR=1.52, 95% CI: 1.01-2.3, p=0.045), similar ORR (OR=1.04, 95% CI: 0.42-2.57, p=0.936) and comparable OS (HR=1.09, 95% CI: 0.61-1.95, p=0.778) relative to Caucasians.

CONCLUSIONS

Our real-world analysis of ICI-treated mRCC patients showed that AAs experienced shorter PFS but similar OS relative to Caucasians. This similarity in survival outcomes is reassuring for the use of ICI amongst real-world patient populations, however, the difference in treatment response is poorly represented in early outcomes data from clinical trials. Thus, the literature requires larger prospective studies to validate these findings.

Novel risk scoring system for metastatic renal cell carcinoma patients treated with cabozantinib

BACKGROUND

Cabozantinib is an effective treatment for metastatic renal cell carcinoma (mRCC). The international mRCC database consortium (IMDC) criteria is the gold standard for risk stratification in mRCC. We created a risk scoring system specific for mRCC patients treated with cabozantinib.

METHODS

We conducted a retrospective review of 87 patients with mRCC treated with cabozantinib at Winship Cancer Institute from 2015 to 2019. Overall survival (OS) and progression free survival (PFS) were used to measure clinical outcomes. Upon variable selection in multivariable analysis (MVA), elevated baseline monocyte-to-lymphocyte ratio (MLR), sarcomatoid histologic component, ECOG PS > 1, and absence of bone metastases were each assigned 1 point. A three-group risk scoring system was then created: low (score=0-1), intermediate (score=2), and high risk (score=3-4). The Cox proportional hazard model and Kaplan-Meier method were used for survival analyses.

RESULTS

The median age was 62 years-old and the majority were males (71%) with clear-cell RCC (75%). Most (67%) received at least 1 prior line of systemic therapy. High risk and intermediate risk pts had significantly shorter OS (high risk HR: 13.84, p<0.001; intermediate risk HR: 3.50, p = 0.004) and PFS (high risk HR: 7.31, p<0.001; intermediate risk HR: 1.87, p = 0.053) compared to low risk patients in MVA.

CONCLUSIONS

RCC patients treated with cabozantinib may benefit from specific risk stratification criteria using RCC histology, ECOG PS, sites of metastatic disease, and MLR. These variables are easily accessible in the clinical setting and may be helpful to determine which mRCC patients may benefit from treatment with cabozantinib.

Baseline Modified Glasgow Prognostic Score Associated with Survival in Metastatic Urothelial Carcinoma Treated with Immune Checkpoint Inhibitors

BACKGROUND

The modified Glasgow prognostic score (mGPS), a clinical tool that incorporates albumin and C-reactive protein, has proven useful in the prognostication of multiple cancers. Several immune checkpoint inhibitors (ICIs) have been approved for the treatment of metastatic urothelial cell carcinoma (mUC), but a prognostic biomarker is needed. We investigated the impact of mGPS on survival outcomes in patients with mUC receiving ICIs.

MATERIALS AND METHODS

We retrospectively reviewed patients with mUC treated with ICIs (programmed cell death protein 1 or programmed cell death ligand 1 inhibitors) at Winship Cancer Institute from 2015 to 2018. Overall survival (OS) and progression-free survival (PFS) were measured from the start date of ICI until death or clinical or radiographic progression, respectively. mGPS was defined as a summary score with one point given for C-reactive protein >10 mg/L and/or albumin <3.5 g/dL. Univariate (UVA) and multivariate (MVA) analyses were carried out using Cox proportional hazard model. These outcomes were also assessed by Kaplan-Meier analysis.

RESULTS

A total of 53 patients were included with a median follow-up 27.1 months. The median age was 70 years, with 84.9% male and 20.8% Black. Baseline mGPS was 0 in 43.4%, 1 in 28.3% and 2 in 28.3%. Increased mGPS at the time of ICI initiation was associated with poorer OS and PFS in UVA, MVA, and Kaplan-Meier analyses.

CONCLUSION

The mGPS may be a useful prognostic tool in patients with mUC when treatment with ICI is under consideration. These results warrant a larger study for validation.

IMPLICATIONS FOR PRACTICE

The ideal prognostic tool for use in a busy clinical practice is easy-to-use, cost-effective, and capable of accurately predicting clinical outcomes. There is currently no universally accepted risk score in metastatic urothelial cell carcinoma (mUC), particularly in the immunotherapy era. The modified Glasgow prognostic score (mGPS) incorporates albumin and C-reactive protein and may reflect underlying chronic inflammation, a known risk factor for resistance to immune checkpoint inhibitors (ICIs). This study found that baseline mGPS is associated with survival outcomes in patients with mUC treated with ICIs and may help clinicians to prognosticate for their patients beginning immunotherapy.

Phase 1 safety and pharmacodynamic study of lenalidomide combined with everolimus in patients with advanced solid malignancies with efficacy signal in adenoid cystic carcinoma

Background

Purpose: The combination of a mammalian target of rapamycin inhibitor and lenalidomide showed enhanced preclinical cytotoxicity. We conducted a phase 1 study in advanced solid tumour patients to assess safety, efficacy and pharmacodynamic (PD) outcomes.

Methods

We employed a 3+3 dose escalation design to establish the safety and recommended phase 2 doses (RP2D) of daily everolimus and lenalidomide in patients with advanced solid tumours. The starting doses were 5 and 10 mg, respectively, with planned escalation to maximum single-agent doses of 10 and 25 mg in the absence of dose-limiting toxicity. PD endpoints of lymphocyte subsets and immune cytokines were assessed in peripheral blood using multiparameter flow cytometry and LUMINEX assay. Efficacy was evaluated by cross-sectional imaging after every two cycles of treatment.

Results

The study enrolled 44 patients, median age of 58 years and 28 males (63.6%). The RP2D was established as 10 and 25 mg daily continuously for everolimus and lenalidomide. Common (>5%) grade ≥3 adverse events included rash (19%), neutropenia (19%), hypokalaemia (11%) and fatigue (9%). Best efficacy outcomes in 36 evaluable patients were partial response in 5 (13.8%), stable disease in 24 (55.8%) and progressive disease in 7 (19.4%) patients. PD assessment revealed significant association of cytokine levels (interleukin-2 (IL2), IL21 and IL17), baseline activated and total CD8+ lymphocytes and change in B cell lymphocytes and activated NK cells with clinical benefit.

Conclusions

The study demonstrated the safety of everolimus and lenalidomide with promising efficacy signal in thyroid and adenoid cystic cancers.

