Should functional renal scans be obtained prior to upper abdominal radiation for pancreatic cancer?

442

Background: Upper abdominal irradiation for pancreas cancer is given in close proximity to the radiation sensitive kidneys. While contemporary 3D and intensity modulated radiation therapy (IMRT) can decrease the total dose of radiation delivered to the kidneys; these plans may potentially exceed the established kidney dose constraints, especially if one kidney is providing most of the renal function. Less than 10% of the general population is estimated to have asymmetrical kidney function. Functional kidney scans using MAG3 clearance can give information about the contribution of each kidney to total renal function. We sought to determine if functional renal scans should be used to identify patients with occult renal dysfunction. Methods: Patients with resectable and borderline resectable pancreatic cancer who received abdominal irradiation therapy and had pre-radiation functional renal scans between 2009-2015 were studied. Asymmetrical kidney function was defined as a difference between the two kidneys that was ≥ 40%/60% on a functional renal scan. Serum studies (BUN, Cr, GFR) were routinely obtained pre-simulation. Restaging abdominal CT scans prior to radiation were screened for disparity in kidney size. Medical history that suggested decreased renal function was also collected. Results: Of the 205 patients examined, 24 (11.7%) had asymmetrical kidney function identified on pre-radiation functional renal scans. Of the patients with asymmetrical kidney function, 4 (2%) had a 75%/25% split or greater and 20 (9.7%) had kidney function between 60%/40% and 75%/25%. Elevated Cr or BUN, a GFR < 60, or a past medical history suggesting abnormal renal function were not significantly associated with asymmetrical kidney function. Only six (25%) of patients with asymmetrical kidney function scans had a notable difference in kidney size. Conclusions: In our series, approximately 12% of patients with pancreatic cancer have asymmetrical kidney function not identified by size, serum BUN, Cr, GFR, or a significant past medical history of renal compromise. These results provide important insight for cases when radiation plans may approach or exceed accepted dose constraints for the kidneys.

Venous thromboembolism prophylaxis during neoadjuvant therapy for resectable and borderline resectable pancreatic cancer-Is it indicated?

PURPOSE

To describe venous thromboembolism (VTE) rates in patients with pancreatic cancer (PC) during neoadjuvant therapy.

METHODS

Factors associated with VTE were evaluated using multivariable logistic regression modeling in patients with resectable and BLR PC treated with neoadjuvant therapy between 2009 and 2014.

RESULTS

Prevalent VTEs were detected in 13 (5%) of the 260 patients. Incident VTEs were detected in 26 patients (10%); 9 (8%) of the 109 resectable and 17 (11%) of the 151 BLR patients (P = 0.53). Of the 26 incident events, 9 (35%) were PEs, 9 (35%) were extremity DVTs, and 8 (31%) involved the SMV/PV. VTEs were catheter-related in 7 (27%) of the 26 patients. Rh(D) antigen positivity was associated with a decreased risk of incident VTE (OR:0.32, 95%CI:0.11-0.85, P = 0.02). Completion of neoadjuvant therapy to include surgery occurred in 176 (75%) of the 234 patients without incident VTE as compared to 14 (54%) of the 26 patients with incident VTE (P = 0.02). The median survival for all 260 patients was 24.3 months: 17.0 months versus 24.6 months for patients who did and did not develop incident VTE during neoadjuvant therapy (P = 0.11).

CONCLUSIONS

Patients with localized PC who receive neoadjuvant therapy are at significant risk of VTE and thromboprophylaxis may be warranted. J. Surg. Oncol. 2016;114:581-586. © 2016 Wiley Periodicals, Inc.

Evolution of the Management of Resectable Pancreatic Cancer

In pancreatic cancer, as with many other solid tumors, a commonly held surgical adage—a chance to cut is a chance to cure—has been promulgated throughout the years. Following such reasoning, surgical extirpation of a localized tumor would prevent tumor dissemination and metastatic tumor progression. However, decades of surgical experience have demonstrated that surgical resection alone provides a limited median survival benefit. Despite the optimization of surgical technique and perioperative management over the past three decades, little progress has been made to improve the limited survival of patients with localized pancreatic cancer who receive surgery. In this article, we discuss the rationale for a novel management strategy for patients with resectable pancreatic cancer, which may improve patient selection and the delivery of multimodality therapy.

Survival of patients with resectable pancreatic cancer who received neoadjuvant therapy

BACKGROUND

Enthusiasm for neoadjuvant therapy is growing from the emerging consensus that pancreatic cancer is a systemic disease at the time of diagnosis. Those who remain in favor of upfront surgery often cite the lack of reported data to support alternative treatment sequencing. We therefore report the results of all patients treated outside of a clinical trial under the direction of a multidisciplinary pancreatic cancer working group.

METHODS

We reviewed all patients with resectable pancreatic cancer treated with neoadjuvant therapy (NeoTx) from 2009 to 2013; we excluded those patients treated on prospective clinical trials as they will be the subject of subsequent reports. Data regarding demographics, NeoTx, operative outcomes, pathology, and survival data were abstracted from a prospective database.

