The View of Turkish Oncologists Regarding MSI Status and Tumor Localization in Stage II and III Colon Cancer

INTRODUCTION

Although several clinical factors which show the benefit of adjuvant chemotherapy (AC) in early-stage colon cancer use for evaluating the risk of relapse, there is no consensus on which risk factors are more reliable. In this study, we evaluated both the utility of MSI and the daily practice of the Turkish oncologists in stage II and III colon cancer.

MATERIAL AND METHOD

We conducted an online questionnaire which was consisting of twenty questions including the treatment choices and duration about stage II-III colon cancer depending on sidedness and risk factors for relapse.

RESULTS

More than 65% of the oncologists declared the use of MSI testing in stage II colon cancer without considering any risk factors. In stage 3 colon cancer oncologists had an equal decision "to do or not to do" in MSI testing. More than 50% of the oncologists had preferred XELOX protocol in high-risk stage II (T4N0) colon cancer, while three out of four preferred observation in low-risk stage II (T3N0) patients without risk factors. Two-thirds of the oncologists had preferred 6 months of treatment in stage II colon cancer with at least one risk factor.

CONCLUSION

Turkish oncologists participating to this trial had declared conflicting results about adjuvant treatment in early-stage colorectal cancer in their daily practice compared with the updated guidelines, especially, MSI evaluation utility in stage III colon cancers, adjuvant chemotherapy (AC) duration, and oxaliplatin adding to AC in elderly and stage II patients.

Characteristics of Newly Diagnosed Hepatocellular Carcinoma Patients Across Turkey: Prospective Multicenter Observational 3K Registry Study

AIMS

To evaluate patient profile for epidemiological and clinicopathological characteristics and potential risk/prognostic factors in newly diagnosed hepatocellular carcinoma (HCC) patients across Turkey.

METHODS

A total of 547 patients (mean (SD) age 62.6 (10.3) years, 81.9% were males) were included in this registry study. Data on patient characteristics, etiologies of HCC, laboratory values, and tumor characteristics and stages were recorded at study enrollment.

RESULTS

HBV infection (68.2%) was the leading etiology, followed by HCV infection (17.2%), HDV infection (5.5%), alcohol (6.4%), and NAFLD (3.5%), as the major etiologies. Considering that 51.6% of the patients had >5 cm HCC, 44% were Child-Pugh B/C and 57% were BCLC B-D, it appears that a significant group of HCC patients were diagnosed at advanced stages. Of 540 patients, 271 (50.2%) were referred or applied with the diagnosis of HCC. Patients with HCC at presentation had larger tumor size (median (min-max) 6.6 (0-30) vs. 4.8 (0-90) cm, P < .001) and more advanced BCLC stage (Stage C-D in 40.8% vs. 26.4%, respectively, P = .005), compared to patients who were diagnosed during follow-up.

CONCLUSIONS

Our findings revealed that HBV infection was the leading etiology and a moderate-to-advanced disease was evident in more than half of patients at the time of diagnosis. HCC patients diagnosed at follow-up had smaller tumor size and earlier BCLC stage.

Quality of life study of patients with unresectable locally advanced or metastatic pancreatic adenocarcinoma treated with gemcitabine+nab-paclitaxel versus gemcitabine alone: AX-PANC-SY001, a randomized phase-2 study

BACKGROUND

Combination of gemcitabine and nab-paclitaxel has superior clinical efficacy than gemcitabine alone. Nevertheless, health-related quality of life. (QoL) associated with this combination therapy when administered at first-line in advanced pancreatic adenocarcinoma is unknown.

METHODS

A total of 125 patients were randomized to combination therapy (1000 mg/m2 gemcitabine + 125 mg/m2 nab-paclitaxel) and single-agent gemcitabine (1000 mg/m2) arms to take treatment weekly for 7 of 8 weeks, and following 3 of 4 weeks, until progression or severe toxicity. Primary endpoints were three-months of definitive deterioration free percent of patients, and QoL.

RESULTS

Overall QoL analyses showed that 34 and 58.3% of cases in gemcitabine and gemcitabine+nab-P arms had no deterioration in 3rd month QoL scores (p = 0.018). These proportions were 27.3 and 36.6% in 6^th month assessments, respectively (p = 0.357). Median overall survivals in combination and single-agent arms were 9.92 months and 5.95 months, respectively (HR: 0.64, 95% CI: 0.42-0.86, p = 0.038). Median progression free survivals in these treatment arms were 6.28 and 3.22 months, respectively (HR: 0.58, 95% CI: 0.39-0.87, p = 0.008). Median time-to-deterioration were 5.36 vs 3.68 months, and objective response rates were 37.1% vs 23.7% (p = 0.009), respectively in combination and single-agent arms.

