Adjuvant chemotherapy for resected stage II and III colon cancer: Comparison of widely used two prognostic calculators

e15031

Background: Two web based prognostic calculators, Adjuvant! and Numeracy (JCO 22:1797–1806, 2004) are widely used to provide individual patient outcome predictions to aid decisions regarding adjuvant therapy for colon cancer. The comparability of these tools has not been studied yet. The aim of this project was to assess whether the Numeracy and Adjuvant! Colon cancer prognostic tools produced similar results for patients with resected stage II and III colon cancer based on a set of hypothetical patients. Methods: All possible hypothetical scenarios were formulated for the Numeracy calculator based on all potential combinations of age, lymph nodes status, tumor stage, and grade of tumor. These were applied to three post- surgical therapy choices: observation, 5-FU (5-fluorouracil), or FOLFOX (5-FU, leucovorin and oxaliplatin). Predictions for these hypothetical scenarios (N= 192 for males and 192 for females) were also entered into the Adjuvant! Program. Predicted relapse free survival (RFS) and overall survival (OS) were obtained using both calculators. Wilcoxon signed rank tests were used to compare the numerical predictions between the calculators for each outcome. Results: In the majority of the 384 hypothetical patient scenarios, predictions for RFS and OS from Adjuvant! were statistically significantly higher than from Numeracy (p value < 0.05), except for age≥70 for FOLFOX, and the number of positive nodes of 0 and 1–4 using FOLFOX, among males. The net estimate of benefit for RFS and OS for 5-FU over surgery, obtained from Adjuvant! and Numeracy, were similar (for both males and females), but the benefit in RFS and OS for FOLFOX over 5-FU obtained from Adjuvant! was significantly lower than the estimate obtained from Numeracy (p value < 0.05). Conclusions: Based on a hypothetical set of patients with resected stage II and III colon cancer, the estimated benefit in RFS and OS of FOLFOX over 5-FU based chemotherapy is lower in Adjuvant! than in the Numeracy tool (but benefit for 5-FU over surgery alone is similar). Further studies are needed to clarify the discrepancy and to assess which of these tools most accurately reflects actual patient outcome.

No significant financial relationships to disclose.

Predictors of adjuvant chemotherapy (AT) decision-making in referred patients (pts) with stage II and III colon cancer (CC)

e15070

Background: Randomized clinical trials have demonstrated a robust survival benefit of AT for node positive (stage III) CC patients; similar evidence for node-negative (stage II) patients is lacking. While guidelines recommend AT for stage III colon cancer but AT is not a routine recommendation for stage II. Actual practice of the evidence varies and suggests the interplay of additional variables. We sought to identify factors associated with practice patterns which vary from conventional AT guidelines, ie no AT in stage III CC and receipt of AT in.stage II CC. Methods: Data pertaining to pt demographics, tumor characteristics, and treatment for pts with resected stage II (n=176) and III CC (n=235) referred to the British Columbia Cancer Agency in 2004 was collected by retrospective chart review. One-sided Fisher's exact test was used to assess statistical significance (p<0.05) by univariate analysis. Results: 28% (n=49) of stage II pts received AT. Compared to untreated pts, stage II pts who received AT were significantly more often younger than 66 years (57% vs 21%), lived in a city with a regional cancer center (71% vs 51%), had T4 disease (33% vs 9%), vascular invasion (22% vs 5%), perineural invasion (10% vs 2%) and high grade (26% vs 2%). Marital status, ethnicity, lymphatic invasion and high CEA were not associated with AT in stage II. 29% (n=69) of stage III pts did not receive AT. Compared to treated pts, stage III pts who did not receive AT were significantly more often older than 65 years (91% vs 51%), had low grade disease (96% vs 84%) and presented for oncology consultation greater than 42 days from surgery (29% vs 11%). Marital status, ethnicity, residence, T4 status or N2 status were not associated with no AT in stage III. Conclusions: For pts with stage II CC, subgroups associated with high risk for relapse were more likely to receive AT although the majority of stage II pts in this cohort remained untreated. For stage III disease, almost one-third of referred pts did not receive AT. Older age and delayed presentation were strongly associated with failure to receive AT. Within the limitations of a retrospective review, these data highlight the significant and commonly observed implications of factors other than stage in AT decision-making for high risk resected CC.

No significant financial relationships to disclose.

