Preliminary Phase II Data Suggest That Entinostat (SNDX275), a Class 1 Selective Histone Deacetylase Inhibitor (HDACi), May Resensitize Breast Cancer Patients Progressing on Aromataste Inhibitor (AI) Therapy to Their AI Therapy

Background: Aromatase inhibitors (AI), reduce peripheral conversion of androgen to estrogen, and are standard treatment for ER+ breast cancer (BCA); however, despite initial benefit, the disease eventually progresses. Once patients become resistant to AI, cytotoxic chemotherapy is often used for palliation. Histone deacetylase inhibitors (HDACi) have been shown preclinically to reverse AI resistance and sensitize tumor to AI. Entinostat, an oral selective HDACi, reverses both de novo and acquired hormone resistance in BCA in cell lines and xenograph models and has been well-tolerated, in humans, as a single agent and in combination with other agents tested to date.Methods: Postmenopausal women with ER+ BCA progressing while receiving AI for > 3 months were enrolled. Eligibility criteria included: measurable disease by RECIST criteria, PS 0 or 1, and ≤ 1 chemotherapy for metastatic disease. Exclusion criteria included: rapidly-progressing BCA, life-threatening metastases, chemotherapy within 3 months, and previous exposure to epigenetic modulating agents. Patients continued the AI therapy on which the cancer was progressing, with the addition of entinostat 5 mg weekly in 28-day cycles. Primary objective was to determine clinical benefit rate during the first 6 cycles, defined as the proportion of patients achieving CR, PR or SD lasting > 6 months. Secondary objectives included ORR and PFS. Exploratory biomarkers for anti-tumor activities and entinostat pharmacology were also measured.Results: To date, 24 patients have been enrolled from October 2008 – May 2009. Interim results from 20 patients are described here. The median age is 69 yrs. Eight (40%) and 12 (60%) patients had ECOG scores of 0 and 1, respectively. Fifteen patients (80%) had received tamoxifen; 12 (60%) had prior chemotherapy or immunotherapy. Nine patients (45%) had visceral involvement (lung, pleura, and liver), and 10 had metastases to bone, 3 to breast, and 1 to skin. Among the 10 patients who have completed ≥ 2 cycles, preliminary analysis indicates that the longest durations of SD thus far are > 6 months in 1 and > 5 months in 2 patients. Preliminary analysis of biomarkers in paired samples from 6 patients indicates that HDAC inhibition correlates with changes in cellular molecular targets. Entinostat has been well-tolerated. The majority of AEs were mild to moderate in severity, and the character of AEs was generally consistent with that seen with AI therapy.Conclusion: Entinostat in combination with AI was well-tolerated in patients with progressive BCA. Disease stabilization in several patients was observed. At dose administered, expected pharmacological effects were achieved.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6111.

Quantitative determination of residual active pharmaceutical ingredients and intermediates on equipment surfaces by ion mobility spectrometry

Ion mobility spectrometry (IMS) is an analytical technique that separates ions based on their gas phase mobility at atmospheric pressure. Since gas phase ion mobility is a function of the shape and structure of the ion, this technique has the potential to provide unique specificity and selectivity. Furthermore, IMS is very sensitive (subnanogram detection limits for many small molecules), and a single analysis is typically completed within 1 min. In principle, these features of IMS should make it an ideal choice for use in cleaning verification analysis of pharmaceutical manufacturing equipment. This report describes the successful development and validation of three different equipment cleaning verification methods using IMS. The methods were developed for a specific intermediate (Compound A) in the synthetic route for a drug substance as well as for final drug substances (active pharmaceutical ingredients Compounds B and C). The cleaning verification methods were validated with respect to specificity, linearity, precision, accuracy, stability, and limit-of-quantitation. In all cases, the limits-of-quantitation were determined to be at the nanogram or sub-nanogram level. Both swab and rinse samples collected from the equipment surfaces were successfully analyzed and manufacturing equipment down-time was significantly minimized due to the reduction in cleaning verification analysis time (for example, the total analysis time for more than 30 samples using IMS was reduced to less than 2h).

