Clinical Outcomes for Patients with Brain Metastases from Upper Gastrointestinal Cancer Treated with Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

Prior studies have reported outcomes for brain metastases from gastrointestinal (GI) primary cancers treated with stereotactic radiosurgery (SRS); however, most include a majority of colorectal cancer. Few studies specifically evaluate SRS treatment response for brain metastases from upper GI cancers. We report our institutional outcomes for patients with upper GI cancers who were treated with SRS for brain metastases.

MATERIALS/METHODS

Patients with an upper GI cancer who underwent SRS for brain metastases between 1991 and 2021 were retrospectively reviewed from a single institution IRB-approved database. The primary endpoint was local failure (LF) and secondary endpoint was overall survival (OS). LF was estimated using the Cumulative Incidence Function with death as a competing risk. Survival analysis was performed with the Kaplan-Meier Method. Predictors of cumulative incidence of LF were assessed using competing risk regression.

RESULTS

Forty-nine patients with 107 brain metastases were analyzed. Forty-two (86%) patients were male. The median follow-up time was 6.7 months (range: 0.4-61.7 months) and median OS was 7.5 months (range: 0.9-61.7 months). The median Karnofsky Performance Score (KPS) was 80 (range: 40-100). The primary disease site was esophagus in 87 (81%) lesions, pancreas in 10 (9.3%) lesions, stomach in 5 (4.7%) lesions, liver in 2 (1.9%) lesions, gallbladder in 2 (1.9%) lesions, and small intestine in 1 (0.9%) lesion. The median metastasis size was 1.4 cm (range: 0.3-6.7 cm). The median prescription dose and fraction number were 24 Gy (range: 14-30 Gy) and 1 fraction (range: 1-2 fractions), respectively. The cumulative incidence of LF at 6 and 12 months was 5.6% (95% CI: 2.3-11%) and 12% (95% CI: 6.9-20%), respectively. Overall survival at 6 and 12 months was 59% (95% CI: 50-69%) and 35% (95% CI: 27-46%), respectively. On univariate analysis, female gender (HR = 0.19, 95% CI: 0.06-0.61, p = 0.005), Black race (HR = 0.09, 95% CI: 0.03-0.23, p = <0.001), and larger tumors (HR = 1.35, 95% CI: 1.03-1.78, p = 0.03) were significantly associated with local failure.

CONCLUSION

SRS for brain metastases from upper GI cancers is an appropriate treatment option and provides excellent local control. Unlike prior studies that have reported lower local control rates for all GI cancers with brain metastases treated with SRS, our data show that local failure rates in brain metastases from upper GI cancers specifically are more consistent with previously published data from other disease sites. Further studies evaluating SRS treatment response for brain metastases from GI cancers should separate upper GI and lower GI cancers.

Clinical Outcomes of Patients with Brain Metastases from Colorectal Cancer Treated with Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

Prior studies have demonstrated that brain metastases from gastrointestinal (GI) primary cancers have a poorer response to stereotactic radiosurgery (SRS) when compared to patients with other primary sites, with reported local control of 62-74%. We report our institutional outcomes for patients with colorectal primary cancer who were treated with SRS for brain metastases.

MATERIALS/METHODS

Patients with colorectal primary cancer who underwent SRS for brain metastases between 1989 and 2021 were retrospectively reviewed from a single institutional IRB-approved database. The primary endpoint was local failure (LF) and secondary endpoint was overall survival (OS). LF was estimated using the Cumulative Incidence Function with death as a competing risk. Survival analysis was performed using the Kaplan-Meier Method. Predictors of cumulative incidence of LF were assessed using competing risk regression.

RESULTS

The study population comprised of 109 patients with primary colorectal adenocarcinoma with 207 brain metastases. The median follow-up was 5.2 months (range: 0.4-124 months) and median OS was 5.8 months (range: 0.5-71.2 months). Fifty-two patients (48%) were male and median Karnofsky Performance Status at the time of treatment was 80 (range: 40-100). The median tumor diameter was 1.55 cm (range: 0.17-5.48 cm). The median prescription dose and number of fractions were 24 Gy (range: 11-36 Gy) and 1 fraction (range: 1-3 fractions), respectively. The cumulative incidence of LF at 3, 6, and 12 months was 9.7% (95% CI: 6.1-14%), 22% (95% CI: 16-28%), and 25% (95% CI: 20-31%), respectively. Overall survival at 3, 6, and 12 months was 81% (95% CI: 76-87%), 49% (95% CI: 42-56%) and 24% (95% CI: 18-31%), respectively. On univariate analysis, age was a significant predictor (HR = 0.96, 95% CI: 0.94-0.98), p < 0.001) of LF. Tumor size (HR = 0.80, p = 0.13) and prescription dose (HR = 1.02, p = 0.54) did not predict for LF.