Analysis of prognostic (prog) Web-based models for stage II and III colon cancer (CC): A population-based validation of Numeracy (NUM) and ADJUVANT! Online (ADJ!)

4044

Background: To aid in decisions regarding adjuvant therapy (AT) for resected high-risk CC, two prog models are in common use: the Mayo Clinic NUM calculator developed from a pooled data analysis of 7 randomized 5FU-based AT trials, and ADJ! developed using SEER data. This study examines the accuracy of NUM and ADJ! utilizing a cohort of patients (pts) referred to the BC Cancer Agency (BCCA). Methods: Demographic, disease and treatment data for pts with stage II/III CC referred to the BCCA from 1995–1996 + 1999–2003 were collected. Observed (obs) 5-year relapse free survival (RFS) and overall survival (OS) were compared to predicted estimates (pred) using NUM and ADJ!, both overall and for all prog subgroups with ≥ 10pts, as stratified by T stage, N stage, tumor grade and age. Data are presented in a descriptive manner and using confidence intervals. Results: Median follow-up was 5.6 yrs for 2,033 pts - 53% male, median age 68y, 40% N0. The mean percentages of 5 year pred outcomes for each of the two models and the actual Kaplan Meier mean survivals are presented in the table . The percentage correct predictions of 5 y status is also presented, with correctness deemed accurate if the pt was alive and predicted to be alive by ≥ 50% as determined by each model or dead while the respective tool predicted < 50% possibility of being alive. For surgery alone pts, ADJ!pred were more often closer to what was observed, as compared to NUMpred, in the prog subgroups (for RFS 56%, OS 88%). For surgery + 5-FU pts, within these subgroups, NUMpred were more often closer to what was observed, as compared to ADJ!pred, for RFS (62%) and for OS (55%). Conclusions: In this independent population-based validation, NUM and ADJ! have acceptable and similar reliability with modest over-estimations of 5y RFS and OS. Both models thus appear to be useful adjuvant decision-aids.

[Table: see text]

No significant financial relationships to disclose.

Impact of bevacizumab (bev) on overall survival (OS) in patients (pts) with metastatic colorectal cancer (MCRC): A population-based study

4114

Background: As of 2003, irinotecan or oxaliplatin in combination with fluorouracil was standard treatment for MCRC in British Columbia (BC). The addition of bev to chemotherapy (CT) was approved in BC in 2006. We compared OS between referred pts diagnosed with MCRC in 2003/2004 (pre-bev era) and 2006 (bev era). Methods: All pts diagnosed with MCRC in 2003/04 and 2006, and referred to the BC Cancer Agency (BCCA) were included. The BCCA is a cancer network with centers throughout BC, ≈60% of MCRC pts in BC are referred to the BCCA. Systemic therapy (ST) is centrally funded and treatment data was obtained from the pharmacy database. The primary endpoint was OS of all pts within each cohort. Secondary endpoints were OS in pts treated with ST, and in those not treated. Kaplan Meier method was used for survival analysis. Subgroup analysis based on age was performed. Results: 1417 pts were included: 969 from 2003/04, and 448 from 2006. Median age at diagnosis of MCRC was 68y in 2003/04 and 69y in 2006. Median follow up time was 47.3 and 21.4 mos respectively. Between 2003/04 and 2006 the proportion of pts treated with ST for MCRC increased from 61.1% to 67.6% (p= 0.02). Proportion of pts who received irinotecan, oxaliplatin and fluorouracil did not change (24.7% to 23.7%, p=0.68). Proportion of pts who received bev increased (5.9% to 30.6%, p<0.001). Median OS significantly improved for the entire cohort (13.8 to 17.3 mos, p<0.001). Median OS for pts who received ST for MCRC improved (18.6 to 23.6 mos, p=0.001). Median OS for pts who did not receive ST did not change (6.1 to 5.9 mos, p=0.65). Of pts who received ST, the proportion who received bev increased in pts <70 (12.7% to 58%, p<0.001) and in pts ≥70 (3.6% to 22.7%, p<0.001). Median OS for pts <70 who received ST for MCRC improved (20.3 to 26.5 mos, p = 0.002). Median OS for pts ≥70 who received ST for MCRC improved (16.5 to 19.9 mos), but this was not significant (p=0.16). Conclusions: In this population based study, median OS for MCRC significantly increased between 2003/04 and 2006. The improvement in survival appears to be limited to pts treated with ST for metastatic disease. The main difference in ST has been the addition of bev. On a population basis, the addition of bev to CT is associated with a significant improvement in OS in MCRC.

