Optimization of the skin multiple analyte profile bioanalytical method for determination of skin biomarkers from D-Squame tape samples

BACKGROUND/PURPOSE

This work was performed to optimize extraction conditions for D-Squame tape skin samples for use in the skin multiple analyte profile (SkinMAP) method, a Linco Research Corporation bead-based assay for skin analytes. The experiments were designed to help identify sources of variability during extraction that may be amenable to further control.

METHODS

Two experimental designs were used to study factors influencing the extraction of skin samples from D-Squame tapes. Visually healthy skin samples were obtained from both female and male adult volar forearms. Factors studied in two experiments included: four surfactant (SDS) levels (0.02-0.2%), two buffer types [Citrate-phosphate buffered saline at pH 5.5, phosphate-buffered saline (PBS) at pH 7.4], two buffer volumes (1.0, 1.5 mL), two propylene glycol (PG) levels (0.1%, 1.0%), two extraction temperatures (7-10 degrees C, 22-30+ degrees C), two extraction times (30, 60 min), and location in sonication bath (two vectors). The response biomarkers were cortisol, fibronectin, human serum albumin, involucrin, keratin-6 and keratins 1, 10. Skin sampling sites were also evaluated as sources of variation.

RESULTS

There was no single set of extraction conditions in our experiments that maximized recovery of all the biomarkers. SDS level had the most consistently significant (P<0.05) and directional effects on biomarker recoveries. In general, higher SDS resulted in higher recovery of all biomarkers. There was less consistency and fewer significant results for the other extraction factors.

CONCLUSIONS

These data enable us to better manage SkinMAP studies and interpret their results. The use of 1.5 mL PBS containing 0.2% SDS and 0.5% PG with 30 min sonication at low (near 4 degrees C) temperature is optimal for the quantitation of a range of SkinMAP analytes. In order to protect researchers from obtaining inflated false positive rates, it is crucial to design such studies and analyze the data using appropriate statistical methodology, especially for those studies involving only a small number of subjects.

Immunohistochemical variability of epidermal growth factor receptor (EGFR) in liver metastases from colonic carcinomas

AIMS

To follow and compare immunohistochemical expression of epidermal growth factor receptor (EGFR) in tumour cells during the entire natural history of colonic carcinoma, from primary tumour to paired lymph node and sequentially resected liver metastases; and to test interobserver reproducibility of EGFR analysis.

METHODS AND RESULTS

Forty patients had resection of colonic adenocarcinoma (27 with metastatic lymph nodes) and at least one partial hepatectomy (PH) for liver metastases; a second and a third PH were performed, respectively, in 14 and three patients; seven patients had tumour liver biopsy. EGFR immunohistochemistry (n = 130) was analysed independently by two pathologists. EGFR expression (membranous staining detected in > or = 1% of tumour cells) was detected in 38/40 colonic carcinomas, 23/26 lymph nodes and 51/64 liver metastases. Both primary tumours and related metastases were EGFR+ in 28 patients (73%). Discrepancies were found in EGFR status between liver and lymph node (23%) and among the different liver samples (31%). Interobserver agreement was very good (intraclass correlation coefficients of 0.81, 0.91 and 0.85, respectively, for interpretation of staining in colon, lymph node and liver metastases).

CONCLUSIONS

Since immunohistochemical detection of EGFR remains a prerequisite for EGFR-targeted therapy eligibility, different tumour samples should be tested to allow every patient a chance to take advantage of this treatment.

Breast cancer liver metastases (BCLM): What may be the role of surgery combined with chemotherapy?

