Definitive chemoradiation therapy with capecitabine in locally advanced pancreatic cancer

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Background: We evaluated safety and efficacy of concurrent chemoradiotherapy (CCRT) with capecitabine in patients with locally advanced pancreatic cancer (LAPC). We also tried to devise a prognostic model for LAPC undergoing definitive CCRT. Methods: Between January 2004 and January 2008, 39 patients with LAPC treated with capecitabine CCRT were reviewed. Capecitabine was administered at 850 mg/m2 bid every day for 5 weeks. Radiotherapy was given 5 days per week, at 1.8 Gy fractions, over the 5 weeks. Results: Thirty seven (94.8%) patients completed CCRT, and 2 patients removed during the treatment for toxicity issues. Of the 36 evaluable patients, 15 (41.7 %) patients achieved partial response, and 13 (36.1 %) had a stable disease with 77.8% of disease control rate. Among the 28 patients who had achieved disease control after CCRT, 8 patients (21.6 %) received gemcitabine-based post-CCRT chemotherapy without dose reduction or delay. With median 1.8 years of follow- up, the overall survival was 14.3 months (95% confidence interval [CI]; 10.6–17.9 months). Median progression free survival was 11.1 (95% CI 7.2–15.1) for all patients, and 7.9 months (95% CI 6.6–9.2) for those not received post-CCRT chemotherapy. No patient had grade 4 hematologic or non-hematologic toxicity. Eight patients (21.6%) had severe grade 3 toxicities, 7 (18.9%) with gastrointestinal toxicity and 1 (2.7%) with hematologic toxicity. Prognostic factors for survival were serum albumin (P=0.014; relative risk [RR], 3.4; 95% CI, 1.4, 8.6), and adjuvant gemcitabine treatment (P = 0.005; RR, 3.5; 95% CI, 1.2, 10.6). The prognostic grouping resulted in three groups with significantly different prognosis: group 1 (0 adverse factor; n=8; 1-year survival, 87.5%), group 2 (1 adverse factor; n=23; 1-year survival, 52.9%) and group 3 (2 adverse factors; n=8; 1-year survival, 25.0%). Conclusions: Combined therapy with capecitabine CCRT was well tolerated. Capecitabine seems to be a promising regimen in the treatment of LAPC, in terms of response, survival, and tolerable adverse effects.

No significant financial relationships to disclose.

The prognostic significance of the number of extranodal sites in the patients with disseminated diffuse large B-cell lymphoma treated with R-CHOP

8570

Background: The combination of rituximab and CHOP chemotherapy (R-CHOP) has improved survival of patients with diffuse large B-cell lymphoma (DLBCL). Recently, several reports have shown that standard International Prognostic Index (IPI) became less powerful prognostic predictor in patients with DLBCL in the era of R-CHOP. We evaluated the prognostic factors of DLBCL patients treated with R-CHOP. Detailed analysis was planned regarding the number of extranodal sites because of its higher frequency in Korea. Methods: Between January 2002 and May 2008, 126 patients with stage III/IV DLBCL treated with R-CHOP were identified. We performed the retrospective analysis of the clinicopathologic factors and verified the predictive power of standard IPI and revised IPI (R-IPI) which was reported by the study group of British Columbia. Various numbers of extranodal sites were analyzed for further stratification and we set E-IPI as the IPI when the number of extranodal sites is stratified in ≤2 vs >2. Results: In the univariate analysis, the number of extranodal sites (≤2 vs >2) was a significant prognostic factor for complete response (CR) (p=0.04), event-free survival (EFS) (p=0.01) and overall survival (OS) (p<0.001). Age was also significant for EFS (p=0.03). When the number of extranodal site was stratified differently (0 vs >0, or ≤1 vs >1), these were not associated with CR, EFS and OS. On the multivariate analysis, the number of extranodal sites (≤2 vs >2) remained significant for EFS (p<0.01, HR 2.6) and OS (p<0.01, HR 3.5). The standard IPI identified 3 risk groups with 2-year EFS; 68%, 55%, 56% (p=0.17) and 2-year OS; 85%, 68%, 58%, respectively (p=0.04). The R-IPI classified 2 risk groups with 2-year EFS; 65%, 50% (p=0.02) and 2-year OS 76%, 62%, respectively (p=0.04). The E-IPI represented 3 risk groups with 2-year EFS; 79%, 56%, 42% (p=0.01) and 2-year OS; 86%, 70%, 39%, respectively (p=0.001). The patient group with survival of less than 50% was only recognized by E-IPI. Conclusions: The number of extranodal sites (≤2 vs >2) is the most significant prognostic factor of EFS and OS. Although all three indices remain predictive, E-IPI is the best model to identify the prognostic group in this cohort with stage III/IV DLBCL treated with R-CHOP.

No significant financial relationships to disclose.

Prognostic role of insulin-like growth factor receptor-1 (IGFR-1) and insulin-like growth factor binding protein-3 (IGFBP-3) expression in small cell lung cancer