No significant financial relationships to disclose.

Phase II trial of erlotinib in advanced pancreatic cancer (PC)

4609

Background: The epidermal growth factor receptor (EGFR) is a potentially important target in PC. Benefit from erlotinib (Tarceva), an oral EGFR tyrosine kinase inhibitor has been associated with the presence of a skin rash. The purpose of this study was to determine the efficacy of erlotinib, dosed to achieve a rash, in patients (pts) with PC. Methods: Erlotinib was given at an initial dose of 150 mg/day to eligible pts with locally advanced (LA) or metastatic PC who had progressed or were unable to tolerate gemcitabine-based chemotherapy. The dose of erlotinib was increased by 50mg every 2 weeks (maximum 300 mg/day) until > grade 1 rash (CTCAE v 3.0) or other dose-limiting toxicities occurred. Erlotinib pharmacokinetic (PK) studies were performed. Baseline tumor tissue was collected for analysis of Kras mutations, EGFR by IHC and FISH. The primary endpoint of this two- stage phase II trial was prolonged disease control (PR + SD > 8 wks) with a rate of >20% assumed to be significant . Results: Fifty pts were accrued (median age 61, M:F = 25:25, ECOG 0:1:2 = 5:41:4, LA:Metastatic = 5:45, prior gemcitabine none:adjuvant:palliative = 2:16:35). 47 and 40 pts were evaluable for toxicity and response, respectively. Dose-escalation to 200–300 mg of erlotinib was possible in 9 pts. Most common treatment adverse events (TAEs) of any grade were: rash (35 pts, 74.5%), diarrhea (18 pts, 38.3 %), and fatigue (8 pts, 17%). Grade 3+ TAEs were rash in 2 pts and diarrhea in 2 pts. Best response was SD in 14 pts, 0.35 (95% CI: 0.2–0.5). Prolonged disease control (SD > 8 wks) was observed in 10/40 evaluable pts, 0.25 (95% CI: 0.12–0.38), which met the primary study endpoint. Median TTP was 1.6 mo (95% CI:1.6–2.1), mOS 4.1 mo (95% CI:3.2–7.3), and 6 mo OS rate was 39% (95%CI: 24–61%). PK and correlative data are being analyzed and will be presented. Conclusions: Erlotinib is associated with prolonged stable disease in a subset of pts with advanced refractory PC. Dose escalation in the absence of toxicity is feasible and safe.

[Table: see text]

Characterization of a degenerative cardiomyopathy associated with domoic acid toxicity in California sea lions (Zalophus californianus)

Domoic acid, produced by marine algae, can cause acute and chronic neurologic sequela in California sea lions (Zalophus californianus) from acute toxicity or sublethal exposure. Eight sea lions, representing acute and chronic cases, both sexes, and all age classes, were selected to demonstrate a concurrent degenerative cardiomyopathy. Critical aspects of characterizing the cardiomyopathy by lesion distribution and morphology were the development of a heart dissection and tissue-trimming protocol and the delineation of the cardiac conducting system by histomorphology and immunohistochemistry for neuron-specific protein gene product 9.5. Histopathologic features and progression of the cardiomyopathy are described, varying from acute to chronic active and mild to severe. The cardiomyopathy is distinguished from other heart lesions in pinnipeds. Based on histopathologic features, immunopositive staining for cleaved caspase-3, and comparison with known, similar-appearing cardiomyopathies, the proposed pathogenesis for the degenerative cardiomyopathy is the primary or at least initial direct interaction of domoic acid with receptors that are suspected to exist in the heart. l-Carnitine, measured in the heart and skeletal muscle, and troponin-I, measured in serum collected at the time of death from additional animals (n = 58), were not predictive of the domoic acid-associated cardiomyopathy. This degenerative cardiomyopathy in California sea lions represents another syndrome beyond central neurologic disease associated with exposure to domoic acid and may contribute to morbidity and mortality.

Liver biochemistry abnormalities in a quaternary care lipid clinic database

BACKGROUND

The metabolic syndrome and non-alcoholic fatty liver disease are increasing at alarming rates.

AIMS

To determine the effect of HMG-CoA reductase inhibitors (statins) on elevated liver enzymes in patients with hyperlipidemia.

