OT1-02-02: HALT MBC: HER2 Suppression with the Addition of Lapatinib to Trastuzumab in HER2−Positive Metastatic Breast Cancer (LPT112515)

Background Lapatinib in combination with trastuzumab enhanced anti-tumor activity in HER2−positive breast cancer (BC) preclinical models. In patients (pts) with trastuzumab-treated, HER2−positive metastatic (M) BC, treatment with the combination was associated with longer progression-free (PFS) and overall survival (OS) compared with lapatinib alone. In pts with stage II/III BC, preoperative treatment with the combination plus paclitaxel resulted in significantly higher pathological complete response rates compared with paclitaxel combined with either agent alone. This evidence supports the concept of dual HER2 blockade as a treatment strategy for HER2−positive BC. This present study is designed to evaluate whether the addition of lapatinib improves PFS among women with HER2−positive MBC receiving trastuzumab as maintenance therapy.

Trial Design In this open-label, Phase III study, pts are stratified by line of treatment (first/second) and hormone receptor status (positive/negative) then randomized 1:1 to receive maintenance treatment with either lapatinib (1000mg once daily, continuously) in combination with trastuzumab (6mg/kg once every 3 weeks [Q3W]) or trastuzumab (6mg/kg Q3W) alone. Pts will receive study treatment until disease progression, death, discontinuation due to adverse events or other reasons.

Eligibility Criteria Pts with HER2−positive MBC who have completed 12–24 weeks of first- or second-line treatment with trastuzumab plus chemotherapy and have objective response or stable disease. Pts with stable brain metastasis are eligible if entering the study on second-line treatment.

Specific Aims The primary objective is to compare PFS of lapatinib in combination with trastuzumab to trastuzumab as continued HER2 suppression therapy. Secondary objectives are to evaluate OS, clinical benefit rate, safety and tolerability.

Statistical Methods Efficacy endpoints will be analyzed in the intent to treat population. A total of 193 PFS events from 280 randomized pts will be required to detect a 50% increase in median PFS in pts who receive lapatinib plus trastuzumab compared with trastuzumab (median PFS time is 27 versus 18 weeks, respectively); hazard ratio of 0.67 with an 80% power and a 1-sided type I error of 0.025.

Present and Target Accrual Sixteen of the target 280 pts have been randomized. The trial is currently open for accrual in the United States and Canada.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-02-02.

Prognostic factors and oncologic outcome in 146 patients with colorectal peritoneal carcinomatosis treated with cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: Italian multicenter study S.I.T.I.L.O

AIM

The present study was specifically designed to assess the major clinical and pathological variables of patients with colorectal peritoneal carcinomatosis in order to investigate whether currently used criteria appropriately select candidates for peritonectomy procedures (cytoreductive surgery) combined with hyperthermic intraperitoneal chemotherapy (HIPEC).

PATIENTS AND METHODS

Preoperative, operative and follow-up data on 146 consecutive patients presenting with peritoneal carcinomatosis of colorectal origin and treated by surgical cytoreduction combined with HIPEC in 5 Italian Hospital and University Centers were prospectively entered in a common database. Univariate and multivariate analyses were used to assess the prognostic value of clinical and pathologic factors.

RESULTS

Over a minimum 24-month follow-up, the overall morbidity rate was 27.4% (mortality rate: 2.7%) and was directly related to the extent of surgery. Peritoneal cancer index (PCI), unfavorable peritoneal sites, synchronous or previously resected liver metastasis and the completeness of cytoreduction, all emerged as independent prognostic factors correlated with survival.

CONCLUSIONS

Until research provides more effective criteria for selecting patients based upon the biomolecular features of carcinomatosis, patients should be selected according to the existing independent prognostic variables.

Laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) in the management of refractory malignant ascites: A multi-institutional retrospective analysis in 52 patients

Malignant ascites is a debilitating condition affecting cancer patients in their terminal stage of disease. Recently, laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) was introduced as a new approach. From September 2001 to August 2008, 52 patients were treated with this new modality. No treatment-related mortality was observed. Median survival was 98 days. One patient developed a clinical recurrence. Laparoscopic HIPEC is a safe and effective method for palliating malignant ascites.