Clinical Trial Registration

NCT01218555

Novel Risk Scoring System for Patients with Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors

BACKGROUND

The International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria are the gold standard for risk-stratifying patients with metastatic renal cell cancer (mRCC). We developed a novel risk scoring system for patients with mRCC treated with immune checkpoint inhibitors (ICIs).

METHODS

We performed a retrospective analysis of 100 ICI-treated patients with mRCC at Winship Cancer Institute from 2015 to 2018. Several baseline variables were collected, including markers of inflammation, body mass index (BMI), and sites of metastatic disease, and all were considered for inclusion in our risk scoring system. Upon variable selection in multivariable model, monocyte-to-lymphocyte ratio (MLR), BMI, and number and sites of metastases at baseline were used for risk score calculation. Patients were categorized using four-level risk groups as good (risk score = 0), intermediate (risk score = 1), poor (risk score = 2), or very poor (risk score = 3-4). Cox's proportional hazard model and the Kaplan-Meier method were implemented for survival outcomes.

RESULTS

Most patients were male (66%) with clear cell renal cell carcinoma (72%). The majority (71%) received anti-programmed cell death protein-1 monotherapy. Our risk scoring criteria had higher Uno's concordance statistics than IMDC in predicting overall survival (OS; 0.71 vs. 0.57) and progression-free survival (0.61 vs. 0.58). Setting good risk (MLR <0.93, BMI ≥24, and D_Met = 0) as the reference, the OS hazard ratios were 29.5 (95% confidence interval [CI], 3.64-238.9), 6.58 (95% CI, 0.84-51.68), and 3.75 (95% CI, 0.49-28.57) for very poor, poor, and intermediate risk groups, respectively.

CONCLUSION

Risk scoring using MLR, BMI, and number and sites of metastases may be an effective way to predict survival in patients with mRCC receiving ICI. These results should be validated in a larger, prospective study.

IMPLICATIONS FOR PRACTICE

A risk scoring system was created for patients with metastatic renal cell carcinoma treated with immune checkpoint inhibitors. The results of this study have significant implications for practicing oncologists in the community and academic setting. Importantly, these results identify readily available risk factors that can be used clinically to risk-stratify patients with metastatic renal cell carcinoma who are treated with immune checkpoint inhibitors.

Novel risk group stratification for metastatic urothelial cancer patients treated with immune checkpoint inhibitors

BACKGROUND

We developed a novel risk scoring system for urothelial cancer (UC) patients receiving immune checkpoint inhibitors (ICI).

METHODS

We conducted a retrospective review of 67 UC patients treated with ICI at Winship Cancer Institute of Emory University from 2015 to 2018. Using stepwise variable selection in Cox proportional hazard model and Sullivan's weighting schema, baseline platelet-to-lymphocyte ratio (PLR), presence of liver metastasis, baseline albumin, and baseline Eastern Cooperative Oncology Group performance status (ECOG PS) were used for risk scoring. Patients were categorized into good risk (risk score 0-1), intermediate risk (risk score 2-3), and poor risk (risk score 4-6). Univariable (UVA) and multivariable analysis (MVA) and Kaplan-Meier method were used to assess overall survival (OS) and progression free survival (PFS).

RESULTS

The Emory Risk Scoring System had C-statistics of 0.74 (Standard Error = 0.047) in predicting OS and 0.70 (Standard Error = 0.043) in predicting PFS. Compared to good risk patients, poor risk patients had significantly shorter OS and PFS in both UVA and MVA (all P < .001), and intermediate risk patients had significantly shorter OS and PFS in both UVA and MVA (all P < .03).

CONCLUSIONS

Risk scoring using baseline PLR, presence of liver metastasis, baseline albumin, and baseline ECOG PS may effectively predict OS and PFS in UC patients receiving ICI.

A Phase I Study of Safety, Pharmacokinetics, and Pharmacodynamics of Concurrent Everolimus and Buparlisib Treatment in Advanced Solid Tumors

PURPOSE

Concurrent inhibition of mTOR and PI3K led to improved efficacy in preclinical models and provided the rationale for this phase I study of everolimus and buparlisib (BKM120) in patients with advanced solid tumor.

PATIENTS AND METHODS

We used the Bayesian Escalation with Overdose Control design to test escalating doses of everolimus (5 or 10 mg) and buparlisib (20, 40, 60, 80, and 100 mg) in eligible patients. Pharmacokinetic assessment was conducted using blood samples collected on cycle 1, days 8 and 15. Pharmacodynamic impact on mTOR/PI3K pathway modulation evaluated in paired skin biopsies collected at baseline and end of cycle 1.

RESULTS

We enrolled 43 patients, median age of 63 (range, 39-78) years; 25 (58.1%) females, 35 (81.4%) Caucasians, and 8 (18.6%) Blacks. The most frequent toxicities were hyperglycemia, diarrhea, nausea, fatigue, and aspartate aminotransferase elevation. Dose-limiting toxicities observed in 7 patients were fatigue (3), hyperglycemia (2), mucositis (1), acute kidney injury (1), and urinary tract infection (1). The recommended phase II dose (RP2D) for the combination was established as everolimus (5 mg) and buparlisib (60 mg). The best response in 27 evaluable patients was progressive disease and stable disease in 3 (11%) and 24 (89%), respectively. The median progression-free survival and overall survival were 2.7 (1.8-4.2) and 9 (6.4-13.2) months. Steady-state pharmacokinetic analysis showed dose-normalized maximum concentrations and AUC values for everolimus and buparlisib in combination to be comparable with single-agent pharmacokinetic.

CONCLUSIONS

The combination of everolimus and buparlisib is safe and well-tolerated at the RP2D of 5 and 60 mg on a continuous daily schedule.

Association Between Pretreatment Neutrophil-to-Lymphocyte Ratio and Outcome of Patients With Metastatic Renal-Cell Carcinoma Treated With Nivolumab

BACKGROUND

Biomarkers to guide treatment in metastatic renal-cell carcinoma (mRCC) are lacking. We aimed to investigate the association between pretreatment neutrophil-to-lymphocyte ratio (NLR) and outcome of patients with mRCC receiving nivolumab.

PATIENTS AND METHODS

Through retrospective chart review, we identified 38 patients with mRCC treated with standard-of-care nivolumab between 2015 and 2016 at Winship Cancer Institute of Emory University. NLR was determined from complete blood count collected before starting treatment, and imaging was performed to assess progression. The NLR cutoff value of 5.5 was determined by log-rank test, and the univariate association with overall survival (OS) or progression-free survival (PFS) was assessed by the Cox proportional hazard model and Kaplan-Meier method.

