Hospital and procedure incidence of pediatric retained surgical items

BACKGROUND

Prevention of retained surgical items (RSIs) is the main objective of the World Health Organization "Guidelines for Safe Surgery" (WHO/GSS) 2008 to improve patient safety.

METHODS

We analyzed Kids' Inpatient Database 1997-2009 for RSI in patients aged <18 y. Incidence of RSI was calculated by per 100,000 admissions and per 100,000 procedures. The incidence was analyzed based on hospital bedsize, teaching status, region, and ownership and rural versus metropolitan location based on per 100,000 admissions.

RESULTS

Overall, 713 cases were identified with a mean (standard deviation) age of 8.31 y (6.62), length of stay of 13 d (20), and total charges of $91,321 (155,054). RSI occurred at a rate of 2.22 per 100,000 admissions and 1.93 per 100,000 procedures; both rates decreased post-WHO/GSS implementation versus pre-WHO/GSS, P < 0.005. On average, public or children's hospitals reported the highest RSI rates (8.89 and 6.07/100,000 admissions, respectively). Small and medium bedsize hospitals had lower rates of RSI post-WHO/GSS, P < 0.05. Nonteaching, non-children's, or public hospitals reported lower rates post-WHO/GSS, P < 0.003. Private (nonprofit) hospitals reported higher rates post-WHO/GSS, P < 0.001. Facilities in the southern United States or in metropolitan areas reported lower rates post-WHO/GSS, P < 0.02. A subanalysis of 107 cases requiring surgical removal demonstrated that fundoplications had the highest rate of RSI, followed by gastric procedures, laparotomy, bile duct procedures, lysis of adhesions, and abdominal wall repair.

CONCLUSIONS

RSI rates have decreased overall after the introduction of the WHO/GSS. The largest reductions have occurred in public or nonteaching hospitals. Only private (nonprofit) hospitals reported increases in RSI since 2008. Higher rates of RSI are associated with fundoplications and other gastric procedures.

Resource utilization patterns of pediatric esophageal foreign bodies

BACKGROUND

Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although some pass spontaneously through the gastrointestinal tract, the majority of esophageal-ingested foreign bodies (EFB) require removal.

MATERIALS AND METHODS

Kids' Inpatient Database (1997-2009) was used to identify children (aged <20 y) with EFB (International Classification of Diseases, Ninth Revision, Clinical Modification code 935.1). Multivariate logistic regression analyses were constructed to identify predictors of resource utilization.

RESULTS

Overall, 14,767 EFB cases were identified. Most patients were <5 y of age (72%), boys (57%), and non-Caucasian (55%), with a median (interquartile range) length of stay (LOS) of 1 (1) d, and total charges of $11,003 (8503). A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). By multivariate logistic regression, increased total charges were associated with a diagnosis of esophageal ulceration (odds ratio [OR] = 1.57), esophagoscopy (OR = 1.42), and bronchoscopy (OR = 1.62), all P < 0.001. Total charges also increased with admission to urban nonteaching hospitals (OR = 1.51) versus urban teaching hospitals, P < 0.001. Prolonged LOS (≥1 d) was associated with admission to a hospital in the Midwest (OR = 3.18) and with esophageal ulceration (OR = 2.11) and esophagoscopy (OR = 1.13), P < 0.03. Boys had higher odds of longer hospitalization (OR = 1.21), P < 0.001. Overall hospital mortality was 0.1% (n = 16).

CONCLUSIONS

Most EFB occur in children <5 y of age. Esophageal ulceration, esophagoscopy, and bronchoscopy are associated with increased total charges. Esophageal ulceration, esophagoscopy, and boys are associated with an increased LOS. Surgery and hospital mortality are both extremely rare in children with EFB.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Pediatric emergency department thoracotomy: a large case series and systematic review

BACKGROUND/PURPOSE

The emergency department thoracotomy (EDT) is rarely utilized in children, and is thus difficult to identify survival factors. We reviewed our experience and performed a systematic review of reports of EDT in pediatric patients.

METHODS

Patients age ≤18 years who received an EDT from 1991 to 2012 at our institution and all published case series were reviewed. Data analyzed include age, sex, mechanism of injury (MOI), injury patterns, presence of vital signs (VS) or signs of life (SOL) in the field/ED, return of spontaneous circulation (ROSC), and survival.

RESULTS

A total of 252 patients were analyzed. 84% were male. 51% sustained penetrating injuries, and median age was 15 years. Upon arrival, 17% had VS, and 35% had SOL. After EDT, 30% experienced ROSC. The survival rate was 1.6% for blunt trauma, 10.2% for penetrating injuries, and 6.0% overall.