Postoperative infections in cytoreductive surgery with hyperthermic intraperitoneal intraoperative chemotherapy for peritoneal carcinomatosis

BACKGROUND

Peritoneal carcinomatosis is a common evolution of many abdominal and pelvic malignancies. Over the last decade novel therapeutic approaches have emerged combining cytoreductive surgery with perioperative intraperitoneal chemotherapy. Aim of our study was to assess frequency, sites, and organisms of postoperative infections in this surgery and to evaluate associated risk factors and clinical outcome.

METHODS

Retrospective study of postoperative infection in 30 patients undergoing combined cytoreductive surgery and hypertermic intraoperative chemotherapy in an oncologic surgery in Rome, between June 2001 and December 2004.

RESULTS

Twenty-nine postoperative infections were recorded in 11 patients (36.7%; 2.6 infections per patient), including 13 surgical site infections, 8 clinical sepsis, 6 bloodstream infections, and 2 pneumonias. At multivariate analysis, total peritonectomy was found as independent variable associated to postoperative infection. Mortality rates were 36.4% and 5% among patients with and without postoperative infections, respectively (P = 0.04). Four of the 5 patients with invasive candidosis died.

CONCLUSIONS

Peritonectomy procedures have an high risk of postoperative infections, prolonged hospital stay, and high morbidity and mortality. The increasing role of this surgery for the treatment of peritoneal carcinomatosis should strengthen the need for a careful evaluation of possible risk factors for postoperative infections, including the role of colonizing organisms.

The Registry of Brain Deaths in Quality Control Program: Evaluation of Potentiality of Each Hospital in Abruzzo and Molise Regions

Quality control procedures in donation and transplantation of organ and tissue, which were started in 2001, are aspects of the activity of Regional Centre for Transplantation. Over the years there has been a significant increase in the number of diagnosed brain deaths that is close to the figure reported in the international literature of 50/60 per million inhabitants (p.m.i). Misidentification of brain death is still the most important cause of loss of organs for transplantation; in fact in Italy, there are some regions that overcome this value, but there are other regions in which the number of brain death identified is still low. Abruzzo and Molise in 2003 achieved the highest registered brain deaths (61 p.m.i.); in 2004, 51; in 2005, 43; and the projection for 2006 is about around 50. For this study we collected data from five hospitals with a neurosurgical unit, which were representative of procurement activity in two regions, because they had identified the most brain deaths, 53/65 in 2005. The data were compared among hospitals and with the Spanish country data (1999-2003), which was avant-garde for the processing of organ donation and transplantation in Europe. Some useful indices to define the theoretical capacity of donation for each hospital (ability to identify brain death, the cause of donor loss) were evaluated for determining the efficacy of the procedure in organ procurement.

Postoperative Infections in Cytoreductive Surgery With Hyperthermic Intraperitoneal Intraoperative Chemotherapy for Peritoneal Carcinomatosis

BACKGROUND

Peritoneal carcinomatosis is a common evolution of many abdominal and pelvic malignancies. Over the last decade novel therapeutic approaches have emerged combining cytoreductive surgery with perioperative intraperitoneal chemotherapy. Aim of our study was to assess frequency, sites, and organisms of postoperative infections in this surgery and to evaluate associated risk factors and clinical outcome.

METHODS

Retrospective study of postoperative infection in 30 patients undergoing combined cytoreductive surgery and hypertermic intraoperative chemotherapy in an oncologic surgery in Rome, between June 2001 and December 2004.

RESULTS

Twenty-nine postoperative infections were recorded in 11 patients (36.7%; 2.6 infections per patient), including 13 surgical site infections, 8 clinical sepsis, 6 bloodstream infections, and 2 pneumonias. At multivariate analysis, total peritonectomy was found as independent variable associated to postoperative infection. Mortality rates were 36.4% and 5% among patients with and without postoperative infections, respectively (P = 0.04). Four of the 5 patients with invasive candidosis died.