RESULTS

The 38 patients had a median age of 69 years. The PFS and OS for all patients at 12 months was 54% and 69%, respectively. The median PFS was 2.6 months in the high NLR group but not reached in the low NLR group. Low NLR was strongly associated with increased PFS with hazard ratio of 0.20 (95% confidence interval, 0.07-0.64; P = .006). The median OS was 2.7 months in the high NLR group but not reached in the low NLR group. Low NLR was significantly associated with a prolonged OS with hazard ratio of 0.06 (95% confidence interval, 0.01-0.55; P = .012).

CONCLUSION

Pretreatment NLR < 5.5 is associated with superior PFS and OS. NLR is a biomarker that can inform prognosis for patients with mRCC and should be further validated in larger cohorts and in prospective studies.

A randomized phase II trial of CRLX101 in combination with bevacizumab versus standard of care in patients with advanced renal cell carcinoma

BACKGROUND

Nanoparticle-drug conjugates enhance drug delivery to tumors. Gradual payload release inside cancer cells augments antitumor activity while reducing toxicity. CRLX101 is a novel nanoparticle-drug conjugate containing camptothecin, a potent inhibitor of topoisomerase I and the hypoxia-inducible factors 1α and 2α. In a phase Ib/2 trial, CRLX101 + bevacizumab was well tolerated with encouraging activity in metastatic renal cell carcinoma (mRCC). We conducted a randomized phase II trial comparing CRLX101 + bevacizumab versus standard of care (SOC) in refractory mRCC.

PATIENTS AND METHODS

Patients with mRCC and 2-3 prior lines of therapy were randomized 1 : 1 to CRLX101 + bevacizumab versus SOC, defined as investigator's choice of any approved regimen not previously received. The primary end point was progression-free survival (PFS) by blinded independent radiological review in patients with clear cell mRCC. Secondary end points included overall survival, objective response rate and safety.

RESULTS

In total, 111 patients were randomized and received ≥1 dose of drug (CRLX101 + bevacizumab, 55; SOC, 56). Within the SOC arm, patients received single-agent bevacizumab (19), axitinib (18), everolimus (7), pazopanib (4), sorafenib (4), sunitinib (2), or temsirolimus (2). In the clear cell population, the median PFS on the CRLX101 + bevacizumab and SOC arms was 3.7 months (95% confidence interval, 2.0-4.3) and 3.9 months (95% confidence interval 2.2-5.4), respectively (stratified log-rank P = 0.831). The objective response rate by IRR was 5% with CRLX101 + bevacizumab versus 14% with SOC (Mantel-Haenszel test, P = 0.836). Consistent with previous studies, the CRLX101 + bevacizumab combination was generally well tolerated, and no new safety signal was identified.

CONCLUSIONS

Despite promising efficacy data on the earlier phase Ib/2 trial of mRCC, this randomized trial did not demonstrate improvement in PFS for the CRLX101 + bevacizumab combination when compared with approved agents in patients with heavily pretreated clear cell mRCC. Further development in this disease is not planned.

CLINICAL TRIAL IDENTIFICATION

NCT02187302 (NIH).

A novel preoperative inflammatory marker prognostic score in patients with localized and metastatic renal cell carcinoma

Objective

Several inflammatory markers have been studied as potential biomarkers in renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate and in non-clear cell histologies. We hypothesize that a combination of specific inflammatory markers into an RCC Inflammatory Score (RISK) could serve as a rigorous prognostic indicator of overall survival (OS) in patients with clear cell and non-clear cell RCC.

Methods

Combination of preoperative C-reactive protein (CRP), albumin, erythrocyte sedimentation rate (ESR), corrected calcium, and aspartate transaminase to alanine transaminase (AST/ALT) ratio was used to develop RISK. RISK was developed using grid-search methodology, receiver-operating-characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. Prognostic value of RISK was analyzed using the Kaplan–Meier method and Cox proportional regression models. Predictive accuracy was compared with RISK to Size, Size, Grade, and Necrosis (SSIGN) score, University of California-LOS Angeles (UCLA) Integrated Staging System (UISS), and Leibovich Prognosis Score (LPS).

Results

Among 391 RCC patients treated with nephrectomy, area under the curve (AUC) for RISK was 0.783, which was comparable to SSIGN (AUC 0.776, p = 0.82) and UISS (AUC 0.809, p = 0.317). Among patients with localized disease, AUC for RISK and LPS was 0.742 and 0.706, respectively (p = 0.456). On multivariate analysis, we observed a step-wise statistically significant inverse relationship between increasing RISK group and OS (all p < 0.001).

Conclusion

RISK is an independent and significant predictor of OS for patients treated with nephrectomy for clear cell and non-clear cell RCC, with accuracy comparable to other histopathological prognostic tools.

Abstract C75: Correlation of nephrectomy status and race with overall survival in patients with metastatic renal cell carcinoma

Introduction: In most settings median overall survival (OS) is longer for non-Hispanic whites when compared to non-Hispanic blacks with metastatic renal cell carcinoma (mRCC). However, the clinical outcome has been equally poor for both groups in patients who do not undergo nephrectomy. The primary objectives of this study were to explore the reasons why patients with mRCC do not undergo nephrectomy and to evaluate the impact of nephrectomy status and race on OS.

Methods: After obtaining approval from the Institutional Review Board of Emory University and the Atlanta Research and Education Foundation, a retrospective chart review was conducted at the Atlanta VA Medical Center in conjunction with a longitudinal biomarker study of patients with mRCC. Patients who were treated with targeted therapy between 2005 and 2015 were eligible for inclusion. Nephrectomy status was assessed and the reasons for not undergoing nephrectomy were documented. Descriptive statistics were employed along with Kaplan-Meier survival analysis.

Results: Forty four of the 46 patients from the biomarker study were included in the analysis of nephrectomy status (31 non-Hispanic whites and 13 non-Hispanic blacks; 2 Hispanics were not included). Of the non-Hispanic patients, 39 had unilateral disease and 5 had bilateral disease for a total of 49 primary tumors. Nephrectomy rates with respect to the number of primary tumors were 59% for non-Hispanic whites (n=20 of 34) and 53% for non-Hispanic blacks (n=8 of 15) for an overall rate of 57% (n=28 of 49). There was no significant difference in OS by race with a median of 29.5 months (2.42 years) for non-Hispanic blacks (95% C.I. 7.4 – 56.9 months) and 35.6 months (2.92 years) for non-Hispanic whites (95% C.I. 19.4 – 61.4 months) with a log-rank p-value of 0.88. Metastasis was present at the time of nephrectomy in 14 cases while the remaining 15 cases were the result of recurrence after nephrectomy with curative intent. Of the 21 primary tumors that were not resected in 19 non-Hispanic patients, metastases were present in most instances at the time decisions were made regarding nephrectomy (n=17 of 21; 81%). There were relative or absolute contraindications to nephrectomy for 12 of the primary tumors that were not resected (57%). These included unresectable tumors and patients with poor performance status, chronic kidney disease or other significant medical comorbidities. For the 9 remaining unresected primary tumors, no contraindications to surgery were identified, yet some patients declined of their own volition, others were not referred or re-referred to urology and some did not keep their follow up appointments with urology. Also, some surgeons did not recommend nephrectomy. As such, no predominant reason for absence of nephrectomy was identified for the group as a whole or by race. However, in the absence of nephrectomy, the median OS was only 15.5 months (1.27 years) with a 95% C.I. of 8.5 to 29.5 months, versus 45.2 months (3.71 years) for patients who had undergone nephrectomy with a 95% C.I. of 30.3 to 100.9 months and a log-rank p-value of 0.0002.