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Background: Insulin-like growth factor receptor-1 (IGFR-1) is a cellular membrane receptor overexpressed in many tumor cell lines and in some human tumors that seems to play a critical role in anti-apoptosis by enhancing cell survival. Also, insulin-like growth factor binding protein-3 (IGFBP-3) was reported to be a growth suppressor in variable pathways. Purpose of this study was to evaluate the state IGFR-1 and IGFBP-3 expression in patients with small cell lung cancer (SCLC) and its prognostic value. Methods: We analyzed IGFR-1 and IGFBP-3 expression in 194 SCLC tissues specimens by immunohistochemical stain. The relationship between IGFR-1 and IGFBP-3 expression and cliniopathological factors was evaluated. Univariate and multivariate analyses were performed to define its prognostic significance. Results: Median age was 63 years (range 38–85), 84% were men. One hundred-seventeen patients had extensive disease (60.3%), and 77 had limited disease (39.7%). With the median follow- up duration of 49.5 months (24–82), the median progression free survival (PFS) and overall survival (OS) were 8 months (95% CI: 7.3–8.7 months), and 14.4 months (95% CI: 12.7–16 months), respectively, The IGFR-1 expression was observed in 154 of 190 tumor tissues (79.4%), whereas there was no tissue stained by IGFBP-3. Multivariate analysis showed that stage (p<0.001), response to treatment (p<0.001), LDH level (p<0.001) were the independent prognostic factors for PFS, and age (p=0.014), LDH level (p<0.001), and stage (p<0.001) for OS. The IGFR-1 positivity was not associated with PFS or OS in the whole cohort. However, 84% of 115 extensive disease patients showed IGFR-1 positivity. The subgroup analysis revealed that OS was significantly longer for patients with IGFR-1 positive compared to those with IGFR-1 negative in extensive disease (11.3% vs 0% at 2year, p=0.034). Conclusions: These results suggest that IGFR-1 expression may be useful as a prognostic marker in patients with extensive disease of SCLC.

No significant financial relationships to disclose.

Predictive role of 18F-FDG-PET/CT 1 month before and after hypofractionated stereotactic body radiation therapy for stage I non-small cell lung cancer

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Background: To know the predictive role of 18F-FDG-PET/CT 1month before and after stereotactic body radiation therapy (SBRT) to stage I non-small cell lung cancer (NSCLC). Methods: Between 2004 and 2007, 20 patients received SBRT with 48 Gy for 4 consecutive days and checked two times of FDG- PET/CT and chest CT with contrast-enhancement at 1 month before and after SBRT. Change of maximal SUV (SUVmax) on FDG-PET/CT and the longest tumor diameter on chest CT before and after SBRT was measured. Patients only with high FDG uptake, SUVmax 3.0 or above, on FDG-PET/CT before SBRT and tumor diameter below 5 cm were analyzed in this study. Change of tumor diameter was classified to PR (partial response), SD (stable disease), and DP (disease progression) as RECIST criteria and change of SUVmax was described as % change. Chest CT was checked at every 3 or 6 months during follow-up. Results: Mean time intervals from SBRT to FDG-PET/CT and chest CT were 32 and 30 days respectively. Mean longest tumor diameter was changed from 2.59 cm (1.36–3.93) to 2.17 cm (1.18–3.41), and its reduction rate was -16.2%. By RECIST criteria, 4 patients showed PR, 15 patients showed SD, and other 1 patient showed DP. Mean decrease rate of SUVmax on FDG-PET/CT was -52.1% and its mean value was changed from 7.1 (3.2–13.1) to 3.4 (0.3–9.8). Median follow-up time was 16 months. Local tumor progression developed in 2 (10%) patients and time to progression was 3.4, 6.1 months. Tumor responses on post-SBRT chest CT were PR in 1 and SD in the other 1 patient, and SUVmax changes were -31.9%, -25.5% in each. Most of patients showing no response, SD or DP, didn't recur after SBRT, and so chest CT at 1 month could not predict actuarial tumor response. On the contrary to chest CT, no patients showing SUVmax decreases over 40% experienced tumor progression after SBRT. High decrease rate of SUVmax over 40% decrease on FDG-PET/CT 1 month after SBRT could warrant good actuarial local tumor control earlier. Conclusions: Change of SUVmax on FDG-PET/CT 1 month before and after SBRT could predict actuarial local tumor control of stage I NSCLC earlier and 1 month after SBRT was adequate timing for the earlier evaluation of tumor response.

No significant financial relationships to disclose.

Phase II randomized trial of bortezomib (B) plus irinotecan (I) or B with addition of I at progression in recurrent (R) or metastatic (M) squamous cell carcinoma of the head and neck (SCCHN) (E1304): A trial of the Eastern Cooperative Oncology Group

6020

Background: B, inhibits activation of NF- κβ and inhibits growth of SCCHN cell lines. NF-κβ dysregulation contributes to chemoresistance, including I. Pretreatment with B increases tumor sensitivity to I in vitro. Methods: Eligibility: 0–1 prior chemo regimens, ECOG PS 0–1. Pts randomized to B 1.3 mg/m2 IV d 1, 4, 8, 11 and I 125 mg/m2 IV d 1, 8 every 21 days (Arm 1) or B with addition of I at time of progression (Arm 2). Primary endpoint was response rate (RR) using RECIST and Simon's optimal 2-stage design. Results: 62 pts analyzable (Arm 1, N = 23; Arm 2, N = 39) of 71 enrolled . Pt. characteristics: median age 61 yrs., ECOG PS 1 - 53 %, and 71% had prior chemo. To date, RR (all PRs) 13% Arm 1 and 3% Arm 2 with SD 17% Arm 1 and 23% Arm 2. However, 3 patients remain on active therapy in Arm 2 and PFS and updated RR will be reported. 7 patients (including 3 pts on Arm 2) received 6–10 cycles of therapy. No responses in all 11 analyzable pts in Arm 2 with I added at progression. Median OS 9.1 months - Arm 1 and 7.3 months - Arm 2. Toxicity of B + I (125 mg/m2): grade 3/ 4 neutropenia (31%), vomiting (15%), diarrhea (15%), dehydration (23%). Grade 5 toxicity in 3 pts, 2 possibly related to therapy. Trial amended to decrease I to 90 mg/m2 3 patients (33%) - grade 3 / 4 diarrhea; no grade 3/ 4 neutropenia or grade 5 toxicities. Arm 2: grade 3 / 4 fatigue (15%). Conclusions: B alone is well tolerated. To date, RR low but prolonged stable disease noted in some pts. B in combination with I is a toxic regimen with disappointing activity.