CONCLUSION

To our knowledge, this is the largest series of patients with brain metastases from colorectal primary cancer treated with SRS. Compared to historical data, LF and OS in our cohort of patients was favorable. Our data confirms relatively higher rates of LF when compared to brain metastases from other primary disease sites. Further studies are warranted to identify factors that predict for LF following SRS and to develop models that predict which patients with colorectal brain metastases may be at higher risk of failure.

How Much Delay Matters? How Time to Treatment Impacts Overall Survival in Early Stage Lung Cancer

OBJECTIVES

The aim of this study was to identify drivers of time from diagnosis to treatment (TTT) of surgically resected early stage non-small cell lung cancer (NSCLC) and determine the effect of TTT on post-resection survival.

SUMMARY BACKGROUND DATA

Large database studies that lack relevant comorbidity data have identified longer TTT asa driver of worse overall survival.

METHODS

From January 1, 2014 to April 1, 2018, 599 patients underwent lung resection for clinical stage I and II NSCLC. Random forest classification, regression, and survival were used to estimate likelihood of TTT = 0 (tissue diagnosis obtained at surgery), >0 (diagnosis obtained pre-resection), and effect of TTT on all-cause mortality.

RESULTS

Patients with TTT > 0 (n = 413) had median TTT of 42 days (25-75 th percentile: 27-59 days). Patients with TTT = 0 (n = 186) had smaller tumors and higher percent predicted forced expiratory volume in 1 second (FEV 1 %). Patients with history of stroke, oncology consultation, invasive mediastinal staging, low and high extremes of FEV 1 % had longer TTT. Higher clinical stage, lack of preoperative stress test, anemia, older age, lower FEV1% and diffusion lung capacity, larger tumor size, and longer TTT were the most important predictors of all-cause mortality. One- and 5-year overall survival decreased when TTT was >50 days.

CONCLUSIONS

Preoperative physiologic workup and multidisciplinary evaluation were the predominant drivers of longer TTT. Patients with TTT = 0have more favorable presentation and should be considered in TTT analyses for early stage lung cancer populations. The time needed to clinically stage and optimize patients for resection is not deleterious to overall survival until resection is performed after 50 days from diagnosis.

COVID-19 and venous thromboembolism: A narrative review

COVID-19 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) is associated with coagulopathy through numerous mechanisms. The reported incidence of venous thromboembolism (VTE) in hospitalized patients with COVID-19 has varied widely, and several meta-analyses have been performed to assess the overall prevalence of VTE. The novelty of this coronavirus strain along with its unique mechanisms for microvascular and macrovascular thrombosis has led to uncertainty as to how to diagnose, prevent, and treat thrombosis in patients affected by this virus. This review discusses the epidemiology and pathophysiology of thrombosis in the setting of SARS-CoV-2 infection along with an updated review on the preventative and treatment strategies for VTE associated with SARS-CoV-2 infection.

Similarities and perspectives on the two C's-Cancer and COVID-19

COVID-19 continues to dominate the health-care burden in the twenty-first century. While health-care professionals around the world try their best to minimize the mortality from this pandemic, we also continue to battle the high mortality from different types of cancer. For the hemostasis and thrombosis specialist, these two conditions present some unusual similarities including the high rate of thrombosis and marked elevation of D-dimers. In this forum article, we discuss these similarities and provide some considerations for future research and therapeutic trials.

197 Survival outcomes and toxicity among patients treated with concomitant radiotherapy and immunotherapy for advanced melanoma: two faces of the abscopal effect?

Background

Combined treatment with radiotherapy (RT) and checkpoint inhibition (CPI) can theoretically increase both treatment response and toxicity. We recently reported a high rate of immune-mediated adverse events (irAEs) among patients with advanced melanoma and Merkel cell carcinoma (MCC) treated with concomitant RT and CPI. We now present survival data from the same cohort.

Methods

The original study population consisted of 30 patients with advanced melanoma and 5 with MCC who underwent RT within 30 days of CPI; eligible patients were identified via an institutional retrospective registry. Information on the development of new irAEs diagnosed within 3 months of RT initiation was collected. Overall survival (OS) was calculated by the Kaplan-Meier method. Outcomes of patients who did or did not develop new irAEs after RT were compared via the log-rank test. To limit heterogeneity, the survival analysis was restricted to patients with melanoma.

Results

Of the 30 patients with melanoma included in the survival analysis, 25 had died and 5 remained alive when data were censored in August 2020. Median follow-up was 18 months. Treatment with concomitant RT and CPI constituted first-line therapy for most patients (21/30); 8 patients had received one previous line of treatment and 1 patient had progressed on multiple regimens. Thirteen patients (43.3%) experienced at least one new irAE following RT in the context of concomitant CPI. Patients who experienced new irAEs post-RT demonstrated longer median OS of 25 months (95% confidence interval (CI): 8.6 - 41.4 months) in comparison to a median OS of 11 months for patients who did not develop post-RT irAEs (95% CI: 0.0 – 24.4 months). In the post-RT irAE group, 1-year and 2-year OS (69.2% and 53.8%, respectively) were higher compared to patients without irAEs (47.1% and 23.5%, respectively). These differences in survival did not reach statistical significance within this limited cohort size (figure 1; p = 0.076).