Summary: No racial disparity in OS was observed in this retrospective study of a small number of patients at a single institution. However, absence of nephrectomy may be a significant confounding factor since it is a strong predictor of short survival irrespective of race. Larger studies are required. Of note, a nephrectomy was much less likely to have been performed in patients who had metastatic disease at the time of diagnosis. Though no predominant reason for absence of nephrectomy was found, key factors were identified such as unresectability, poor performance status, significant medical comorbidities, the failure to schedule or keep appointments with surgical staff, and patient choice to forego nephrectomy.

Citation Format: Dale Kesley Robertson, Yuan Liu, Chao Zhang, Theresa Gillespie, John Petros, Muta Issa, Maria Ribeiro, Wayne B. Harris. Correlation of nephrectomy status and race with overall survival in patients with metastatic renal cell carcinoma. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C75.

A novel preoperative inflammatory marker prognostic score in patients with clear cell renal cell carcinoma

566

Background: Several inflammatory markers have been singularly studied as potential biomarkers in clear cell renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate. We hypothesize that a combination of preoperative C-Reactive Protein (CRP), albumin, Erythrocyte Sedimentation Rate (ESR), corrected calcium, and AST/ALT ratio into a RCC Inflammatory Score (RISC) could serve as a rigorous prognostic indicator in patients with clear cell RCC. Methods: Patients that underwent nephrectomy for localized clear cell RCC were queried from our nephrectomy database. The optimal threshold for individual biomarkers was determined using grid search methodology, receiver operating characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. The final score, RISC, was the sum of all points accrued from each biomarker (Table). ROC and chi-square analysis was performed to compare the prognostic ability of RISC to SSIGN and UISS. Impact on overall survival was analyzed with multivariate logistic regression analysis. Results: 280 patients were included in the study. Area under the curve (AUC) for RISC, SSIGN and UISS was 0.77, 0.78, and 0.81, respectively. Chi-square analysis of AUCs revealed no statistically significant difference between RISC, SSIGN, and UISS (p= 0.975 and p =0.299, respectively). On multivariate analysis, after adjusting for confounding variables, each unit increase in RISC was associated with a 31% increase in mortality (HR=1.31, 95%CI 1.13-1.50, p<0.001). Conclusions: RISC is an independent and significant predictor of overall survival in clear cell RCC with accuracy at least as good as other established prognostic tools. Notably, RISC is composed of standardized laboratory markers easily and cost-effectively obtained preoperatively, allowing crucial prognostic information to be integrated into medical decision making prior to surgery. [Table: see text]

A novel preoperative inflammatory marker prognostic score in patients with clear cell and non-clear cell renal cell carcinoma

530

Background: Several inflammatory markers have been studied as potential biomarkers in clear cell renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate and in non-clear cell histologies. We hypothesize that a combination of preoperative C-Reactive Protein (CRP), albumin, Erythrocyte Sedimentation Rate (ESR), corrected calcium, and AST/ALT ratio into a RCC Inflammatory Score (RISC) could serve as a rigorous prognostic indicator in patients with clear cell and non-clear cell RCC. Methods: Patients that underwent nephrectomy for localized RCC were queried from our nephrectomy database. The optimal threshold for individual biomarkers was determined using grid search methodology, receiver operating characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. The final score, RISC, was the sum of points accrued from each biomarker (Table). ROC and chi-square analysis was performed to compare the prognostic ability of RISC to SSIGN and UISS. Impact on overall survival was analyzed with multivariate logistic regression analysis. Results: 391 patients were included in the study. Area under the curve (AUC) for RISC, SSIGN, and UISS was 0.78, 0.78, and 0.81, respectively. Chi-square analysis of AUCs revealed no statistically significant difference between RISC, SSIGN, and UISS (p= 0.820, and p =0.317, respectively). On multivariate analysis, after adjusting for confounding variables, each unit increase in RISC was associated with a 32% increase in mortality (HR=1.32, 95%CI 1.17-1.49, p<0.001). Conclusions: RISC is an independent and significant predictor of overall survival in clear cell and non-clear cell RCC with accuracy at least as good as other established prognostic tools. Notably, RISC is composed of standardized preoperative laboratory markers, allowing crucial prognostic information to be integrated into medical decision making prior to surgery. [Table: see text]

Nephrectomy status, race, and overall survival in patients with metastatic renal cell carcinoma

529

Background: In most settings median overall survival (OS) is longer for non-Hispanic whites relative to non-Hispanic blacks with metastatic renal cell carcinoma (mRCC). However, absence of nephrectomy has been a predictor of shorter OS for both groups. The primary objectives of this study were to define the reasons why patients with mRCC do not undergo nephrectomy and to correlate absolute contraindications to surgery with race and OS. Methods: Retrospective chart reviews of patients treated with targeted therapy for mRCC were conducted at the Winship Cancer Institute of Emory University and the AVAMC after obtaining institutional authorizations. Reasons for not undergoing nephrectomy were categorized as absolute, relative or no contraindication to nephrectomy. Descriptive statistics were employed along with Kaplan-Meier survival analysis. Results: See Table. The median OS (months) by nephrectomy status was 15.9 (6.8 – 24.7) vs. 41.8 (25.6 – 49.4), p value 0.0003, for patients at Emory with no nephrectomy vs. nephrectomy, respectively. The corresponding AVAMC values were 15.5 (8.5 – 29.5) vs. 45.2 (30.3 – 100.9), p value 0.0002. Conclusions: The number of patients with absolute contraindications to nephrectomy varied widely by race and institution, yet absence of nephrectomy was the predominant predictor of shorter OS in both settings. [Table: see text]

Abstract 593: Kinetic risk assessment with biomarkers of systemic inflammation in patients with metastatic renal cell carcinoma

Background: Empiric prognostic scoring systems for metastatic renal cell carcinoma (mRCC) are routinely employed as baseline risk stratification tools for clinical trials. However, these systems have limited clinical utility after therapeutic intervention has begun. The goal of the current study was to develop clinically useful, hypothesis-driven, kinetic risk assessment tools based exclusively on biomarkers of systemic inflammation.

