What are the factors that predict outcome at relapse after previous esophagectomy and adjuvant therapy in high-risk esophageal cancer?

OBJECTIVES

The present study investigated factors affecting outcome at relapse after previous surgery and adjuvant chemoradiation (crt) in high-risk esophageal cancer patients.

PATIENTS AND METHODS

From 1989 to 1999, we followed high-risk resected esophageal cancer patients who had completed postoperative crt therapy. Patients who relapsed with a disease-free interval of less than 3 months were treated with palliative crt when appropriate. Patients with a disease-free interval of 3 months or more were treated with best supportive care. Post-recurrence survival was estimated using the Kaplan-Meier technique, and statistical comparisons were made using log-rank chi-square tests and Cox regression.

RESULTS

Of the 69 patients treated with adjuvant crt after esophagectomy, 46 experienced recurrence. Median time to relapse was 28 months (range: 0.1-40 months). Among the 46 relapsed patients, median age was 61 years (range: 37-82 years), and 42 were men. At the initial staging, 44 of 46 were node-positive; 31 of 46 had adenocarcinoma. In 33 of 46, post-esophagectomy resection margins were clear. Median follow-up after recurrence was 30.5 months (range: 1.3-100 months). Median overall survival after recurrence was 5.8 months, and the 12-month, 24-month, and 36-month survival rates were 20%, 10%, and 5% respectively. Of the prognostic factors analyzed, only resection margin status and interval to recurrence were statistically significant for patient outcome in univariate and multivariate analysis. Patients who had positive resection margins and who relapsed 12 or fewer months after surgery and adjuvant crt had a median post-recurrence overall survival of 0.85 months as compared with 6.0 months in other patients (more than 12 months to relapse, or negative resection margins, or both; log-rank p = 0.003).

CONCLUSIONS

Resection margin status and interval to disease relapse are significant independent prognostic factors for patient outcome after adjuvant crt therapy.

Postoperative extended-volume external-beam radiation therapy in high-risk esophageal cancer patients: a prospective experience

Background and Purpose

Extended-volume external-beam radiation therapy (rt) following esophagectomy is controversial. The present prospective study evaluates the feasibility of extended-volume rt treatment in high-risk esophagectomy patients with a cervical anastomosis receiving postoperative combined chemoradiation therapy.

Patients and Methods

From 2001 to 2006, 15 patients with resected esophageal cancer were prospectively accrued to this pilot study to evaluate the adverse effects of extended-volume rt. Postoperative management was carried out at London Regional Cancer Program. Eligibility criteria were pathology-proven esophageal malignancy (T3–4, N0–1), disease amenable to surgical resection, and esophagectomy with or without resection margin involvement. Patients with distant metastases (M1) and patients treated with previous rt were excluded. All 15 study patients received 4 cycles of 5-fluorouracil–based chemotherapy. External-beam rt was conducted using conformal computed tomography planning, with multi-field arrangement tailored to the pathology findings, with coverage of a clinical target volume encompassing the primary tumour bed and the anastomotic site in the neck. The radiation therapy dose was 50.40 Gy at 1.8 Gy per fraction. The rt was delivered concurrently with the third cycle of chemotherapy. The study outcomes—disease-free survival (dfs) and overall survival (os)—were calculated by the Kaplan–Meier method. Treatment-related toxicities were assessed using the U.S. National Cancer Institute’s Common Toxicity Criteria.

Results

The study accrued 10 men and 5 women of median age 64 years (range: 48–80 years) and TNM stages T3N0 (n = 1), T2N1 (n = 2), T3N1 (n = 11), and T4N1 (n = 1). Histopathology included 5 adenocarcinomas and 10 squamous-cell carcinomas. Resection margins were clear in 10 patients. The median follow-up time was 19 months (range: 3.5–53.4 months). Before radiation therapy commenced, delay in chemotherapy occurred in 20% of patients, and dose reduction was required in 13.3%. During the concurrent chemoradiation therapy phase, 20% of the patients experienced chemotherapy delay, and 6.6% experienced dose reduction. No patient experienced treatment-related acute and chronic esophagitis above grade 2. Disease recurred in 40% of the patients (6/15), and median time to relapse was 24 months. No tumour recurred at the anastomotic site. The median dfs was 23 months, and the median os was 21 months.