RESULTS

NeoTx was initiated in 69 patients; median age was 65 years (interquartile range [IQR]: 11) and median carbohydrate antigen 19-9 at diagnosis was 96.5 (IQR 210). NeoTx consisted of chemotherapy alone (n = 10, 14%), chemotherapy and radiation (chemoradiation, n = 53, 77%), or both (n = 6, 9%). Median carbohydrate antigen 19-9 after NeoTx was 39 (IQR 104) corresponding to a median decrease of 60%. Operative resection was completed in 60 (87%) of the 69 patients. At restaging after NeoTx, 5 (7%) of 69 patients were not considered candidates for surgery because of the development of metastatic disease (n = 4) or an inadequate performance status (n = 1). At the time of surgery, 4 (6%) of 64 patients had metastatic disease found at laparoscopy. Of the 60 patients who underwent surgical resection, a complete pathologic response was observed in 2 (3%) patients; 20 (33%) had positive lymph nodes, and the median number of positive lymph nodes was 2 (IQR 3). R0 resections were achieved in 58 (97%) of the 60 patients. Additional postoperative adjuvant therapy was administered to 37 (62%) of the 60 patients. Median survival of all 69 patients was 31.5 months; 44.9 months for the 60 patients who completed all NeoTx and resection compared with 8.1 months for the 9 patients who were not resected (log rank P < .001).

CONCLUSION

NeoTx for resectable pancreatic cancer was associated with a median overall survival of 32 months; something not reported for patients treated with surgery first if based on intent-to-treat analysis. Treatment sequencing may provide an oncologic benefit beyond that of the selection bias afforded surgery after a period of induction therapy.

Rapid immunohistochemical analysis of pancreatic cytology from endoscopic ultrasound-guided fine-needle aspirates: A prospective clinical trial

400

Background: Acquisition of pancreatic cancer (PC) tissue specimens from endoscopic ultrasound-guided fine needle aspirates (EUS-FNA) is crucial to investigational pancreatic cancer trials seeking to utilize molecular profile directed therapy. Methods: In an ongoing prospective clinical trial we have utilized molecular profiling of EUS-FNA specimens from patients with resectable and borderline resectable pancreatic cancers. Cytologic specimens were evaluated for six biomarkers to guide the choice of neoadjuvant therapy: secreted protein acid rich in cysteine (SPARC), thymidylate synthase (TYMS), ribonucleotide reductase M1 (RRM1), human equilibrative nucleoside transporter 1 (ENT1), excision repair cross-complementing 1 (ERCC), and topoisomerase 1 (TOPO). Final immunohistochemical (IHC) interpretation was scored by a single pathologist using both staining intensity and percent immunochemically reactive cells. Results: The trial has enrolled 99 patients to date; 47 (47%) resectable patients and 52 (52%) borderline resectable patients. No patient experienced a EUS-FNA related complication. IHC profiling was reported in a median of 5 business days (IQR:3). Of the 99 patient samples, 73 (74%) had adequate cellularity for IHC profiling and this was not affected by stage of disease (n = 35, resectable; n = 38 borderline resectable; p = 0.82). Analysis of SPARC expression was limited to specimens with adequate stromal cells for analysis (n = 50, 51%). Among the 73 patients with adequate tissue for profiling, expression profiling was interpreted to be favorable for the following therapeutic agents: nab-paclitaxel, (SPARC, n = 35, 48%), 5-fluorouracil (TYMS, n = 68, 93%), gemcitabine (RRM1, n = 34, 47%; ENT1, n = 38, 52%), platinum agents (ERCC, n = 30, 41%), and irinotecan (TOPO, n = 62, 85%). Conclusions: The use of EUS-FNA specimens for molecular diagnostics is feasible and IHC analysis was possible in 74% of patient specimens, with preservation of stromal components in over 50%. Further refinement of molecular techniques may expand the breadth of analysis which may be performed, to include quantitative polymerase chain reaction and genetic sequencing Clinical trial information: NCIT01726582.

Can the sequence of chemotherapy regimens influence outcome in patients with metastatic pancreatic adenocarcinoma (MPAC)?

428

Background: FOLFIRINOX(FFX)/FOLFOX(FX) and Nab-paclitaxel plus Gemcitabine (NabG) represent standard first line (FL) treatment options for MPAC, but there is no prospective data to ascertain the ideal sequence of these regimens when used off protocol for patients with MPAC. We reviewed our single institution experience to evaluate whether the sequence of these regimens influenced clinical outcome. Methods: All MPAC patients treated with FFX/FX or NabG, in either sequence, from 1/1/11 to 12/31/14 at the Froedtert and Medical College of Wisconsin (MCW) Clinical Cancer Center were identified and their charts reviewed. This study was approved by the Froedtert & MCW Institutional Review Board. Results: Among 64 patients reviewed, the median age at diagnosis was 62. 64.1% were male and 95.3% were Caucasian. Median Ca19-9 and CEA at diagnosis were 855 and 10.4 respectively. 37/64 (57.8%) patients received SL therapy. Details of treatment and disease control rate (DCR) are summarized in the Table. Of patients who were refractory to FL FFX/FX, 4/7 (57.1%) demonstrated disease control (DCR) with SL NabG; numbers were too small for reverse analysis. Median overall survival (OS) of patients who received 2 lines of therapy was 12.1 months, while median OS of patients who received one line was 4.1 months. Median OS associated with sequential therapy is summarized in the Table. Conclusions: Both FFX/FX and NabG are active in the SL setting. Outcomes appear to be fairly similar regardless of sequence. The numerically superior median OS associated with FL NabG followed by SL FFX should be interpreted with caution in the context of small number of patients in this subset. A substantial minority of patients do not receive second line chemotherapy due to deteriorating clinical status and/or patient preference suggesting unfavorable tumor biology. [Table: see text]

Outcomes in metastatic pancreatic adenocarcinoma (MPAC) patients treated with FOLFIRINOX (FFX)/FOLFOX(FX) and gemcitabine + nab-paclitaxel (NabG)