CONCLUSION

Survival of pediatric patients following EDT is comparable to recent analyses in adults. Children who sustain blunt injury and are without SOL have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL or are without SOL for a short time prior to arrival have been salvageable. There are no reported EDT survivors less than 14 years of age following blunt injury.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Genetic variant predicts bevacizumab-induced hypertension in ECOG-5103 and ECOG-2100

BACKGROUND

Bevacizumab has broad anti-tumour activity, but substantial risk of hypertension. No reliable markers are available for predicting bevacizumab-induced hypertension.

METHODS

A genome-wide association study (GWAS) was performed in the phase III bevacizumab-based adjuvant breast cancer trial, ECOG-5103, to evaluate for an association between genotypes and hypertension. GWAS was conducted in those who had experienced systolic blood pressure (SBP) >160 mm Hg during therapy using binary analysis and a cumulative dose model for the total exposure of bevacizumab. Common toxicity criteria (CTC) grade 3-5 hypertension was also assessed. Candidate SNP validation was performed in the randomised phase III trial, ECOG-2100.

RESULTS

When using the phenotype of SBP>160 mm Hg, the most significant association in SV2C (rs6453204) approached and met genome-wide significance in the binary model (P=6.0 × 10(-8); OR=3.3) and in the cumulative dose model (P=4.7 × 10(-8); HR=2.2), respectively. Similar associations with rs6453204 were seen for CTC grade 3-5 hypertension but did not meet genome-wide significance. Validation study from ECOG-2100 demonstrated a statistically significant association between this SNP and grade 3/4 hypertension using the binary model (P-value=0.037; OR=2.4).

CONCLUSIONS

A genetic variant in SV2C predicted clinically relevant bevacizumab-induced hypertension in two independent, randomised phase III trials.

EGFR expression is associated with decreased benefit from trastuzumab in the NCCTG N9831 (Alliance) trial

BACKGROUND

Epidermal growth factor receptor (EGFR) has been hypothesised to modulate the effectiveness of anti-HER2 therapy. We used a standardised, quantitative immunofluorescence assay and a novel EGFR antibody to evaluate the correlation between EGFR expression and clinical outcome in the North Central Cancer Treatment Group (NCCTG) N9831 trial.

METHODS

Tissue microarrays were constructed that allowed analysis of 1365 patients randomly assigned to receive chemotherapy alone (Arm A), sequential trastuzumab after chemotherapy (Arm B) and chemotherapy with concurrent trastuzumab (Arm C). Measurement of EGFR was performed using the EGFR antibody, D38B1, on the fluorescence-based AQUA platform. The result was validated using an independent retrospective metastatic breast cancer cohort (n=130).

RESULTS

Epidermal growth factor receptor assessed as a continuous (logarithmic transformed) variable shows an association with disease-free survival in Arm C (P=0.009) but not in Arm A or B. High EGFR expression was associated with worse outcome (Hazard ratio (HR)=2.15; 95% CI 1.28-3.60, P=0.004). Validation in a Greek metastatic breast cancer cohort showed an HR associated with high EGFR expression of 1.92 (P=0.0073).

CONCLUSIONS

High expression of EGFR appears to be associated with decreased benefit from adjuvant concurrent trastuzumab. Since other treatment options exist for HER2-driven tumours, further validation of these data may select patients for alternative or additive therapy.

Trauma induced hypercoagulablity in pediatric patients

PURPOSE

Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response.

METHODS

A prospective observational study was conducted in hospitalized patients (age 8months to 14years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors.

RESULTS

Forty three patients (22 trauma, median injury severity score =9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p<0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p=0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p<0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1+2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p<0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults.

CONCLUSION

A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges.

A nationwide analysis of clinical outcomes among newborns with esophageal atresia and tracheoesophageal fistulas in the United States

BACKGROUND

The aim of this study was to examine national outcomes in newborn patients with esophageal atresia and tracheoesophageal fistula (EA/TEF) in the United Sates.

METHODS

Kids' Inpatient Database (KID) is designed to identify, track, and analyze national outcomes for hospitalized children in the United States. Inpatient admissions for pediatric patients with EA/TEF for kids' Inpatient Database years 2000, 2003, 2006, and 2009 were analyzed. Patient demographics, socioeconomic measures, disposition, survival and surgical procedures performed were analyzed using standard statistical methods.

RESULTS

A total of 4168 cases were identified with diagnosis of EA/TEF. The overall in-hospital mortality was 9%. Univariate analysis revealed lower survival in patients with associated acute respiratory distress syndrome, ventricular septal defect (VSD), birth weight (BW) < 1500 g, gestational age (GA), time of operation within 24 h of admission, coexisting renal anomaly, imperforate anus, African American race, and lowest economic status. Multivariate logistic regression identified BW < 1500 g (odds ratio [OR] = 4.5, P < 0.001), operation within 24 h (OR = 6.9, P < 0.001), GA <28 wk (OR = 2.2, P < 0.030), and presence of VSD (OR = 3.8, P < 0.001) as independent predictors of in-hospital mortality. Children's general hospital and children's unit in a general hospital were found to have a lower mortality rate compared with not identified as a children's hospital after excluding immediate transfers (P = 0.008).