CONCLUSIONS

Combination therapy with gemcitabine + nab-paclitaxel had better overall and progression-free survival than gemcitabine alone. Also, combination therapy showed increased response rate without toxicity or deteriorated QoL. Combination treatment with gemcitabine and nab-paclitaxel may provide significant benefit for advanced pancreatic cancer.

TRIAL REGISTRATION

This study has been registered in ClinicalTrials.gov as NCT03807999 on January 8, 2019 (retrospectively registered).

Safety and efficacy of regorafenib in patients with treatment-refractory metastatic colorectal cancer in Turkey: the single-arm, open-label REGARD study

OBJECTIVES

Regorafenib improved overall survival in patients with metastatic colorectal cancer (mCRC) refractory to standard therapies in two randomised, phase III trials, but has not been evaluated in Turkey. REGARD evaluated the safety and efficacy of regorafenib in Turkish patients with treatment-refractory mCRC.

DESIGN

Open-label, single-arm, phase IIIb study conducted between July 2013 and April 2015.

SETTING

11 tertiary centres in Turkey.

PARTICIPANTS

Eligible patients were adults with mCRC who had disease progression within 3 months after receiving their last dose of approved standard therapies and who had an Eastern Cooperative Oncology Group performance status ≤1. Patients were excluded if they had previously received regorafenib. Of 139 patients screened, 100 were treated and completed the study, and all 100 were analysed. Fifty-eight per cent were male.

INTERVENTIONS

Patients received oral regorafenib, 160 mg once daily, for the first 3 weeks of each 4-week cycle until disease progression, death or unacceptable toxicity.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was safety, assessed by incidence of treatment-emergent adverse events (TEAEs). Progression-free survival (PFS) per investigator was the primary efficacy endpoint. There were no secondary endpoints.

RESULTS

The median treatment duration was 2.5 months (range 0.1 to 20.6). Ninety-six per cent of patients had at least one TEAE and 77% had a grade ≥3 TEAE. The most common grade ≥3 regorafenib-related TEAEs were hypophosphataemia (11%), fatigue (8%), hyperbilirubinaemia (6%), hand-foot skin reaction (5%), hypertension (5%), anorexia (5%) and increased alanine aminotransferase (5%). TEAEs led to dose reduction in 30% of patients. Regorafenib-related TEAEs led to treatment discontinuation in 17% of patients. Median PFS was 3.1 months (95% CI 2.9 to 3.8).

CONCLUSION

The regorafenib safety profile and PFS in REGARD were consistent with the results of previous trials of regorafenib in mCRC. Regorafenib is an option for patients in Turkey with treatment-refractory mCRC.

TRIAL REGISTRATION NUMBER

NCT01853319, ClinicalTrials.gov.

Objective response rate assessment in oncology: Current situation and future expectations

The tumor objective response rate (ORR) is an important parameter to demonstrate the efficacy of a treatment in oncology. The ORR is valuable for clinical decision making in routine practice and a significant end-point for reporting the results of clinical trials. World Health Organization and Response Evaluation Criteria in Solid Tumors (RECIST) are anatomic response criteria developed mainly for cytotoxic chemotherapy. These criteria are based on the visual assessment of tumor size in morphological images provided by computed tomography (CT) or magnetic resonance imaging. Anatomic response criteria may not be optimal for biologic agents, some disease sites, and some regional therapies. Consequently, modifications of RECIST, Choi criteria and Morphologic response criteria were developed based on the concept of the evaluation of viable tumors. Despite its limitations, RECIST v1.1 is validated in prospective studies, is widely accepted by regulatory agencies and has recently shown good performance for targeted cancer agents. Finally, some alternatives of RECIST were developed as immune-specific response criteria for checkpoint inhibitors. Immune RECIST criteria are based essentially on defining true progressive disease after a confirmatory imaging. Some graphical methods may be useful to show longitudinal change in the tumor burden over time. Tumor tissue is a tridimensional heterogenous mass, and tumor shrinkage is not always symmetrical; thus, metabolic response assessments using positron emission tomography (PET) or PET/CT may reflect the viability of cancer cells or functional changes evolving after anticancer treatments. The metabolic response can show the benefit of a treatment earlier than anatomic shrinkage, possibly preventing delays in drug approval. Computer-assisted automated volumetric assessments, quantitative multimodality imaging in radiology, new tracers in nuclear medicine and finally artificial intelligence have great potential in future evaluations.