1039

Background: Despite recent treatment improvements, the prognosis of BCLM is still poor. Hepatic resection (HR) has been associated with better outcome in selected patients, but its place in multimodality treatment of BCLM remains controversial. This study aimed to examine the outcome of a large cohort of patients selected for HR of BCLM and to define prognostic factors of survival, in a way to better define the place of surgery. Methods: A standardized questionnaire reviewing the main diagnostic and treatment modalities of primary tumor, liver metastases, response to medical therapies, type of surgical procedures, postoperative outcome, and survival following surgery, was sent to all contributing centers. Results: 460 patients treated with liver resection for BCLM from 1980 to 2000, were collected from 31 hepatobiliary surgery centers. Mean age was 51.8 years. Primary tumor, mainly adenocarcinoma, was treated by resection combined with chemotherapy and/or radiotherapy in most cases. Diagnosis of BCLM was made after an average of 54 months from the treatment of the primary tumor. BCLM were unique in 56% and associated to limited extrahepatic disease in 18.5% of patients. After initial treatment by systemic therapy (70% of patients), HR achieved a R0 resection in 82% of patients and was combined to extrahepatic resection for distant metastases in 9% of patients. Postoperative mortality (= 2 months) was 0.2%. Median survival was 45.4 months after HR, with an overall survival of 41% and 22% at 5 and 10 years, respectively. Disease-free survival rates were 14% and 10%, respectively. Four predictive factors were independently associated to an unfavourable outcome: tumor progression on chemotherapy before surgery (p = 0.0006, RR = 2.9), disease-free interval < 12 months after treatment of the primary tumor (p = 0.0003, RR = 2.1), extrahepatic metastases (p = 0.0002, RR = 1.9) and R2 liver resection (p < 0.0001, RR = 3.0). Conclusions: Inclusion of HR in the multimodality treatment of BCLM is safe and associated with a hope of long term survival (22% at 10 years). Surgery should be discussed on a multidisciplinary basis, particularly when potentially radical, in patients well controlled by chemotherapy with a long disease-free interval, and in the absence of extrahepatic disease.

No significant financial relationships to disclose.

Hepatic artery triplet chemotherapy for liver metastases from colorectal cancer

14554

Background: Chronomodulated (Chrono) irinotecan (I), 5-fluorouracil (F), leucovorin and oxaliplatin (O) offered sustained tumor control in CRC patients (pts) failing several chemo (Gholam et al. The Oncologist 2006). The relevance of Chrono IFO as hepatic artery infusion (HAI) for long term outcome was investigated in CRC pts with liver metastases. Methods: 32 heavily pretreated non hospitalized CRC pts received 5-day (d) q21 d courses (c) with d1 I (160 mg/m2 from 2 to 8 am, peak at 5 am) and d2–5 F (600 mg/m2/d from 10 pm to 10 am, peak at 4 am) and O (20 mg/m2/d from 10 am to 10 pm, peak at 4 pm). Intravenous cetuximab was also given to 3 pts. 172 courses (c) were given (median, 5; 1–15) using a multichannel pump (Mélodie, Aguettant, F). Toxicity was assessed q21 d and response q3 c with CT scan. Results: Prior chemo lines 1/2/3/4+: 3/5/10/14 pts; WHO Performance Status 0/1/2/3: 14/11/6/1 pts; median age: 63 years (32–73); liver only: 25 pts; liver and lung: 7 pts. Treatment was withdrawn for thrombosis (7 pts, 21%) and/or Grade (G) 3 abdominal pain (4 pts ). G3–4 diarrhea occurred in 6 pts (12%). G3–4 leucopenia, anemia and thrombocytopenia were respectively found in 5, 2 and 1 pt. G3 sensory neuropathy occurred in 3 pts with similar G at baseline. 3 pts displayed alopecia. Of 29 pts with measurable lesions, disease progressed in 12 pts (exclusively outside the liver for 4 pts) and was controlled in 17 pts (58%), including 10 objective responses - 34% [95% C.L. 13.4 to 50.6]. Partial hepatectomy was performed in 4 pts with measurable disease (14%): R0 (3 PR) and R1 (1 SD). Median Progression free survival (months, m) is 5 m [1.9 to 8.0] and median survival is 18.4 m [9.9 to 26.9], with 6 pts alive at 2.9 to 63 m. Conclusions: Triplet chronoHAI is safe in heavily pretreated pts and achieves consistent activity against CRC liver metastases despite prior failure on the same 3 drugs. The combination of systemic cetuximab with triplet HAI is feasible and could prevent extra hepatic dissemination, a hypothesis to be soon tested in a prospective European trial. Supported by ARTBC, Hôpital P. Brousse, Villejuif, France.

No significant financial relationships to disclose.

Hepatic resection following rescue cetuximab treatment for colorectal liver metastases previously refractory to conventional systemic therapy