CONCLUSIONS

BW < 1500 g, operation within 24 h, GA < 28 wk, and presence of VSD are the factors that predict higher mortality in EA/TEF population. Despite dealing with more complicated cases, children's general hospital and children's unit in a general hospital were able to achieve a lower mortality rate than not identified as a children's hospital.

A review of 218 pediatric cases of hepatocellular carcinoma

PURPOSE

This study evaluates the incidence trends and clinical outcomes of children with hepatocellular carcinoma (HCC) and assesses factors predictive of patient survival.

METHODS

The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2009 for all patients between ages 0 and 19 with primary HCC. Demographics, tumor histology, surgical intervention, and patient survival were collected.

RESULTS

Overall, 218 patients were identified. The annual age-adjusted incidence was 0.05 cases per 100,000 in 2009. Fibrolamellar subtype tumors were exclusive to children >5years old and exhibited greater survival compared to non-fibrolamellar subtype (57% vs. 28%, respectively, p=0.002). Tumor extirpation for patients with resectable disease significantly improved overall survival at 5years compared to no surgery (60% vs. 0%, respectively, p<0.0001). Overall 5-, 10- and 20-year survival for the entire cohort was 24%, 23%, and 8%, respectively. Independent prognostic factors of lower mortality according to multivariate analysis were surgical resection (hazard ratio (HR)=0.18), non-Hispanic ethnicity (HR=0.52), and local disease at presentation (HR=0.46).

CONCLUSION

Over the past four decades, the incidence of HCC has remained relatively stable. Children of Hispanic ethnicity have high mortality rates. However, HCC resection for curative intent significantly improves outcomes.

Abstract P2-16-23: The ENCHANT-1 trial (NCT01677455): An open label multicenter phase 2 proof of concept study evaluating first line ganetespib monotherapy in women with metastatic HER2 positive or triple negative breast cancer (TNBC)

Background: Hsp90 is a molecular chaperone protein required for the stabilization and activation of many proteins, referred to as Hsp90 ‘clients’, such as HER2, HIF1-a, EGFR, ER, PI3K, AKT, P53 and VEGFR. The drug candidate, ganetespib is a novel triazolone inhibitor of Hsp90, with over 700 patients treated to date. Ganetespib has shown activity in preclinical models of HER2+, ER+/PR+ and TNBC. Early clinical trials documented ganetespib single agent activity in heavily pretreated HER2+ and TNBC patients. Ganetespib has been well tolerated in clinical trials with a favorable safety profile. This efficacy-screening study is designed to provide further evidence of ganetespib activity and identify potentially predictive biomarkers in metastatic breast cancer (BC).

Methods: The ENCHANT-1 Trial is an international, first-line 2-cohort Phase 2 study in BC patients: Cohort A, HER2 amplified (n = 35), and Cohort B, TNBC (n = 35). Patients who present with previously untreated metastatic disease are eligible for treatment with ganetespib at 150 mg/m2 twice weekly on 3 out of 4 wks, for a total of up to 12 wks. Primary endpoint: ORR assessed using RECIST1.1 criteria. Key secondary endpoints include metabolic response as assessed by PET/CT at wk 3 utilizing modified EORTC criteria. Disease progression (PD) at wk 3 by PET imaging indicates discontinuation of study therapy, and is performed to quickly offer patients with metabolic PD a standard of care treatment.

The study is designed as Simon 2-stage requiring at least one OR in 15 patients for the respective cohort to expand to 35 patients. A Steering Committee is established to oversee the overall study and review the interim results.

Results: The study was initiated in 23 centers globally. At the time of submission, a total of 17 patients had been enrolled; TNBC (n = 15) and HER2 (n = 2). Here we report the interim analysis in the TNBC cohort. The median age was 54 years (range 30 -77) with ECOG PS 0 (n = 7/15). Most patients (n = 9) presented with de novo metastatic disease. 5 patients were not evaluable for PET assessment (3 had not yet reached wk 3 and 2 withdrawn before wk 3 for clinical progression), and 9 patients were not evaluable for objective response at wk 6 (3 withdrawn before or at wk 3 for clinical progression and 6 had not yet reached wk 6 evaluation). In the 10 patients with evaluable PET imaging, 9 patients achieved metabolic (m) response (2 mPR, 4 mSD with dominant tumor shrinkage and 3 SD) and one patient with mPD. In the 6 patients evaluable for OR at wk 6, one patient achieved PR, 2 SD and 3 PD. Treatment with ganetespib was well tolerated; the most common AEs were mild or moderate diarrhea (8/15, 53%), fatigue (5/15, 33%), decreased appetite (4/15, 27%), insomnia (4/15, 27%), and nausea (4/15, 27%).