Conclusions

Extended-volume external-beam rt encompassing the tumour bed and the anastomotic site is feasible and safe for high-risk T3–4, N0–1 esophageal cancer patients after esophagectomy.

Treatment patterns and health care resource utilization of metastatic colorectal cancer (mCRC) patients who received bevacizumab or cetuximab in second-line regimen

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Background: Targeted therapies such as bevacizumab (BV) and cetuximab (CX) are important treatment options in mCRC. Real-world treatment patterns and resource utilization of mCRC patients (Pts) receiving BV and CX in second-line (2L) treatment are not well studied.

Methods: Pts with mCRC were identified from the PharMetrics pharmacy and medical insurance claims database (2002-2009). Included Pts received BV or CX in 2L therapy. 2L was defined as change in therapy from first-line (1L) at least 4 weeks after 1L initiation. Healthcare resource utilization and costs were evaluated during the 6 months following 2L start.

Results: A total of 2,188 Pts were included in the analysis, including 1,808 2L BV Pts and 380 2L CX Pts. Demographic and baseline characteristics were similar between groups. Pts' mean age was 61 years and 56% were male. Among all study Pts, 34.1% and 2.7% received BV and CX in 1L, respectively. 60.1% of Pts received oxaliplatin-based regimens in 1L. In 2L, irinotecan and oxaliplatin containing regimens were most commonly used. During the 6 months period following 2L therapy start, BV vs. CX Pts incurred significantly lower risk-adjusted total costs (difference: -$10,231, p=0.020) and inpatient costs ($-3,681, p<0.001). Mean targeted therapy cost was significantly higher for CX ($33,425) than BV ($23,622) (-$10,260, p<0.001). BV Pts incurred significantly less inpatient visits (0.5 vs. 0.7, p<0.001) compared to CX Pts and shorter duration of total hospital stay (3.6 vs. 5.6 days, p=0.007).

Conclusions: In 2L treatment of mCRC Pts in the real world setting, BV was most used with oxaliplatin- and irinotecan-based regimens, whereas CX was commonly used with irinotecan-based regimens. Overall, less healthcare resource utilization and costs were observed in patients treated with 2L BV compared to 2L CX. Use of BV in 2L treatment of mCRC was associated with lower number of claims for targeted agents, lower healthcare costs and fewer hospitalizations than CX.

[Table: see text]

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Patient (Pt)-reported symptoms of chemotherapy (chemo) and VEGFR/EGFR antibody therapies for the treatment of metastatic colorectal cancer (MCRC) in a U.S. community-based oncology practice network

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Background: Targeted therapies for MCRC have increased treatment (Tx) options in multiple therapy lines. Symptoms associated with MCRC Tx have not been well studied from the Pt perspective. Objective: To characterize symptoms reported by MCRC Pts treated with chemotherapy and/or targeted drugs at a large US oncology network.

Methods: Pt reported symptom data were linked to electronic medical records and Pt charts from Georgia Cancer Specialists in Southeast US. MCRC Pts aged ≥18 years with ≥1 administration of chemo or targeted therapy between 1/2007-3/2009 were included. Pt reports captured 13 symptoms, onset, and severity. Due to small sample sizes, no statistical comparisons were conducted.

Results: 332 MCRC Pts were included (median age 62 years, 47% male, median weight 74 kg, 48% ECOG PS 0 or 1). Amongst Pts receiving 1L Tx (n=299), 78% received bevacizumab (BV) +/- chemo, 4% cetuximab (CX) +/- chemo, 15% chemo only, and 2% other. 162 Pts received 2L Tx: 49% BV +/- chemo, 17% chemo only, 28% CX +/- chemo, and 6% other. The 5 most common symptoms in 1L Tx for all severity ratings were 36% fatigue, 20% nausea, 17% weight (wt) loss, 15% diarrhea, and 9% constipation. The 5 most common symptoms in all 2L Tx groups were 44% fatigue, 27% nausea, 19% diarrhea, 16% wt loss, and 11% abdomen pain. 2L moderate, severe, or disabling symptoms reported in >10% Pts receiving BV +/- chemo, CX +/- chemo, and chemo only Tx are shown in the table.

