Abstract P032: Berzosertib plus irinotecan in patients with TP53 mutant gastric/gastroesophageal junction adenocarcinoma: A phase II study

Background: Nearly 50% of patients with advanced gastric/gastroesophageal junction (GEJ) adenocarcinoma possess somatic TP53 mutations, with most mutations falling within exons 2 or 4-11. Though the presence of TP53 mutations has historically been considered a poor prognostic factor in advanced gastric/GEJ adenocarcinoma, cancer cells with mutations in TP53 tend to depend on ataxia telangiectasia and Rad3-related protein kinase (ATR) as a primary mediator of DNA damage repair (DDR). In preclinical studies, topoisomerase 1 inhibitors and ATR inhibitors demonstrate synergy in TP53 mutant gastrointestinal cancer cell lines. Based on the dearth of active later-line treatments in patients with advanced gastric/GEJ adenocarcinoma, we initiated a combinatorial study of the highly selective ATR inhibitor berzosertib (formerly VX-970/M6620) with irinotecan in this disease population. Methods: The study is a single arm phase II trial of berzosertib plus irinotecan in patients with advanced (progressive on at least one prior line of therapy) TP53 mutant (with mutations in exons 2 or 4-11) gastric/GEJ adenocarcinoma and is sponsored by the National Cancer Institute [NCT03641313]. The primary endpoint of the study is objective response rate (ORR) with key secondary endpoints of overall survival (OS), progression-free survival (PFS), duration of response (DOR) and measuring pharmacodynamic biomarkers of DNA damage induction (γ-H2AX, KAP1 p-Ser 824 and p-ATR) from on-treatment biopsies in select patients. Exploratory aims of the study are to assess ORR, OS, PFS and DOR in patients based upon the presence of other tumor DDR mutations (e.g. BRCA1, BRCA2, MRE11, RAD50, RAD51, NBN, ATM). The study utilizes a Simon's Optimal two-stage design to assess ORR. If 2 or more responses are not observed in the first 9 response-eligible patients on the study, it will close for futility. If the interim efficacy threshold is achieved, 14 more response-eligible patients will be enrolled for a total of 23. A safety lead-in is being utilized for the initial 6 patients as the RP2D of the experimental combination had not yet been fully defined from its preceding phase I study. Results: The initial 6 patients have been treated with irinotecan (180 mg/m2 D1,D15 every 28 days) and berzosertib (270 mg/m2 D1,D15 every 28 days). No dose limiting toxicities were observed during cycle 1 in these patients and thus this dose was established as a safe dose for the remainder of the study patients. Patients have experienced grade 3/4 adverse events in 7 instances (most have been hematologic with 1 case of grade 4 neutropenia and 1 case each of grade 3 anemia, neutropenia and thrombocytopenia). Of the initial 6 patients, 1 has demonstrated a partial response while 3 others have demonstrated stable disease on initial response assessment (by RECIST 1.1). Conclusion: Berzosertib plus irinotecan appears to be safe in patients with TP53 mutated gastric/GEJ adenocarcinoma. The interim efficacy analysis, along with pharmacodynamic assessments of DNA damage induction, remain pending.

Citation Format: Satya Das, G. Dan Ayers, Jennifer Whisenant, Anwaar Saeed, Edward Kim, Vaia Florou, George Yacoub, Percy Ivy, Charles Kunos, Jordan Berlin. Berzosertib plus irinotecan in patients with TP53 mutant gastric/gastroesophageal junction adenocarcinoma: A phase II study [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P032.

Optimal Timing of Systemic Therapy in Resectable Colorectal Liver Metastases

Perioperative chemotherapy has been shown to improve disease-free survival compared with surgery alone for resectable colorectal liver metastases (CLM). We examined our experience with systemic chemotherapy in this clinical setting. A prospectively collected liver surgery database identified 210 patients treated for resectable CLM from 1996 to 2010. Results were correlated to four treatment groups: posthepatectomy adjuvant only, prehepatectomy preoperative only, peri-operative (preoperative and adjuvant), and surgery only. Seventy-nine (37.6%) patients received posthepatectomy adjuvant only treatment, 33 (15.7%) received prehepatectomy preoperative only treatment, 46 (21.9%) received perioperative (preoperative and adjuvant) treatment, whereas 52 (24.8%) received surgery alone. Preoperative and adjuvant systemic chemotherapy regimens were as follows: 23 (29.1%) and 18 (14.4%) received a 5-fluorouracil monotherapy regimen, 19 (24.1%) and 31 (24.8%) received an irinotecan-based regimen, and 28 (35.4%) and 37 (29.6%) received an oxaliplatin-based regimen. Nine (11.4%) and 12 (9.6%) received some other unknown combination. Treatment groups showed no difference in gender, mean tumor size, number of tumors, margin status, or postoperative complications with the only difference being a higher incidence of metachronous tumors in the preoperative only and perioperative groups (P = 0.01). Median follow-up and overall survival were 25 and 41 months, respectively. The adjuvant, preoperative, perioperative, and surgery only groups had a median survival time of 48, 35, 39, and 29 months, respectively (log-rank P = 0.04). Independent predictors of overall survival on multivariate analysis included treatment algorithm used and postoperative complication status. Adjuvant only systemic therapy was associated with an improved survival in resectable CLM. Prospective randomized trials are needed to confirm these findings.