397

Background: Standard front line (FL) chemotherapy regimens for MPAC include FOLFIRINOX (FFX)/FOLFOX(FX) and Nab-paclitaxel plus Gemcitabine (NabG). Outcome data in patients treated with both FFX/FX and NabG has not been well characterized. We retrospectively reviewed our single institution experience in MPAC patients treated with FFX/FX and NabG in either sequence. Methods: All MPAC patients treated with FFX/FX or NabG, in either sequence, from 1/1/11 to 12/31/14 at the Froedtert and Medical College of Wisconsin (MCW) Clinical Cancer Center were identified and their charts reviewed. This study was approved by the Froedtert & MCW Institutional Review Board. Results: Among the 64 patients reviewed, median age at diagnosis was 62 years, 64.1% were male and 95.3% were Caucasian. Median Ca19-9 and CEA at diagnosis were 855 and 10.4 respectively. Liver, lung and peritoneal metastases were appreciated in 87.5%, 20.3% and 35.9% of patients. 37/64 (57.8%) patients received second line (SL) therapy. Response Rate (RR) with FFX/FX and NabG in both FL and SL therapy are summarized in the Table. The median Progression Free Survival (PFS) with FL therapy was 3.7 months and 3.5 months with SL therapy. Median overall survival (OS) of the entire cohort was 8.7 months. In patients who received 2 lines of therapy the median OS was 12.1 months. Median OS in patients who received only one line of therapy was 4.1 months. Conclusions: In patients with MPAC, sequential therapy with FFX/FX and NabG is both feasible and effective in either sequence. RR and DCR with these regimens, while modest, are acceptable in the SL setting. Patients who received two lines of therapy have a substantially better OS than patients who receive one line of therapy, suggesting a more favorable tumor biology in the former population. [Table: see text]

Can response to treatment predict outcome in patients with metastatic pancreatic adenocarcinoma (MPAC)?

443

Background: Front-line (FL) chemotherapy regimens for MPAC include FOLFIRINOX (FFX)/FOLFOX (FX) and Nab-paclitaxel plus Gemcitabine (NabG). We examined our hypothesis that objective response (OR) to these regimens can influence clinical outcome when employed sequentially. Methods: All MPAC patients treated with FFX/FX or NabG from 1/1/2011 to 12/31/2014 at the Froedtert and Medical College of Wisconsin (MCW) Clinical Cancer Center were reviewed. This study was approved by the MCW Institutional Review Board. Results: 64 patients were evaluated and the baseline characteristics are summarized in the table below. OR to FL chemotherapy included partial response(PR) - 23/64 (35.9%), stable disease (SD) - 14/64 (21.9%) and disease control rate (DCR) of 57.8%; OR to second line (SL) therapy included PR - 7/37 (18.9%), SD - 14/37 (37.8%) and DCR of 56.7%. Only 57.8% patients received SL chemotherapy. Among patients who demonstrated PR to FL chemotherapy, 64% were refractory to SL chemotherapy, while 33% of patients who were refractory to FL chemotherapy demonstrated a PR to SL chemotherapy. 3/64 patients who demonstrated PR to both FL and SL chemotherapy had excellent outcomes with overall survival (OS) of 20.9 months, 37 months and not met (PFS of 11 months to FL chemo and ongoing response of > 4 months to SL chemo). Median OS of patients who demonstrated a PR/SD to FL and SL chemotherapy (15/64; 23.4 %) was 20.9 months. The patients who demonstrated progressive disease(PD) to both FL and SL chemotherapy (5/64; 7.8%) had a median OS of 3.8 months. Conclusions: Patients with MPAC who are refractory to FL chemotherapy may demonstrate a response to SL chemotherapy. Patients who are able to undergo sequential therapy with FFX/FX and NabG (in either sequence) and demonstrate either a PR or SD with both treatment regimens have an excellent clinical outcome. The minority of patients who demonstrate PR to both sequential regimens have a distinctly different outcome compared to patients who demonstrate PD to both regimens; tumors from these two subsets of patients need to be better characterized to improve our understanding of pancreatic cancer biology. [Table: see text]

Interim results of a randomized phase II study of PEGPH20 added to nab-paclitaxel/gemcitabine in patients with stage IV previously untreated pancreatic cancer

439

Background: Poor outcome in pancreatic cancer (PDA) is associated partly with stromal hyaluronan (HA) accumulation, which compromises chemotherapy perfusion. PEGPH20, PEGylated recombinant human hyaluronidase, potentiates chemotherapy by depleting HA in tumors. Methods: In an ongoing, phase II, open-label, randomized study of PEGPH20+nab-paclitaxel (Nab)+Gemcitabine (Gem) (PAG) vs Nab+Gem (AG) in previously untreated stage IV PDA, pts receive PEGPH20 3 µg/kg twice weekly (C1), then weekly (C2+) with standard AG dosing. HA status was tested retrospectively. After a temporary clinical hold (Apr-Jul 2014) for an imbalance in thromboembolic (TE) events (29% PAG vs 15% AG), the protocol was amended to exclude high-TE-risk pts and add enoxaparin (LMWH) prophylaxis. Endpoints are PFS and TE events (primary); PFS and ORR by HA level and OS (secondary). Efficacy and safety data through Dec 2014 are for pts enrolled up to clinical hold (Stage 1); TE data are through Sep 2015 (Stage 2). Results: 135 pts were treated (74 PAG, 61 AG). PFS results are shown below (median follow-up 7 mo). In HA-high pts receiving PAG vs AG, ORR was 52% (1 CR) vs 24% (P=.038); ORR was 37% vs 38% in HA-low pts. OS was 12 mo vs 9 mo (HR=0.62) despite 12/23 PAG pts discontinuing PEGPH20 at clinical hold. Common ADRs (PAG vs AG) included peripheral edema (58% vs 31%), muscle spasms (55% vs 1.6%), and neutropenia (32% vs 18%). TE events were: Stage 1 42% vs 25% (no LMWH); Stage 2 (with LMWH; 40 mg/d or 40 mg/d increased to 1 mg/kg/d) 28% vs 29%; (1 mg/kg/d) 5% vs 6%; overall (40 mg/d or 1 mg/kg/d) 13% each arm (to be updated). Conclusions: Pts with HA-high tumors receiving PAG, vs AG, showed significant improvements in PFS and ORR and a trend toward improved OS. PAG was well tolerated, with TE events reduced with LMWH prophylaxis. A global phase III trial of PAG will initiate Q1 2016. Clinical Trial Information: NCT01839487. Clinical trial information: NCT01839487. [Table: see text]