Conclusion: Ganetespib single agent was generally well tolerated and showed anti-tumor activity TNBC patients as early as 3 weeks following treatment. PET seems to be a good tool to screen antitumor activity of new agents in early settings rather that in heavily pretreated patients. The TNBC cohort has met the protocol criteria for proceeding to stage 2.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-23.

Abstract P3-13-04: Effect of age on tolerability and efficacy of eribulin and capecitabine in patients with metastatic breast cancer treated in study 301

Background:

The Phase III trial (NCT00337103) compared eribulin (E) with capecitabine (C) in patients (pts) with metastatic breast cancer (MBC) in the 1st-, 2nd-, and 3rd-line setting. Median overall survival (OS) was 15.9 and 14.5 months (HR 0.88; 95% CI 0.77, 1.00; P = 0.056) and median progression-free survival (PFS) was 4.1 and 4.2 months (HR 1.08; 95% CI 0.93, 1.25; P = 0.30) for E and C, respectively. This analysis compares toxicity and efficacy of E and C in relation to age.

Material and methods:

In this post-hoc exploratory analysis, the effect of age on the incidence of adverse events (AEs), OS, PFS, and objective response rate (ORR) with E and C were analyzed for two age groups: ≤65 years (E, n = 468; C, n = 491) and &gt;65 years (E, n = 86; C, n = 57). For OS and PFS, analyses were stratified by HER2 and geographic region.

Results:

With increasing age, the proportion of pts with worse performance status (PS ≥1: 54.5% vs 69.2% for ≤65 and &gt;65 years, respectively), ER+ (47.4% vs 57.3%), and PgR+ MBC (41.3% vs 45.5%) increased, and the proportion with triple-negative MBC decreased (26.6% vs 20.3%). With both treatments, AEs were reported in a higher proportion of pts in the older age group, this becoming more apparent for grade 3+ AEs (E: 64.6% vs 70.2%, and C: 45.0% vs 54.4% for ≤65 and &gt;65 respectively). With E, there was a trend for increased incidence of grade 3/4 neutropenia (45.0% vs 50.0%) and leukopenia (13.7% vs 22.6%) but, in contrast, decreased peripheral sensory neuropathy (3.9% vs 1.2%) with increasing age. For C, there was a trend for increased palmar-plantar erythrodysethesia syndrome (total: 44.4% vs 50.9%; grade 3/4: 14.1% vs 17.5%), and grade 3/4 fatigue (1.8% vs 7.0%) and diarrhea (4.7% vs 10.5%) with increasing age; emesis and nausea were similar for both age groups. Dose adjustments due to AEs with E were slightly higher in the older age group: withdrawals 7.4% vs 10.7%; dose reductions 31.1% vs 36.9%; and dose delays 30.9% vs 36.9%. With C, there was a trend for an increased incidence of withdrawals (9.2% vs 21.1%) and dose delays (34.2% vs 49.1%) due to AEs with increasing age: the incidence of dose reductions was slightly higher in the older age group (31.3% vs 36.8%). In an unadjusted analysis, a trend for improved OS with E vs C was observed in both subgroups (≤65 years: median 15.8 vs 14.5 months; HR 0.90; 95% CI 0.78, 1.04; P = 0.16, and &gt;65 years: median 18.4 vs 14.1 months; HR 0.74; 95% CI 0.50, 1.12; P = 0.16). PFS and ORR for E and C were: median PFS: E, 4.0 and 5.4 months; C, 4.2 and 5.9 months; ORR: E, 10.9% and 11.6%; C, 11.6% and 10.5%, in the ≤65 and &gt;65 groups respectively.

Conclusions:

This exploratory and unadjusted analysis suggests a trend for improved OS with E in both younger and older pts with MBC. With both treatments there was a suggestion that AEs were reported in a higher proportion of pts in the older age group, this becoming more apparent for grade 3+ events. Specifically, these data suggest an increased incidence of grade 3/4 diarrhea, dose delays, and study withdrawal due to AEs in pts treated with C, and potentially suggest that with E there may be less difference between the AE profile in younger vs older pts than with C.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-13-04.

Abstract P4-01-11: Limits of [18F]-FLT PET as a clinical biomarker of proliferation in breast cancer

Background:

Imaging biomarkers of cellular division offer promise as non-invasive measures of tumor response. 3’-deoxy-3’[18F]-fluorothymidine ([18F]-FLT) positron emission tomography (PET) imaging generally correlates with pathology-based measurements of cancer proliferation, especially the Ki67 score. Though clinical studies have associated changes in [18F]-FLT uptake with therapeutic response, clinical studies validating its ability to assess cell proliferation are comparatively lacking. The goal of this study was to determine quantitative relationships between [18F]-FLT compared with molecular and cellular metrics of proliferation during treatment for locally advanced breast cancer (LABC).