[Table: see text]

Leptomeningeal carcinomatosis of gastric cancer: Multicenter retrospective analysis of 54 cases

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Background: Leptomeningeal carcinomatosis occurs in approximately 5% of patients with cancer. The most common cancers involving the leptomeninges are breast and lung cancer. However, gastric adenocarcinoma has been rarely reported with leptomeningeal carcinomatosis (LMC). Methods: We analyzed 54 cases of cytological confirmed gastric LMC at 4 institutions from 1994 to 2007. Results: Male to female ratio was 1.5:1. Median age of these patients was 49 years. The majority of patients had advanced disease at the initial diagnosis of gastric cancer. The clinical or pathologic TNM stages of the primary gastric cancer were IV in 38 patients (70%). The median interval from the diagnosis of the primary malignancy to the diagnosis of LMC was 6.3 months (range, 0 - 73.1 months). Of the initial endoscopic finding available 45 patients, Bormann type III and IV were 23 (51%) and 15 (33%) patients, respectively. Headache (85%) and nausea/vomiting (58%) were most common presenting symptoms of LMC. The intrathecal (IT) chemotherapy was administered to 36 patients - mainly with methotraxate alone (59%) or combination with ara- C/hydrocortisone (41%). Median IT treatment number was 7 (range, 1–18). Concomitant radiotherapy or chemotherapy was done in 25 patients and 10 patients, respectively. 17 patients (46%) were achieved cytological negative conversion. Median OS duration from diagnosis of LMC was 6.7 weeks (95% CI; 4.3–9.1 weeks). Clinically, initial advanced stage was predictive value of poor prognosis (P=0.009). But, Cytology negative conversion was predictive value of relatively longer survival duration (P=0.005). And, not only IT chemotherapy but also intravenous chemotherapy had been shown improvement of survival duration (P=0.010, P=0.005, respectively). Conclusions: Although gastric LMC has dismal prognosis, IT and IV chemotherapy could be help to extend survival duration of gastric LMC.

No significant financial relationships to disclose.

Cytoplasmic expression of HuR and cyclooxygenase-2 expression in colon cancer

e22161

Background: HuR, human family embryonic-lethal abnormal vision-like protein, can bind to mRNAs and stabilizes them in the cytoplasm, resulting in more efficient translation. HuR is predominantly present in the nucleus and shuttles between the nucleus and cytoplasm. The mRNA of cyclooxygenase-2 (Cox-2) is stabilized by HuR in several cancers, including breast, stomach, lung and brain. Methods: We investigated the expression and its cellular location of HuR, and Cox-2 expression in 79 colorectal cancer patients with immunohistochemistry, and evaluated the biological implications in colorectal carcinoma. Results: Nuclear HuR expression was observed in 59 (74.7%) and cytoplasmic HuR expression was seen in 25 (31.6%). Cox-2 immunoreactivity was noted in 42 (53%). The expression of cytoplasmic HuR was significantly associated with Cox-2 expression (p=0.004). And cytoplasmic expression of HuR showed correlation with lymphatic invasion (p=0.025) and lymph node metastasis (p=0.027). Nuclear HuR showed no correlation with Cox-2 expression or other clinicopathological parameters examined. Conclusions: These results suggest that cytoplasmic translocation of HuR is associated with Cox-2 expression in some colorectal carcinoma.

No significant financial relationships to disclose.

Phase II trial of neoadjuvant fixed dose rate (FDR) gemcitabine with capecitabine (GX) combination chemotherapy in locally advanced pancreatic adenocarcinoma (LAPA)

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Background: To determine the efficacy and safety of fixed dose rate (FDR) gemcitabine and capecitaibne (GX) combination chemotherapy for locally advanced pancreatic adenocarcinoma Methods: Patients with histologically confirmed LAPA were eligible for this prospective phase II trial. Dynamic pancreas/pelvic CT, MRI and FDG-PET were undertaken to assess the resectability. EUS was also performed as needed basis. ‘Borderline resectable (BR)’ and ‘unresectable (UR)’ criteria developed by our pancreatico-biliary multidisciplinary management team (PBMMT) and NCCN criteria were used. After confirmation of resectability, patients received 3 cycles of FDR gemcitabine 1,250 mg/m2 on D1 and D8 and capecitabine 950 mg/m2 from D1-D14 every 3 weeks. Thereafter, staging was repeated and patients underwent surgery if the disease was not unresectable. For patients with R0 resection, additional 6 cycles of GX were administered. For patients with R1 resection, chemoradiotherapy (CRT) (54 Gy over 5 weeks with concurrent 5-FU and leucovorin or capecitabine) followed by FDR-GX was administered. Patients with stable or better response to chemotherapy but assessed unresectable at reassessment received additional chemotherapy up to 9 cycles followed by CRT. Results: Between August 2006 and July 2008, 38 eligible patients (14 with BR and 24 with UR based on NCCN criteria; 29 with BR and 9 with UR based on our PBMMT criteria) entered on this study. The median age was 61 yo (42–76) and 71% had cT4 disease. The response to neoadjuvant chemotherapy was PR in 6 (16%), SD in 26 (68%) and PD in 3 (8%). Metabolic response was achieved in 20 patients (53%) with 2 metabolic CR out of 31 evaluable patients. Grade 3 or worse adverse effects were mainly HFS (n=5) and gastrointestinal (n=3) with no grade 4 in severity. Surgery was performed in 9 patients (24.0%, R0=8, R1=1, 6 in NCCN-BR and 3 in NCCN-UR, 9 in PBMMT-BR) and five patients refused surgery although their diseases seemed not to be unresectable. The median PFS was 9.4 months (95% CI, 8.3–10.4) and estimated median OS was 13.5 months (95% CI, 12.4- 14.5). Conclusions: FDR-GX was effective as neoadjuvnat chemotherapy in LAPA with favorable toxicity profile.

No significant financial relationships to disclose.