PATIENTS

Patients with AST above 60 U/L prior to or during treatment with statin therapy at a quaternary care lipid clinic were reviewed.

METHODS

A retrospective analysis was conducted. Patients were separated into two groups: Group 1--elevated AST prior to statin therapy; and Group 2--elevated AST during statin therapy.

RESULTS

Forty six patients with one or more measurements of AST >60 U/L remained after exclusion criteria were applied. Ten of 13 (77%) group 1 patients had reduced AST levels after initiation of statin therapy. Thirty two of 33 patients (97%) in group 2 had transient AST elevations while on statin therapy; one patient had persistently elevated AST after initiation of treatment. There were no significant adverse events reported.

CONCLUSION

Use of HMG-CoA reductase inhibitors in patients with elevated AST resulted in normalization of AST levels. HMG-CoA reductase inhibitors were safe in patients with mildly elevated AST. This may translate to use of HMG-CoA reductase inhibitors in diseases such as non-alcoholic fatty liver disease and non-alcoholic steatohepatitis.

The pregnancy-induced increase in baseline circulating growth hormone in rats is not induced by ghrelin

The elevation in baseline circulating growth hormone (GH) that occurs in pregnant rats is thought to arise from increased pituitary GH secretion, but the underlying mechanism remains unclear. Distribution, Fourier and algorithmic analyses confirmed that the pregnancy-induced increase in circulating GH in 3-week pregnant rats was due to a 13-fold increase in baseline circulating GH (P < 0.01), without any significant alteration in the parameters of episodic secretion. Electron microscopy revealed that pregnancy resulted in a reduction in the proportion of mammosomatotrophs (P < 0.01) and an increase in type II lactotrophs (P < 0.05), without any significant change in the somatotroph population. However, the density of the secretory granules in somatotrophs from 3-week pregnant rats was reduced (P < 0.05), and their distribution markedly polarised; the granules being grouped nearest the vasculature. Pituitary GH content was not increased, but steady-state GH mRNA levels declined progressively during pregnancy (P < 0.05). In situ hybridisation revealed that pregnancy was accompanied by a suppression of GH-releasing hormone mRNA expression in the arcuate nuclei (P < 0.05) and enhanced somatostatin mRNA expression in the periventricular nuclei (P < 0.05), an expression pattern normally associated with increased GH feedback. Although gastric ghrelin mRNA expression was elevated by 50% in 3-week pregnant rats (P < 0.01), circulating ghrelin, GH-secretagogue receptor mRNA expression and the GH response to a bolus i.v. injection of exogenous ghrelin were all largely unaffected during pregnancy. Although trace amounts of 'pituitary' GH could be detected in the placenta with radioimmunoassay, significant GH-immunoreactivity could not be observed by immunohistochemistry, indicating that rat placenta itself does not produce 'pituitary' GH. Although not excluding the possibility that the pregnancy-associated elevation in baseline circulating GH could arise from alternative extra-pituitary sources (e.g. the ovary), our data indicate that this phenomenon is most likely to result from a direct alteration of somatotroph function.

Role of low-dose, noncontrast computed tomography from integrated positron emission tomography/computed tomography in evaluating incidental 2-deoxy-2-[F-18]fluoro-D-glucose-avid colon lesions

PURPOSE

To assess the contribution of concurrent low-dose, noncontrast CT in the assessment of the malignant potential of incidental focal 2-deoxy-2-[F-18]fluoro-D-glucose (FDG)-avid colonic lesions on positron emission tomography/computed tomography (PET/CT).

PROCEDURES

Routine FDG-PET/CT scans were reviewed for identification of focal FDG-avid colon lesions, and the CT component was independently reviewed for an anatomical lesion and malignant potential based on CT criteria. Clinical, endoscopic, and histopathology follow-up was obtained.

RESULTS

A total of 85/2,916 (3%) oncology FDG-PET/CT scans had incidental focal colon lesions. Clinical and/or endoscopic follow-up was available in 83/85 (98%) patients. Focal, corresponding CT lesions were found in 44/83 (53%) patients, but features of malignancy were not assessable. Of the 44 patients with a final diagnosis, 32/44 (73%) were FDG-PET/CT true positives; 5/44 (11%) were false positives; and 7/44 (16%) had inconclusive FDG-PET/CT findings.