Methods:

Baseline [18F]−FLT-PET scans were obtained prior to the initiation of chemotherapy for LABC from patients enrolled at several academic oncology study sites. MRI scans, and transmission CT scans were obtained. Core needle biopsies were obtained to determine Ki-67 indices using immuno-histochemistry and to assess an mRNA signature based measurement of proliferation. Prospectively specified quantitative relationships between PET, Ki67 immunohistochemistry and the mRNA signature were evaluated using image-matched tumor specimens. Correlations between volumetric MRI changes and pathologic responses were evaluated in a post-hoc exploratory analysis.

Results:

Motivated by the hypothesis that effective chemotherapies should decrease tumor cell proliferation, FLT-PET was compared with biomarkers of proliferation including Ki67 and the mRNA signature during neoadjuvant treatment for LABC. [18F]-FLT correlated both with the Ki67 labeling index (SUVmean r = 0.53) and with the proliferation signature (SUVmean r = 0.7), validating the principle of thymidine analogue imaging. However, variability in the [18F]-FLT PET and tumor cell proliferation measures likely contributed to correlations less than pre-specified target values considered appropriate for clinical use (r &gt; 0.78). Moreover, none of the proliferation biomarkers predicted pathologic complete responses at the end of neoadjuvant therapy ∼16 weeks after the 3 week response scan. In contrast, an evaluation of change in tumor volume measured by MRI after 3 weeks of therapy confirmed its superior ability to predict pCR and tumor re-staging.

Conclusion:

With large numbers of cancer drugs entering therapeutic pipelines, early efficacy measures remain critical for drug development. The 3-4 month neoadjuvant treatment paradigm for LABC offers unique opportunities for drug evaluation. Functional imaging using [18F]-FLT has been advanced as an assessor of cellular proliferation, potentially offering a non-invasive approach to response evaluation. While [18F]-FLT generally correlated with proliferation, its lack of association with patient responses likely limit its clinical utility. On the other hand, the predictive value of MRI offers unique opportunities for future trial designs and confirms previous reports (1).

1. N. M. Hylton et al., Locally advanced breast cancer: MR imaging for prediction of response to neoadjuvant chemotherapy. Radiology 263, 663 (2012).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-11.

Abstract P2-16-10: Safety of pertuzumab plus trastuzumab plus vinorelbine for first-line treatment of patients with HER2-positive locally advanced or metastatic breast cancer

Background: HER2 overexpression or amplification, occuring in ∼15-20% of breast cancers (BC), is associated with a poor prognosis. Trastuzumab (T) and pertuzumab (P) are humanized monoclonal antibodies that bind to different HER2 epitopes, inhibiting HER2 signaling. It was previously shown that first-line (1L) treatment of patients (pts) with HER2-positive metastatic breast cancer (MBC) with vinorelbine (V)+T had similar efficacy to docetaxel+T, but with fewer adverse events (AEs) (HERNATA). In a recent study, P+T+docetaxel significantly improved progression-free survival (PFS) and overall survival (OS) compared with T+docetaxel in pts with HER2-positive 1L MBC (CLEOPATRA). The objective of the VELVET study is to investigate the efficacy and safety of P+T+V for 1L treatment of HER2-positive MBC.

Methods: This is a multicenter, open-label, single-arm, two-cohort, Phase II study. The recruitment target is 105 pts per cohort. Pts in Cohort 1 receive P+T+V as separate infusions. Pts in Cohort 2 receive P+T from a single infusion bag followed by V. The initial dose of P is 840 mg, followed by 420 mg q3w; the initial dose of T is 8 mg/kg, followed by 6 mg/kg q3w; V is administered at 25 mg/m2 in Cycle 1, followed by 30-35 mg/m2, on Days 1 and 8 of each cycle, q3w. Pts must have HER2-positive MBC or locally advanced BC (LABC) and a baseline left ventricular ejection fraction (LVEF) of ≥55%. Previous treatment with systemic nonhormonal anticancer therapy in the metastatic setting is not allowed. The primary endpoint is independently assessed overall response rate. Secondary endpoints include PFS, OS, and safety.

Results: Interim safety data are presented for Cohort 1; 106 pts were enrolled. Median age at screening was 56 years. Median interval between initial BC diagnosis and enrollment was 2.6 years. 33% of pts had Stage IV BC at initial BC diagnosis. At diagnosis of advanced disease, 13% and 87% of pts had LABC and MBC, respectively. 54% of pts had previously received chemotherapy, including taxane (38%) and anthracycline (36%). 41% had prior T exposure. A median of 6 cycles of P, T, and V was received at the time of this analysis. An AE overview is shown in the table.