Interobserver and interlaboratory variability of mismatch repair protein expression in ovarian tumors

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Background: Immunohistochemistry (IHC) for mismatch repair (MMR) protein (MLH1, MSH2, MSH6) expression has been a useful strategy for identifying tumors with MMR deficiency. However, despite its wide use, interpretation of results suffers from poor reproducibility. Methods: To assess inter-observer (IO) and inter-laboratory (IL) variability of MMR protein expression, 41 epithelial ovarian cancer (EOC) samples were arrayed in triplicate for construction of a tissue microarray (TMA). Six slides were made from this donor TMA block, of which 3 were stained at the Moffitt Cancer Center (MCC) and 3 were stained at the University of South Florida (USF), using different lab procedures. IHC for MMR protein expression was performed using the avidin-biotin-complex (ABC) method with appropriate controls. Subsequently, all slides were independently scored for protein expression by two pathologists. The Concordance Correlation Coefficient (CCC) value was computed to evaluate IO and IL concordance, with a value >0.75 indicating excellent concordance. Results: The CCC value for the IO analysis was 0.95 (for MCC-stained slides; 95% C.I.: 0.89–0.98) and 0.85 (for USF-stained slides; 95% C.I.: 0.66, 0.93), indicating excellent concordance. The CCC value for IL analysis was 0.53 (95% C.I.: 0.37–0.66). Conclusions: Our findings demonstrate that variability in IHC protocols may contribute to the interpretation of IHC results. Our data suggest that when pathologists are given the same slide, there is excellent agreement between two observers; however, when the same slides are stained in a separate laboratory using the same method (ABC) but different protocol, there may be considerable disagreement. These findings are of great clinical significance due to the widespread use of IHC as diagnostic, prognostic and therapeutic tools in cancer care.

No significant financial relationships to disclose.

A UGT1A1 genotype-directed phase I study of irinotecan (CPT-11) combined with fixed dose of capecitabine in patients with metastatic colorectal cancer (mCRC)

2554

Background: The risk of severe toxicity of CPT-11 can be in part explained by polymorphism of UGT1A1. The most common polymorphism in Whites is UGT1A1*28. UGT1A1*6 is another common polymorphism in Asians. We designed a phase I study to investigate UGT1A1 genotype-directed maximum tolerated dose (MTD) of CPT-11 plus fixed dose of capecitabine in patients (pts) with Korean mCRC. Methods: Pts with mCRC screened UGT1A1 genotyping (*28 and *6) and were stratified into one of 3 groups according to the number of defective allele (DA): 0 (none of *28 or *6 allele), 1(only one of *28 or *6 allele), and 2 (*28/*28, *6/*6, or double heterozygous for *28 and *6). The dose of CPT-11 was escalated as following: Level -I:200, I:240, II:280, III:320, IV: 350, V: 380 mg/m2 (IV, once every 3 weeks). Capecitabine (1,000 mg/m2 PO BID) was administered on days 2–15 every 3 weeks. Dose limiting toxicity (DLT) and pharmacokinetic analyses was determined at cycle 1. Results: Forty-two pts, median age 50 years, EOOG performance ≤1 were recruited: 0 DA group (18 pts), 1 DA (18), and 2 DA (6). In 0 DA group, two of six pts experienced DLT at 380 mg/m2 with grade III asthenia (1 pts) and febrile neutropenia (1). In 1 DA group, all of two pts experienced DLT at 380 mg/m2 with grade III asthenia. In 2 DA group, two of three pts experienced DLT at 240 mg/m2 with febrile neutropenia (1) and grade IV neutropenia (1). The MTD was defined as CPT-11 350 mg/m2 for pts with 0 and 1 DA group and CPT-11 200 mg/m2 for pts with 2 DA group, with capecitabine. Median SN-38G/SN-38 AUC was 10.45, 8.78, and 1.66 in pts with 0, 1, and 2 DA group, respectively. Conclusions: CPT-11 dosing by UGT1A1*28 and *6 genotypes is feasible in Korean pts with mCRC. A dose of CPT-11 350 mg/m2 IV for pts with 0 and 1 DA group and CPT-11 200 mg/m2 for pts with 2 DA group, with capecitabine every 3 weeks, is recommended for further study.

[Table: see text]

No significant financial relationships to disclose.

Effect of interval between diagnosis of advanced cancer and cessation of active anti-cancer treatment on survival in terminally ill cancer patients

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Background: Although various prognostic factors have been proposed to predict survival in terminally ill cancer patients, accurate prognostication is still a challenging task for oncologists. The objective of this study was to evaluate whether the time interval between diagnosis of advanced cancer and cessation of active anti-cancer treatment (ATP; active treatment period) can predict survival in terminally ill cancer patients. Methods: We prospectively evaluated 79 patients with advanced (recurrent or metastatic) cancer who were determined as terminal stage, namely cessation of active anti-cancer treatment and transition to palliative care, by attending oncologists. ATP and other known prognostic factors including clinical symptoms and signs, performance status, laboratory tests, and clinical prediction of survival (CPS) were analyzed. Results: Of the 79 patients, 46 were male (58%) and 33 were female (42%) with a median age of 60 years (range, 21–82). Median overall survival after being diagnosed with advanced cancer was 11.6 months (95% confidence interval (CI), 8.02–15.18), and survival after being determined as terminal stage was 1.9 months (95% CI, 1.38–2.42). According to 3 ATP categories (< 3months, 3–12 months, and >12 months), terminal stage survival were 1.0 month, 1.8 months, and 3.6 months, respectively (p=0.002). On multivariate analysis, short ATP, non-colorectal cancer, fatigue, and Karnofsky performance status less than 50 were significantly associated with a poor prognosis. Conclusions: Our study suggests that ATP is an independent prognostic factor for survival in terminally ill cancer patients who cannot receive active anti-cancer treatment anymore. Future prognostic models should include ATP as a prognostic variable.

No significant financial relationships to disclose.