Outcomes of postoperative concurrent chemoradiotherapy for locally advanced major salivary gland carcinoma

OBJECTIVE

To investigate the potential value of postoperative concurrent chemoradiation among patients with high-risk salivary gland carcinomas.

DESIGN

Case control study based on retrospective medical record review.

SETTING

A tertiary care comprehensive cancer center.

PATIENTS

A total of 24 patients, 12 with major salivary gland carcinoma who were treated with postoperative concurrent chemoradiotherapy from 1998 to 2007 (chemoradiation group), and a control group of 12 patients treated with postoperative radiation alone.

MAIN OUTCOME MEASURES

Overall survival, progression-free survival, toxic effects.

RESULTS

All but 1 patient had stage III or IV disease; close or positive surgical margins were identified in 20 patients (83%). The median radiation dose was 63 Gy. In the chemoradiation group, platinum-based regimens were used in all. Treatment was well tolerated, but toxic effects, predominantly hematologic, were increased in the chemoradiation group. To date, 8 patients have died; the median overall survival was 53 months. The overall survival in the chemoradiation group was significantly better than in the radiation-alone group: 3-year survival rates were 83% and 44%, respectively (P = .05).

CONCLUSIONS

Locally advanced or high-grade salivary gland carcinomas follow an aggressive clinical course. Based on our limited experience, postoperative chemoradiation with a platinum-based regimen seems to be effective in selected patients and warrants further investigation.

Long term follow-up of primary B and T cell non-Hodgkin's lymphoma (NHL) of the gastrointestinal (GI) tract

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Background: Anthracycline based chemotherapy is the treatment of choice for aggressive primary lymphomas of the GI tract, with surgery reserved for management of complications. We report long term follow up of 71 cases of primary GI NHL treated with chemotherapy and/or surgery. Methods: Cases were identified from the institutional histology database & records reviewed. Results: 71 patients over an 24 year period were identified; 43 (61%) male, 28 (39%) female. Median age at diagnosis was 60 (15–83). 52 (73%) were DLBCL, 11 (16%) were T-cell, 8 (11%) were MALT. The 8 patients with MALT were treated with single agent chemotherapy; 7 (88%) are alive at median follow up of 8.5 years (2–16). Of the aggressive lymphomas (63), all patients with T cell lymphoma had small bowel as primary site and histological evidence of celiac associated enteropathy, even in the absence of known celiac disease. Primary sites of DLBCL were stomach 35 (67%), small bowel 11 (21%) & colon 6 (12%). 39 (62%) patients underwent surgery at diagnosis due to acute presentation with perforation, bleeding or obstruction, or to obtain histology. Following confirmed diagnosis, 61 patients received anthracycline based chemotherapy. 2 patients with T cell lymphoma presented with perforation, were treated with surgery only and died of rapid disease progression. Of the 63 patients with aggressive NHL, 37 (59%) remain alive & disease free at median follow up of 13 years (1–24). 35 (67%) patients with DLBCL are alive & disease free. Only 2 (18%) of the T cell lymphomas are alive & disease free. 5 deaths in the DLBCL group were not related to cancer or treatment. All deaths in the T cell group were due to progressive disease. There was no difference in survival between patients treated with chemotherapy only and those who also underwent surgery. Conclusions: Patients with aggressive primary B cell GI NHL have almost 70 % survival following anthracycline based chemotherapy. However, in contrast, coeliac enteropathy associated T-cell lymphomas present with rapidly progressive disease & have a survival of < 20% with chemotherapy and/or surgery. A novel therapeutic approach is required to improve outcome in this group.

No significant financial relationships to disclose.