Methods: A retrospective chart review was conducted with authorization from the Emory University Institutional Review Board. Inclusion criteria included treatment at the Winship Cancer Institute with a targeted agent for mRCC as well as concomitant serum C-reactive protein (CRP) and albumin levels on at least three occasions that were at least 10 days apart. The modified Glasgow Prognostic Score (mGPS) was used to quantify the intensity of systemic inflammation and to formulate the Inflammation Intensity Index for kinetic risk assessment.

Findings: Intensity of systemic inflammation was assessed 2465 times in 135 patients with cohorts used for training (n = 55; cutoff date 06/30/2012) and validation (n = 80; cutoff date 06/30/2014). Kinetic risk was assigned on the basis of time to onset of refractory systemic inflammation. The median overall survival (OS) was 44.7, 19.8, 13.0, and 6.7 months for kinetic risk categories A, B, C and D, respectively, with a median follow up of 29.3 months for the combined cohorts and none lost to follow up (censored log rank p &lt;.0001). OS was 40.6 months for whites (n = 99) vs. 9.8 months for blacks (n = 30; p &lt;.0001).

Conclusions: The correlation of dramatic differences in OS with the onset of refractory systemic inflammation provides strong evidence in support of the clinical utility of the Inflammation Intensity Index and, as a consequence, the underlying theoretical constructs, including a plausible biological hypothesis for differences in clinical outcome by race.

Citation Format: Wayne B. Harris, Omer Kucuk, Bradley Carthon, Yuan Liu, John Pattaras, Kenneth Ogan, Viraj Master. Kinetic risk assessment with biomarkers of systemic inflammation in patients with metastatic renal cell carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 593. doi:10.1158/1538-7445.AM2015-593

Abstract C15: Inflammation-free survival as a surrogate endpoint for overall survival in patients with metastatic renal cell carcinoma

Background: The primary objective of the present study was to determine the degree to which factors other than race or ethnicity contribute to large disparities in clinical outcome for patients treated with targeted therapy for metastatic renal cell carcinoma (mRCC).

Methods: A single institution retrospective study was conducted at the Winship Cancer Institute of Emory University. Inclusion criteria were as follows: (1) diagnosis of mRCC, (2) treatment with at least 1 targeted agent for mRCC and (3) concurrent serum C-reactive protein and albumin levels on at least 3 occasions that were at least 2 weeks apart. Statistical analysis was conducted using SAS V9.3 and R2.15.2. Kinetic risk assessment was performed with the newly devised inflammation intensity index (I3). Univariate and multivariate analyses were also completed.

Results: The median overall survival (OS) for the entire cohort (n=55) was 30.6 months (95% CI 19.8, 49.4) with a median follow up of 27.1 months (95% CI 22.0, 31.3). The median OS for non-Hispanic whites (n=39) was 38.4 months (95% CI 23.7, 49.4) vs. 8.6 months (95% CI 5.0, 25.6) for African Americans (n=14) and Hispanics (n=2) with a log-rank p value of &lt;0.0001. Multivariate analysis demonstrated OS was most closely associated with kinetic risk as defined by the I3 risk assessment tool (type 3 p value &lt;0.001) and nephrectomy status (type 3 p value 0.010), but not race/ethnicity.

Conclusions: Prolonged OS was most closely associated with persistent inflammation free survival and shorter OS with increases in the intensity and duration of systemic inflammation.

Citation Format: Wayne B. Harris, Dana C. Nickleach, Yuan Liu, Omer Kucuk, Viraj A. Master. Inflammation-free survival as a surrogate endpoint for overall survival in patients with metastatic renal cell carcinoma. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C15. doi:10.1158/1538-7755.DISP13-C15

External validation of the modified Glasgow prognostic score for renal cancer

PURPOSE

The modified Glasgow prognostic Score (mGPS) incorporates C-reactive protein and albumin as a clinically useful marker of tumor behavior. The ability of the mGPS to predict metastasis in localized renal cell carcinoma (RCC) remains unknown in an external validation cohort.

PATIENTS AND METHODS

Patients with clinically localized clear cell RCC were followed for 1 year post-operatively. Metastases were identified radiologically. Patients were categorized by mGPS score as low-risk (mGPS = 0 points), intermediate-risk (mGPS = 1 point) and high-risk (mGPS = 2 points). Univariate, Kaplan-Meier and multivariate Cox regression analyses examined Recurrence -free survival (RFS) across patient and disease characteristics.

RESULTS

Of the 129 patients in this study, 23.3% developed metastases. Of low, intermediate and high risk patients, 10.1%, 38.9% and 89.9% recurred during the study. After accounting for various patient and tumor characteristics in multivariate analysis including stage and grade, only mGPS was significantly associated with RFS. Compared with low-risk patients, intermediate- and high-risk patients experienced a 4-fold (hazard ratios [HR]: 4.035, 95% confidence interval [CI]: 1.312-12.415, P = 0.015) and 7-fold (HR: 7.012, 95% CI: 2.126-23.123 P < 0.001) risk of metastasis, respectively.

CONCLUSIONS

mGPS is a robust predictor of metastasis following potentially curative nephrectomy for localized RCC. Clinicians may consider mGPS as an adjunct to identify high-risk patients for possible enrollment into clinical trials or for patient counseling.

Abstract 13: Ethnic disparities in prognosis associated with persistence of the systemic inflammatory response in metastatic renal cell carcinoma