Preoperative chemoradiation and postoperative adjuvant tetrathiomolybdate for patients with resectable esophageal cancer

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Background: Tetrathiomolybdate (TM) is an oral copper chelator. Copper is necessary for blood vessel growth, and so TM functions as an antiangiogenic agent. Methods: Pts with resectable esophageal cancer were treated at the University of Michigan with chemoradiation followed by surgery, and then 2 years of TM. Chemoradiation was cisplatin 60 mg/m2 on days #1 and 22, paclitaxel 60 mg/m2 on days #1, 8, 15, and 22, and radiation 1.5 Gy fractions b.i.d. x 3 weeks to a total of 45 Gy. Transhiatal esophagectomy was performed on approximately day #50. TM 20 mg p.o. q.d. was started approximately 4 weeks post-op, and continued for 2 years. Doses were adjusted to maintain the ceruloplasmin level between 5 and 15. Results: Between 1/23/02 and 1/24/06, 69 pts were enrolled. Pt characteristics: males - 62 (90%), females - 7 (10%); median age - 60 (range 42–74); adenocarcinoma - 56 (81%), squamous cell carcinoma 13 (19%). The chemoradiation was well tolerated: grade 3 leukopenia in 15 pts (22%), and 17 pts (25%) required feeding tubes. 66 pts went to surgery. 61 pts had a complete resection; 4 pts had metastases discovered at surgery, and 1 pt had extensive positive margins. Histologic complete response rate was 10%. 21 pts never received TM because of metastases noted in the peri-operative period, long post-op recovery time, or pt refusal. 48 pts started TM after surgery and it was well tolerated. Grade 3 toxicities were diarrhea -2 (3%), nausea - 2 (3%), dizziness - 2 (3%). 13 pts completed the full 24 mos of treatment, 12 completed 10–23 mos, 15 completed 2–8 mos, and 8 completed only 1 month or less. 27 pts have had disease recurrence, the majority (23 of the 27) of which was distant. Current status of pts with median follow-up time of 55 months: 25 alive and disease-free, 1 alive with disease, and 43 have died. 3-year survival probability is 47% (95% CI 35%-58.6%). 3-year recurrence-free probability is 51% (95% CI 38%- 62.7%). Conclusions: TM is an antiangiogenic agent which is fairly well tolerated. Prolonged adjuvant treatment over 2 years is difficult but not impossible to complete. Disease-free survival and overall survival are promising when compared to historical controls treated with a very similar chemoradiation regimen without TM in the past at the University of Michigan.

[Table: see text]

Use of peripheral blood genomic markers whose expression levels reflect that of breast tumor genomic markers to predict drug treatment and sensitivity

3588

Background: Tumor gene expression signatures have been used to predict drug response, and we have previously reported drug-induced signatures to be more informative than the untreated baseline signatures. However, repeated tumor sampling during treatment is not feasible for most patients. We studied peripheral mononuclear cell (PBMC) gene expression levels in association with tumor gene expression levels in an attempt to identify peripheral blood markers that may serve as more accessible surrogates to predict drug treatment and response. Methods: Chemonaive breast cancer patients were treated with an alternating sequential regimen of doxorubicin and docetaxel and randomized to start with either drug. RNA from primary tumor before and 3 weeks, and from PBMC before and 24 hours after the first cycle of each drug was hybridized on the Affymetrix HG-U133+2 array containing 54,675 probe sets. Results: Pre- and post-treatment tumors from 47 patients were studied, including 35 with paired PBMC samples. 230 pre- and 85 posttreatment PBMC probe sets showed strong correlation in expression level (Pearson correlation coefficient >0.9) with the corresponding pre- and posttreatment tumor probe set, and included genes involved in transcription regulation and binding. Of the 975 tumor probe sets whose changes distinguished doxorubicin from docetaxel treatment, 12 corresponding PBMC probe sets were identified (p < 0.001) whose changes at 24 hours distinguished the two treatments with 77% accuracy. Of the 1,081 and 1,526 tumor probe sets whose changes predicted treatment response to doxorubicin and docetaxel, 19 and 15 informative PBMC probe sets predicted response to each drug with 100% and 80% accuracy, and included TNF receptor associated protein 1 and trefoil factor 1 for doxorubicin-, and folliculin and dynein for docetaxel-response. When the PBMC probe sets were validated in an independent test set treated with docetaxel (n = 23), 87% was correctly classified as docetaxel-treated, while 89% of non-responders clustered together. Conclusions: Peripheral blood contains genomic markers whose expression levels closely reflect that of breast tumor markers, and may be promising as surrogates to predict drug treatment and sensitivity.

No significant financial relationships to disclose.

Outcomes in patients with primary gastric diffuse large B-cell lymphoma after rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) chemotherapy

e19543

Background: The optimal therapy for primary gastric diffuse large B- cell lymphoma (DLBCL) still needs to be defined. The aim of this study was to investigate the patient's outcomes after rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) treatment in primary gastric DLBCL in a single institution. Methods: We searched AMC Registry for Non-Hodgkin's Lymphoma and found 26 patients with primary gastric DLBCL, who received R-CHOP as first-line chemotherapy. Ten of 26 patients had localized disease. Remaining patients had disseminated disease. R-CHOP was repeated every 21 days in all patients. Results: Overall, complete response (CR) was observed in 20 of 26 patients (76.9%). Three-year event free survival (EFS) and overall survival (OS) was 76.5% and 75.0%, respectively. After analyses of 10 patients with localized disease, we found that these patients had received a total 38 cycles, with a median of 3 cycles per patient. Of 10 patients, one patient had 2 cycles of R-CHOP, 4 had 3 cycles, and one had 4 cycles, all 6 patients above followed by consolidation radiotherapy. Remaining one patient and 4 patients had 5 cycles and 6 cycles of R-CHOP, respectively. In patients with localized disease, CR was observed in 10 of 10 patients (100%), and both 3-year EFS and OS was 100% (10 of 10 patients). In analyses with 16 patients with disseminated disease, all patients had received a total 91 cycles, with a median of 6 cycles per patient. In these patients, two patients had radiation therapy after R-CHOP, one patient had CR before consolidation radiation therapy, and another had partial response before radiation therapy. CR after R-CHOP treatment was observed in 10 of 16 patients (62.5%), partial response in 3 patients, stable disease in 1 patient, and progressive disease in 1 patient. Three-year EFS and OS was 61.1% and 57.8% in patients with disseminated disease. Conclusions: R-CHOP regimen showed a promising result in primary gastric DLBCL. Combination with rituximab in CHOP regimen showed excellent prognosis especially in patients with localized disease. In localized disease, CR was 100%, 3-year EFS and OS was 100%. In disseminated disease, CR was 62.5%, 3-year EFS and OS was 61.1% and 57.8%.