Review of neoplastic brachial plexopathy at the Mater Misericordiae University Hospital, Ireland

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Background: Neoplastic brachial plexopathy (NBP) may occur with benign or malignant neoplasms. Symptomatic NBP is estimated to occur in about 0.4% of all patients with cancer. Despite therapy NBP is often irreversible. The aim of this review was to determine the incidence of brachial plexopathy occurring in patients with cancer at our centre. Methods: A retrospective review was done of the MRIs (magnetic resonance images) of brachial plexus performed at the Mater Misericordiae University Hospital over a 5 year period from 1st January 2004 to 31st December 2008. Results: A total of 66 MRIs of brachial plexus were performed during this period. 29 were performed for assessment of suspected traumatic injuries to the brachial plexus. 18 MRIs were performed in patients with a known cancer diagnosis, 1 was performed in a patient with a benign thymoma, 1 with a neurofibroma and the remaining 17 MRIs were ordered for other conditions. In total, 13 MRIs were positive for brachial plexopathy (7 traumatic, 5 due to cancer, 1 neurofibroma). Of the 20 MRIs performed (18 in patients with cancer, 2 in patients with a history of benign neoplasms), 6 (30%) confirmed a diagnosis of NBP. 27.8% (5/18) of patients with a diagnosis of cancer had NBP (3 had metastatic breast cancer, 2 had non-small cell lung cancer (NSCLC). Female to male ratio was 5:1. Median age at diagnosis was 67 years (range 35 to 86 years). 80% of patients had MRI of cervical spine also performed. Radiotherapy was the treatment of choice for 5 patients with cancer diagnosis, followed by chemotherapy also for one patient. Data was missing on treatment for the patient with neurofibroma. Some improvement in pain control was achieved with radiotherapy. However, there was no improvement in neurology. Conclusions: In our series in the past 5 years, 9% (6/66) of total number of MRIs of brachial plexus performed were positive for a diagnosis of NBP. NBP is devastating diagnosis. Physicians should have a high degree of suspicion for NBP in patients presenting with upper limb pain, paraesthesia and weakness.

No significant financial relationships to disclose.

Prognostic factors for survival after salvage reirradiation of head and neck cancer

PURPOSE

Patients who develop recurrent or new primary head and neck cancer in a previously irradiated site have poor prognosis. Reirradiation is a treatment option, although it is associated with substantial toxicities. We investigated potential prognostic factors, including comorbidity and pre-existing organ dysfunction, for survival after reirradiation.

METHODS

Institutional electronic records of patients treated with reirradiation between January 1998 and 2008 were reviewed. Comorbidity was assessed by Charlson index and Adult Comorbidity Evaluation-27 (ACE-27) grading. Organ dysfunction was defined as feeding tube dependency, functioning tracheostomy, or soft tissue defect.

RESULTS

There were 103 patients, including 46 patients who underwent salvage surgery before reirradiation. Median progression-free and overall survivals were 12.1 months (95% CI, 9.7 to 16.6) and 19.3 months (95% CI, 13.9 to 29.9), respectively. Significant comorbidity was present in 36% of patients by Charlson index and 24% by ACE-27. Baseline organ dysfunction was present in 37% of patients. Median overall survivals were 5.5 months among those with both organ dysfunction and comorbidity per Charlson index, and 4.9 months per ACE-27, compared with 59.6 and 44.2 months, respectively, among the patients with neither organ dysfunction nor comorbidity (P < .001 and < .001). Other independent prognostic factors were interval from previous radiation, recurrent tumor stage, tumor bulk at reirradiation, and reirradiation dose. A nomogram to predict the probability of death within 24 months after reirradiation was developed (concordance index = 0.75).

CONCLUSION

Comorbidity and pre-existing organ dysfunction are among several important prognostic factors for patients undergoing reirradiation. For those with both comorbidity and organ dysfunction, reirradiation largely serves as a palliative therapy.