Background: Significant racial disparities in survival have been reported for kidney cancer patients in studies from the Surveillance, Epidemiology, and End Results program. These disparities could not be attributed to age, gender, tumor stage or size, histologic subtype or surgical treatment. Comparable studies of medical therapy with targeted agents for metastatic renal cell carcinoma (mRCC) are needed with a focus on defining possible biological mechanisms for these disparities. Methods: A single institution retrospective study was conducted at the Winship Cancer Institute of Emory University. Inclusion criteria were as follows: (1) diagnosis of mRCC, (2) treatment with at least 1 targeted agent and (3) serum C-reactive protein and albumin monitored on at least 3 separate occasions that were at least 2 weeks apart. Risk stratification was performed on the basis of the Inflammation Intensity Index of the Systemic Inflammatory Response (SIR) Kinetics Model. Ethnicity was not a risk stratification factor. Statistical analysis was conducted using SAS V9.3 and R V2.15. The Kaplan-Meier method was used to generate overall survival (OS) curves. One- and 2-year OS estimates were calculated with significant differences determined by the log-rank test. Results: A cohort of 55 patients was identified from among 635 patients who were evaluated for kidney cancer during the screening period of January 1, 2005 to June 30, 2011. Twenty seven patients were alive as of the cut off date of July 1, 2012. One patient was alive when lost to follow up on Day 961. The SIR was assessed a total of 804 times with a median of 14 time points per patient (range 3 to 49). A total of 113 lines of systemic therapy were administered with a median of 2 per patient (range 1 to 5). The median OS for the entire cohort was 30.6 months with a median follow up of 27.1 months (95% CI = 22.0, 31.3). The projected 1-Yr and 2-Yr OS rates were 78% and 56%, respectively for the cohort as a whole. The median OS for non-Hispanic whites (n=39) was 38.4 months (95% CI 5.0, 25.6) vs. 8.6 months (95% CI 23.7, 49.4) for blacks (n=14) and Hispanics (n=2) with a log-rank p value of &lt;0.0001. The median age was 65 (range 26-83) for non-Hispanic whites and 56 (41-73) for blacks and Hispanics. No significant differences were observed in terms of gender or lines of systemic therapy, however, the rates of nephrectomy were 97% for non-Hispanic whites (38/39), 100% for Hispanics (2/2) but only 43% for blacks (6/14). Conclusions: There is a robust inverse correlation between the intensity of the SIR of the host's innate immune system and OS in cancer patients. Nephrectomy has been associated with decreases in the intensity of the SIR in patients with mRCC. The survival advantage of Non-Hispanic whites may be related to the lack of nephrectomy among blacks as well as possible drug resistance associated with an unrelenting SIR in blacks and Hispanics in spite of targeted therapy.

Citation Format: Wayne B. Harris, Jingjing Gao, Dana C. Nickleach, Yuan Liu, Omer Kucuk, Viraj Master. Ethnic disparities in prognosis associated with persistence of the systemic inflammatory response in metastatic renal cell carcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 13. doi:10.1158/1538-7445.AM2013-13

Note: This abstract was not presented at the AACR Annual Meeting 2013 because the presenter was unable to attend.

Phase I pharmacokinetic and pharmacodynamic study of the pan-PI3K/mTORC vascular targeted pro-drug SF1126 in patients with advanced solid tumours and B-cell malignancies

BACKGROUND

SF1126 is a peptidic pro-drug inhibitor of pan-PI3K/mTORC. A first-in-human study evaluated safety, dose limiting toxicities (DLT), maximum tolerated dose (MTD), pharmacokinetics (PK), pharmacodynamics (PD) and efficacy of SF1126, in patients with advanced solid and B-cell malignancies.

PATIENTS AND METHODS

SF1126 was administered IV days 1 and 4, weekly in 28day-cycles. Dose escalation utilised modified Fibonacci 3+3. Samples to monitor PK and PD were obtained.

RESULTS

Forty four patients were treated at 9 dose levels (90-1110 mg/m(2)/day). Most toxicity was grade 1 and 2 with a single DLT at180 mg/m(2) (diarrhoea). Exposure measured by peak concentration (C(max)) and area under the time-concentration curve (AUC(0-)(t)) was dose proportional. Stable disease (SD) was the best response in 19 of 33 (58%) evaluable patients. MTD was not reached but the maximum administered dose (MAD) was 1110 mg/m(2). The protocol was amended to enrol patients with CD20+ B-cell malignancies at 1110 mg/m(2). A CLL patient who progressed on rituximab [R] achieved SD after 2 months on SF1126 alone but in combination with R achieved a 55% decrease in absolute lymphocyte count and a lymph node response. PD studies of CLL cells demonstrated SF1126 reduced p-AKT and increased apoptosis indicating inhibition of activated PI3K signalling.

CONCLUSION

SF1126 is well tolerated with SD as the best response in patients with advanced malignancies.

Abstract 5571: Inflammatory response as a novel prognostic parameter in patients with metastatic renal cell carcinoma treated with pazopanib

Over sixty thousand patients were diagnosed with metastatic renal cell carcinoma (mRCC) in 2010, yet no tumor markers have been identified. Standard prognostic systems only measure characteristics at baseline and do not assess the potential benefit of therapeutic intervention. The introduction of receptor tyrosine kinase inhibitors has significantly changed the management of mRCC. Pazopanib, a selective, multi-targeted, receptor tyrosine kinase inhibitor, was approved for mRCC in 2009. The modified Glasgow Prognostic Score (mGPS), a prognostic system based on inflammatory biomarkers (serum C-reactive protein (CRP) and albumin), has been validated in the pre-treatment setting for mRCC treated with surgery or cytokines. In this study, we present data demonstrating the correlation of serial mGPS measurements with objective responses to targeted therapy with pazopanib in patients with mRCC. We conducted a retrospective chart review of patients seen at the Winship Cancer Institute for whom serial CRP and albumin measurements as well as imaging studies were available while taking pazopanib. In these patients we assessed the correlation of pre- and post-treatment mGPS scores to objective responses by imaging. Twenty patients met inclusion criteria. Of these patients, 12 (60%) had progressive disease, and 8 (40%) had clinical benefit response (defined as stable disease, partial response, or complete response) by imaging. An elevated pre-treatment mGPS score had 75% sensitivity (95% confidence interval 35.5%-95.5%; P&lt;0.01) and 83.3% specificity (95% confidence interval 50.9%-97.1%; P&lt;0.01) for disease progression at the end of treatment. On the other hand, an elevated post-treatment mGPS score had 100% sensitivity (95% confidence interval 59.8%-100%; P&lt;0.01) and 100% specificity (95% confidence interval 69.9%-100%; P&lt;0.01) for disease progression at the end of treatment. Although these data require prospective validation, they suggest that serial measurements of serum inflammatory biomarkers may improve the sensitivity and specificity of mGPS for response to therapy. If confirmed, inflammatory response rates based on mGPS may become a valuable and cost effective tool to guide patient care and drug development for mRCC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5571. doi:1538-7445.AM2012-5571

Abstract 5169: Simple perioperative algorithm for serum C-reactive protein: A potent, independent, adverse prognostic factor for renal cell carcinoma