Bevacuzimab May Be Less Effective in Obese Metastatic Colorectal Cancer Patients

PURPOSE

The purpose of this study was to investigate whether obesity affects survival in metastatic colorectal cancer (mCRC) patients treated with bevacizumab combined with chemotherapy.

METHODS

A total of 563 patients with mCRC who had received first-line chemotherapy in combination with bevacizumab were studied. Patients were grouped as obese (BMI levels > 30) or non-obese (BMI levels < 30). Progression-free survival (PFS) and overall survival (OS) were analyzed. Primary tumor location was also investigated in terms of PFS and OS.

RESULTS

The median age of the patients was 59 years. The non-obese group had longer PFS than the obese group (P = 0.030). The 2-year survival rate of the non-obese group was also significantly higher (P = 0.036). The median PFS of non-obese patients was significantly longer in Kras wild-type patients (10.1 vs. 8.1 months, P = 0.010). Among patients with left-sided primary tumor location, median PFS and OS were significantly higher in the non-obese group (PFS non-obese, 11.5 months; obese, 8.8 months; P = 0.002) (OS non-obese, 29.4 months; obese, 21.4 months; P = 0.026).

CONCLUSIONS

Efficacy of bevacizumab may be lower in obese patients. Among patients with Kras wild-type left-sided tumors treated with bevacizumab-based regimens, the prognosis could be worse for obese patients than that for non-obese patients. There is a need for prospectively designed studies of obese patients to prove the efficacy and dosages of bevacizumab in treatment of mCRC.

Kras-mutation influences outcomes for palliative primary tumor resection in advanced colorectal cancer-a Turkish Oncology Group study

PURPOSE

We aimed to investigate the prognostic effect of primary tumor resection (PTR) prior to bevacizumab-based treatments in unresectable metastatic colorectal cancer (mCRC).

METHODS

We retrospectively collected 341 mCRC cases with unresectable metastases at diagnosis. PTR was performed in 210 cases (the surgery group) and the other patients (n = 131) were followed without PTR (the no-surgery group). All the patients were treated with bevacizumab combined chemotherapy regimens.

RESULTS

The median progression free survival (PFS) of the surgery group was 10.4 months (95% CI: 8.9-11.9), which was significantly better than that of the no-surgery group (7.6 months, 95% CI: 6.4-8.8, P=0.000). The median overall survival (OS) of the surgery group was longer than that of the no-surgery group (27.4 months vs. 18.3 months, respectively, P=0.000). The median PFS and OS of the surgery group were 10.4 months and 28.2 months, which were significantly longer than that of the no-surgery group in Kras-mutant patients (7.8 months and 18.3 months; P=0.004, P=0.028, respectively). There was no difference in terms of PFS and OS between the surgery and the no-surgery groups in Kras-wild type patients.

CONCLUSION

Palliative PTR may improve the survival outcomes for unresectable mCRC patients. PTR may be preferred, particularly in Kras-mutant patients.

Neoadjuvant volumetric modulated arc therapy in rectal cancer and the correlation of pathological response with diffusion-weighted MRI and apoptotic markers

PURPOSE

In this prospective observational study, we aimed to report the applicability and tolerability of neoadjuvant volumetric modulated arc therapy with simultaneous integrated boost (SIB-VMAT) and concurrent chemotherapy in patients with locally advanced rectal cancer (LARC), and to evaluate the correlation of pathological response with apparent diffusion coefficient (ADC) measurements on diffusion-weighted magnetic resonance imaging (DW-MRI) and apoptotic markers.

METHODS

The study enrolled 30 patients with T3 to T4 and/or N+ rectal cancer who preoperatively received SIB-VMAT and concurrent chemotherapy. Before and after the neoadjuvant treatment, apoptotic markers including the nucleosomes and cell-free DNA fragments in the serum samples were examined; DNA integrity was assessed by amplifying the ACTB gene; and the ADC measurements on the DW-MRI were analyzed.