Conclusions: The most commonly reported symptoms by 1L and 2L MCRC Pts were fatigue, nausea, diarrhea, and weight loss. Overall, a numerically higher % of 2L Pts treated with CX +/- chemo reported moderate, severe, and disabling symptoms than Pts receiving BV +/- chemo and chemo alone. Rash was not observed in the BV +/- chemo group. Further research of MCRC Pt reported symptoms in a larger sample size are warranted.

[Table: see text]

[Table: see text]

Patterns of care and survival trends in elderly metastatic colorectal cancer patients: A SEER-Medicare analysis

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Background: Over the last decade, the treatment of metastatic colorectal cancer (mCRC) has changed dramatically as new drugs and hepatic resection have been incorporated into practice. The goal of this study is to examine treatment patterns and survival trends for older patients (pts) with mCRC.

Methods: Pts ≥ age 65 with mCRC diagnosed (dx) 2001-2005 were identified from the SEER-Medicare database. Pts were excluded for lack of Medicare parts A and B in the year prior to dx, second malignancy, or non- adenocarcinoma histology. First-line (1L) chemotherapy (CTx) use was identified by claims within 3 months of dx. Metastatectomy was identified by various claims for liver resection. Comorbidity was assessed by Klabunde index. A Cox proportional hazards regression model was used to assess the effect of demographic and treatment factors on survival.

Results: A total of 5,725 pts (median age 77) met inclusion criteria. 274 pts (5%) underwent hepatic resection and 2,647 (46%) received CTx. From 2001-2003, 43% of pts received 1L CTx (34% and 1% with regimens containing irinotecan (Iri) and oxaliplatin (Ox) and 49% with 5-FU/cap alone). From 2004-2005, 51% of pts received 1L CTx (25%, 14%, and 37% with regimens containing bevacizumab (Bv), Iri, and Ox and 40% with 5-FU/cap alone). In the multivariate analysis using the Cox proportional hazards model, survival was significantly improved in pts receiving CTx or hepatic resection and in pts dx 2004-2005 (Table).

Conclusions: In an older mCRC population, hepatic resection, CTx use, and mCRC dx in 2004-2005 are associated with improved survival. Improved survival of pts dx in 2004-2005 coincides with the 2004 approval dates and uptake of Bv and Ox, and may be associated with the use of these therapies. Further analysis will examine the associations between specific Ctx regimens, Bv, and survival and will include pts dx through 2007.

[Table: see text]

[Table: see text]

Gabapentin for the treatment of carpal tunnel syndrome: a randomized controlled trial

OBJECTIVE

Based on its efficacy in treating neuropathic pain, gabapentin may be effective for the treatment of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the efficacy of gabapentin for symptom relief in CTS.

METHODS

We conducted a randomized, double-blinded, placebo-controlled trial recruiting patients with newly diagnosed idiopathic CTS of more than a period of three months. Diagnosis was based on characteristic symptoms with electrophysiological confirmation. Patients were randomly assigned to an active group receiving gabapentin (starting dose 300 mg once daily to a target of 900 mg daily) or a placebo group. Primary end-point was the global symptom score (GSS), which was measured at baseline, two, and eight weeks.

RESULTS

There was no significant difference in baseline variables between the two treatment groups. Hundred and forty patients were enrolled in the study, of whom 71 were randomly assigned to gabapentin group and 69 assigned to placebo group. Both gabapentin and placebo produced significant improvement in symptoms at two and eight weeks. The GSS at 2 and 8 weeks was 16.4 (SD 9.4) and 13.4 (SD 9.7), respectively, in the active group versus 14.9 (SD 9.0) and 12.5 (SD 8.9) in the control group (P < 0.01). But by eight weeks, the mean reduction in symptom severity of patients on gabapentin [-10.4 (SD 10.8)] was not significant when compared with placebo [-8.7 (SD 8.1), P < 0.39]. Adverse events were not severe and included dizziness, somnolence, and headache.

CONCLUSIONS

Gabapentin did not produce a significant reduction in symptom severity compared with placebo over an eight-week period.

Acute hyperammonemic encephalopathy in adults: imaging findings

BACKGROUND AND PURPOSE

Acute hyperammonemic encephalopathy has significant morbidity and mortality unless promptly treated. We describe the MR imaging findings of acute hyperammonemic encephalopathy, which are not well-recognized in adult patients.