Abstract 197 Figure 1

Overall survival (OS) analysis of patients who experienced new irAEs following RT and concomitant CPI vs those who did not

Conclusions

The use of concomitant RT and CPI was associated with an elevated rate of new irAEs. Patients who developed new irAEs following RT experienced a substantial absolute increase in median OS of 14 months, an observation from a limited cohort which warrants further investigation. These data support prior reports of increased OS among patients experiencing irAEs and may suggest that RT and CPI in combination can meaningfully potentiate immune response in certain clinical contexts.

Ethics Approval

The study was approved by the Cleveland Clinic Foundation Institutional Review Board, approval number 18–1225

A pilot clinical trial of the cytidine deaminase inhibitor tetrahydrouridine combined with decitabine to target DNMT1 in advanced, chemorefractory pancreatic cancer

DNA methyltransferase 1 (DNMT1) is scientifically validated as a molecular target to treat chemo-resistant pancreatic ductal adenocarcinoma (PDAC). Results of clinical studies of the pyrimidine nucleoside analog decitabine to target DNMT1 in PDAC have, however, disappointed. One reason is high expression in PDAC of the enzyme cytidine deaminase (CDA), which catabolizes decitabine within minutes. We therefore added tetrahydrouridine (THU) to inhibit CDA with decitabine. In this pilot clinical trial, patients with advanced chemorefractory PDAC ingested oral THU ~10 mg/kg/day combined with oral decitabine ~0.2 mg/kg/day, for 5 consecutive days, then 2X/week. We treated 13 patients with extensively metastatic chemo-resistant PDAC, including 8 patients (62%) with ascites: all had received ≥ 1 prior therapies including gemcitabine/nab-paclitaxel in 9 (69%) and FOLFIRINOX in 12 (92%). Median time on THU/decitabine treatment was 35 days (range 4-63). The most frequent treatment-attributable adverse event was anemia (n=5). No deaths were attributed to THU/decitabine. Five patients had clinical progressive disease (PD) prior to week 8. Eight patients had week 8 evaluation scans: 1 had stable disease and 7 PD. Median overall survival was 3.1 months. Decitabine systemic exposure is expected to decrease neutrophil counts; however, neutropenia was unexpectedly mild. To identify reasons for limited systemic decitabine effect, we measured plasma CDA enzyme activity in PDAC patients, and found a > 10-fold increase in those with metastatic vs resectable PDAC. We concluded that CDA activity is increased not just locally but also systemically in metastatic PDAC, suggesting a need for even higher CDA-inhibitor doses than used here.

Abstract 1170: Socioeconomic disparities in patients with esophageal cancer at time of diagnosis: A national cancer data base analysis

Introduction: There have been noted to be significant gender and socioeconomic disparities in the incidence, prognosis, and clinical outcomes of patients with esophageal cancer. The purpose of this study was to characterize disparities amongst patients with esophageal cancer at time of diagnosis, as stratified by their stage, as there is a paucity of published data in this realm.

Methods: We identified patients in the National Cancer Data Base diagnosed with esophageal cancer, from 2004 to 2016 and grouped them by stage: early stage (stage I-III) and advanced stage (stage IV). These groupings were then compared based on various patient demographics and socioeconomic factors, including age, gender, insurance status, education, and income. p-values were determined by chi-square test.

Results: 102,540 patients (79.5% male; 84.0% Caucasian) were included in our analysis. There was a statistically significant increase in the diagnosis of de novo metastatic disease seen with younger age (⇐59 years), male gender, lack of insurance coverage, residential communities with lower education, and lower income (&lt;$38,000 annual income) as shown in Table 1.

Summary Table of Stage at Diagnosis by Patient CharacteristicsTotal NTotal %Stage 0-IIINStage 0-III%Stage IVNStage IV %p-valueAge⇐59298301001840361.691142738.31&lt;0.000160-74475031003244668.31505731.7&gt;=75252071001789971.01730828.99GenderFemale210701001510671.69596428.31&lt;0.0001Male814701005364265.842782834.16InsuranceUnknown2902100194967.1695332.84Government612231004204368.671918031.33&lt;0.0001Not Insured3450100184053.33161046.67Private349651002291665.541204934.46Community Median IncomeUnknown52610035567.4917132.51&lt;38K185611001221065.78635134.22&lt;0.000138-63K526941003531767.021737732.98&gt;=63K307591002086667.84989332.16Percent No High School Degree Quartiles 2012-2016Unknown142710091664.1951135.81&gt;=17.6%197021001290265.49680034.51&lt;0.000110.9-17.5%274621001845067.18901232.826.3-10.8%300291002013867.06989132.94&lt;6.3%239201001634267.053379232.95

Conclusion: Data from the National Cancer Data Base supports the association of younger age and lower socioeconomic status with higher stage at diagnosis in patients with esophageal cancer, highlighting the need for increased awareness and education in these at-risk subgroups.