Pre-treatment carbohydrate antigen 19-9 does not predict the response to neoadjuvant therapy in patients with localized pancreatic cancer

BACKGROUND

The prognostic value of CA19-9 in patients with pancreatic cancer (PC) treated with neoadjuvant therapy has not been well described.

METHODS

Pre-treatment CA19-9 levels (with concomitant normal bilirubin level) in patients with localized PC were categorized as normal (≤35), low (36-200), moderate (201-1000), or high (>1000). Post-treatment CA19-9 was measured after neoadjuvant therapy, prior to surgery.

RESULTS

Pre-treatment CA19-9 levels were evaluable in 235 patients, levels were normal in 60 (25%) patients, low in 78 (33%) patients, moderate in 69 (29%) and high in 28 (12%). After neoadjuvant therapy, post-treatment CA19-9 normalized (≤ 35) in 40 (51%) of the patients in the low group, 14 (21%) of the moderate and 5 (19%) of the high group (P < 0.001). Of the 235 patients, 168 (71%) completed all intended therapy including a pancreatectomy; 44 (73%), 62 (79%), 46 (67%) and 16 (57%) of the normal, low, moderate and high groups (P = 0.10). Among these 168 patients, the median overall survival was 38.4, 43.6, 44.7, 27.2 and 26.4 months for normal, low, moderate and high CA19-9 groups (log rank P = 0.72). Among resected patients, an elevated pre-treatment CA19-9 was of little prognostic value; instead, it was the CA19-9 response to neoadjuvant therapy that was prognostic [hazard ratio (HR): 1.80, P = 0.02].

CONCLUSIONS

Among patients who completed neoadjuvant therapy and surgery, pre-treatment CA19-9 obtained at the time of diagnosis was not predictive of overall survival, but normalization of post-treatment CA19-9 in response to neoadjuvant therapy was highly prognostic.

Use of neoadjuvant therapy in patients 75 years of age and older with pancreatic cancer

BACKGROUND

Treatment sequencing in older patients is difficult because of concomitant comorbidities and often decreasing performance status. The present study sought to examine the effect of neoadjuvant therapy and pancreatic surgery in older patients with resectable or borderline-resectable (BLR pancreatic cancer (PC).

METHODS

Patients with resectable or BLR PC treated with neoadjuvant therapy were classified as older (≥ 75 years) or younger (<75 years).

RESULTS

Neoadjuvant therapy was initiated in 246 patients; 210 (85%) younger than 75 years and 36 (15%) older. Older patients had a greater median Charlson comorbidity index (CCI): 6 vs 4 (P < .01). Completion of all intended therapy (neoadjuvant therapy and surgery) occurred in 177 (72%) of the 246 patients; 153 (73%) of the 210 younger and 24 (67%) of the 36 older patients (P = .43). Failure to complete all therapy was associated with BLR clinical stage (odds ratio [OR] 0.26, P = .001), increased posttreatment/preoperative serum levels of CA19-9 (OR 0.27, 95% confidence interval 0.14-0.53), and CCI ≥ 6 (OR 0.44, 95% confidence interval 0.22-0.86). Median overall survival for all study patients was 26.1 and 19.7 months (P = .13) for younger and older patients, respectively. Of the 177 patients who completed all therapy, the difference in survival between younger and older patients was not statistically significant (36.5 months vs 27.2 months, P = .47).

CONCLUSION

Failure to complete neoadjuvant therapy and eventual pancreatic resection is associated with BLR stage, increased posttreatment/preoperative CA19-9, and CCI ≥ 6, but not older age. Older patients who completed neoadjuvant therapy and underwent resection experienced a survival benefit compared with those who did not complete all intended therapy. Balancing the toxicity of sequential therapies with their cumulative effect on tolerance and risk for pancreatic surgery will be the key to developing optimal treatment sequencing in older patients with PC.

Neoadjuvant therapy for localized pancreatic cancer: guiding principles

The management of localized pancreatic cancer (PC) remains controversial. Historically, patients with localized disease have been treated with surgery followed by adjuvant therapy (surgery-first approach) under the assumption that surgical resection is necessary, even if not sufficient for cure. However, a surgery-first approach is associated with a median overall survival of only 22-24 months, suggesting that a large proportion of patients with localized PC have clinically occult metastatic disease. As a result, adjuvant therapy has been recommended for all patients with localized PC, but in actuality, it is often not received due to the high rates of perioperative complications associated with pancreatic resections. Recognizing that surgery may be necessary but usually not sufficient for cure, there has been growing interest in neoadjuvant treatment sequencing, which benefits patients with both localized and metastatic PC by ensuring the delivery of oncologic therapies which are commensurate with the stage of disease. For patients who have clinically occult metastatic disease, neoadjuvant therapy allows for the early delivery of systemic therapy and avoids the morbidity and mortality of a surgical resection which would provide no oncologic benefit. For patients with truly localized disease, neoadjuvant therapy ensures the delivery of all components of the multimodality treatment. This review details the rationale for a neoadjuvant approach to localized PC and provides specific recommendations for both pretreatment staging and treatment sequencing for patients with resectable and borderline resectable (BLR) disease.

Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument

OBJECTIVES

Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT).

METHODS

Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year).

RESULTS

Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients.

CONCLUSIONS

The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.

Utility of invasive staging procedures in patients (pts) with localized esophageal cancer (EC)

54

Background: Definitive treatment for localized EC involves surgery alone or tri-modality therapy (TMT-chemotherapy, radiation, and surgery). TMT is administered to pts with clinical T2 or higher and lymph node (LN) positive ECs. Standard staging includes Computerized Tomography (CT)/Positron Emission Tomography (PET) imaging and Endoscopic Ultrasound (EUS). We investigated whether performing an EUS altered treatment decision in localized EC pts where a combination of imaging and clinical symptoms suggested the need for TMT. Methods: We performed a retrospective review to identify pts with localized EC who had their staging work up and treatment at the Medical College of Wisconsin between 2003 and 2012. Relevant clinical information was collected through review of the electronic medical record. Results: We identified 65 pts; median age at diagnosis was 62 years, 49 (75%) were male, and 56 (86%) were Caucasian. Histology was adenocarcinoma in 48 (74%) pts with 21 (44%) having background Barrett’s esophagus. Common presenting symptoms included dysphagia (83%), weight loss (73%), and odynophagia (25%). Staging evaluation included CT, PET, and EUS in 100%, 98%, and 89% of pts respectively. EUS staging results are in the table below. Dysphagia was reported by 67% of T1, 80% of T2, 84% of T3, 50% of T4, and 100% of Tx pts; 70% of pts with dysphagia were node positive by EUS. PET positive primary tumors/LNs were found in 89%/29% of all pts and 89%/33% of pts with dysphagia. Of the pts with PET positive LNs, 68% had node positive disease on EUS. Eighteen (28%) pts had both dysphagia and PET positive LNs, none with T1-2N0 staging by EUS; 36 pts had dysphagia and PET negative LNs, 7 (19%) with T1-2N0 staging by EUS. Among those 7 pts, 4 underwent surgery (1 pt-pT3N1aMx; 3pts-pT1bN0Mx). Conclusions: Localized EC pts with both dysphagia and PET positive LNs are candidates for TMT even in the absence of EUS staging. The role of EUS in this population may be limited to investigating adjacent organ invasion or confirmation of LN involvement. With improving PET capabilities, the role of EUS in this pt population needs to be studied prospectively. [Table: see text]

Abstract 813: A combination of cisplatin, irinotecan, and paclitaxel (CIP) as frontline treatment of patients with metastatic esophageal cancer (mEC)

Introduction: Median survival associated with mEC is 9-12 months. While systemic therapy is the mainstay of treatment for mEC, there is no consensus regarding the best frontline chemotherapy combination. We evaluated the efficacy of CIP (Cisplatin 30 mg/m2, Irinotecan 50 mg/m2 and Paclitaxel 50 mg/m2 on days 1 and 8 of a 21 day cycle) in patients with mEC.

Methods: We performed a retrospective review to identify mEC patients at the Medical College of Wisconsin (MCW) who were treated with frontline CIP between January 1, 2005 and December 31, 2010. Relevant clinical information was collected through a review of the electronic medical record. This study was approved by the Institutional Review Board at MCW.

Results: We identified 13 patients who were treated with CIP as frontline therapy for mEC. The median age at diagnosis was 59 years (range 48-71 years), 12 (92%) patients were male, and 9 patients (69%) had adenocarcinoma with the remaining being squamous cell carcinoma. Eleven patients (85%) presented with metastatic disease, while 2 patients (15%) were diagnosed with metastatic disease after having undergone initial surgical resection with disease free intervals of 39 and 14 months respectively. The most common sites of metastases were lymph nodes (11 patients), liver (6 patients), lung (4 patients), bone (3 patients), and peritoneum (2 patients); 77% of patients had at least 2 sites of metastases. The median number of chemotherapy cycles administered was 7 (range 1-14). Four patients (31%) developed grade 3/4 toxicities including neutropenia in 3 patients, nausea in 1 patient, and anemia in 1 patient. One patient (8%) had a complete response (CR), 7 patients (54%) had a partial response (PR), 2 patients (15%) had stable disease (SD), and 3 patients (23%) developed progressive disease (PD). The median progression free survival (PFS) was 5 months (range 0-29 months) and the median overall survival (OS) was 10 months (range 3-36 months).

Conclusion: CIP is an active and well tolerated regimen in patients with mEC that merits prospective evaluation.

Citation Format: Thomas A. Giever, Paul S. Ritch, James P. Thomas, Lauren A. Wiebe, George B. Haasler, Mario G. Gasparri, David Johnstone, Candice A. Johnstone, Elizabeth M. Gore, Ben George. A combination of cisplatin, irinotecan, and paclitaxel (CIP) as frontline treatment of patients with metastatic esophageal cancer (mEC). [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 813. doi:10.1158/1538-7445.AM2014-813