Pts, n(%)N = 106Any AE102(96)Grade 338(36)Grade 417(16)Grade 52(2)aAny serious AE25(24)Most frequent (≥4 pts) grade ≥3 AEs Neutropeniab21(20)Febrile neutropenia6(6)Leukopenia5(5)Asthenia4(4)Constipation4(4)Diarrhea4(4)a Myocardial infarction and septic shock; b Covers ‘neutropenia’ and ‘neutrophil count decreased’

Grade ≥3 neutropenia/febrile neutropenia was experienced by 8% of pts in Cycle 1 and by 14% of pts in Cycle 2; this proportion decreased during subsequent cycles. There was no overall decrease in mean LVEF from baseline.

Conclusions: The combination of P+T+V was well tolerated; no new safety signals were observed. The incidences of grade ≥3 neutropenia, febrile neutropenia, and leukopenia were lower than those previously observed in pts with HER2-positive MBC treated with 1L P+T+docetaxel in CLEOPATRA or those treated with T+V in HERNATA; however, it should be noted that the treatment period in these two studies was longer. Efficacy data for Cohorts 1 and 2 will be reported at the end of the study.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-10.

N0539 phase II trial of fulvestrant and bevacizumab in patients with metastatic breast cancer previously treated with an aromatase inhibitor: a North Central Cancer Treatment Group (now Alliance) trial

BACKGROUND

Based on preclinical studies, the vascular endothelial pathway is an important mechanism for estrogen receptor resistance. We conducted a phase II study of fulvestrant and bevacizumab in patients with aromatase inhibitor pretreated metastatic breast cancer.

PATIENTS AND METHODS

A single-stage phase II study was conducted with these objectives: 6-month progression-free survival (PFS), tumor response, toxic effect, and overall survival. Regimen: 250 mg fulvestrant days 1 and 15 (cycle 1) then day 1 (cycle 2 and beyond) and 10 mg/kg bevacizumab days 1 and 15 of each 4-week cycle.

RESULTS

At interim analysis, 20 eligible patients initiated treatment, 11 were progression free and on treatment at 3 months, not meeting the protocol-specified efficacy requirements (at least 12 of 20). Accrual remained open during interim analysis with 36 patients enrolling before final study closure. Among the 33 eligible patients, the median PFS was 6.2 months [95% confidence interval (CI) 3.6-10.1 months]. Of the 18 with measurable disease, 4 (22%) patients (95% CI 6% to 48%) had a confirmed tumor response (1 complete, 3 partial). The most common grade 3/4 adverse events were hypertension 3 (9%) and headache 3 (9%).

CONCLUSIONS

The fulvestrant/bevacizumab combination is safe and tolerable; however, it did not meet its statistical end point.

Predictors of survival and incidence of hepatoblastoma in the paediatric population

OBJECTIVES

This study evaluates current trends in incidence, clinical outcomes and factors predictive of survival in children with hepatoblastoma (HB).

METHODS

The Surveillance, Epidemiology and End Results (SEER) database was queried for the period 1973-2009 for all patients aged <20 years with HB.

RESULTS

A total of 606 patients were identified. The age-adjusted incidence was 0.13 patients per 100 000 in 2009. An annual percentage change of 2.18% (95% confidence interval (CI) 1.10-3.27; P < 0.05) was seen over the study period. Overall survival rates at 5, 10 and 20 years were 63%, 61% and 59%, respectively. Ten-year survival rates significantly improved in patients with resectable disease who underwent operative treatment in comparison with those with non-resectable HB (86% versus 39%; P < 0.0001). Multivariate analysis showed surgical treatment (hazard ratio (HR) = 0.23, 95% CI 0.17-0.31; P < 0.0001), Hispanic ethnicity (HR = 0.61, 95% CI 0.43-0.89; P = 0.01), local disease at presentation (HR = 0.43, 95% CI 0.29-0.63; P < 0.0001) and age < 5 years (HR = 0.63, 95% CI 0.41-0.95; P < 0.03) to be independent prognostic factors of survival.

CONCLUSIONS

The incidence of paediatric HB has increased over time. Hepatoblastoma is almost exclusively seen in children aged < 5 years. When HB presents after the age of 5 years, the prognosis is most unfavourable. Tumour extirpation markedly improves survival in paediatric patients with local disease.

A unique presentation and rare pathological finding for urachal sinus

We report an otherwise well developing 2-year-old girl who presented with a urachal sinus with its opening located at the midline between umbilicus and the pubic symphysis. Diagnosis was made by ultrasound preoperatively, and confirmed during surgery. Additionally, columnar epithelium was found in the portion of sinus tract traversing the abdominal wall. Metaplasia of the sinus tract is worrisome, as urachal carcinomas have been traditionally characterized to result from this process.

Primary pediatric cardiac malignancies: the SEER experience

PURPOSE

Pediatric cardiac malignancies are exceedingly rare. We sought to examine demographics, presentation, and outcomes for this pathology.