CONCLUSIONS

Peritonectomy procedures have an high risk of postoperative infections, prolonged hospital stay, and high morbidity and mortality. The increasing role of this surgery for the treatment of peritoneal carcinomatosis should strengthen the need for a careful evaluation of possible risk factors for postoperative infections, including the role of colonizing organisms.

120 peritoneal carcinomatoses from colorectal cancer treated with peritonectomy and intra-abdominal chemohyperthermia: a S.I.T.I.L.O. multicentric study

A multicentric study has been carried out on 120 patients affected by peritoneal carcinomatosis from colorectal cancer. Patients have been treated by cytoreductive surgery and intra-operative hyperthermic chemoperfusion (HIPEC) with cisplatin (CDDP) and mitomycin-c (MMC). A small group of patients were treated with oxaliplatin (LOHP) following the Elias et al. scheme [intravenous 5-fluorouracil (400 mg/m2) and leucovorin (20 mg/m2) followed by intraperitoneal perfusion with LOHP (460 mg/m2) in 2 l/m2, during 30 min at 43 degrees C]. CC-0 cytoreduction was achieved in 85.2% of the patients. Major morbidity and mortality was 22.5% and 3.3%, respectively. No G4 toxicity was registered. The three-year survival was 25.8%. The difference in survival evaluating complete cytoreduction (CC-0) vs. incomplete (CC1-2; residual tumor nodules greater than 2.5 mm) was statistically significant (p < 0.0001). Evaluating only the patients that could be cytoreduced to CC-0, the 3-year survival was raised to 33.5%. In our experience the peritoneal cancer index (PCI) has been demonstrated to be a weak prognostic factor reaching a statistical significance only after the exclusion of patients with resected hepatic metastases. The patients treated with oxaliplatin were alive and free-of-disease after a 16-month median follow-up.

An approach to the stereo-controlled synthesis of polycyclic derivatives of l-4-thiazolidinecarboxylic acid active against HIV-1 integrase

Herein, we describe a new strategy for the preparation of thiazolothiazepine-based inhibitors of human immunodeficiency virus type-1 integrase (IN). The present method allows facile preparation of the title compounds in a single enantiomeric form starting from l-4-thiazolidinecarboxylic acid. This method could be easily extended to the synthesis of several analogs derived from optically active cyclic aminoacids. We also present a putative model showing the interaction between l- and d-isomers of compound 1 in the IN active site. A sensibly lower IC(50) value was found for (-)-1 over racemic-1 in an anti-IN assay.

[Clinical guidelines for the management of gastrointestinal stromal tumors]

Treatment of gastrointestinal stromal tumors (GIST) has been revolutioned by the recently discovered molecular mechanism responsible for the oncogenesis of this disease. In addition, due to the rapid progress at molecular and clinical level observed in the last few years, there is a need to review the current state of the art in order to delineate appropriate guidelines for the optimal management of these tumors. A panel of experts from several specialities, including medical oncology, surgery, pathology, molecular biology and imaging, were invited to participate in a meeting to present and discuss a number of pre-selected questions, and to achieve a consensus according to the categories of the National Comprehensive Cancer Network (NCCN) and the Standard Options Recommandations (SOR) of the French Federation of Cancer Centers. Generally, consensus points were from categories 2A of the NCCN and B2 of the SOR. Conventional histologic examination with immunohistochemistry for CD117, CD34, SMA, S-100 and desmin is considered standard. Molecular analysis for the identification of KIT and PDGFRA mutation may be indicated in CD117-negative GIST. Complete tumor resection with negative margins is the optimal surgical treatment. Adjuvant imatinib should be considered an experimental approach. Neoadjuvant imatinib is also experimental, although its use may be justified in unresectable or marginally resectable GIST. Imatinib should be started in metastatic or recurrent disease, and should be continued until progressive disease or drug intolerance. In these cases, sunitinib can be used. The optimal criteria for the assessment and monitoring of GIST undergoing imatinib therapy are not well known, but they should include reduction in tumor size and disease stabilization, as well as reduction of tumor density on CT scan and metabolic activity on PET scan.