Neoadjuvant therapy for pancreatic cancer in patients older than age 75

287

Background: Multiple treatments in series may be difficult for older patients (pt) to tolerate. We sought to examine the outcomes associated with neoadjuvant therapy in older pt with resectable (R) or borderline resectable (BLR) pancreatic cancer (PC). Methods: Pt ≥75 years (O) with those <75 (Y) with R or BLR PC receiving neoadjuvant therapy from 2008-2012 were identified. Clinicopathologic and treatment data were abstracted. Completion of all therapy was defined as the receipt of neoadjuvant therapy followed by surgical resection. Results: We identified 77 (42.5%) R and 104 (57.5%) BLR pt; 29 (16%) were ≥ 75 years. Higher Charlson Comorbidity Index (CCI) (median CCI 4 vs. 2, p<0.01) and more hospitalizations during neoadjuvant therapy (50% vs. 28%, p=0.04) were associated with O vs. Y pt. Older pt were less likely to complete all therapy as compared to Y pt (72.4 vs. 89.5%, p<0.01). Poor performance status was the most common reason for failure to complete all therapy in O vs. Y pt (17.2% vs. 0.7%; p<0.01). Higher CCI (OR 0.25; 95% CI: 0.08-0.74, p=0.01) and higher clinical stage (OR 0.17; 95%CI: 0.06-0.48, p<0.01) were associated with failure to complete all therapy. Of the 138 pt that completed all therapy, no significant differences in complication rates (15 vs. 15.3%, p=0.33), median length of hospital stay (10 vs. 9 days, p=0.29), 30 day readmission rates (10 vs. 11.9%, p=0.81), or median overall survival (24.3 mo vs. 36.7 mo, p=0.20) were observed between O vs. Y pt. Conclusions: After neoadjuvant therapy, 25% of pt ≥ 75 years of age will not undergo surgical resection. The most common reason for not completing all therapy is a decline in performance status. Whether neoadjuvant therapy improves the selection of older pts who should not undergo an operation or prevents successful resection of pt who may have tolerated an operation is unclear. With evolving paradigms of treatment sequencing, the management of PC pt with advanced age will require further assessment.

Phase II clinical trial of biomarker-directed therapy for localized pancreatic cancer

TPS4147

Background: Several candidate biomarkers exist for the common chemotherapeutic agents used to treat pancreatic cancer (PC) (Table). The predictive value of these markers in the treatment of PC has not been established. This is the first prospective clinical trial utilizing biomarker-directed therapy for localized pancreatic cancer. Methods: Patients with localized pancreatic cancer undergo endoscopic ultrasound-guided fine needle aspiration (FNA) for confirmation of diagnosis and immunohistochemical profiling . Six biomarkers (STREET profile) were selected based on their relevance to accepted pancreatic chemotherapy regimens (table). The treatment algorithm selected for each individual patient is based on the clinical stage of resectability (resectable/borderline resectable) and the STREET profile results. Neoadjuvant therapy is followed by restaging (CT and serum Ca19-9) and in the absence of disease progression, patients undergo surgery. Post-surgical (adjuvant) therapy is determined by the STREET profile of the resected specimen. The primary endpoint is an increase in the rate of surgical resection 20% compared with historical controls treated with best available neoadjuvant therapy which was not biomarker-directed. Secondary endpoints include assessment of overall and progression-free survival, comparative STREET profiling of pre- and post-treatment specimens, and changes in radiographic response. Eligbility Criteria: Patients with resectable or borderline resectable pancreatic cancer undergo endoscopic ultrasound-guided fine needle aspiration (FNA) for confirmation of diagnosis and immunohistochemical profiling. Enrollment: 26 of planned 100 patients have been enrolled. Clinical trial information: NCT01726582. [Table: see text]

Association of decline in serum Ca19-9 after neoadjuvant therapy with improved survival among borderline resectable pancreatic cancer patients

e15082

Background: Serum Ca19-9 (19-9) decline in response to therapy has been associated with an increased overall survival in metastatic pancreatic cancer patients (pts). However, the prognostic value of a 19-9 decline after neoadjuvant therapy in pts with localized disease is less well defined. Methods: We evaluated 73 pts with NCCN defined BRPC who received neoadjuvant therapy with induction chemotherapy (CRX) followed by chemoradiation (CRT). Staging with CT and 19-9 was obtained at three defined time points: baseline (bilirubin normal), after CRX, and following CRT (pre-surgical). Change in 19-9 (δ19-9) was defined as: (baseline 19-9- pre-surgical 19-9)/baseline 19-9. δ19-9 was classified as: absent (δ19-9<0) or minimal (0 <δ19-9<0.25), low (0.25<δ19-9<0.50), moderate (0.50<δ19-9<0.75), high (δ19-9> 0.75). Results: Of the 73 pts, 20 pts had normal/undetectable 19-9 and were excluded from the analysis. Of the remaining 53 pts, mean 19-9 levels at baseline, after CRX, and after CRT were 956, 164, and 139 U/mL, respectively. The mean change in 19-9 after CRX was 44%. Changes in 19-9 after CRX correlated with continued decline in 19-9 after CRT (Spearman rho = 0.81, p<0.001). δ19-9 was high in 38 (71%), moderate in 9 (17%), min/low in 1 (2%), and absent in 5 (9%). Of the 53 pts, 49 (92%) were considered for surgery after neoadjuvant therapy and 38 (72%) underwent pancreatectomy. In a multivariate logistic regression, higher δ19-9 was associated with a 5.4 fold increased odds of completing all neoadjuvant therapy including surgery as compared to pts with no change in 19-9 (absent δ19-9; HR 5.4, p=0.12). Patients with absent δ19-9 had a worse overall survival than pts with minimal to high δ19-9 (median survival 11.5 mo vs. 30.1 mo, p = 0.0002). In a multivariate Cox proportional hazard, a decline in pre-surgical 19-9 from baseline was associated with improved survival (HR 0.21, p =0.02). Conclusions: Following neoadjuvant therapy, a decline in 19-9 is associated with surgical resection and improved overall survival. An increase in 19-9 above baseline (the absent δ19-9 group) prior to surgery is a poor prognostic marker and such patients may benefit from additional systemic therapy.