No significant financial relationships to disclose.

Phase III trial of adjuvant capecitabine/cisplatin (XP) versus capecitabine/cisplatin/RT (XPRT) in resected gastric cancer with D2 nodal dissection (ARTIST trial): Safety analysis

4537

Background: Although the adjuvant chemoradiation therapy has gained popularity and has become the standard of care in patients with resected gastric cancer in U.S., the role of chemoradiation therapy after extended D2 dissection has been questioned. We conducted a phase III trial to compare capecitabine/cisplatin (XP) vs XP + radiotherapy (RT) in curatively D2 resected gastric cancer patients in terms of disease free survival and overall survival. Methods: Eligibility criteria were as follows: stage Ib (T1N1, T2bN0) - IV (M1 excluded), curatively ≥ D2 resected gastric adenocarcinoma. XP only: X 2,000 mg/m2/d D1∼14, CDDP 60 mg/m2 D1 repeated every 3 weeks, 6 cycles; XP + RT: X 2,000 mg/m2/d D1∼14, CDDP 60 mg/m2 D1 x 2 cycles ⋄ RT 45 Gy (25 fractions) + X 1,650 mg/m2/d during RT ⋄ X 2,000 mg/m2/d D1∼14, CDDP 60 mg/m2 D1 x 2 cycles. The primary endpoint is 3-year disease-free survival. Results: From October 2004 to April 2008, 458 patients (XP arm: 228 patients; XP/RT arm: 230 patients) were enrolled. In XP arm, 172 (75%) of 228 enrolled patients completed 6 cycles of chemotherapy. In XP + RT arm, 188 (82%) of 230 patients completed the full course of XP 2 cycles - X + RT - XP 2 cycles. Conclusions: Safety and feasibility analysis of the two arms will be reported at the meeting.

No significant financial relationships to disclose.

Underweight and breast cancer recurrence and death

e22054

Background: The association of body mass index or body weight and breast cancer outcome is controversial. Furthermore, the impact of underweight on breast cancer recurrence and death has not been adequately addressed. Methods: We investigated this issue in a large nation-wide database of 14,039 Korean breast cancer patients (Korean Breast Cancer Registry). Furthermore, to test whether the association was due to more frequent non-cancer death in underweight women, we used breast cancer recurrence data of 4,345 women from single institution (Seoul National University Hospital). Results: The results from Korean Breast Cancer Registry data showed significantly lower overall survival in underweight patients compared to normal weight after adjusting known prognostic factors [hazard ratio=1.36 (95% CI 1.08–1.72)], which was not observed in obese patients. The association between body mass index and breast cancer recurrence was further investigated in Seoul National University Hospital data. Underweight women had significantly higher risk of distant metastasis and local recurrence of breast cancer [hazard ratio=1.86 (95% CI 1.25–2.76) and 2.62 (95% CI 1.55–4.41), respectively]. Conclusions: These findings suggest that underweight could be considered as high risk factor of death and recurrence after breast cancer surgery.

No significant financial relationships to disclose.

A phase II study of imatinib mesylate as adjuvant treatment for curatively resected high-risk localized gastrointestinal stromal tumors

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Background: In our previous study, the presence of c-kit mutation as well as tumor size and mitotic count was an independent poor risk factor for relapse after curative resection of primary localized GIST. The patients with all the 3 poor risk factors had only 30% of 2 year relapse free survival rate (RFSR). (Kim, et al. Clin Cancer Res, 2004) It is also well known that c-kit exon 11 mutant GISTs respond better to imatinib treatment than the other mutant or wild type GISTs. Therefore, the patients who have primary localized GISTs with large size, high mitotic count, and c-kit exon 11 mutation may be the best candidate of adjuvant imatinib treatment. In this phase II study, we have evaluated the efficacy and safety of adjuvant imatinib for this patient group. Methods: Patients who underwent complete resection of a primary GIST with 1) c-kit exon 11 mutation, and 2) ≥10 mitoses/50 HPF, or tumor size ≥10 cm, or ≥5 mitoses/50 HPF and tumor size ≥5 cm were eligible. Patients received imatinib 400mg p.o. daily until recurrence of disease, intolerable toxicities, or for 2 years. The primary end point was relapse-free survival (RFS). Results: A total of 47 patients from 4 centers in Korea were enrolled. The median age was 57.0 years. Stomach was the most common primary site (n=31). Median primary tumor size was 7.5cm and median mitoses index was 12/50 HPF. With a median follow-up of 26.9 months, the median RFS and overall survival (OS) have not yet been reached. RFSR was 97.7% at 1-year and 92.7% at 2-years. Six relapses (12.8%) were documented among the 47 patients. The treatments were generally well tolerated. Grade 3–4 toxicities included neutropenia 27.7%, rash 8.5%, constipation 4.3%, anorexia 2.1%, vomiting 2.1%, and pruritis 2.1%. There were no episode of febrile neutropenia and treatment-related death. Conclusions: Postoperative adjuvant imatinib for 2 years were safe and could prolong the RFS in patients with high-risk of recurrence following complete surgical resection of the primary GIST. However, it remains unknown if this benefit in RFS can be translated into OS benefit. So, further follow-up is needed with comparison of OS with historical controls who could be use imatinib after recurrence.