RESULTS

No patients had acute or chronic grade III-IV toxicity. Pathologic complete response (pCR) was achieved in 8 patients (27%), while in 10 patients (33%) near-complete pathological response was obtained. Posttreatment ADC was significantly higher in patients with pCR compared with the others (1.28 vs. 1.10, p = 0.017). ROC curve analysis showed that posttreatment ADC values had a sensitivity of 75% and a specificity of 77.3% for distinguishing the patients with pCR from other responders. On the other hand, posttreatment DNA integrity values were revealed lower than the pretreatment values (p = 0.36). Also, the results revealed an insignificant increase in the posttreatment serum level of nucleosomes (p = 0.72).

CONCLUSIONS

Neoadjuvant SIB-VMAT with concurrent chemotherapy was proved to be a feasible treatment regimen in LARC with tolerable side effects, and improved local control rate and pCR rate.

Imatinib response of gastrointestinal stromal tumor patients with germline mutation on KIT exon 13: A family report

Familial gastrointestinal stromal tumor (GIST) is a rare autosomal dominant disorder associated with mutations in the KIT gene in the majority of cases. Although, exon 11 appears to be the hot spot region for approximately 95% of germline mutations, pathogenic variations have also been identified in exon 8, 13 and 17. Exon 13 germline mutations are extremely rare amongst familial GISTs and seven families with a germline mutation have been reported to date. Moreover, the role of imatinib mesylate in this rare familiar settings is not completely known so far. We describe here clinical, imaging, pathological and genetic findings of a family with four affected members; grandmother, his son and two grand-sons having a germline gain-of-function mutation of KIT in exon 13 and discuss the imatinib mesylate treatment surveillance outcomes towards disease management.

Benefit of Bevacizumab-Based Frontline Therapy in Patients with Metastatic Colorectal Cancer (mCRC): a Turkish Oncology Group Study

BACKGROUND

Several chemotherapy regimens using bevacizumab have been developed. Our goal was to investigate regimens that have demonstrated significant clinical activity in patients with metastatic colorectal cancer (mCRC).

MATERIALS AND METHODS

Six hundred and sixty six patients with mCRC who received first-line chemotherapy combination with bevacizumab were studied. Fluoropyrimidine (F) plus irinotecan (I)-based (FI-bev), F plus oxaliplatin (O)-based (FO-bev), and F-based (F-bev) treatment regimens were compared with respect to progression-free survival (PFS) and overall survival (OS).

RESULTS

The median PFS of FI-bev (n = 414) was 10.9 months (95 % CI 10-11.8), of FO-bev (n = 211) was 9.4 months (95 % CI 8.3-10.4), and of F-bev (n = 41) was 9.5 months (95 % CI 5.9-13.1) (p = 0.089). The median OS of FI-bev was 26.3 months (95 % CI 21.7-30.9), of FO-bev was 27 months (95 % CI 24.3-29.7), and of F-bev was 23.3 months (95 % CI 12.7-33.9) (p = 0.102). In KRAS wild-type patients, the median PFS of FI-bev group was significantly longer than FO-bev group (10.5 vs. 9.1 months, p = 0.006). The FI-bev group had better OS than FO-bev group with borderline significance (p = 0.058). The FI-bev group had significantly longer OS than F-bev group. Patients who underwent metastasectomy or those with Eastern Cooperative Oncology Group performance status (ECOG-PS) ≤1 had longer PFS and OS independent of the type of chemotherapy regimen.

CONCLUSION

FI-bev may be the preferred frontline regimen for patients with KRAS wild-type mCRC. Metastasectomy and performance score were the strongest positive predictors of OS and PFS regardless of backbone chemotherapy regimen.

Evaluation of Serum Interleukin-17 (IL-17) Levels as a Diagnostic Marker in Pancreatic Adenocarcinoma

BACKGROUND

Inflammatory cytokines modulate immune responses in the tumor microenvironment during progression. The role of interleukin (IL-17) in cancer is currently under debate. This study was conducted to investigate the serum levels of IL-17 in patients with pancreatic adenocarcinoma (PA) and the relationship with tumor progression and known prognostic parameters.

MATERIAL AND METHODS

Thirty-five patients with PA were investigated. Serum samples were obtained on first admission before treatment and follow-up. Both serum IL-17 levels were determined using enzyme-linked immunosorbent assay (ELISA). Age- and sex-matched 35 healthy controls were included in the analysis.