Citation Format: Meena Sadaps, Neal Mehta, Wei Wei, Katherine Tullio, Amit Bhatt, Alok Khorana. Socioeconomic disparities in patients with esophageal cancer at time of diagnosis: A national cancer data base analysis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1170.

Accuracy of the Ottawa score in risk stratification of recurrent venous thromboembolism in patients with cancer-associated venous thromboembolism: a systematic review and meta-analysis

In patients with cancer-associated venous thromboembolism, knowledge of the estimated rate of recurrent events is important for clinical decision-making regarding anticoagulant therapy. The Ottawa score is a clinical prediction rule designed for this purpose, stratifying patients according to their risk of recurrent venous thromboembolism during the first six months of anticoagulation. We conducted a systematic review and meta-analysis of studies validating either the Ottawa score in its original or modified versions. Two investigators independently reviewed the relevant articles published from 1st June 2012 to 15th December 2018 and indexed in MEDLINE and EMBASE. Nine eligible studies were identified; these included a total of 14,963 patients. The original score classified 49.3% of the patients as high-risk, with a sensitivity of 0.7 [95% confidence interval (CI): 0.6-0.8], a 6-month pooled rate of recurrent venous thromboembolism of 18.6% (95%CI: 13.9-23.9). In the low-risk group, the recurrence rate was 7.4% (95%CI: 3.4-12.5). The modified score classified 19.8% of the patients as low-risk, with a sensitivity of 0.9 (95%CI: 0.4-1.0) and a 6-month pooled rate of recurrent venous thromboembolism of 2.2% (95%CI: 1.6-2.9). In the high-risk group, recurrence rate was 10.2% (95%CI: 6.4-14.6). Limitations of our analysis included type and dosing of anticoagulant therapy. We conclude that new therapeutic strategies are needed in patients at high risk for recurrent cancer-associated venous thromboembolism. Low-risk patients, as per the modified score, could be good candidates for oral anticoagulation. (This systematic review was registered with the International Prospective Registry of Systematic Reviews as: PROSPERO CRD42018099506).

Metastatic Pancreatic Cancer: ASCO Clinical Practice Guideline Update

Purpose In 2016, ASCO published a guideline to assist in clinical decision making in metastatic pancreatic cancer for initial assessment after diagnosis, first- and second-line treatment options, palliative and supportive care, and follow-up. The purpose of this update is to incorporate new evidence related to second-line therapy for patients who have experienced disease progression or intolerable toxicity during first-line therapy. Methods ASCO convened an Expert Panel to conduct a systematic review of the literature on second-line therapy published between June 2015 and January 2018. Recommendations on other topics covered in the 2016 Metastatic Pancreatic Cancer Guideline were endorsed by the Expert Panel. Results Two new studies were found that met the inclusion criteria. Recommendations For second-line therapy, gemcitabine plus nanoparticle albumin-bound paclitaxel should be offered to patients with first-line treatment with FOLFIRINOX (leucovorin, fluorouracil, irinotecan, and oxaliplatin), an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 to 1, and a favorable comorbidity profile; fluorouracil plus nanoliposomal irinotecan can be offered to patients with first-line treatment with gemcitabine plus NAB-paclitaxel, an ECOG PS of 0 to 1, and a favorable comorbidity profile; fluorouracil plus irinotecan or fluorouracil plus oxaliplatin may be offered when there is a lack of availability of fluorouracil plus nanoliposomal irinotecan; gemcitabine or fluorouracil should be offered to patients with either an ECOG PS of 2 or a comorbidity profile that precludes other regimens. Testing select patients for mismatch repair deficiency or microsatellite instability is recommended, and pembrolizumab is recommended for patients with mismatch repair deficiency or high microsatellite instability tumors. Endorsed recommendations from the 2016 version of this guideline for computed tomography, baseline performance status and comorbidity profile, defining goals of care, first-line therapy, and palliative care are also contained within the full guideline text. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines .

Renal Impairment, Recurrent Venous Thromboembolism and Bleeding in Cancer Patients with Acute Venous Thromboembolism—Analysis of the CATCH Study

Objective This article assesses the impact of renal impairment (RI) on the efficacy and safety of anticoagulation in patients with cancer-associated thrombosis from the Comparison of Acute Treatments in Cancer Hemostasis (CATCH) study (NCT01130025).