4061

Background: The impact of cetuximab-containing chemotherapy on resectability of previously unresectable colorectal liver metastases (CLM) is unknown, especially in patients resistant to first-line chemotherapy. This study was performed to determine the cetuximab resectability rate, and to examine the outcomes of these heavily pretreated patients after hepatic resection. Methods: From February 2004 to April 2006, we evaluated 151 patients with unresectable CLM resistant to initial chemotherapy and subsequently treated with cetuximab-containing regimens. 133 patients (88%) were completely treated at our institution and 18 patients (12%) received systemic therapy elsewhere. Resectability rates, perioperative outcomes, survivals, and histopathological analysis of the tumoral and non- tumoral liver were assessed. Results: 27 patients were operated after a median of 6 cycles of cetuximab + irinotecan (20/27), oxaliplatin (4/27), or both (1/27). 18 of these patients (67%) had failed at least 2 lines of prior chemotherapy. 25 patients underwent hepatectomy, including 9 of 133 patients completely treated at our institution (resectability rate: 7%) and 16 of 18 referred patients. Postoperative mortality was 3.7% (1/27), with a complication rate of 50%. Complete tumor necrosis was observed in 2 patients (8%). Histopathological liver abnormalities were found in 9 patients (36%), without any specific lesion related to cetuximab. After a median follow-up of 16 months (range 6–39), all but one resected patients were alive, 10 of whom were disease-free. Conclusions: For CLM refractory to conventional chemotherapy, combination chemotherapy with cetuximab significantly increased resectability rates with no appreciable increase in operative mortality or liver injury. Longer follow-up is awaited to confirm the encouraging results of this new oncosurgical strategy.

No significant financial relationships to disclose.

Complete pathological response of colorectal liver metastases after neoadjuvant chemotherapy: myth or reality?

4063

Background: A complete clinical response (CCR) of colorectal liver metastases (CLM) following chemotherapy has been shown unrelated to the real disappearance of active tumor. By contrast, a complete pathological response (PCR) could be more clinically relevant, but has not been explored. The aim of this study was to evaluate the incidence and outcome as well as predictive factors of PCR, in patients resected from CLM after neoadjuvant chemotherapy. Methods: In our institution 791 consecutive patients with CLM underwent liver resection after neoadjuvant chemotherapy. CCR was defined as the disappearance of all lesions after chemotherapy, and PCR was defined as the total necrosis of all metastases on the resection specimen. Both were selected from a prospective database. Patients with and without PCR were compared, survivals were determined and predictive factors for PCR were analyzed using a multivariate risk model. Results: There were 0.4% CCR (3/791) and 4% PCR (31/791). Among the 31 patients with PCR, the median number of CLM was 2.0 (range 1–13) with a maximum diameter = 3 cm for most cases (73%) at diagnosis. Ten patients (32%) had extrahepatic metastases. Compared to patients without PCR, patients with PCR were younger (p< 0.05) and had a smaller maximum tumor size (p=0.007). Rate of objective response was higher (81% vs. 52%; p=0.002) and last chemotherapy regimen contained more frequently oxaliplatin than irinotecan (p=0.05). Number of chemotherapy cycles and treatment lines were not different. At multivariate analysis, 4 predictive factors of PCR were identified: age = 60 yrs, maximum size at diagnosis = 3 cm, CEA = 40 ng/ml at diagnosis and achievement of an objective response. The probability of PCR ranged from 0.2% when all were absent to 33.8% when all were present. PCR strongly impacted overall survival (OS) that was 69% and 62% at 5 and 10 years with a disease-free survival (DFS) of 42% for both. Conclusions: PCR concerns overall 4% of patients receiving neoadjuvant chemotherapy allowing for surgery, but as much as one third of those aged less than 60 years, developing response on liver metastases smaller than 3 cm, with low CEA values. Uncommon high survival rates are observed in this setting. PCR more than CCR is a reality and strongly impacts patient outcome.

No significant financial relationships to disclose.

Vinflunine in patients with advanced unresectable hepatocellular carcinoma and liver impairment