METHODS

The SEER registry from 1973 to 2008 was queried for all patients <20 years of age with cardiac malignancies.

RESULTS

A total of 25 pediatric patients were identified with primary cardiac malignancies, with age-adjusted incidence of 0.00686 per 100,000 United States population. Median age at diagnosis was 10 years. The majority of patients were adolescent (n = 13, 52 %), Caucasian (n = 17, 68 %) and males (n = 14, 56 %). The most common histology was soft tissue sarcoma (n = 10, 40%), followed by non-Hodgkin lymphoma and teratoma (both n = 3, 12 %). Six patients presented with distant disease. More than half of patients (n = 16, 64 %) underwent surgical resection, while four patients (16 %) underwent radiation. The mean survival time for the cohort was 47 ± 67 months, with 14 (56 %) patients dying over the study period. Lymphomas had significantly longer survival than other malignancies (108 ± 66 vs. 36 ± 66, p = 0.03), while lack of surgical treatment was associated with worse survival (p = 0.016).

CONCLUSIONS

Primary malignant cardiac tumors are exceedingly rare in pediatric patients. They are most commonly soft tissue sarcomas and lymphomas demonstrated longer survival.

Use of CT enterography for the diagnosis of lower gastrointestinal bleeding in pediatric patients

Diagnosis of lower gastrointestinal bleeding (LGIB) represents a significant diagnostic and therapeutic challenge for any physician. While CT enterography (CTE) has been applied in adults with occult LGIB, its use in children has been limited to evaluation of Crohn's disease. We reviewed 6 patients ages 4-15 who underwent CTE for LGIB at a tertiary pediatric institution. In sum, CTE appears to be a valuable tool for localizing the source of LGIB prior to surgical or endoscopic intervention. However, rapid lesion identification must be weighed against the increased radiation exposure and patient discomfort due to bowel distention associated with this diagnostic technique.

Impact of premenopausal status at breast cancer diagnosis in women entered on the placebo-controlled NCIC CTG MA17 trial of extended adjuvant letrozole

BACKGROUND

MA17 showed improved outcomes in postmenopausal women given extended letrozole (LET) after completing 5 years of adjuvant tamoxifen.

PATIENTS AND METHODS

Exploratory subgroup analyses of disease-free survival (DFS), distant DFS (DDFS), overall survival (OS), toxic effects and quality of life (QOL) in MA17 were performed based on menopausal status at breast cancer diagnosis.

RESULTS

At diagnosis, 877 women were premenopausal and 4289 were postmenopausal. Extended LET was significantly better than placebo (PLAC) in DFS for premenopausal [hazard ratio (HR) = 0.26, 95% confidence interval (CI) 0.13-0.55; P = 0.0003] and postmenopausal women (HR = 0.67; 95% CI 0.51-0.89; P = 0.006), with greater DFS benefit in those premenopausal (interaction P = 0.03). In adjusted post-unblinding analysis, those who switched from PLAC to LET improved DDFS in premenopausal (HR = 0.15; 95% CI 0.03-0.79; P = 0.02) and postmenopausal women (HR = 0.45; 95% CI 0.22-0.94; P = 0.03).

CONCLUSIONS

Extended LET after 5 years of tamoxifen was effective in pre- and postmenopausal women at diagnosis, and significantly better in those premenopausal. Women premenopausal at diagnosis should be considered for extended adjuvant therapy with LET if menopausal after completing tamoxifen.

Pediatric trauma recidivism in an urban cohort

BACKGROUND

Recidivism is a well-known problem in adult trauma patients. Trauma recidivists are a population that warrants further intervention to prevent future trauma. Among pediatric patients, the recidivism rate, demographics, mechanism, and mortality are unknown. We hypothesized that specific groups of pediatric trauma recidivists could be identified for targeted prevention efforts.

METHODS

All pediatric trauma patients admitted to a level 1 pediatric trauma center in an urban county hospital between 1991 and 2010 were reviewed. Age, sex, Glasgow Coma Scale, injury location, injury cause, disposition, length of stay, and mortality were collected and compared between nonrecidivist and recidivist cohorts.

RESULTS

The recidivism rate among patients aged 0-19 y was 1.5% compared with 0.9% in those aged 0-16 y. Recidivists were more likely males (P < 0.001) suffering from penetrating injuries. They were less frequently injured in motor vehicle collisions. Two of every three recidivist gunshot wound (GSW) victims were injured by a GSW on their prior admission.

CONCLUSIONS

The pediatric recidivism rate in our population is small. Nevertheless, recidivists are more than twice as likely to be injured by penetrating trauma, especially GSWs. Targeted screening and counseling in this demographic may be helpful in reducing youth trauma recidivism.