MATERIALS AND METHODS

We retrospectively reviewed the clinical and imaging data and outcome of consecutive patients with documented hyperammonemic encephalopathy seen at our institution. All patients underwent cranial MR imaging at 1.5T.

RESULTS

Four patients (2 women; mean age, 42 ± 13 years; range, 24-55 years) were included. Causes included acute fulminant hepatic failure, and sepsis with a background of chronic hepatic failure and post-heart-lung transplantation with various systemic complications. Plasma ammonia levels ranged from 55 to 168 μmol/L. Bilateral symmetric signal-intensity abnormalities, often with associated restricted diffusion involving the insular cortex and cingulate gyrus, were seen in all cases, with additional cortical involvement commonly seen elsewhere but much more variable and asymmetric. Involvement of the subcortical white matter was seen in 1 patient only. Another patient showed involvement of the basal ganglia, thalami, and midbrain. Two patients died (1 with fulminant cerebral edema), and 2 patients survived (1 neurologically intact and the other with significant intellectual impairment).

CONCLUSIONS

The striking common imaging finding was symmetric involvement of the cingulate gyrus and insular cortex in all patients, with more variable and asymmetric additional cortical involvement. These specific imaging features should alert the radiologist to the possibility of acute hyperammonemic encephalopathy.

Gorham's disease of the maxilla: a case report

A case of Gorham's disease in the maxilla of a 56-year-old male patient is described. The clinical presentation, radiographic and histopathological features and treatment are presented. A discussion of the current understanding of this rare disease, based on review of the literature, is offered.

The Effect of Disease Progression on Patient Reported Outcomes in HER-2 Negative Metastatic Breast Cancer Patients

Background: Patients with HER-2 neg metastatic breast cancer (MBC) often experience a wide range of cancer related symptoms, which may impact their quality of life (QoL). We conducted a retrospective analysis to characterize the differences between patient-reported outcomes (PROs) of MBC patients prior to progression of disease (PD) and following PD, and examined the effect of metastases in bone, lung, liver, peritoneum and central nervous system (CNS) on PROs.Methods: 102 HER-2 neg MBC patients were enrolled from 7 community oncology practices within the U.S. The source data comprised data abstracted from medical records and PROs from the 38-item Patient Care Monitor (PCM). The PCM consists of 6 indices including impaired ambulation, impaired performance, general physical symptoms, treatment-related side effects, despair and depression, and acute distress. Linear mixed-effect models were used to analyze change in PCM index scores over time, controlling for individual, disease, and treatment characteristics. Minimum important difference for PCM index scores was estimated to be 1.5 to 3 points (Ringash 2000).Results: The sample (n=102) consists of 72% Caucasian, 25% African American, 3% other race patients, with mean age of 57 years. The ECOG performance status (PS) was unknown in 58% of the cases. Among those with known PS, 79% had a status of 0 or 1. Most patients (87%) had previous surgery, and 62% had received adjuvant chemotherapy. The mean time from metastatic diagnosis to first PD was 14 months. The predominant sites of metastasis were bone (66%), lung (35%), and liver (33%). First line treatment was hormone therapy only for 29%, no treatment recorded for 4%, taxane based for 42%, and non-taxane based for 25%. Linear mixed-effect model results showed modest but statistically significant (p&lt;0.005) worsening for General Physical Symptoms (2.4 points), Acute Distress (2.3 points), and Impaired Performance (1.7 points) scores following PD. The effect of PD was non significant for other index scores. Changes in symptoms severity following PD varied depending on metastasis location, being on chemotherapy, and ECOG status at baseline. There were marked detrimental effects of liver metastasis on Treatment related Side Effects, and of brain metastasis on Acute Distress. The most consistent effect on PROs was associated with PS. Patients with PS of 2 – 4 had worse scores in all areas except Acute Distress and Treatment Side effects.Conclusions: PD was associated with modest but significant worsening of general physical symptoms, acute distress, and impaired performance scores. Patients with poor ECOG PS at baseline were most affected. These findings suggest that delaying disease progression may have a positive impact on patients' QoL.Reference: Ringash J et al. Minimal important difference for quality of life measures is about five to ten percent of the instrument range. Presented at Proc Am Soc Clin Oncol. May 20-23, 2000. New Orleans, LA.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5050.