[Table: see text]

Prognostic impact of response to second-line chemotherapy on overall survival of patients with advanced gastric cancer

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Background: It has been debated on whether tumor response to first-line chemotherapy (CT) would be reliable predictor for overall survival (OS) of cancer patients (pts). In case of advanced gastric cancer (AGC), many pts receive 2nd line CT after failure to 1st line treatment, so response to 2nd line CT as well as 1st line could affect OS. Methods: We retrieved clinical data of a total of 1,335 pts with AGC treated with palliative CT from January 2000 to December 2006 in National Cancer Center, Korea, including 757 pts who also received 2nd line CT. Responses to 1st and 2nd line CT were evaluable in 504 pts. Retrospective analysis was done to find correlation between objective tumor response to 1st and 2nd line CT and OS of the 504 pts, whom we divided into 4 groups: responders to both 1st and 2nd line CT (RR group); responders to 1st but not to 2nd line CT (RN group); responders to 2nd but not to 1st line CT (NR group); and nonresponders to both 1st and 2nd line CT (NN group). Results: Objective response rate of 1st and 2nd line CT was 41.7% and 12.3%, respectively. Responders to 1st line CT had a trend to respond to 2nd line CT (ORR of 2nd line CT in responders vs nonresponders to 1st line CT: 15.7% vs 9.9%, p = 0.049). 33/177/29/265 pts were assigned to each of RR/RN/NR/NN group, respectively. With median follow-up of 48.7 mo (range 23.2 - 93.7), median OS was 12.7 mo (95% CI 11.8–13.6). Baseline characteristics were balanced between 4 groups except higher hemoglobin and serum albumin level in RR group, younger median age in NN group, and fewer pts with poor performance status or poorly differentiated histology in NR group. Overall survival of RR, RN, NR, and NN group was 31.8 mo, 15.5 mo, 18.9 mo, and 9.2 mo, respectively (p<0.001). Multivariate analysis revealed relapsed disease after curative surgery, well-differentiated histology, absence of pulmonary metastasis, higher serum albumin level, lower serum bilirubin and alkaline phosphatase level, response to both of 1st line and 2nd line CT were reliable factors for favorable survival. Conclusions: Among the patients who received 2nd line chemotherapy for AGC, response to 2nd line CT was strongly associated with OS regardless of previous response to 1st line CT.

No significant financial relationships to disclose.

The role of oophorectomy for colon cancer with ovarian metastasis

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Background: A recent study demonstrated that colorectal cancer with ovarian metastases were less responsive to chemotherapy compared to extraovarian metastases. Hence, the ovary may actually represent a “sanctuary” for metastatic cells from CRC. The aim of the study was to investigate the impact of oophorectomy on survival of colorectal cancer patients with ovarian metastasis. Methods: Between 1996 and 2008, 83 colorectal cancer patients underwent oophorectomy. For the historical control, 47 colorectal cancer patients without oophorectomy were included in the analysis. Survival and its associated factors were analyzed using Kaplan-Meier method, log-rank test and Cox-regression analysis. Results: The median age was younger (48 years) in the oophorectomy group when compared to the historical control (54 years) (P =.012). The proportion of synchronous metastasis was higher in the oophorectomy than the control group (57% vs 30%, respectively; P=.003). After a median follow-up duration of 60.8 months (range, 7.4 - 169.7 months), the median OS was significantly longer in the oophorectomy group (28.1 vs 21.2 months, oophorectomy vs non-oophoreectomy; P=.038). For ovary-specific survival (date of ovarian metastasis diagnosis to death), colorectal cancer patients with oophorectomy showed significantly favorable survival than the control group (20.8 vs 10.9 months, respectively; P<.001). At univariate analyses, no oophorectomy (P=.038), bilaterality of ovarian metastasis (P=0.032), the presence of extraovarian metastasis (P<0.001), elevated CEA (p<0.001), poor performance status (p=0.001), no palliative chemotherapy(p=0.001), no primary disease resection(p=0.005) were identified as significantly poor prognostic factors for overall survival. The no oophorectomy, no chemotherapy, extraovarian metastasis, elevated CEA, poor performance status retained statistical significance at multivariate level. (p=0.003, p=0.004, p=0.005, p=0.015, p=0.029, respectively). Conclusions: Based on this retrospective analysis, the oophorectomy significantly prolonged survival in colorectal cancer patients with ovarian metastases. A potential role of oophorectomy in the management of colorectal cancer should be prospectively studied.

No significant financial relationships to disclose.

Hemodynamic changes in rat leg muscles during tourniquet-induced ischemia-reperfusion injury observed by near-infrared spectroscopy

In this study, we hypothesized that non-invasive continuous wave near-infrared spectroscopy (CWNIRS) can determine the severity or reversibility of muscle damage due to ischemia/reperfusion (I/R), and the results will be highly correlated with those from physical examination and histological analysis. To test this hypothesis, we performed CWNIRS measurements on two groups of male Sprague-Dawley rats ( approximately 400 g) that underwent 2 h (n = 6) or 3 h (n = 7) of pneumatic tourniquet application (TKA). Tissue oxyhemoglobin [HbO(2)] and deoxyhemoglobin [Hb] concentration changes were monitored during the 2 h or 3 h of 250 mmHg TKA and for an additional 2 h post-TKA. Rats were euthanized 24 h post-TKA and examined for injury, edema and viability of muscles. Contralateral muscles served as controls for each animal. In both groups, [HbO(2)] dropped immediately, then gradually decreased further after TKA and then recovered once the tourniquet was released. However, releasing after 2 h of TKA caused [HbO(2)] to overshoot above the baseline during reperfusion while the 3 h group continued to have lower [HbO(2)] than baseline. We found a significant correlation between the elapsed time from tourniquet release to the first recovery peak of [HbO(2)] and the muscle weight ratio between tourniquet and contralateral limb muscles (R = 0.86). Hemodynamic patterns from non-invasive CWNIRS demonstrated significant differences between 2 h and 3 h I/R. The results demonstrate that CWNIRS may be useful as a non-invasive prognostic tool for conditions involving vascular compromise such as extremity compartment syndrome.