Abstract P1-12-06: N0937 (Alliance): Preliminary results of a phase II clinical trial of cisplatin and the novel agent brostallicin in patients with metastatic triple negative breast cancer (mTNBC)

Background: TNBC is characterized by unique molecular profiles, aggressive behavior, poor prognosis and lack of targeted therapies. Brostallicin is a novel synthetic compound from the class of DNA minor groove binding (MGB) anti-cancer agents, making it a logical agent to evaluate in the setting of TNBC. It retains activity in cancer cells resistant to alkylating agents, topoisomerase I inhibitors and is fully active against DNA-mismatch repair deficient tumor cells. Preclinical models using cell lines demonstrate that cells expressing relatively high glutathione/glutathione S-transferase (GSH/GST) levels are more susceptible to brostallicin's antitumor efficacy. Cisplatin administration increases expression of GSH/GST in tumor cells, thus leading to an increased anti-tumor efficacy of brostallicin.

Methods: Phase II cooperative group study in pts with mTNBC (³18 years of age with measurable metastatic disease, ER/PR ≤1%; HER2 negative, who had received 0–4 prior chemotherapy regimens in the metastatic setting; with adequate hematologic, renal and hepatic functions; and no active CNS metastases; prior exposure to cisplatin allowed). Cisplatin on Day 1 followed by brostallicin on Day 2, repeated every 21 days. Aim: efficacy of brostallicin and proof of concept of its mechanism of action in mTNBC. Primary endpoint progression-free survival (PFS) at 3 months with 89% power (0.10 significance level) to detect an absolute difference of 20% (35% vs 55%), based on the median PFS of 60 days in pts with mTNBC from the N0234 trial of erlotinib and gemcitabine as 1st/2nd line. Secondary endpoints include ORR, duration of response (DOR), 6-month PFS, OS and AE profile. Tertiary endpoints include assessment of 1) GSH levels prior to the administration of cisplatin and of brostallicin; and 2) the prevalence of BCRA-1 mutation by IHC in primary or metastatic tumor.

Results: Study closed on 3/28/12 and it accrued 48 pts (median f/u 2.3 mo; 0–15.3); 33 pts are off treatment and 15 pts remain on study; 38 pts evaluable for response, and 43 evaluable for AEs. 50% received therapy as 3rd to 5th line. Median number of cycles 2.5 (off-treatment: 2; on-treatment: 3, range 0–15). There are currently 5 confirmed responses (4 PR and 1 CR); DOR: 2.8–13.3 months. The 6-mo PFS is currently 19.2% (95% CI: 8.9%, 41.3%); the median TTP is 3.0 months (95% CI: 1.7 months, 4.2 months). Current data are premature to determine the primary endpoint (3-mo PFS) but we expect to report such data by November 2012. Current toxicity data: 69.7% G3/4 heme toxicity. Non-heme toxicity G3 (30.2%) and G4 (9.3)% (febrile neutropenia 21%; fatigue G3 14%); and no G5 non-heme AE.

Conclusions: The current preliminary data of this trial show very encouraging activity of this regimen (brostallicin plus cisplatin) in mTNBC. Near 1/3 of pts are still currently receiving therapy, and we expect to provide primary and additional secondary endpoint data at SABCS 2012.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-12-06.

Abstract P1-05-24: Pharmacologic reversion of epigenetic silencing of the PRKD1 promoter blocks breast tumor cell invasion and metastasis

Epigenetic silencing of tumor suppressing genes by promoter-specific DNA methylation is common in many types of cancer. As an early event, this process has been well shown to promote tumor initiation and progression; however little is known how such epigenetic silencing can contribute to tumor metastasis. The PRKD1 gene encodes Protein Kinase D1 (PKD1), a serine/threonine kinase expressed in epithelial cells of the normal mammary gland that maintains the epithelial phenotype of normal breast cells and prevents epithelial-to-mesenchymal transition (EMT). PKD1 is also a critical suppressor of tumor cell invasion and is silenced in expression and activity during breast tumor progression. Here, we show that aberrant methylation of PRKD1 promoter region is not only correlated with the silencing of its expression but is also associated with invasiveness of breast cancer cell lines and with aggressiveness of breast tumors. Using the highly invasive MDA-MB-231 cells, we show that the inhibition of PRKD1 promoter methylation with the DNA methyltransferase inhibitor decitabine restores PKD1 expression and significantly decreases their invasive abilities in vitro. More importantly, in a tumor xenograft model it dramatically blocks tumor spread and metastasis to the lung in a PKD1-dependent fashion. Our data suggest that the status of epigenetic regulation of the PRKD1 promoter can provide valid information on the invasiveness of breast tumors, and therefore could serve as an early diagnostic marker. Moreover, targeted upregulation of PKD1 expression may be used as a therapeutic approach to reverse the invasive phenotype of breast cancer cells.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-05-24.