Local control in resectable and borderline resectable pancreatic cancer (PCa) treated with preoperative chemoradiation using IMRT or chemotherapy alone

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Background: The primary objective is to review local control and failure patterns in PCa patients treated with preoperative chemoradiation (chemoXRT) using IMRT compared to patients treated with chemotherapy alone. Methods: All patients with resectable and borderline resectable PCa treated between 1/1/2009 -11/1/2011 were reviewed. During the study period, 68 patients (40 borderline resectable, 28 resectable) were treated with preoperative chemoXRT (50.4 Gy [1.8 Gy/fx] with concurrent gemcitabine [n=59] or capecitabine [n=7]). 12 patients with resectable tumors received gemcitabine based chemotherapy alone and did not receive radiation therapy due to enrollment on chemotherapy only protocols (n=10) or to patient preference (n=2). Radiation was delivered to a CTV that includes the primary mass, the SMA and SMV, +/- the celiac axis. A 4D-CT and daily image guidance were used in all patients. The local failure free interval was defined as the time from surgical resection to local failure or last documented CT scan of the abdomen with no evidence of local disease progression. Results: Following preoperative chemoXRT, 48/68 patients underwent resection with 47(98%) R0 resections. 11/12 patients in the No XRT group undwerent resection with 10 (91%) R0 resections. In the No XRT group, 8/11 (73%) patients failed locally at the SMA/SMV or resection bed as a component of first failure compared to 1/48 (2%) patients who received preoperative chemoXRT (p<0.001). Local failure was the sole site of first failure in 5/11 patients in the No XRT group and 0/48 patients who received preoperative chemoXRT. The actuarial rate of local failure 1 year from surgery was 5% in the preoperative chemoXRT group vs 27% in the No XRT group (p<0.001). All local failures in the No XRT group would have been encompassed using the CTV target volumes used in patients treated with preoperative chemoXRT. Conclusions: IMRT-based, conformal, preoperative chemoXRT for resectable and borderline resectable PCa may facilitate margin negative resection and increase local control. Omission of radiation therapy may result in high rates of local failures at the SMA/SMV vasculature or in the pancreatic bed.

5-FU/leucovorin, irinotecan, oxaliplatin (FOLFIRINOX) induction followed by chemoXRT in borderline resectable pancreatic cancer

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Background: FOLFIRINOX improves overall survival compared to gemcitabine in patients with metastatic PCa. We retrospectively evaluated the feasibility of using induction FOLFIRINOX followed by chemoXRT to improve resectability in borderline resectable PCa. Methods: All patients with borderline resectable, biopsy-proven PCa treated with the FOLFIRINOX between 1/2009 -11/2011 were reviewed. Borderline resectable PCa was defined by computerized tomography (CT) imaging as tumor-induced SMA abutment of <180 degrees, SMV occlusion, or findings suspicious but not diagnostic for metastatic disease. CT imaging was obtained following induction chemotherapy and after chemoXRT prior to surgery. Results: Twelve patients with borderline resectable disease were treated with FOLFIRINOX induction (median of 4 cycles [range 3-8]). Chemotherapy details are listed in table 1. Tumors in 9 patients had SMA abutment or SMV occlusion and the median pre-treatment CA 19-9 was 297 U/ml (1-3432 U/ml ). Following induction chemotherapy, all patients proceeded to chemoXRT (50.4 Gy [1.8 Gy/fx] with concurrent gemcitabine [n=8] or capecitabine [n=4]). The median CA 19-9 reduction following systemic therapy alone was 58%. One patient did not complete chemoXRT due to infectious and hematologic toxicities. Following all neoadjuvant treatment, 7 (58%) of the 12 patients underwent successful PD. All 7 patients who underwent PD had an RO resection and only one patient had lymph node metastases. The median survival has not been met with median follow up of 13 months. Conclusions: In medically fit patients with borderline resectable PCa, induction FOLFIRINOX followed by chemoXRT is feasible and may facilitate a margin negative resection and histologic response in regional lymph nodes. [Table: see text]

Multicenter, randomized phase II trial of bevacizumab plus folinic acid, fluorouracil, gemcitabine (FFG) versus bevacizumab plus folinic acid, fluorouracil, oxaliplatin (FOLFOX4) as first-line therapy for patients with advanced colorectal cancer

PURPOSE

To assess safety and efficacy of folinic acid, 5-fluorouracil, gemcitabine (FFG) and folinic acid, fluorouracil, oxaliplatin (FOLFOX4) regimens with added bevacizumab as first-line treatment in patients with advanced colorectal cancer (CRC).

PATIENTS AND METHODS

Patients with Stage III unresectable or Stage IV adenocarcinoma of the colon or rectum were randomly assigned to either FFG weekly for 6 weeks of an 8-week cycle or FOLFOX4 every 2 weeks. After FDA approval, bevacizumab 5 mg/kg was added every 2 weeks. Treatment continued until disease progression. Planned enrollment was 190 patients. Primary endpoint was overall response rate (ORR); secondary endpoints included evaluation of adverse events, time to progression (TTP), and overall survival (OS). Disease Control Rate (DCR; % of patients with complete or partial responses or stable disease) was a post hoc analysis.

RESULTS

The trial was stopped prematurely due to low enrollment. Of 84 enrolled patients (42 to each arm), 36 patients (18 in each arm) received bevacizumab. ORR was greater (P = .002) for FOLFOX4 (17/42; 40.5%) than for FFG (4/42; 9.5%); however, TTP, OS, and DCR results were not statistically different comparing FOLFOX4 and FFG. Peripheral neuropathy was more frequent (P = <.001) with FOLFOX4 (18/42; 42.9%) than with FFG (1/42; 2.4%).