15023

Background: In patients (pts) with advanced hepatocellular carcinoma (HCC) and liver cirrhosis, systemic chemotherapy has most commonly been associated with a very low response rate and high toxicity leading to death from liver failure. Vinflunine (VFL) is a new microtubule inhibitor of the vinca alkaloid class which has demonstrated clinical activity in several tumour types. Methods: A phase I trial was designed to determine VFL dose adjustments in cancer pts with various degrees of liver dysfunction. A high number of pts with HCC and concomitant liver cirrhosis (Child-Pugh grades A and B) were included in the study (18/30 pts). Therefore, a subgroup analysis was carried out in order to determine the safety profile of VFL in these pts (NCI-CTC version 2.0) and to estimate its anti-tumour activity (WHO criteria). Results: Eighteen pts (15 males) of median age 60.7 [26.4–75.3] years with advanced stage and unresectable HCC were treated with VFL. All these pts were outside Milan criteria and ineligible for liver transplantation. Thirteen pts had been previously treated by chemotherapy. The WHO performance status was 0: 11 pts, 1: 5 pts, 2: 2 pts. They received a median number of 4 cycles [1.0–31.0] of different doses of VFL according to the severity of the underlying liver impairment 320 mg/m2 (3 pts), or 250 mg/m2 (6 pts) or 200 mg/m2 (9 pts). One partial response (PR) was observed while 11 pts (61.1%) had stable disease (SD) yielding a disease control rate (PR + SD) of 66.7%. The median progression free survival was 3.4 months [95% confidence interval (CI): 2.6–6.0]. Haematological toxicity: grades (G) 3 anaemia = 4 pts, G3/4 neutropenia = 11 pts, G3 thrombocytopenia = 7 pts, no febrile neutropenia. Other G3 toxicities included G3 abdominal pain (2 pts), constipation (3 pts), neutropenic infection (1 pt). Six pts experienced G3 (5 pts) or 4 (1 pt) fatigue. Conclusions: Vinflunine can be given safely at 320 mg/m2 or 250 mg/m2 or 200 mg/m2 in pts with unresectable advanced HCC with different degrees of liver impairment. The disease control rate is promising (66.7%).

No significant financial relationships to disclose.

Relevance of a medicosurgical strategy combining cetuximab and chronomodulated (Chrono) chemotherapy (chemo) with metastases resection as 3rd line treatment for patients (pts) with metastatic colorectal cancer (MCRC)

14505

Background: Metastases surgery offers long tem survival for pts with chemo-downstaged MCRC (Adam et al. Ann Surg 2004). The relevance of this medicosurgical strategy was investigated in pts given cetuximab (Cetux) and Chrono after chemo failure. Methods: 56 pts with progressive MCRC on prior chemo received Cetux (400 mg/m2 on 1st dose then 250 mg/m2/week) and q2w Chrono based on irinotecan (34 pts), oxaliplatin (14 pts) or both (8 pts). Toxicity grades (G) and response were assessed q2w and q8w, respectively. Tumour EGFR was determined by immunohistochemistry (all pts) and gene copies by fluorescence in situ hybridisation (27 pts). Metastases surgery was attempted whenever complete resection was foreseen. Results: Median of 3 prior chemo (1 to 8); median age: 61 years (35 to 79); M/F: 34/22; WHO PS 0/1/2/3: 37/14/4/1; colon/rectum: 32/24; M sites 1/2/=3: 15/22/19; liver/lung: 45/40. EGFR was detected in the tumor of 39 pts (69.6%). 3 pts had G4 allergy. 53 evaluable pts received a median of 5 courses of Cetux-Chrono (1–22). G2–3 acneiform rash occurred in 36 pts (67.8%; G3: 30.4%). Main G3–4 toxicities were diarrhea (26.5%), neutropenia (23.1%) and neuropathy (22.6%). The objective response rate (ORR) was 32% [95% CI, 19.4 to 44.6] (13 PR and 3 CR). ORR was correlated positively with acneiform rash (p= 0.019) but negatively with the detection of EGFR+ tumor cells (0%, ORR=54.5%; 1–10%, 33%; >10%, 16.7%; p = 0.044). No EGFR amplification was documented including 8 OR. Median progression-free survival (PFS) and overall survival were 5.1 [3.2–6.9] and 13.9 months [6.5–21.3] respectively. Metastases surgery was performed in 10 pts (8 R0, 2 R1) after 3–15 courses of Cetux-Chrono as 2nd-5th line. Median PFS in resected pts was 11.7 months [5.8–17.6], with a survival estimate of 80% at 21 months. Conclusions: Cetux-Chrono safely reverted MCRC resistance and allowed successful metastases resection in 17.8% of these pts, like 1st line chemo. This medicosurgical strategy impacted favourably on long term survival, despite its application as 3rd treatment line. Supported by ARTBC, Hôpital Paul Brousse, Villejuif, France

No significant financial relationships to disclose.