CONCLUSIONS

Concurrent low-dose, noncontrast CT improves localization, but does not provide independent information on the malignant potential of incidental focal colonic activity on FDG-PET/CT.

Trends in chemotherapy (CT) utilization for colorectal cancer: A provincial population-based analysis

17014

Background: Significant advances have been made in the treatment of colorectal cancer in both the adjuvant and metastatic setting. The purpose of this study is to examine CT prescribing patterns for adjuvant therapy of colon cancer and metastatic colorectal cancer over the last 15 years in British Columbia, Canada. Methods: All patients (pts) with stage 2 or 3 colon cancer, or stage 4 colorectal cancer at presentation referred to the BC Cancer Agency during a one year period for three time cohorts: 1990, 2000 and 2004, were reviewed. A pt was considered to be treated with CT if they received a cycle of CT within 6 months of referral. Results: A total of 1421 pts were included: stage 2/3 n=915, stage 4 n=506. Chemotherapy utilization increased significantly from 1990 to 2004 for adjuvant CT (1990: 49 (29%), 2000: 129 (45%), 2004: 235 (52%), p<0.001) and for palliative CT (1990: 41(35%), 2000: 100 (51%), 2004 120 (63%), p<0.001). The proportion of pts with stage 2 disease treated with adjuvant CT dramatically increased (1990: 3(4%), 2000: 38 (26%), 2004: 50 (30%), p<0.001). CT utilization was associated with a later time cohort and younger age of presentation ( Table 1 ). The use of palliative CT was significantly associated with male gender (p=0.025). This gender bias was not observed in the adjuvant setting. Among pts >70y, only 25% (99/394) received adjuvant CT [1990: 5(8%), 2000:38 (28%), 2004: 57 (28%] and 31% (50/162) received palliative CT [1990:4 (15%), 2000:17 (24%), 2004:30 (45%)]. Conclusions: In this population-based cohort, adjuvant and palliative CT utilization has increased since 1990 however there is room for improvement. Despite the lack of conclusive evidence, the use of adjuvant CT for stage II disease has increased significantly. Female pts appear less likely to receive palliative CT. Despite evidence that the elderly can accrue similar proportional benefits, the majority of referred pts >70y did not receive adjuvant or palliative CT. Such discrepancies in CT utilization require further investigation.

[Table: see text]

No significant financial relationships to disclose.

Targeted chemoradiation for metastatic colorectal cancer: A phase I trial of oral capecitabine combined with 131I- huA33

4078

Background: HuA33 is a humanized antibody that targets the A33 antigen, which is highly expressed in intestinal epithelium and >95% of human colon cancers, but not other normal tissues. Previous studies have shown huA33 can target and be retained in a metastatic tumor for 6 weeks, but eliminated from normal colonocytes within days. This phase 1 study used radio-labeled huA33 in combination with capecitabine chemotherapy to target chemoradiation to metastatic colorectal cancer. Methods: The primary objective was safety and tolerability of the combination of capecitabine and 131I-huA33. Pharmacokinetics, biodistribution, immunogenicity, and tumor response were also assessed. Eligibility included measurable metastatic colorectal cancer, adequate hematological and biochemical function, and informed consent. An outpatient scout 131I-huA33 dose was followed by a single therapy infusion one week later, when capecitabine was commenced. Dose escalation occurred over 5 dose levels. Patients were evaluated weekly, with tumor response assessment at the end of the12 week trial. Tumor targeting was assessed using gamma camera and single photon emission computerized tomography (SPECT) imaging. Results: 16 patients have enrolled with 2 currently on treatment, including one in the final dose cohort. Accrual will be completed by March 2007. The dose escalation protocol was amended following 2 dose limiting toxicities in the second cohort, but subsequent cohorts demonstrated good tolerability. Biodistribution analysis demonstrated excellent tumor targeting of the known tumor sites, expected transient bowel uptake, but no other normal tissue uptake. Maximal duration of stable disease is currently 3 years. Conclusions: 131I-huA33 achieves specific targeting of radiotherapy to sites of metastasis and can be safely combined with chemotherapy. This provides an opportunity to deliver chemoradiation specifically to metastatic disease in colorectal cancer patients.

[Table: see text]

No significant financial relationships to disclose.