Ion spectrometer composed of time-of-flight and Thomson parabola spectrometers for simultaneous characterization of laser-driven ions

An ion spectrometer, composed of a time-of-flight spectrometer (TOFS) and a Thomson parabola spectrometer (TPS), has been developed to measure energy spectra and to analyze species of laser-driven ions. Two spectrometers can be operated simultaneously, thereby facilitate to compare the independently measured data and to combine advantages of each spectrometer. Real-time and shot-to-shot characterizations have been possible with the TOFS, and species of ions can be analyzed with the TPS. The two spectrometers show very good agreement of maximum proton energy even for a single laser shot. The composite ion spectrometer can provide two complementary spectra measured by TOFS with a large solid angle and TPS with a small one for the same ion source, which are useful to estimate precise total ion number and to investigate fine structure of energy spectrum at high energy depending on the detection position and solid angle. Advantage and comparison to other online measurement system, such as the TPS equipped with microchannel plate, are discussed in terms of overlay of ion species, high-repetition rate operation, detection solid angle, and detector characteristics of imaging plate.

Animal-type melanoma: a clinical and histopathological study of 22 cases from a single institution

Background Animal-type melanoma is a rare distinct melanoma subtype, characterized by proliferation of heavily pigmented epithelioid and spindled melanocytes that resembles the heavily pigmented melanomas seen in grey horses. While animal-type melanoma is generally considered to be more indolent than conventional melanoma, only a limited number of cases have been reported and, as such, the clinical characteristics of animal-type melanoma are incompletely understood. Objectives To characterize the clinical and histopathological features of animal-type melanoma, and determine any features that may predict outcome. Patients/Methods Data was extracted from a prospectively collected melanoma database (1994-2008), and a retrospective pathology database (1991-2008) for all patients with a diagnosis of both equivocal (8) and unequivocal (14) malignant animal-type melanoma. We reviewed the clinical and histopathological features, including the sentinel lymph node biopsy (SLNB) status. Results A total of 22 patients were identified, with a median age of 35 years. The median Breslow depth was 2.22 mm. A SLNB was performed in 17 patients, eight (47%) were positive. Younger age was associated with: (i) animal-type melanoma with features equivocal for malignancy (median age of 7 vs. 48 years, P = 0.01), and (ii) a negative SLNB (median age 12 vs. 53 years, P = 0.03). Four patients with unequivocal animal-type melanoma developed recurrent metastatic disease, with one patient death. No patient with an equivocal animal-type melanoma or negative SLNB developed recurrent disease; however, this did not reach statistical significance (P = 0.13 and P = 0.09, respectively). Conclusions Animal-type melanoma has a propensity for regional lymphatic metastasis and is rarely capable of disseminated metastatic disease and death. Animal-type melanoma appears to exhibit a spectrum of biological behaviour, with young patient age associated with more indolent disease.

Effect of short term calorie restriction on pro-inflammatory NF-kB and AP-1 in aged rat kidney

OBJECTIVE

To compare the effect of short-term calorie restriction (CR) on aging with that of already known long-term CR, the anti-inflammatory efficacy of 10-day CR was explored in aged rat kidney.

TREATMENT

Two different age groups, 6 months (young) and 24 months (old) were used. In the old group, one sub-group was control, fed ad libitum (AL) and the other was fed CR for 10 days with 40 % of the food intake of the AL subgroup (n = 5).

METHODS

Reactive species (RS), lipid peroxides and COX-2 activity were measured. The activities of proinflammatory transcription factors NF-kB and AP-1 were measured by electro-mobility shift assay (EMSA). Upstream signaling cascades of NF-kB and AP-1 as well as proinflammatory gene expression were detected by Western blot.

RESULTS

10-day CR suppressed RS, lipid peroxides, and COX-2 activity in aged rat kidney. CR also inhibited upstream signaling cascades and DNA binding activity of NF-kB and AP-1, and thioredoxin/Ref-1 pathway. CR blocked expression of NF-kB-and AP-1-responsive gene COX-2, iNOS, VCAM-1 and ICAM-1.

CONCLUSIONS

We report for the first time that 10-day CR can attenuate the altered signaling transduction for inflammatory processes which is mediated through RS-induced NF-kB and AP-1 in aged kidney.

Disturbances in the spontaneous attribution of social meaning in schizophrenia

BACKGROUND

Schizophrenia patients show disturbances on a range of tasks that assess mentalizing or 'Theory of Mind' (ToM). However, these tasks are often developmentally inappropriate, make large demands on verbal abilities and explicit problem-solving skills, and involve after-the-fact reflection as opposed to spontaneous mentalizing.

METHOD

To address these limitations, 55 clinically stable schizophrenia out-patients and 44 healthy controls completed a validated Animations Task designed to assess spontaneous attributions of social meaning to ambiguous abstract visual stimuli. In this paradigm, 12 animations depict two geometric shapes 'interacting' with each other in three conditions: (1) ToM interactions that elicit attributions of mental states to the agents, (2) Goal-Directed (GD) interactions that elicit attributions of simple actions, and (3) Random scenes in which no interaction occurs. Verbal descriptions of each animation are rated for the degree of Intentionality attributed to the agents and for accuracy.

RESULTS

Patients had lower Intentionality ratings than controls for ToM and GD scenes but the groups did not significantly differ for Random scenes. The descriptions of the patients less closely matched the situations intended by the developers of the task. Within the schizophrenia group, performance on the Animations Task showed minimal associations with clinical symptoms.

CONCLUSIONS

Patients demonstrated disturbances in the spontaneous attribution of mental states to abstract visual stimuli that normally evoke such attributions. Hence, in addition to previously established impairment on mentalizing tasks that require logical inferences about others' mental states, individuals with schizophrenia show disturbances in implicit aspects of mentalizing.