Materials and Methods Renal function was assessed using the Modification of Diet in Renal Disease equation in patients with cancer-associated thrombosis who received either tinzaparin (175 IU/kg) once daily or warfarin for 6 months, in an open-label, randomized, multi-centre trial with blinded adjudication of outcomes. Associations between baseline RI (glomerular filtration rate [GFR] <60 mL/min/1.73m2) and recurrent symptomatic or incidental venous thromboembolism (VTE), clinically relevant bleeding (CRB), major bleeding and death were assessed using Fisher's exact test.

Results Baseline-centralized GFR data were available for 864 patients (96% of study population). RI was found in 131 patients (15%; n = 69 tinzaparin). Recurrent VTE occurred in 14% of patients with and 8% of patients without RI (relative risk [RR] 1.74; 95% confidence interval [CI] 1.06, 2.85), CRB in 19% and 14%, respectively (RR 1.33; 95% CI 0.90, 1.98), major bleeding in 6.1% and 2.0%, respectively (RR 2.98; 95% CI 1.29, 6.90) and mortality rate was 40% and 34%, respectively (RR 1.20; 95% CI 0.94, 1.53). Patients with RI on tinzaparin showed no difference in recurrent VTE, CRB, major bleeding or mortality rates versus those on warfarin.

Conclusion RI in patients with cancer-associated thrombosis on anticoagulation was associated with a statistically significant increase in recurrent VTE and major bleeding, but no significant increase in CRB or mortality. No differences were observed between long-term tinzaparin therapy and warfarin.

Neoadjuvant chemoradiation for non-metastatic pancreatic cancer increases margin-negative and node-negative rates at resection

OBJECTIVE

To compare neoadjuvant to adjuvant chemoradiation in non-metastatic pancreatic cancer patients.

METHODS

Single-institution data were obtained for patients with non-metastatic pancreatic cancer treated with concurrent chemoradiation from 2011 to 2014. Univariate analyses were performed to evaluate clinical and pathological outcomes.

RESULTS

Fifty-two well-matched patients were enrolled (21 underwent neoadjuvant chemoradiation, 11 with adjuvant chemoradiation and 20 in the definitive group). Median tumor size was 2.6 cm pretreatment and 2.5 cm after neoadjuvant chemoradiation but 3.2 cm on pathology, with a treatment effect in 95.2% of specimens. Clinical node positivity at diagnosis for neoadjuvant and adjuvant chemoradiation groups was similar (28.6% vs 27.3%, P = 0.12). Of the 36 neoadjuvant patients, 21 (58.3%) underwent complete resection. In the neoadjuvant vs adjuvant chemoradiation groups, positive margins were decreased (4.8% vs 63.6%, P < 0.001), as was pathological nodal positivity (23.8% vs 90.9%, P < 0.001). After a median follow-up of 13.3 months, locoregional control for neoadjuvant and adjuvant chemoradiation was 7.7 and 7.2 months, respectively (P = 0.12) and the definitive group was 1.2 months (P = 0.014 compared with the surgical cohort). One-year overall survival was better with neoadjuvant than with adjuvant chemoradiation but this was not significant (94% vs 82%, P = 0.20); 1-year survival for the definitive group was 59% (P = 0.03 compared with the surgical cohort).

CONCLUSIONS

Neoadjuvant chemoradiation remains a promising approach for non-metastatic pancreatic cancer for improving resectability and pathological and clinical findings. Computed tomography may not fully demonstrate the effectiveness of neoadjuvant treatment.

Venous thromboembolism following hematopoietic stem cell transplantation-a systematic review and meta-analysis

Venous thromboembolism (VTE) is a common complication of hematopoietic stem cell transplantation (HSCT). Graft-versus-host disease (GVHD) is another complication of HSCT that may modify the risk of VTE. Our objective was to explore the incidence of VTE (deep venous thrombosis and pulmonary embolism) following HSCT and to evaluate its association with GVHD. A comprehensive search of Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus was conducted to search for both retrospective and prospective HSCT studies which had reported VTE. Random-effects meta-analysis was used to pool incidence rates. We included 17 studies reporting on allogeneic- and 10 on autologous-HSCT; enrolling 6693 patients; of which 5 were randomized. The overall incidence of VTE after HSCT was 5 % (4-7 %). Incidence in allogeneic-HSCT was 4 % (2-6 %) and in autologous-HSCT was 4 % (1-15 %). Eleven and nine studies reported data on acute and chronic GVHD, respectively. The incidence of VTE in chronic GVHD was 35 % (20-54 %), whereas in acute GVHD it was 47 % (32-62 %). Based on the results of this meta-analysis, VTE is a fairly common complication after HSCT, emphasizing the importance of assimilating guidelines for both treatment and prophylaxis in this patient population.