Introduction: Approximately 20 to 30% of patients who undergo nephrectomy with curative intent for kidney cancer will recur and die of the disease. No adjuvant therapy has been shown to reduce the risk of relapse. Risk of recurrence is largely based on T stage, Fuhrman nuclear grade and nodal status allowing the frequency of surveillance to be adjusted based on low, intermediate and high risk categories. Though C-reactive protein (CRP) has long been recognized as an adverse prognostic factor for clear cell renal cell carcinoma (ccRCC), it has not been incorporated into the risk stratification protocols of current adjuvant clinical trials. Methods: Patients with clinically localized (T1-T3N0M0) ccRCC were followed for 1 year postoperatively. Metastases were identified radiographically and mortality confirmed with the social security death registry. Univariate and multivariate binary logistic regression analyses examined 1-year relapse-free survival (RFS) and overall survival (OS) across patient and disease characteristics. Serum CRP levels were measured prior to nephrectomy and approximately one month after surgery. Patients were assigned retrospectively to the pCRP(+) group if the perioperative (either preoperative or postoperative) serum CRP level was &gt;10 mg/L. All others were assigned to the pCRP(−) group. Results: Of the 109 patients in the study, 17 patients (15.6%) developed metastases and 6 died (5.5%). The pCRP algorithm was employed to ascertain risk of recurrence with 25 patients assigned to the high risk category and 84 patients to the low risk category. Fourteen of 25 patients in the pCRP(+) group recurred at 1 year including all 6 who died. Only 3 of the remaining 84 patients in the pCRP(−) group recurred with no deaths. The sensitivity and specificity of the pCRP algorithm for metastasis were 82% and 88%, respectively, with a positive predictive value (PPV) of 56% and a negative predictive value (NPV) of 96%. The sensitivity and specificity of the pCRP algorithm for mortality were 100% and 82%, respectively, with a PPV of 24% and a NPV of 100%. The p values for metastasis and mortality were both &lt;0.0001. The pCRP algorithm appears to be independent of T-stage and Furhman nuclear grade. Conclusions: When applied retrospectively, the pCRP algorithm accurately identified patients among those considered to be at low risk of recurrence whose actual risk was, in fact, extremely high. The pCRP algorithm also identified patients considered to be at high risk whose actual risk may be somewhat lower. The high NPV of the pCRP algorithm may allow patients in the pCRP(−) group to be spared the potential toxicity and expense of adjuvant therapy. External validation of the pCRP algorithm is needed to establish CRP as a clinically relevant biomarker with a potential role as a novel therapeutic target for ccRCC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5169. doi:10.1158/1538-7445.AM2011-5169

Postoperative better than preoperative C-reactive protein at predicting outcome after potentially curative nephrectomy for renal cell carcinoma

OBJECTIVES

Preoperative C-reactive protein (CRP) predicts metastasis and mortality in localized renal cell carcinoma (RCC). However, the predictive potential of after resection of localized RCC remains unclear. Therefore, we assessed the absolute ability of postoperative CRP to predict metastases and mortality as a continuous variable.

METHODS

Patients with clinically localized (T1-T3N0M0) clear-cell RCC were followed for 1 year postoperatively. Metastases were identified radiologically and mortality by death certificate. Univariate and multivariate binary logistic regression analyses examined 1 year relapse-free survival (RFS) and overall survival (OS) across patient and disease characteristics.

RESULTS

Of the 110 patients in this study, 16.4% developed metastases and 6.4% died. Mean (SD) postoperative CRP for patients who did and did not develop metastases were 69.06 (73.55) mg/L and 5.27 (7.80), respectively. Mean (SD) postoperative CRP for patients who did and did not die were 89.31 (69.51) mg/L and 10.88 (30.32), respectively. In multivariate analysis, T-stage (OR: 12.452, 95% CI: 2.889-53.660) and postoperative CRP ((B: .080, SE: .025; P < .001) were significant predictors of RFS. T-Stage (OR: 11.715; 95% CI: 1.102-124.519) and postoperative CRP (B: .017; SE: .007; P < .001) were also significant predictors of OS. After adjusting for postoperative CRP, preoperative CRP was not predictive of these outcomes.

CONCLUSIONS

Postoperative, not preoperative, CRP is the better predictor of metastasis and mortality following nephrectomy for localized RCC. Clinicians should consider absolute postoperative CRP to identify high-risk patients for closer surveillance or additional therapy. Predictive algorithms should consider incorporating postoperative CRP as a continuous variable to maximize predictive ability.

Sleep/Wake patterns of individuals with advanced cancer measured by ambulatory polysomnography

PURPOSE

Sleep/wake disturbances are prevalent in patients with advanced cancer, but 24-hour polysomnography (PSG) examinations of these patterns have not been undertaken. The purpose of this study was to describe these sleep/wake patterns using continuous PSG and to explore relationships with selected demographic and clinical variables.

PATIENTS AND METHODS

The sample included patients with advanced cancer (solid tumors); those with neurologic disorders or psychosis, substance abuse, or brain metastasis were excluded. The final sample included 114 participants with a mean age of 51.1 years (+/- 9.1 years). Participants underwent continuous, ambulatory PSG for 42 hours in their home environments. Standard PSG measures were calculated. Analysis included data from 2 nights and the intervening day. Descriptive statistics were used to summarize sleep/wake parameters of the average of the 2 nights and the intervening day. Nonparametric analyses were used to detect differences and relationships among the variables.

RESULTS

Compared with normative data, participants had reduced quantity and quality of nocturnal sleep and episodes of sleep scattered throughout the day. Increased daytime sleep was negatively associated with several key parameters of nocturnal sleep quantity and quality. Women, whites, and those who were married/partnered and had more education had better nocturnal sleep. Cancer type and selected medications may be risk factors for disturbed sleep and waking.

CONCLUSION

Participants experienced severe difficulty with "state maintenance", or the ability to maintain both the sleep and waking states. Research designed to identify the etiology of these problems is needed to develop effective interventions.

Suppression of androgen receptor expression by dibenzoylmethane as a therapeutic objective in advanced prostate cancer

BACKGROUND

The androgen receptor (AR) plays an important role in the development and progression of prostate cancer. Functional AR expression persists in most cases of hormone-refractory prostate cancer and may play a role clinically in the progression from hormone-responsive to hormone-refractory or advanced prostate cancer. In order to combat the progression of this disease, one needs to identify new chemotherapeutic agents with novel mechanisms of action.

MATERIALS AND METHODS

In this study, we attempt to clarify the molecular mechanism by which dibenzoylmethane (DBM), a beta3-diketone, inhibits the growth of androgen-responsive human LNCaP prostate cancer cells and down-regulates expression of the AR. To this end, we treated LNCaP cells with different concentrations of DBM to monitor function and expression of AR and an AR-associated protein.