Sandifer syndrome--a multidisciplinary diagnostic and therapeutic challenge

Sandifer syndrome, named after the neurologist Paul Sandifer, was first reported by M. Kinsbourne in 1962 who noticed a disorder of the upper gastrointestinal tract with neurological manifestations occurring in children and adolescents. Sandifer syndrome is a combination of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements with or without hiatal hernia. It is hypothesised that the positioning of the head provides relief from abdominal discomfort caused by acid reflux. The true pathophysiological mechanisms of the condition are still unclear. We report the diagnosis of Sandifer syndrome in a 9-year-old boy with a history of chronic torticollis and dystonic episodes for 5 years associated with abdominal symptoms. The cause of the dystonic body movements had not been found, although multiple neuropsychiatric diseases were suspected. The patient had been seen by many different specialities including Paediatrics, Paediatric Neurology, Psychology, Orthopaedic Surgery and ENT but the reason for the torticollis remained elusive. Unclear abdominal discomfort was the indication for an endoscopy that revealed severe gastro-oesophageal reflux disease with oesophagitis III degrees and a hiatal hernia which led to the correct diagnosis of Sandifer syndrome. After medical treatment and laparoscopic floppy Nissen fundoplication the symptoms nearly resolved 3 months after operation. Few reports of this syndrome exist, but Sandifer syndrome is probably underrecognised. Children with torticollis, dystonic episodes or atypical seizures should be evaluated for GERD and Sandifer syndrome. Early surgery, for example a laparoscopic floppy Nissen fundoplication or a Toupet procedure, can resolve the symptoms.

Colorectal cancer with synchronous liver metastases

Management in a state of flux

Parental perceptions of feeding practices in five European countries: an exploratory study

OBJECTIVE

To gain an insight into parental perceptions of infant feeding practices in five European countries.

DESIGN

An exploratory investigation using focus group discussions. Various aspects addressed included social and cultural setting for the consumption of food, infant feeding practice and behaviour, consumer health awareness and sources of information, and attitudes towards a healthy infant diet.

SETTING

Focus group participants were recruited from centres in five countries, Germany, Italy, Scotland, Spain and Sweden, with three focus groups being conducted in each centre.

SUBJECTS

A total of 108 parents with infants up to the age of 12 months participated in focus group discussions across these centres.

METHODS

Focus groups were conducted with participants from centres in five countries.

RESULTS

The majority of parents in this study chose to initiate breastfeeding and prepare infant food at home. Parents did not strictly adhere to infant feeding guidelines when introducing complementary foods into their infant's diets. There were cross-cultural differences in sources of information on infant feeding practice with the paediatrician in Germany, Italy and Spain. The health visitor in Scotland and the child welfare clinics in Sweden were the most popular sources.

CONCLUSIONS

A number of cultural differences and similarities in attitudes towards infant feeding practice were revealed. This makes European wide approaches to promoting healthy infant feeding difficult as different infant feeding practices are influenced not only by parental perceptions but also by advice from health professionals and feeding guidelines. Further data need to be available on parents' attitudes and beliefs towards infant feeding practice to investigate further the rationale for differing beliefs and attitudes towards infant feeding practice.

SPONSORSHIP

EU Fifth Framework QLRT 2002 02606.

Adult liver transplantation: the Paul Brousse experience

During the past 3 decades, more than 2,250 liver transplants were performed at Paul Brousse Hospital. Overall patient survival was 82% at one year, 71% at 5 years and 64% at 10 years. Our group has developed a variety of approaches to liver transplantation, including: 1. Anti HBs immunoglobulin prophylaxis for the prevention of HBV recurrence. Combination prophylaxis with lamivudine and anti HBs immunoglobulins reduced the rate of HBV re-infection to 20%. 2. Transplantation of HIV-HCV and HIV-HBV infected patients. These transplants are feasible and we achieved 2- year survival rates of 70% and 90%, respectively. The main problem was HCV recurrence which was more severe in HIV co-infected patients. 3. Transplantation for hepatocellular carcinoma on a cirrhotic liver with a single tumor <5 cm or <3 tumors <3 cm. 4. Transplantation for familial amyloidotic polyneuropathy (FAP). The 5- and 10-year survival rates were 76% and 72%, respectively. More than 100 livers obtained after hepatectomy from FAP patients were transplanted as "domino" living donor livers to patients with unresectable liver cancers with a 5-year survival rate of 64%. In some domino recipients, symptoms of FAP disease occurred more rapidly than expected and this could be an indication for a second transplantation of a non FAP-liver. 5. Split-liver transplantation for pediatric patients. This has increased the number of transplantable livers for children by 28%. 6. Split-liver transplantation for 2 adults. The grafts were prepared by ex-vivo or in-situ splitting and the overall 5-year survival rate was 56%. 7. Adult -to-adult living-related liver transplantation. There has been no mortality nor late complications in donors and the overall 5-year survival rate among recipients was 73%. 8. Liver retransplantation with good results in the elective situation. Retransplantation should be used with discretion in the emergency setting.