Laparoscopic intraperitoneal hyperthermic chemotherapy for palliation of debilitating malignant ascites

AIM

To report the use of laparoscopic Intraperitoneal Hyperthermic Chemotherapy (LIPHC) in the treatment of malignant ascites.

METHODS

From September 2001 to December 2003, 14 patients between the age of 56 and 78years were treated. Ascites was from gastric cancer (5 cases), colorectal cancer (3 cases), ovarian cancer (3 cases), breast cancer (2 cases) and peritoneal mesothelioma (1 case). The LIPHC was carried out at 42 degrees C for 90 min with 1.5% dextrose solution as a carrier. Chemotherapy was cisplatin and doxorubicin or mitomycin depending on the type of primary tumor. The drains were left in situ after surgery and removed when perfuse drainage ceased.

RESULTS

Ascites was controlled in all the treated cases. A CT scan performed in follow-up showed a small, clinically undetectable, fluid accumulation in the pelvis of one patient.

CONCLUSIONS

This method resulted in benefit for those peritoneal carcinomatosis patients with debilitating malignant ascites who were excluded from cytoreductive surgery. Proficiency in laparoscopic staging procedures and experience in the management of carcinomatosis and intraperitoneal hyperthermic chemotherapy (IPHC) are required for the success of the procedure.

D.M.R. ("Double Reasoned Maturing"): innovative technique of agronomic ecologic control of grey mould on grapevine. trials and various considerations

A study was carried out in order to identify agronomic ecologic solutions in the indirect grey mould control on grapevine. These specific trials started since 1990 and, after years of validation, now they are applied by the entrepreneur to the business practice in the different pedological and climatic area and on different cultivars and forms of growing. The technique of "Doppia Maturazione Ragionata" (D.M.R.) ("Doubles Reasoned Maturing") consists of far "completing" the maturing of the grape for wilting on the plant through the reasoned cut of the heads to fruit e/o of shoots. The application of D.M.R., besides determining valid and important technical and qualitative (organoleptic, economic and social quality) improvements on the product, is particularly effective in the indirect grey mould control on grapevine. Such technique, in fact, allows us to vintage the grape during the business demands and not when imposed by Botrytis cinerea; it has been possible, in some cases, to vintage in December and over, without problems of B. cinerea. The trials have shown the technical, economic, social sustainability of D.M.R. application. This paper reports all trials that have brought, by now from years, to apply in the practice DMR (Double Reasoned Maturing).

[Jaundice from neoplastic lymphangitis in patients undergoing D2/3 lymphadenectomy for gastric neoplasms. Our experience]

The surgical treatment of gastric adenocarcinoma foresees, toghether with the gastric resection, the lymph nodes resection as indicated by the Japanese Research Society for Gastric Cancer. Obstructive jaundice, as a consequence of lymph nodes metastases, is one of the most debilitating pattern of recurrence. In the present paper three cases of jaundice, observed during the follow-up, after D2-D3 gastric adenocarcinoma resection, with no evidence of lymph nodes recurrence either at the restaging or at the intraoperative esploration are reported. We believe that the jaundice etiology, in the present series, could be due to neoplastic lymphangites of the biliar wall.

[Integrated treatment of peritoneal carcinomatosis: preliminary experience]

A prospective study has been carried on 37 patients, 35 of them affected by peritoneal carcinomatosis from ovarian (16), appendiceal (7), colorectal (5), mesothelial (4), gastric (3) primary and 2 affected by sarcomatosis. Mean PCI was 22 (median, 22). Eighty-five percent of the patients presented debilitating ascites associated in 23% to initial symptoms of intestinal obstruction. All the patients have been treated with peritonectomy and intraoperative hyperthermic chemoperfusion and CC 0-1 cytoreduction was achieved in 81%. Major morbidity and mortality was respectively 37.8% and 16.2%, where 5 out 6 deaths recorded in the first 19 months of our experience, representing our learning curve. At a median follow-up of 8 months (range, 1-54), 18 patients are alive and disease-free and 4 patients are alive with disease. Two-yr overall survival was 49.1% for all series. Difference in survival evaluating CC 0-1 vs CC 2 patients was statistically significant.