CONCLUSIONS

FFG and FOLFOX4 were generally well tolerated. Based on ORR, FOLFOX4 was superior to FFG. However, differences in TTP and OS comparing regimens were inconclusive. General use of gemcitabine as a biomodulator of 5-fluorouracil in CRC cannot be recommended at this time and the regimen remains investigational.

Palliative stenting for late malignant gastric outlet obstruction

Malignant gastric outlet obstruction (MGO) is a late complication of pancreatobiliary and gastric cancers. Although surgical gastrojejunostomy provides good palliation, many of these patients may be nonoperative candidates or underwent previous extensive resection such as a Whipple procedure. Recently, endoscopically placed self-expanding metallic stents (SEMS) have been used to palliate MGO. The aim of this study was to evaluate the efficacy of SEMS for palliation of late MGO. Medical records of patients with endoscopic placement of SEMS for palliation of MGO were reviewed. Results showed that 30 patients with MGO had SEMS placed for late gastroduodenal (n = 20) or jejunal (n = 10) obstruction. Twenty-one patients (70%) had previous surgery. Return to oral feeding was observed in 90% of patients who presented with recurrent obstruction after prior bypass surgery and in 88% of nonoperative patients in whom SEMS were placed as the primary therapy for obstruction. No major complications were observed, and median survival after SEMS was 4.1 months (0.1 to 10.5 months). SEMS also did not interfere with biliary drainage. In conclusion, endoscopically placed SEMS are safe and provide good palliation for late malignant gastroduodenal and jejunal strictures and are an excellent complement to recurrent obstruction after surgical gastrojejunostomy.

Modulation of glioma BK channels via erbB2

Glioma cells show up-regulation and constitutive activation of erbB2, and its expression correlates positively with increased malignancy. A similar correlation has been demonstrated for the expression of gBK, a calcium-sensitive, large-conductance K(+) channel. We show here that glioma BK channels are a downstream target of erbB2/neuregulin signaling. Tyrphostin AG825 was able to disrupt the constituitive erbB2 activation in a dose-dependent manner, causing a 30-mV positive shift in gBK channel activation in cell-attached patches. Conversely, maximal stimulation of erbB2 with a recombinant neuregulin (NRG-1beta) caused a 12-mV shift in the opposite direction. RT-PCR studies reveal no change in the BK splice variants expressed in treated glioma cells. Furthermore, isolation of surface proteins through biotinylation did not show a change in gBK channel expression, and probing with phospho-specific antibodies showed no alteration in channel phosphorylation. However, fura-II Ca(2+) fluorescence imaging revealed a 35% decrease in the free intracellular Ca(2+) concentration after erbB2 inhibition and an increase in NRG-1beta-treated cells, suggesting that the observed changes most likely were due to alterations in [Ca(2+)](i). Consistent with this conclusion, neither tyrphostin AG825 nor NRG-1beta was able to modulate gBK channels under inside-out or whole-cell recording conditions when intracellular Ca(2+) was fixed. Thus, gBK channels are a downstream target for the abundantly expressed neuregulin-1 receptor erbB2 in glioma cells. However, unlike the case in other systems, this modulation appears to occur via changes in [Ca(2+)](i) without changes in channel expression or phosphorylation. The enhanced sensitivity of gBK channels in glioma cells to small, physiological Ca(2+) changes appears to be a prerequisite for this modulation.

Improved survival in resected biliary malignancies

BACKGROUND

For many years the prognosis for patients with biliary malignancies has been poor. However, recent advances in radiology and laparoscopy have improved staging, and active biliary stent management may improve outcome in these patients. In the past the goal with surgery was to excise all gross tumor. Now, the surgical goal is to achieve negative microscopic margins even if a major hepatic resection is required. Similarly, chemotherapy or radiation was frequently given in isolation, but chemoradiation has become the standard. Therefore, the aim of this analysis was to determine whether survival has improved with better staging, active stent management, more aggressive surgery, and chemoradiation.

METHODS

From 1990 through 2001, 140 patients with biliary malignancies were treated at the Medical College of Wisconsin. One hundred eleven malignancies were cholangiocarcinomas (intrahepatic, 22%; perihilar, 65%; and distal, 13%), and 29 were gallbladder (GB) cancers. Eighty-six of the 140 patients (61%) underwent exploration (intrahepatic, 58%; perihilar, 57%; distal, 67%, and GB, 72%). Forty-four of these 86 patients (51%) underwent resection (intrahepatic, 64%; perihilar, 41%; distal, 70%; and GB, 52%). Chemoradiation with confocal radiation, 5-fluorouracil, and gemcitabine was used more frequently in the patients resected since 1998.

RESULTS

Thirty-day operative mortality was 4%. In the resected patients (n = 44) the 5-year actuarial survival was 31% and the median survival was 27.8 months. Patients resected between 1998 and 2001 (n = 25) had a median survival longer than 44 months with a 3-year actuarial survival of 70% as compared to patients resected between 1990 and 1997 (n = 19), who had a median survival of 13 months and a 3-year actuarial survival of 21% (P <.01).

CONCLUSIONS

These data suggest that (1) approximately one third of patients with biliary malignancies have resectable disease and (2) surgery in carefully selected patients with adjuvant chemoradiation has improved survival in resected patients. We suspect that a combination of improved staging, active biliary stenting, safe but extensive surgery to obtain negative margins, and newer techniques for chemoradiation have resulted in improved outcomes for patients with biliary malignancies.