Total hip arthroplasty in secondary systemic lupus erythematosus femoral head avascular necrosis

Systemic lupus erythematosus is a multisystem disease with a large spectrum of clinical manifestations and a variable course. Lupus is marked by both humoral and cellular immunologic abnormalities, including multiple auto-antibodies especially anti DNA antibodies. Epidemiology - female predominance, occurring usually between second and fourth decade of life, more frequently in hispanic and black patients. Family predominance has been noticed. Provocative agents - ultraviolet light, viral infections, drugs and situational stresses. Pathogenesis - pathological features can affect a large spectrum of internal organs and systems - osteoarticulary injuries, skin rash, lymphadenopathy, glomerulonephritis, myocarditis, digestive system lesions. Musculo skeletal abnormalities include migratory arthritis, effusion and stiffness in small and large joints. Articular erosions are uncommon. Skeletal abnormalities include osteopenia and osteonecrosis, due to two pathological mechanisms: vasculitis and long term corticotherapy. Fifteen to twenty percent of SLE patients are affected by femoral head avascular necrosis (FHAN). Diagnosis rests on clinical signs - hip pain, limited range of motion, walking with a limp.; radiological findings - best grouped in Arlet-Ficat standing system; MRI - high sensitivity, especially in infraradiological stages. Treatment - in incipient stages core decompression represents the best therapeutical option. In advanced, arthritis stages, total hip arthroplasty (THA) is the standart treatment. Three implant types are available: bipolar, uncemented and cemented. An increased number of cotyloidites occurred after bipolar implants. Emphasised osteopenia and excessive bleeding represent contraindications for uncemented implants. Considering all of this, cemented implants are considered, the right choice, methacrylate cement providing strong and durable fixation of THA implants to bone. No meaningful differences were observed in postoperative functional recovery between LSE patients and other etiology FHAN patients.

TLR4 mutations (Asp299Gly and Thr399Ile) are not associated with ankylosing spondylitis

BACKGROUND

Immunoregulatory genes and Gram negative gut bacteria are thought to be important in disease expression in ankylosing spondylitis (AS).

OBJECTIVE

To compare the frequency of two common and functional TLR4 mutations (Asp299Gly, and Thr399Ile) between patients with AS and HLA-B27 healthy controls.

METHODS

The TLR4 genotypes of patients and healthy HLA-B27 controls were determined using allele-specific PCR and restriction fragment length polymorphism analysis. Asp299Gly genotype was determined in 193 patients and 125 HLA-B27 positive controls and Thr399Ile genotype in 184 patients and 113 HLA-B27 controls. Allele frequencies were compared using a chi(2) test of association.

RESULTS

29/193 (15%) patients with AS had a polymorphism in the Asp299 site compared with 18/125 (14.4%) healthy HLA-B27 controls. Of the patients genotyped for the Thr399Ile allele, 29/184 (15.8%) carried the polymorphism compared with 19/113 (16.8%) HLA-B27 controls. No significant difference between the frequencies of the Asp299Gly genotype or the Thr399Ile genotype between patients with AS and healthy HLA-B27 controls was found. No significant difference in allele frequency was found at either site.

CONCLUSION

Two common TLR4 polymorphisms, which cause a functional deficiency in host immune response to Gram negative bacteria, are not overrepresented in patients with AS.

LiverMetSurvey: Analysis of clinicopathologic factors associated with the efficacy of preoperative chemotherapy in 2,122 patients with colorectal liver metastases

3521

Background: LiverMetSurvey is an international, internet-based registry designed to assess the efficacy of multimodality treatment options for colorectal liver metastases (CLM) by analyzing outcomes following hepatic resection (HR) in a large number of patients. Methods: Data were analyzed for the 2,122 patients entered into LiverMetSurvey by six hepatobiliary centers from inception to August 2004 (HR: 1974 to 2004; 1,306 men: 816 women; mean age: 61 years). The distributions of potential prognostic factors including age, sex, primary tumor site, timing of metastasis diagnosis, tumor number, diameter of the largest metastasis, bilaterality, and treatment with chemotherapy were compared to survivals using univariate and multivariate statistics. Results: Metastases originated in the colon in 69% of patients and were synchronous (diagnosed within 3 mo of primary tumor treatment) in 49% of patients. 34% of patients had ≥ 3 metastases and tumors were distributed bilaterally in 43% of cases. The mean size of the largest metastasis was 41.8 mm. 55% of patients were treated with preoperative systemic chemotherapy. Following resection, 60-day mortality was 1.2% and median, 5-year, and 10-year overall survivals (OS) were 46 mo, 42%, and 26%, respectively. Variables independently associated with poor prognosis included number of metastases > 3 (p<0.0001), bilateral metastases (p=0.0002), and size of the largest metastasis > 5 cm (p=0.03). Preoperative chemotherapy (PC) did not appear to benefit patients with solitary CLM (5-yr OS: PC 45% vs. no PC 58%), but was associated with improved survival in patients with > 5 metastases (5-yr OS: PC 22% vs. no PC 12%). Conclusions: Assessment of outcomes for the first 2,122 registrants to LiverMetSurvey not only confirms the prognostic importance of intrahepatic tumor burden, but also indicates that the ability of preoperative systemic chemotherapy to improve survivals is limited to patients with multiple (> 5) metastases. In addition, this analysis demonstrates the potential for LiverMetSurvey, which is now prospectively enrolling patients from over 40 centers, to determine the therapeutic value of current and future treatment strategies.