Abstract 210: Evaluation of US Prescription Patterns: Are Treatment Guidelines For Cancer-associated Venous Thromboembolism (VTE) Followed?

Background: VTE is a major contributor to morbidity and mortality in cancer patients. Although low-molecular-weight heparins (LMWHs) are recommended by most guidelines for treatment of cancer-associated VTE, compliance with this recommendation is unknown.

Aims: To assess treatment patterns of anticoagulation for treatment of cancer-associated VTE in the United States.

Methods: We conducted a retrospective cohort study utilizing MarketScan® Treatment Pathways dataset (80 million insured lives) between 1/2009 and 7/2014. Patients were included if they had a new diagnosis of cancer of lung, breast, prostate, stomach, colon, pancreas genitourinary, gynecologic, or brain and developed VTE. Patients with prior VTE or anticoagulation were excluded. Time to VTE diagnosis, utilization, and switching patterns of anticoagulants were evaluated.

Results: Of 1.7 million newly diagnosed cancer patients, 105399 (6.2%) developed VTE at a median of 181 days. Rates of VTE varied by cancer site, ranging from 4% (breast) to 17% (pancreas). Median time to VTE diagnosis ranged from 74 (brain) to 365 days (prostate). Of 52911 patients who were prescribed anticoagulants as outpatients, half (N=26456) received warfarin, 40% (N=21164) received LMWH, and 10% (N= 5291) received other oral anticoagulants. Patients on injectables persisted less on treatment than those on oral anticoagulants. Amongst patients on LMWH, 44% switched to warfarin (79%) and other anticoagulants (21%), while 28% on warfarin switched to LMWH (77%) and other anticoagulants (23%). Median time to switch was 23 days for LMWH and 98 days for warfarin.

Conclusion: Despite guidelines recommendations, warfarin was the most utilized anticoagulant for outpatient treatment of VTE in cancer. Even of those treated with LMWH, nearly half switched to other anticoagulants, often early in the course. More patients persisted on oral than injectable agents, which may be related to the burden of self-injection or costs.

Clinical roundtable monograph. The oncologist's role in management of venous thromboembolism

Thromboembolism is the second leading cause of death in cancer patients. Patients with venous thromboembolism (VTE) and malignancy have a significantly higher probability of death. Pulmonary embolism can lead to a fatal outcome, and this condition often goes undiagnosed in cancer patients despite the presence of symptoms. Risk of VTE is increased by a number of clinical factors, which can be patient-derived, cancer-related, and treatment-related. Increasingly, clinicians are seeking predictable biomarkers to identify those patients at the greatest risk. To that end, a newly developed and validated predictive risk model may help identify patients who could benefit from prophylaxis. In addition, serum levels of coagulation cascade factors may predict the survival rate of cancer patients; elevated D-dimer levels are associated with decreased survival time. Anticoagulants, particularly low-molecular-weight heparin, can be useful in preventing the recurrence of clots in cancer patients with VTE. Current and future investigations are aimed at determining if prophylaxis with anticoagulants can improve patient survival. Future management strategies may involve the use of low-molecular-weight heparin or other novel anticoagulants as part of palliative care for high-risk patients. Although treatment with low-molecular-weight heparin can significantly reduce the risks of clots, the impact on cancer survival is unclear.

Identifying cancer patients at risk for venous thromboembolism

Venous thromboembolism (VTE) is a known complication of cancer which impacts on patient mortality and quality of life. Despite the known deleterious effects of VTE, the benefits of thromboprophylaxis have not been fully established. Identification of patients at highest risk of VTE could lead to better targeting of thromboprophylaxis. Several risk factors have been identified as contributing to VTE such as site and stage of cancer, age, comorbidities, obesity, and acquired prothrombotic states. Anti-cancer agents as well as the use of growth factor support have also been implicated in VTE. Recent data have identified biomarkers such as blood counts, tissue factor and P-selectin. In this review, we briefly summarize the risk factors for VTE as well as candidate biomarkers for VTE in cancer patients. We also review a validated risk score that can identify cancer patients at high risk for VTE. Risk stratification of cancer patients will allow clinicians to identify those patients at highest risk for VTE, who may derive the most benefit from thromboprophylaxis.