RESULTS

Previous studies showed that DBM could inhibit cell proliferation in LNCaP cells by arresting the cells at the G1 phase without causing cell death. Western blot and RT-PCR/Northern blot analyses showed a reduction in AR protein and mRNA expression by DBM in a dose-dependent manner. Furthermore, stable transfections of an androgen-independent human prostate cancer cell line, transfected with a full-length human AR cDNA sequence, showed that DBM down-regulated AR protein levels. DBM also inhibited the secretion of the AR-regulated tumor marker, prostate-specific antigen (PSA). Moreover, the relative binding affinity of DBM to AR was lower than that of the synthetic androgen R1881 (methyltrienolone) suggesting that DBM must suppress AR expression independent of an AR-DBM bound interaction.

CONCLUSION

These data provide new insights into how DBM regulates AR function and cell growth, as well as providing promising evidence to support DBM as a chemotherapeutic agent for prostate cancer through suppression of the function of the androgen receptor.

Proteomic analysis of proteins altered by dibenzoylmethane in human prostatic cancer LNCaP cells

This paper explores the use of proteomics as a tool for identifying protein species whose expression has been altered by dibenzoylmethane (DBM) in LNCaP cells. Although DBM, a constituent of licorice, has been shown to induce cell cycle arrest and regulate androgen receptor (AR) expression, the mechanism by which these events occur is unknown. To develop a better understanding of the effect of DBM on cancer cells, we analyzed changes in protein expression induced by DBM in LNCaP cells using two-dimensional (2-D) gel electrophoresis. The proteomic approach used to study LNCaP cells has lead to the analysis and identification of a number of protein species that increase or decrease as a result of exposure to DBM. In particular, twenty features were found to be differentially expressed in this study based on the quantitation of two separate 2-D-fluorescence difference gel electrophoresis analyses. Thirteen of these features were identified through mass spectrometric analysis. The intensity of 10 out of the 13 spots identified increased 2- to 3-fold in response to 25 micro M and 50 micro M DBM and the remaining three spots decreased 2-fold in response to the same DBM treatment. This study investigates proteomic changes induced by treatment of cells with DBM in order to develop a model for the mechanism by which DBM induces cell cycle arrest and represses AR expression.

Neoadjuvant induction chemotherapy followed by chemoradiation: a phase I trial of gemcitabine, cisplatin, and 5-fluorouracil for advanced pancreatic/gastrointestinal malignancies

The authors developed a strategy that includes a novel approach of induction full-dose chemotherapy followed by traditional chemoradiation as a neoadjuvant therapy for pancreatic cancer. Here they report the results of a phase I/II trial of gemcitabine, cisplatin, and 5-FU for patients with advanced gastrointestinal malignancies.

Dibenzoylmethane, a natural dietary compound, induces HIF-1 alpha and increases expression of VEGF

Hypoxia-inducible factor 1 (HIF-1) is the major transcription factor activated during hypoxia. It is composed of HIF-1 alpha and HIF-1 beta subunits. While HIF-1 beta is constitutively expressed, HIF-1 alpha is targeted to proteasome degradation under normoxic conditions. Under hypoxia, HIF-1 alpha is stabilized and heterodimerizes with HIF-1 beta. Iron chelators have also been reported to stabilize HIF-1 alpha protein and activate HIF-1. In this study, we investigated the effects of dibenzoylmethane (DBM), a natural dietary compound and an iron chelator, on HIF-1 pathway. We found that DBM increases HIF-1 alpha protein levels in a dose- and time-dependent manner. This induction was accompanied with activation of HIF-1, measured by reporter gene assay and increased production of its downstream target, the vascular endothelial growth factor. Mechanistically, HIF-1 alpha was stabilized by DBM at a step prior to ubiquitination. The effect of DBM on HIF-1 and its low toxicity profile might be therapeutically beneficial in ischemic diseases.

Dibenzoylmethane induces cell cycle deregulation in human prostate cancer cells

Dibenzoylmethane (DBM), a minor beta-diketone constituent of licorice and sunscreens, has been shown to exhibit anti-neoplastic effects in chemically induced skin and mammary cancers in several animal models. To date, no mechanism for the growth inhibitory effects of DBM on prostate cancer cells has been proposed. In this study, we examined the effects of DBM on the growth and cell cycle kinetics of several human prostate carcinoma cell lines. Using an MTT cytotoxicity assay, IC50 values of 25-100 microM were observed following 72 h exposure to DBM. LNCaP, DU145, and PC-3 prostate carcinoma cell lines were particularly sensitive in comparison to the cells with the vehicle alone. Flow cytometric analyses showed deregulation of the cell cycle, which correlated with the observed cytostatic effects of DBM in prostate carcinoma cells. These data suggest a potential role for DBM in the prevention and treatment of prostate cancer.

Effect of difluoromethylornithine on host and tumor polyamine metabolism during total parenteral nutrition

Clinical and experimental data suggest that erythrocyte (RBC) polyamine (PA) levels are markers of tumor proliferation during total parenteral nutrition (TPN). The purpose of this experiment was to determine whether the inhibition of PA synthesis during TPN was greater in tumors than in normal host tissue. Rats bearing a subcutaneous fibrosarcoma were randomized to receive a chow diet (n = 5), TPN (n = 5), or TPN + difluoromethylornithine (DFMO) (an irreversible inhibitor of ornithine decarboxylase (ODC), at 1000 mg/kg body wt/day n = 4) for 6 days by continuous central venous infusion. TPN + DFMO resulted in a higher plasma albumin level and lower tumor ODC activity compared with chow feeding or TPN. Liver ODC activity was similar for the chow fed, TPN, and TPN + DFMO groups. RBC putrescine, tumor putrescine, and tumor spermidine levels were significantly lower in the TPN + DFMO group compared with the chow fed and TPN groups. RBC spermidine, RBC spermine, and tumor spermine levels were significantly increased with TPN + DFMO compared with TPN alone. DFMO did not produce diarrhea or weight loss. Increased RBC spermidine may indicate a toxic effect of DFMO on the tumor, resulting in leakage of tumor spermidine into the extracellular space. The data suggest that DFMO during TPN can selectively inhibit tumor PA synthesis and may improve host utilization of nutrients.

Fertilizer responses with non-irrigated Shiraz grapevines, 1944-1966

A long-term factorial trial with nitrogen, phosphorus, and potassium fertilizers was started at Nuriootpa Viticultural Station, South Australia on the grape cultivar Shiraz in 1944. Results show a significant yield response to superphosphate. Long-term applications of ammonium sulphate resulted in severe reduction of vine growth and yield, and a significant lowering of soil pH. No direct response to potassium sulphate was obtained except in one year, but a positive interaction between potassium and phosphorus occurred in some years. An analysis of the components of yield in 1964 showed that the increase in yield with superphosphate was due to an increase in the number of berries per bunch. The nitrogen, phosphorus, and potassium contents of petioles were determined and related to available reference standards.