No significant financial relationships to disclose.

Cetuximab plus gemcitabine/oxaliplatin (GEMOX) for patients with unresectable/recurrent intrahepatic cholangiocarcinoma refractory to GEMOX

14084

Background: Gemcitabine-oxaliplatin (GEMOX) is active and well tolerated in advanced biliary tract adenocarcinomas. We report a single institution retrospective study on using cetuximab plus GEMOX in patients with intrahepatic cholangiocarcinoma that expresses Epidermal Growth Factor Receptor (EGFR) and who have progressed on first line chemotherapy (GEMOX). Methods: 9 patients (5 females, 4 males, mean age: 54 years, range: 27–74, performance status: 0–1) with a recurrent or unresectable intrahepatic cholangiocarcinoma (peripheral n=6, hilar n=3, histologically proven) resistant to GEMOX received cetuximab 400 mg/m2 on day 1 then 250mg/m2 weekly, in combination with gemcitabine 1,000 mg/m2 as a 10 mg/m2/min infusion on day 1 and oxaliplatin 85mg/m2 as a 4-h infusion on day 2, every 3 weeks. EGFR expression was determined by immunohistochemistry (n=9) and EGFR gene copy number on tumour cells was detected by fluorescent in situ hybridization (FISH) (n=8). Tumor response was measured using standard RECIST criteria. Results: EGFR was detected by immunohistochemistry (9/9) in more than 10% tumour cells without gene amplification (8/8). A total of 57 cycles were given (range: 3–11 per patient). Median duration follow-up was 7 months (range: 6–12). At 3 months, 3/9 had partial response, 3/9 stable disease and 3/9 a progression disease. At 6 months, CT scan showed 1 complete response, 1 partial response, 1 stable disease and 6 progression diseases. The median time to tumour progression was 6 months, with a median duration of response of 3 months (range: 2–8). Five patients died. Of the 4 patients who are still alive, the mean duration follow-up is 11 months (range: 10–14). There was no treatment related death, no anemia, no neurotoxicity. One grade 3 neutropenia was noted and acne-like rash was observed in 7/9 patients. The median survival from time of initiation of treatment was 10 months. Conclusions: Even if there is no amplification of EGFR gene, Cetuximab plus GEMOX is well tolerated and provides good palliative effects in advanced cholangiocarcinoma. A prospective phase II trial with GEMOX with and without cetuximab is being planned to assess the real impact of cetuximab in unresectable cholangiocarcinoma expressing EGFR.

No significant financial relationships to disclose.

Effective salvage therapy of liver-only colorectal cancer metastases with chronomodulated irinotecan-fluorouracil-oxaliplatin via hepatic artery infusion