Mutational Landscapes of Smoking-Related Cancers in Caucasians and African Americans: Precision Oncology Perspectives at Wake Forest Baptist Comprehensive Cancer Center

Background: Cancers related to tobacco use and African-American ancestry are under-characterized by genomics. This gap in precision oncology research represents a major challenge in the health disparities in the United States. Methods: The Precision Oncology trial at the Wake Forest Baptist Comprehensive Cancer Center enrolled 431 cancer patients from March 2015 to May 2016. The composition of these patients consists of a high representation of tobacco-related cancers (e.g., lung, colorectal, and bladder) and African-American ancestry (13.5%). Tumors were sequenced to identify mutations to gain insight into genetic alterations associated with smoking and/or African-American ancestry. Results: Tobacco-related cancers exhibit a high mutational load. These tumors are characterized by high-frequency mutations in TP53, DNA damage repair genes (BRCA2 and ATM), and chromatin remodeling genes (the lysine methyltransferases KMT2D or MLL2, and KMT2C or MLL3). These tobacco-related cancers also exhibit augmented tumor heterogeneities. Smoking related genetic mutations were validated by The Cancer Genome Atlas dataset that includes 2,821 cases with known smoking status. The Wake Forest and The Cancer Genome Atlas cohorts (431 and 7,991 cases, respectively) revealed a significantly increased mutation rate in the TP53 gene in the African-American subgroup studied. Both cohorts also revealed 5 genes (e.g. CDK8) significantly amplified in the African-American population. Conclusions: These results provide strong evidence that tobacco is a major cause of genomic instability and heterogeneity in cancer. TP53 mutations and key oncogene amplifications emerge as key factors contributing to cancer outcome disparities among different racial/ethnic groups.

A brief yoga intervention implemented during chemotherapy: A randomized controlled pilot study

OBJECTIVES

Fatigue and other treatment-related symptoms (e.g., sleep disturbance) are critical targets for improving quality of life in patients undergoing chemotherapy. Yoga may reduce the burden of such symptoms. This study investigated the feasibility of conducting a randomized controlled study of a brief yoga intervention during chemotherapy for colorectal cancer.

DESIGN

We randomized adults with colorectal cancer to a brief Yoga Skills Training (YST) or an attention control (AC; empathic attention and recorded education).

SETTING

The interventions and assessments were implemented individually in the clinic while patients were in the chair receiving chemotherapy.

INTERVENTIONS

Both interventions consisted of three sessions and recommended home practice.

MAIN OUTCOME MEASURES

The primary outcome was feasibility (accrual, retention, adherence, data collection). Self-reported outcomes (i.e., fatigue, sleep disturbance, quality of life) and inflammatory biomarkers were also described to inform future studies.

RESULTS

Of 52 patients initially identified, 28 were approached, and 15 enrolled (age Mean = 57.5 years; 80% White; 60% Male). Reasons for declining participation were: not interested (n = 6), did not perceive a need (n = 2), and other (n = 5). Two participants were lost to follow-up in each group due to treatment changes. Thus, 75% of participants were retained in the YST and 71% in the AC arm. Participants retained in the study adhered to 97% of the in-person intervention sessions and completed all questionnaires.

CONCLUSIONS

This study demonstrated the feasibility of conducting a larger randomized controlled trial to assess YST among patients receiving chemotherapy for colorectal cancer. Data collected and challenges encountered will inform future research.