Impact of irinotecan and oxaliplatin on overall survival in patients with metastatic colorectal cancer (MCRC): A population- based study

4077

Background: Over the past 10 years, chemotherapeutic options for MCRC has significantly expanded from 5-FU based therapy, to include irinotecan and oxaliplatin. The effect of the availability of these treatments on overall survival is evaluated among patients in 3 time cohorts referred to the British Columbia Cancer Agency (BCCA). Methods: Patients with newly diagnosed or relapsed metastatic colorectal cancer referred to the BCCA in 1995/96, 2000 and 2003/04 were included. In 1995/96, 5-FU was the only palliative chemotherapy agent available at BCCA and irinotecan and oxaliplatin were available in 2000 and 2003, respectively. A one year period was used for the irinotecan cohort to minimize overlap between groups. Overall survival estimates were generated using the Kaplan Meier method. Survival was calculated from time of diagnosis of distant metastatic disease to either death or last contact date. Results: Cohorts were generally similar, however, a significantly higher proportion of patients received chemotherapy in more recent eras ( Table 1 ). Only 25% of patients received both irinotecan and oxaliplatin in 2003/4 and only 10 % received biologic therapies. An improvement in median survival of 3.6 months was observed. The improvement in the treated subgroup was 4.2 months. Outcomes of patients untreated with chemotherapy were unchanged between cohorts. Conclusions: In this population based study, the proportion of patients with MCRC treated with chemotherapy significantly increased between 1995/6 and 2000/2003/4. Patients treated with chemotherapy experienced a 4.2 month increase in median survival in 2003/4 compared to 1995/6. Survival improvements were only significant in the time period when all three effective chemotherapies (5FU, irinotecan and oxaliplatin) were available. As bevacizumab was not available until 2006, its survival impact in this population is not yet known.

[Table: see text]

No significant financial relationships to disclose.

Surgical treatment of pulmonary aspergilloma: a series of 72 cases

BACKGROUND

The objective of this study was to evaluate the immediate and long-term result of resectional surgery in pulmonary aspergilloma.

METHODS

Seventy-two patients who underwent pulmonary resectional surgery for symptomatic aspergilloma between 1990 to 2002 were studied. Seventy-nine definitive operations were carried out, including one bilateral lobectomy for recurrent lesions and six thoracoplasties to deal with post-operative complications, besides 21 pneumonectomies and 51 lobectomies. There were 10 bilobectomies as well, included in the lobectomy group.

RESULTS

At a mean follow-up of 3.5 years, there were two post-operative deaths and a few complications occurred in 20 cases translating into a morbidity of 28.57% and a mortality of 2.77 percent. Major complications included were persistent air leak, persistent pleural space, empyema, bronchopleural fistula and massive haemorrhage. All events were seen in cases of complex aspergilloma; cases of simple aspergillomas had an uneventful course.

CONCLUSIONS

Surgery offers definitive and long-term symptom-free survival in cases of pulmonary aspergilloma at a negligible risk; though almost one-third of those undergoing surgery develop some complications, these are largely manageable.

Role of VraSR in antibiotic resistance and antibiotic-induced stress response in Staphylococcus aureus

Exposure of Staphylococcus aureus to cell wall inhibitors induces massive overexpression of a number of genes, provided that the VraSR two-component sensory regulatory system is intact. Inactivation of vraS blocks this transcriptional response and also causes a drastic reduction in the levels of resistance to beta-lactam antibiotics and vancomycin. We used an experimental system in which the essential cell wall synthesis gene of S. aureus, pbpB, was put under the control of an isopropyl-beta-d-thiogalactopyranoside-inducible promoter in order to induce reversible perturbations in cell wall synthesis without the use of any cell wall-active inhibitor. Changes in the level of transcription of pbpB were rapidly followed by parallel changes in the vraSR signal, and the abundance of the pbpB transcript was precisely mirrored by the abundance of the transcripts of vraSR and some additional genes that belong to the VraSR regulon. Beta-lactam resistance in S. aureus appears to involve a complex stress response in which VraSR performs the critical role of a sentinel system capable of sensing the perturbation of cell wall synthesis and allowing mobilization of genes that are essential for the generation of a highly resistant phenotype. One of the sites in cell wall synthesis "sensed" by the VraSR system appears to be a step catalyzed by PBP 2.