Survival outcomes of squamous cell carcinoma arising from sinonasal inverted papilloma: report of 6 cases with systematic review and pooled analysis

BACKGROUND

Inverted papilloma (IP) is an uncommon sinonasal tumor. Squamous cell carcinoma (SCC) is associated with IP in about 7% of cases. To date, there has been no pooled analysis to formulate a survival outcome associated with this rare condition.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with IP and SCC treated at our institution during 1999-2007. Including our series, a systematic review of literature on Medline database and pooled analysis were performed to establish a survival estimate.

RESULTS

Six patients were identified. Squamous cell carcinoma was metachronous to the initial diagnosis of IP in 1 case and synchronous in 5 cases. Of 5 patients who had completed therapy at the time of this report, only 1 remained disease-free at 74 months. The median overall survival in our series was 33 months. Three patients developed distant metastases in brain, lung, bone, and liver. Literature review and pooled survival analysis consisting of 76 cases indicated a median overall survival of 126 months with 3- and 5-year survival rates of 63% and 61%, respectively.

CONCLUSION

Although the survival outcome of SCC arising from IP seems comparable with sinonasal SCCs, some patients with this disease do have a highly aggressive disease, including hematogenous distant metastasis. Overall, about 40% of patients will die of the disease within the first 3 years.

Thyroid carcinoma

Although thyroid carcinoma is relatively uncommon, approximately 33,550 new cases will be diagnosed in the United States in 2007. It occurs 2 to 3 times more often in women than in men, and with the incidence increasing by 4% per year, it is currently the eighth most common malignancy diagnosed in women. Although it occurs more often in women, mortality rates are higher for men, probably because they are usually older at the time of diagnosis (65–69 years vs. 50–54 years in women). Interestingly, the incidence of thyroid carcinoma increased almost 240% between 1950 and 2000, but mortality rates decreased more than 44%. Important updates to the 2007 guidelines include revised criteria for categorizing disease, revised recommendation for thyroid-stimulating hormone–stimulated thyroglobulin in some cases, and expanded CT recommendations for anaplastic carcinoma.

For the most recent version of the guidelines, please visit NCCN.org

The use of CA15.3 in breast cancer: A single institution experience

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Background: Breast cancer is a significant cause of morbidity and mortality worldwide. Recent advanced its treatment are promising. Gathering prognostic information may optimise treatment delivery. In addition to clinical parameters, the use of tumour markers may aid this process. CA 15.3, is a transmembrane glycoprotein.. Its clinical application varies from detecting disease recurrence in asymptomatic patients, assessing response in metastatic setting and monitoring the clinical course of the disease. Methods: A retrospective analysis was conducted evaluating medical record data of all the patients treated for breast cancer in our institution between 1999- 2005. CA15.3 was carried out using Roche 2010 (Elecsys system). Results: A total of 176 patients were identified. Table (1) Group A, one hundred patients remained disease free at follows up (58%). 95 patients had their CA15.3 within normal range, a diagnostic specificity of 95%. Group B, 61 patients developed metastatic/recurrent disease at follow up. 39 patients (64%) developed metastatic disease later. Group C, 15 patients had metastatic disease at diagnosis. We found that CA15.3 has a sensitivity value of 64% and a specificity of 95% in our institution.. This correlates well with ASCO review 67% and 92% respectively. In patients with no evidence of metastatic disease at diagnosis, a postive CA15.3 during follow up is strongly suggestive of disease recurrence. Giving a positive predictive value of 89%. In Two patients (5%) CA15.3 was the first predictor of recurrence. Radiology was the first indicator of recurrence in six cases (15%), while both radiological and serological correlation was noted in 31 patients (80%). Conclusions: We found CA15.3 a reliable marker in assessing response for therapy. In clinical practice, raised CA15.3 can be incorporated in decision making to change current chemotherapeutic regimen whenever there is a delay in obtaining prompt radiological evaluation.

[Table: see text]

No significant financial relationships to disclose.