[Association of mutations of K-RAS oncogene and deletions of 18Q with lymph node metastasis of colorectal cancer]

Molecular characterization of gastrointestinal cancer has greatly helped the definition of the key steps of the malignant transformation process and made it the best understood among the malignant cancers. Genetic influences on prognosis may have important implications for the management of the disease and help to design patient-tailored therapy. In order to acquire additional knowledge on this issue we have commenced an institutional study with the aim to identify the most frequent molecular alterations and make a correlation with the conventional histopathological parameters.

[Assessment of the presence of mutations of the epidermal growth factor receptors in tumors of various histologies]

Recent reports from US and Japan have established that mutations in the tyrosine kinase (TK) domain of the epidermal growth factor receptor (Egfr) occur in a subset of patients with lung cancer that respond to therapy with gefitinib, a TK inhibitor. To gain further insights into the role of Egfr in carcinogenesis of lung and tumors of diverse histology, that are currently under investigation with drugs of the same class, we have taken in examination a panel of tumors consisting in 110 pulmonary adenocarcinomas, 40 pulmonary squamous carcinomas, 40 gastric adenocarcinomas and 40 colorectal adenocarcinomas. The sequence analysis of exon 19 and 21 of the Egfr has allowed the identification of 10 cases exhibiting specific deletions in exon 19 and 1 case with point mutation in a conserved residue in exon 21. All Egfr mutations occur specifically in lung adenocarcinomas while tumors of different histology result unaffected. The rate of mutation affecting these other tumors is either very rare, involves different domains of the receptor or other tyrosine kinases. The molecular analysis of the Egfr gene can help identify patients that will benefit from gefitinib therapy.

[Laparoscopic intraperitoneal antiblastic hyperthermic chemoperfusion in the treatment of refractory neoplastic ascites. Preliminary results]

A method of laparoscopic continuous hyperthermic peritoneal perfusion (CHPP) is proposed for the treatment of debilitating malignant ascites. The authors report 14 cases of peritoneal malignancy, not amenable to peritonectomy due to massive infiltration of the small bowel. The ascites disappeared in all treated cases.

[Peritonectomy and chemohyperthermia in the treatment of peritoneal carcinomatosis: learning curve]

A prospective study has been carried on 37 patients affected by peritoneal carcinomatosis from various primary. Patients have been treated by cytoreductive surgery and intraoperative hyperthermic chemoperfusion. CC 0-1 has been achieved in 81%. The temperature distribution study showed a "barrier effect" with no statistically significant correlation to the survival. Major morbidity and mortality was respectively 37.8% and 16.2%. Two-yr overall survival was 49.1% for all series. Morbidity was significantly directly correlated to the duration of the surgical treatment. A learning curve of 19 months have been observed, after that only one death out 21 procedures has been recorded. Peritoneal carcinomatosis patients, that are submitted to integrated treatment, need a peculiar management that is not comparable to any other in the oncological setting and that requires specific competence.

[Remission of intraoperative complications in videolaparoscopic surgery of the colorectum]

Intraoperative morbidity in the laparoscopic approach for colorectal surgery is 5.6%. We tried our experience in 4 out of 70 laparoscopic procedures. In 3 cases it was dealt with one missed estate of the suture of the rectal stump. Two of them were treated with new resection of the rectal stump using in one case the opening of the anastomosis. In 1 case of bleeding of a sacral vessel we practiced a service 6 cm Pfannestiel incision of 6 cm to handle the hemorrhage. Intraoperative morbidity has not modified the course of the postoperative one.