Outcomes of patients with metastatic colorectal carcinoma (MCRC) treated with first and second line chemotherapy at a multicenter cancer clinic

13529

Background: In British Columbia (BC), FOLFIRI and FOLFOX were approved for the treatment of MCRC in 2002. The effect on survival of various treatment and patient related factors was determined for patients with MCRC treated with sequential doublet chemotherapy. Methods: Eligible patients received either FOLFOX or FOLFIRI first-line with a cross over to the alternative regimen for second-line therapy. Patient records were retrospectively reviewed for patient and disease characteristics, treatment, toxicity and survival. Analysis of survival was performed by the Kaplan-Meier method. Results: Between March 2002 and June 2004, 106 new patients met the criteria above. Sixty five patients were treated with a sequence of FOLFOX-FOLFIRI (Group A): 67% M, median age 57y, rectal 20%. Forty-one were treated with the sequence FOLFIRI-FOLFOX (Group B): 64% M, median age 58y, 27% rectal. Survival was statistically similar in both groups. Progression requiring second line chemotherapy within 4 weeks of a first line treatment was associated with inferior survival (13 months vs. 21 months (p<0.018). Grade 3 or 4 toxicity was experienced in 27.5% of the patients treated with FOLFOX and 22% of the patients treated with FOLFIRI. Conclusions: In the general population with MCRC, the median survival achieved with sequential doublet therapy is consistent with that reported in clinical trials. A superior sequence was not identified. The median number of first line chemotherapy cycles with FOLFOX and FOLFIRI was similar, reflecting the general clinical practice in BC to give 10 - 12 cycles of therapy followed by a planned break. Patients who required initiation of second line chemotherapy within 4 weeks of stopping the first line therapy experienced an inferior prognosis. Univariate and multivariate analysis showed no significance of sex, age, site (colon versus rectal), and ECOG status as predictive factors. [Table: see text]

No significant financial relationships to disclose.

A phase II trial of oblimersen sodium (G3139) in combination with doxorubicin (DOX) in advanced hepatocellular carcinoma (HCC). NCI protocol # 5798

14072

Background: Advanced HCC is refractory to most standard forms of chemotherapy, however responses to DOX are seen. The bcl-2 protein confers resistance to apoptosis in cancer cells and is important in tumor progression and resistance to chemotherapy. The bcl-2 antisense oligonucleotide, G3139 (G), has been shown to enhance the activity of DOX in tumor models by blocking bcl-2 synthesis. This argues for evaluating G + DOX in combination in HCC. By decreasing tumor bcl-2 protein levels, HCC may be sensitized to the apoptotic effects of DOX. Methods: We completed a phase II trial evaluating treatment with G at 7 mg/ kg for 7 days cont. i.v. infusion (d1–8) plus DOX at 45 mg/m2 i.v. bolus d5, every 28 d (as determined from our phase I HCC study). Eligible patients (pts) had path-confirmed, measurable, advanced HCC. Minimal eligibility included Childs-Pugh A cirrhosis, adequate hematological (hem) parameters and ECOG PS <2. Tumor biopsies for correlative studies were obtained at baseline and cycle 1 d 4 in consenting pts. Results: 19 patients were accrued, 1 was ineligible, 18 evaluable for toxicity, 17 evaluable for response; receiving a median (med) of 2 cycles (range 1,10). Risk for HCC was 39% HBV, 22% HCV, 17% alcohol, 22% other. Most common toxicities were hem and could be attributed to both G+DOX and to G alone. Overall grade 3–4 toxicities seen were: ANC- 67% (med nadir d 24–25), lymphopenia - 44%, thrombocytopenia - 6%, transaminitis - 33% and grade 1–2 G-fever - 67%. No responses were seen and the trial was stopped at stage 1. Six patients (35%) had stable disease, with one pt completing 10 cycles as per protocol (pt # 22). Med TTP is 1.8 months (1.7-NA) and 6-month PFS is 17.2% (5.3–56.4). 18 of 19 pts have died with med OS of only 5.4 months (2.7–11.6). Correlative studies on 3 available pts’ paired tumor biopsies showed absent baseline bcl-2 expression but moderate expression of both bcl-xl and BAX protein and with no change after exposure to G (includes pt #22). Conclusions: G + DOX is inactive in HCC at this dose and schedule. The overlap of hem toxicity may have resulted in suboptimal DOX dosing in HCC. Low baseline bcl-2 tumor expression relative to bcl-xl seen may suggest a relative insensitivity to the effects of bcl-2 inhibition in these HCC tumors.

[Table: see text]