3585

Background: Cell cycle and pharmacology genes are controlled by the molecular clock in normal liver but not in tumors (Filipski et al. JNCI 2005). As a result, circadian-based hepatic artery infusions of 3 main active drugs (ChronoHAI) could improve both tolerability and efficacy in patients (pts) with liver metastases from colorectal cancer. Methods: The therapeutic potential of 3-drug chronoHAI was evaluated in 28 heavily pretreated non hospitalized pts with metastatic colorectal cancer (MCC). They received 5-day (d) q21 d courses (c) with d1 irinotecan (160 mg/m2 from 2 to 8 am, peak at 5 am) and d2–5 oxaliplatin (20 mg/m2/d from 10 am to 10 pm, peak at 4 pm) and 5-fluorouracil (600 mg/m2/d from 10 pm to 10 am, peak at 4 am). 149 courses (c) were given (median, 5 ; 1–15) using a multichannel pump (Mélodie, Aguettant, F). Toxicity was assessed q21 d and response q3 c with CT scan. Results: Pt characteristics: prior chemotherapy lines 1/2/3/4+: 3/4/8/13 pts; WHO Performance Status 0/1/2/3 : 12/9/6/1 pts; median age: 63 years (32–73); liver only: 21 pts; liver and lung: 7 pts. Treatment was withdrawn for thrombosis (6 pts) and/or Grade (gr) 3 abdominal pain (3 pts). Grade 3–4 diarrhea and vomiting respectively occurred in 6 pts (21%) and 4 pts (14%) and were the main toxicities. Leucopenia, anemia and thrombocytopenia were respectively encountered in 5, 2 and 1 pt (< 18%). NCIC gr 3 sensory neuropathy occurred in 4 pts and alopecia in 3 pts. Of 25 pts with measurable lesions, disease progressed in 11 pts (exclusively outside the liver for 3 pts) and was controlled in 14 pts (56%), including 8 objective responses - 32% [95% C.L. 13.4 to 50.6]. Partial hepatectomy was performed in 3 pts with measurable disease (12%): R0 (2 PR) and R1 (1 SD). Median Progression free survival is 5 months [2.5 to 7.5] and median survival is 18.4 mo [10.5 to 26.3]. Five pts are alive at 2 to 51 mo. Conclusions: 3-drug chronoHAI is safe in heavily pretreated pts and achieves consistent activity against colorectal cancer liver metastases despite prior failure to oxaliplatin, irinotecan and fluorouracil. The addition of systemic molecular targeted therapy could be useful for preventing extra hepatic dissemination. Supported by ARTBC, Hôpital P. Brousse, Villejuif, France

No significant financial relationships to disclose.

Cetuximab reversal of resistance to chronomodulated chemotherapy in heavily-pretreated patients with metastatic colorectal cancer (MCC) without amplification of epidermal growth factor receptor (EGFR) gene

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Background Skin toxicity and EGFR amplification reportedly predicted for Cetux-reversal of MCC resistance to standard chemotherapy. We explored these relations for Cetux reversal of resistance to chronomodulated chemotherapy (Chrono) with irinotecan (CPT11, peak at 5 am), 5-fluorouracil-leucovorin (FU-LV, peak at 4 am) and oxaliplatin (l-OHP, peak at 4 pm). Methods: 40 pts with progressive MCC on 3 prior chemotherapy lines received weekly Cetux (250 mg/m2) and q2–3 wks CPT11-based (30 pts) or oxaliplatin-based (10 pts) Chrono. Toxicities and response were assessed q2–3 wks and q2 months (mo) respectively. Tumor EGFR expression was determined by immunohistochemistry for all pts and gene copies by fluorescent in situ hybridization (FISH) for 25 pts. Results: All pts had prior progression on CPT11, FU-LV and l-OHP. Median age: 61 yo; M/F: 24/16; WHO PS 0/1/2: 27/9/4; colon/rectum: 21/19; M sites 1/2/≥ 3: 12/15/13; liver/lung: 32/29; pre-existing peripheral sensory neuropathy grade ≥ 2: 11 pts. A median of 8 courses of Cetux-Chrono was given (1 to 22). Three pts withdrew for grade 4 allergy. 37 pts were assessable for other toxicities and 36 for response (1 too early). Gr 2–3 acneiform skin rash occurred in 27 pts (73%), with gr3 in 11 pts (29.7%). Other main gr 3–4 toxicities were diarrhea (27% of the pts), neutropenia (24.3%) and neuropathy (21.6%). Disease progressed in 12 pts (33.3%) and was controlled in 24 pts (66.7%) including 13 stable disease (36.1%) and 10 objective responses (8 PR and 2 CR) - 27.8% [95% C.L. 12.9 to 42.7]. EGFR was expressed in 32 pts (80%), with >10% + tumor cells for 14 pts (35%). 3/6 EGFR- pts (50%) and 7/32 EGFR+ pts (21.9%) responded. No gene amplification was documented in the 25 tumors (7 responders). A positive correlation between skin rash and disease control was suggested (p from χ2 = 0.08). Median progression free and overall survival (mo) are 5.3 [2.9–8.4] and 11.1 [8.6–13.6] respectively. Conclusions: Cetux partly alleviated MCC resistance to Chrono, independently of tumor EGFR protein expression or gene amplification, possibly through interfering with TGFα. This EGFR ligand carries poor prognosis for MCC and alters circadian clock function.

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