Metastatic pancreatic acinar cell carcinoma in a younger male with marked AFP production: A potential pitfall on fine needle aspiration biopsy

A 30-year-old male presented to his doctor with complaints of abdominal pain and was found to have retroperitoneal as well as multiple hepatic masses. A serum alpha-fetoprotein (AFP) level was significantly elevated (17,373 ng mL^-1 ), raising suspicions for a metastatic germ cell tumor. Fine needle aspiration biopsy of the pancreatic lesion revealed atypical epithelioid cells with round nuclei, large prominent nucleoli, and granular cytoplasm. The morphologic differential diagnosis included pancreatic neoplasm, metastatic germ cell tumor, other metastatic carcinoma, and melanoma. An extensive panel of immunohistochemical stains confirmed the diagnosis of acinar cell carcinoma. The diagnosis of acinar cell carcinoma could be confounded by the markedly increased AFP level, particularly in the setting of a retroperitoneal mass in a younger male. The increased AFP level in the setting of an acinar cell tumor is a potential pitfall to correct diagnosis by cytology. As the treatment for these two entities differs considerably, acute awareness of the phenomenon is important. We present a case of pancreatic ACC with an increased AFP level diagnosed on a cytology specimen. Diagn. Cytopathol. 2017;45:133-136. © 2016 Wiley Periodicals, Inc.

Oncologic management of hereditary colorectal cancer

Colorectal cancer (CRC) is the second most common cancer in females and the third most common cancer diagnosed in males. Familial CRC comprises ~20 to 30% of all CRC cases. Lynch syndrome (LS), previously called hereditary nonpolyposis CRC (HNPCC), is the most common of the hereditary CRC syndromes. In this review, the oncological management of hereditary colorectal cancer from the medical oncologist perspective is discussed with special emphasis on Lynch syndrome. Lynch syndrome is characterized by the presence of germline mutations in the mismatch repair genes (MMR)-MSH2, MLH1, MSH6, and PMS2. The available data regarding the prognostic role of mismatch repair genes (MMR), the predictive role of MMR genes, and the implications of that in the management of patients with deficient MMR genes (dMMR/MSI-H) tumors including Lynch syndrome patients are also discussed.

Optimal timing of systemic therapy in resectable colorectal liver metastases

Perioperative chemotherapy has been shown to improve disease-free survival compared with surgery alone for resectable colorectal liver metastases (CLM). We examined our experience with systemic chemotherapy in this clinical setting. A prospectively collected liver surgery database identified 210 patients treated for resectable CLM from 1996 to 2010. Results were correlated to four treatment groups: posthepatectomy adjuvant only, prehepatectomy preoperative only, perioperative (preoperative and adjuvant), and surgery only. Seventy-nine (37.6%) patients received posthepatectomy adjuvant only treatment, 33 (15.7%) received prehepatectomy preoperative only treatment, 46 (21.9%) received perioperative (preoperative and adjuvant) treatment, whereas 52 (24.8%) received surgery alone. Preoperative and adjuvant systemic chemotherapy regimens were as follows: 23 (29.1%) and 18 (14.4%) received a 5-fluorouracil monotherapy regimen, 19 (24.1%) and 31 (24.8%) received an irinotecan-based regimen, and 28 (35.4%) and 37 (29.6%) received an oxaliplatin-based regimen. Nine (11.4%) and 12 (9.6%) received some other unknown combination. Treatment groups showed no difference in gender, mean tumor size, number of tumors, margin status, or postoperative complications with the only difference being a higher incidence of metachronous tumors in the preoperative only and perioperative groups (P = 0.01). Median follow-up and overall survival were 25 and 41 months, respectively. The adjuvant, preoperative, perioperative, and surgery only groups had a median survival time of 48, 35, 39, and 29 months, respectively (log-rank P = 0.04). Independent predictors of overall survival on multivariate analysis included treatment algorithm used and postoperative complication status. Adjuvant only systemic therapy was associated with an improved survival in resectable CLM. Prospective randomized trials are needed to confirm these findings.

Dacryocystitis: an unusual form of Mucorales infection

Mucormycosis is an acute fungal infection in humans that is often fulminant and potentially fatal. It occurs most frequently in immunocompromised individuals. We report a diabetic patient who presented in ketoacidosis with lacrimal sac infection from this organism. To the best of our knowledge, this is only the second patient with dacryocystitis caused by this fungus described in the medical literature. Our patient is unique in that she had no evidence of concurrent sinus involvement. Surgical debridement and antifungal therapy were combined to ensure a successful outcome.

IgA nephropathy and small cell lung carcinoma

The occurrence of glomerular disease as a paraneoplastic manifestation of malignancy is well documented in the medical literature. The strongest association is between membranous glomerulonephritis and solid tumors. We report a patient with IgA nephropathy associated with small cell lung cancer. To our knowledge, this is the second documented occurrence of an IgA nephropathy with a casual association with small cell bronchogenic cancer. This observation leads to the hypothesis that IgA nephropathy might be a paraneoplastic manifestation of this histiologic type of lung cancer.