Wilms’ tumour in adults: a case report and review of the literature

BACKGROUND

Wilms' tumour is a very rare adult malignancy representing 1% of adult renal tumours. It is however the most common renal tumour of childhood, and adult patients are treated in accordance with paediatric protocols.

AIM

To review modern day management of adult Wilms' tumour.

METHODS

We report a case of adult Wilms' tumour and discuss the management including the use of newer treatment modalities.

RESULTS

Following diagnostic nephrectomy, our patient was treated with chemotherapy in accordance with North American paediatric protocols and PET scanning was used to diagnose early relapse.

CONCLUSION

In the absence of randomised controlled data, central reporting of cases of adult Wilms' Tumour may help improve management. The incorporation of newer chemotherapeutic agents, high-dose therapy and PET scanning into treatment protocols should improve outcome for these patients.

Association between paclitaxel and necrotic pancreatitis

To our knowledge this is the first reported case of paclitaxel associated necrotic pancreatitis requiring a pancreatic necrostomy. This was a near fatal complication associated with paclitaxel with a high resulting morbidity. Although this is a rare association physicians should be wary of the potential to develop severe pancreatitis in patients receiving this therapeautic agent. Monitoring of serum amylase during therapy is therefore warranted.

Thyroid Cancer Clinical Practice Guidelines in Oncology

In 2005, approximately 1,490 cancer deaths will occur among persons living with thyroid carcinoma in the United States. Interestingly, although thyroid carcinoma occurs more often in women, mortality rates are higher for men, probably because men are usually older at the time of diagnosis. The incidence of thyroid carcinoma increased almost 240% between 1950 and 2000, but mortality rates decreased more than 44%. Although the causes of these statistically significant changes are uncertain, the increasing incidence may be caused by the increase in radiation-induced thyroid carcinoma. Conversely, the decrease in mortality may be related to earlier diagnosis, when the disease is presumably more amenable to intervention. However, this conclusion is confounded by a possible lead time bias.

For the most recent version of the guidelines, please visit NCCN.org

Paclitaxel, estramustine phosphate, and carboplatin in patients with advanced prostate cancer

PURPOSE

To determine the safety and activity of weekly paclitaxel in combination with estramustine and carboplatin (TEC) in patients with advanced prostate cancer.

PATIENTS AND METHODS

In a dose-escalation study, patients with advanced prostate cancer were administered paclitaxel (weekly 1-hour infusions of 60 to 100 mg/m(2)), oral estramustine (10 mg/kg), and carboplatin (area under the curve, 6 mg/mL-min every 4 weeks). Paclitaxel levels were determined 0, 30, 60, 90, and 120 minutes and 18 hours after infusion, and a concentration-time curve was estimated. Once a safe dose was established, a multi-institutional phase II trial was conducted in patients with progressive androgen-independent disease.

RESULTS

Fifty-six patients with progressive androgen-independent disease were treated for a median of four cycles. The dose of paclitaxel was escalated from 60 to 100 mg/m(2) without the occurrence of DLT. Posttherapy decreases in serum prostate-specific antigen levels of 50%, 80%, and 90% were seen in 67%, 48%, and 39% (95% confidence interval, 55% to 79%, 35% to 61%, 26% to 52%) of the patients, respectively. Of the 33 patients with measurable disease, two (6%) had a complete response and 13 (39%) had a partial response. The overall median time to progression was 21 weeks, and the median survival time for all patients was 19.9 months. Major grade 3 or 4 adverse effects were thromboembolic disease (in 25% of patients), hyperglycemia (in 38%), and hypophosphatemia (in 42%). Significant leukopenia, thrombocytopenia, and peripheral neuropathy were not observed.

CONCLUSION

TEC has significant antitumor activity and is well tolerated in patients with progressive androgen-independent prostate cancer.