Portal vein and systemic thromboses in hepatocellular carcinoma

15048

Background: Hemostatic activation may be important for tumor growth and metastasis. Hepatocellular carcinoma (HCC) is commonly associated with portal vein thrombosis (PVT). Very little is known about factors predictive for PVT in patients with HCC or its correlation with systemic venous thromboembolism (VTE). Methods: We conducted a retrospective chart review of 194 patients diagnosed with HCC at the University of Rochester between 1998 and 2004. The primary endpoints of this study were presence of PVT and any systemic VTE. The secondary endpoint was overall survival calculated from time of diagnosis. Univariate and multivariate logistic regression analyses were conducted to assess the association of PVT with a set of clinical covariates, and the survival curve was estimated using the method of Kaplan-Meier. Results: The mean age of the total population was 60.4 ± 11.9, and one-third of the patients underwent liver transplant. The incidence of PVT in the total population was 31% (60/194) with a higher incidence in the non-transplant group compared to transplanted patients (34% vs. 24%; p= 0.08). In univariate analysis, advanced stage, major vessel involvement, higher MELD score, higher Child-Turcotte-Pugh (CTP) classification, lower serum albumin, elevated serum bilirubin, elevated serum alpha-fetoprotein (AFP) level, and elevated INR were associated with development of PVT (p <0.05 for each). In multivariate analysis CTP class, stage, major vessel involvement, serum albumin, and serum AFP were independently and significantly associated with PVT (p <0.05 for each). The presence of PVT was associated with reduced survival (median survival 4.61 months for those with PVT versus 17.55 months for those without PVT, HR 2.01, p <0.001). The incidence of systemic VTE in the total population was 6.7%, and patients with PVT had a higher rate of systemic VTE compared to patients without PVT (11.5% vs. 4.4%; p 0.044). Conclusions: PVT is common in patients with HCC and is associated with worse outcomes. The correlation between PVT and systemic VTE suggests a common mechanism of hemostatic activation. Advanced stage, higher CTP class, major vessel involvement, and serum albumin and AFP levels are predictive of PVT. Identifying patients at high-risk for PVT and instituting prophylaxis may affect HCC outcomes.

No significant financial relationships to disclose.

Phase II study of weekly docetaxel in combination with capecitabine (C) in advanced gastric (AGA) and gastro-esophageal adenocarcionma (AGEA)

15139

Background: Chemotherapy regimens for AGA and AGEA have shown considerable toxicity and most require continuous IV administration. Both D and C are active agents in AGA. D upregulates thymidine phosphorylase, the enzyme which catalyzes the conversion of C to 5-FU, with preclinical evidence of synergy for the combination. A phase I study of D and C showed acceptable tolerability and activity in patients (pts) with AGA (Ramanathan et al., 2005). This multi-institutional phase II trial evaluates the combination of D and C in 1st or 2nd line treatment of AGA and AGEA. Methods: Pts with AGA/AGEA who received ≤ 1 prior chemotherapy regimen were eligible. D 30 mg/m2 on d 1, 8 and C 825 mg/ m2 BID were administered on days 1–14 of a 21 day cycle. The one stage study design had an accrual goal of 40 pts. The primary endpoint was to detect a 50% improvement in median survival in previously untreated pts to 10 months (mo), by one-sided log-rank test at level a = 0.05. Results: Enrollment is complete with 40 pts, all are evaluable for response and toxicity. Pt characteristics: 79% male; 94% with ECOG performance status 0/1; median age 60 yrs (34–84), 32 pts (80%) were previously untreated. Overall response rate is 25% with 1CR and 9 PR. The projected median time to progression (TTP) and survival are 6.2 and 7.8 mo respectively. Dose modifications were required in 9%. Median cycles administered 4 (range 1–10). Grade 3/4 adverse events include: diarrhea (13%), hand-foot syndrome (13%), dehydration (6%), abd pain, anorexia, fatigue, febrile neutropenia, gastric ulcer, hyperglycemia, vertigo, and vomiting (3% each). Conclusion: The combination of D and C is well tolerated and active. The preliminary TTP (6.2 mo) and survival (7.8 mo) compare favorably with published regimens for 1st line therapy, but did not meet study endpoint. The combination of D and C is an easily administered outpatient regimen for AGA and AGEA and may be worthy of further investigation with a targeted agent. (Funded by Sanofi-Aventis and Roche Pharmaceuticals).

No significant financial relationships to disclose.

Inpatient chemotherapy and risk for venous thromboembolism

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Background: Chemotherapy is a known risk factor for venous thromboembolism (VTE) but contemporary rates and risk factors for chemotherapy-associated VTE are not well described. Furthermore, it is linked to increased hospital length of stay and has negative impact on patient quality of life (QOL). Methods: We used discharge codes to identify all patients admitted to the University of Rochester Medical Center in Rochester, NY from January, 2000 through December, 2005 for chemotherapy and conducted a retrospective chart review to identify those that developed VTE. Inclusion criteria consisted of patients with a malignancy, age greater than eighteen years and no prior history of VTE. VTE was defined as any deep venous thrombosis (DVT) or pulmonary embolism (PE) occurring within 4 weeks of receiving inpatient chemotherapy. Results: A total of 659 patients were admitted for inpatient chemotherapy during the study period. Fifty-four patients developed a DVT and 14 patients developed a PE for a total VTE rate of 9.6%. Median time to developing VTE was 12 days (range, 1 to 28 days). Common sites of cancer among patients who developed VTE included lymphoma (36%) followed by leukemia (28%), multiple myeloma (13%) and gastrointestinal malignancies (8%) among others. Fifteen patients (23%) had stage IV disease. Twelve patients (18%) had a pre-chemotherapy platelet count greater than 350,000/mm3, a known risk factor for chemotherapy-associated VTE. Conclusions: VTE is common in patients receiving chemotherapy, including those with hematologic malignancies and can have significant impacts on patient QOL. The risk for VTE extends beyond the period of inpatient hospitalization. Increased efforts to improve compliance with thromboprophylaxis are warranted to reduce the burden of VTE among cancer patients receiving inpatient chemotherapy.