RESULTS

The median age at diagnosis was 61 years, range 38-84 years; 21 (60%) patients were men. The tumor was located in the head of pancreas in 24 (69%) patients. The most common metastatic site was liver in 20 patients with metastasis (n = 18, 90%). The median follow-up time was 24.0 weeks (range 1.0-191.0 weeks). At the end of the observation period, 12 (34%) patients experienced disease progression and 23 patients (66%) were dead. Forty-four percent of 18 metastatic patients who received palliative chemotherapy (CTx) were CTx-responsive. Median progression-free survival and overall survival of the whole group were 13.7 ± 2.3 weeks [95% confidence interval (CI) = 9-18 weeks] and 48.0 ± 12.8 weeks (95% CI = 23-73 weeks), respectively. The baseline serum IL-17 levels were significantly higher in patients with PA than in the control group (p = 0.001). Moreover, serum IL-17 levels were significantly higher in the patients with large pathologic tumor status and low albumin levels (p = 0.04 and p = 0.03, respectively). However, serum IL-17 assays had no prognostic roles on outcome.

CONCLUSION

Although serum levels of IL-17 assays were found to be diagnostic value, no predictive and prognostic value was determined in PA patients.

Serum nectin-2 levels are diagnostic and prognostic in patients with colorectal carcinoma

INTRODUCTION

Nectins are a family of integral protein and immunoglobulin-like cell adhesion molecules involved in the formation of functioning adherence and tight junctions. Aberrant expression is associated with cancer progression, apoptosis and cell proliferation but little is known how these effects change in cell behavior. The objective of this study was to evaluate the serum levels of nectin-2 with regard to diagnostic, predictive and prognostic value in colorectal cancer (CRC) patients.

MATERIALS AND METHODS

One-hundred and forty CRC patients were enrolled in this study. Serum nectin-2 levels were determined by enzyme-linked immunosorbent assay method. Age- and sex-matched 40 healthy controls were included in the analysis.

RESULTS

Median age of patients was 60 years old, range 24-84 years. The localization of tumor in majority of the patients was colon (n = 81, 58 %). Non-metastatic (stage II and III) and metastatic patients' baseline serum nectin-2 levels were significantly higher than those in the healthy control group (p < 0.001; for two group). However, known clinical variables including response to CTx (chemotherapy) were not found to be correlated with serum nectin-2 concentrations (p > 0.05). While non-metastatic group patients with elevated serum nectin-2 levels showed significant adverse effect on PFS, metastatic group patients with elevated serum nectin-2 levels showed no significant adverse effect on PFS (p = 0.05 and p = 0.29, respectively). On the other hand, our study results did not show statistically significant serum nectin-2 concentrations regarding overall survival rates.

CONCLUSION

Serum levels of nectin-2 may have diagnostic roles for CRC patients. Moreover, our study results show the prognostic role of nectin-2 in non-metastatic group patients.

Clinical significance of serum interleukin-17 levels in colorectal cancer patients

PURPOSE

The proinflammatory cytokine, interleukin-17 (IL-17) plays a potent role in T-cell mediated angiogenesis and promotes tumorigenicity. The objective of this study was to determine the clinical outcomes of colorectal cancer (CRC) patients in relation to serum IL-17 levels.

METHODS

Ninety-six CRC patients were enrolled in this study. Pre-treatment serum IL-17 levels were determined by enzyme- linked immunosorbent assay (ELISA). Thirty age - and sex-matched healthy controls were included in the analysis.

RESULTS

The median patient age was 60 years (range: 24-84) and the most frequent localization was colon (N=59;61%). Median follow-up time was 14 months, 27 patients (28%) experienced disease progression, and 20 of the remaining patients (20%) died. The estimated and 1-year progression-free survival (PFS) and 2-year overall survival (OS) rates for the whole patient group were 26.9% (95% confidence interval [CI]=9.9-44.0) and 71% (95% CI=56.0- 85.0), respectively. The number of patients who received neoadjuvant treatment was 25. Of the patients who received palliative treatment, 11 had oxaliplatin whereas 18 and 7 had irinotecan and FU/capecitabine, chemotherapy (CTx). Twenty-four and nine of the patients who received targeted therapy had bevacizumab and cetuximab, respectively. Thirty-three percent of 36 metastatic patients who received palliative CTx were CTx-responsive. The baseline median serum IL-17 levels were significantly lower in patients with CRC than in the healthy control group (p=0.01). Moreover, known clinical variables including older age, poor grade and low albumin levels were found to be correlated with high serum IL-17 concentrations (p=0.02, p=0.02, and p=0.04, respectively). No statistically significant serum IL- 17 concentrations were noted regarding PFS and OS.

CONCLUSION

Serum levels of IL-17 may be diagnostic marker in CRC patients. However, no predictive and prognostic values were determined.