Men's attitudes toward prostate cancer and seeking prostate-specific antigen testing

BACKGROUND

Although the Australian Cancer Society recommends against performing PSA tests to screen for prostate cancer, many Australian men currently undergo such screening. This study investigated attitudinal variables that may predict prostate cancer screening behaviors in this context.

METHODS

A questionnaire was administered by mail in a two-phase procedure, first to a sample of 1,461 men (46% response), then to 919 men from the initial sample. Prostate cancer screening behaviors of men > 40 years old were examined. The questionnaire assessed worry about prostate cancer, perceived vulnerability to prostate cancer, belief in the efficacy of PSA testing for detection, having received a PSA test for detection, and the presence of urologic symptoms at the time of testing.

RESULTS

Men who had had PSA testing with urologic symptoms at the time of the test were more worried about prostate cancer and perceived themselves as more vulnerable to prostate cancer compared with both asymptomatic tested and untested men. Men who had undergone PSA testing believed the test to be more effective in the detection of prostate cancer than did men who had not.

CONCLUSIONS

Urologic symptoms act as a risk cue for men to prostate cancer. Asymptomatic men should be considered separately from symptomatic men in the investigation of psychological variables predictive of seeking screening for prostate cancer. These findings are discussed in terms of both the focus and design of interventions to alter prostate cancer screening behavior and their implications for the clinical management of men with urologic symptoms.

Phase II trial of pyrazoloacridine in patients with cisplatin-refractory germ cell tumors

Thirteen patients with cisplatin-refractory germ cell tumors were treated on a Phase II trial with pyrazoloacridine. Pyrazoloacridine was given intravenously at 600 mg/m2 every three weeks. The median nadir leucocyte count was 2.5 cells/mm3, hemoglobin was 10.8 g/dl, and platelet count was 126,000 cells/m3. None of the thirteen evaluable patients achieved a major response. Pyrazoloacridine is not efficacious in the treatment of cisplatin-refractory germ cell tumors.

Disruption of retinoblastoma protein family function by human papillomavirus type 16 E7 oncoprotein inhibits lens development in part through E2F-1

Complexes between the retinoblastoma protein (pRb) and the transcription factor E2F-1 are thought to be important for regulating cell proliferation. We have shown previously that the E7 oncoprotein from human papillomavirus type 16, dependent upon its binding to pRb proteins, induces proliferation, disrupts differentiation, and induces apoptosis when expressed in the differentiating, or fiber, cells of the ocular lenses in transgenic mice. Mice that carry a null mutation in E2F-1 do not exhibit any defects in proliferation and differentiation in the lens. By examining the lens phenotype in mice that express E7 on an E2F-1 null background, we now show genetic evidence that E7's ability to alter the fate of fiber cells is partially dependent on E2F-1. On the other hand, E2F-1 status does not affect E7-induced proliferation in the undifferentiated lens epithelium. These data provide genetic evidence that E2F-1, while dispensible for normal fiber cell differentiation, is one mediator of E7's activity in vivo and that the requirement for E2F-1 is context dependent. These data suggest that an important role for pRb-E2F-1 complex during fiber cell differentiation is to negatively regulate cell cycle progression, thereby allowing completion of the differentiation program to occur.

A phase II study of pyrazoloacridine in patients with advanced renal cell carcinoma

The aim of this study was to determine the antitumor activity of pyrazoloacridine in patients with renal cell carcinoma. Eligible patients had advanced renal cell carcinoma with bidimensionally measurable disease, a Karnofsky performance status of at least 70, life expectancy of greater than three months, no prior treatment with chemotherapy, and no evidence of brain metastases. Patients were treated intravenously with 750 mg/m2 every three weeks. Twelve patients were enrolled in this study and all were evaluable for response and toxicity. Of the twelve patients, no major responses were achieved. Toxicity was mild, with three patients requiring a 20% dose reduction. At the dose and schedule used in this trial, pyrazoloacridine is inactive in renal cell carcinoma.