No significant financial relationships to disclose.

Survival outcomes in liver transplantation for hepatocellular carcinoma, comparing impact of hepatitis C versus other etiology of cirrhosis

The incidence of hepatocellular carcinoma (HCC) is on the rise worldwide as the most common primary hepatic malignancy. In the US approximately one half of all HCC is related to Hepatitis C virus (HCV) infection. The relationship between the primary disease and HCC recurrence after liver transplantation is unknown. We hypothesized that the primary hepatic disease underlying the development of cirrhosis and HCC would be associated with the risk of recurrent HCC after transplantation. A retrospective review was conducted of all primary liver transplants performed at the University of Rochester Medical Center from May 1995 through June 2004. The pathology reports from the native livers of 727 recipients were examined for the presence of HCC. There were 71 liver transplant recipients with histopathological evidence of HCC. These patients were divided in two groups on the basis of HCV status. Group 1 consisted of 37 patients that were both HCV and HCC positive, and Group 2 consisted of 34 patients that were HCC positive but HCV negative. Patient characteristics were analyzed, as well as number of tumors, tumor size, presence of vascular invasion, lobe involvement, recipient demographics, donor factors, pretransplantation HCC therapy, rejection episodes, and documented HCC recurrence and treatment. There were no statistically significant differences between the 2 groups, with the exception of recipient age and the presence of hepatitis B coinfection. The tumor characteristics of both groups were similar in numbers of tumors, Milan criteria status, vascular invasion, incidental HCC differentiation, and largest tumor size. The HCV positive population had a far lower patient survival rate with patient survival in Group 1 at 1, 3, and 5 years being 81.1%, 57.4%, and 49.3% respectively, compared with 94.1%, 82.8%, and 76.4% in Group 2 (p = 0.049). Tumor-free survival in Group 1 at 1, 3, and 5 years was 70.3%, 43%, and 36.8% respectively, vs. 88.1%, 73%, and 60.8% in Group 2. In a subgroup analysis, tumor-free survival was further examined by stratifying the patients on the basis of Milan criteria. Group 1 patients outside of Milan criteria had a statistically lower tumor-free survival. By contrast, there was no statistical difference in tumor-free survival in Group 2 patients stratified according to Milan criteria. Cox regression analysis identified HCV and vascular invasion as significant independent predictors of tumor-free survival. Our results suggest that Milan selection criteria may be too limiting and lose their predictive power when applied to patients without HCV infection.

A phase II multicenter study of CAMPATH-1H antibody in previously treated patients with nonbulky non-Hodgkin's lymphoma

CAMPATH-1H is a humanized antilymphocyte monoclonal antibody (mAb) directed against the CD52 antigen expressed on normal and malignant lymphocytes. We report the results of a multicenter phase II trial using intravenous CAMPATH-1H in previously treated patients with nonbulky non-Hodgkin's lymphoma (NHL) or minimal residual NHL. Sixteen previously treated patients with nonbulky NHL and two patients with minimal residual NHL, were treated with CAMPATH-1H. Changes in peripheral blood lymphocyte subsets were analyzed by multiparameter flow cytometric techniques in eleven patients. The 18 patients enrolled in the studies received CAMPATH-1H for a median duration of 6 weeks (range, 3 to 14 weeks), and a median cumulative dose of 470 mg (range, 180 to 1185 mg). Two of the sixteen patients with nonbulky NHL achieved a complete response (CR) and one patient achieved a partial response (PR). One of the two patients with minimal residual NHL achieved a molecular CR. Infusional complications were seen with the majority of patients but were more common with initial infusions. Significant hematologic toxicity was also observed with grade (3/4) thrombocytopenia (n=10), grade (3/4) neutropenia (n=4) and grade 3 anemia (n=3). Due to excessive infectious complications observed with the patients enrolled, the trials were terminated early. Anti-tumor activity was demonstrated in a small subset of previously treated low-grade lymphoma patients with nonbulky or minimal residual disease. Future studies evaluating the effect of different drug schedules, modes of mAb administration, and concurrent use of prophylactic antibiotics/antiviral/antifungal agents to optimize anti-tumor activity and limit infectious toxicities are planned.