Intrahepatic Cholangiocarcinoma Treated with Transarterial Yttrium-90 Glass Microsphere Radioembolization: Results of a Single Institution Retrospective Study

PURPOSE

To evaluate the efficacy and safety of transarterial yttrium-90 glass microsphere radioembolization in patients with unresectable intrahepatic cholangiocarcinoma (ICC).

MATERIALS AND METHODS

Retrospective review of 85 consecutive patients (41 men and 44 women; age, 73.4 ± 9.3 years) was performed. Survival data were analyzed by the Kaplan-Meier method, Cox regression models, and the log-rank test.

RESULTS

Median overall survival (OS) from diagnosis was 21.4 months (95% confidence interval [CI]: 16.6-28.4); median OS from radioembolization was 12.0 months (95% CI: 8.0-15.2). Seven episodes of severe toxicity occurred. At 3 months, 6.2% of patients had partial response, 64.2% had stable disease, and 29.6% had progressive disease. Median OS from radioembolization was significantly longer in patients with Eastern Cooperative Oncology Group (ECOG) scores of 0 and 1 than patients with an ECOG score of 2 (18.5 vs 5.5 months, P = .0012), and median OS from radioembolization was significantly longer in patients with well-differentiated histology than patients with poorly differentiated histology (18.6 vs 9.7 months, P = .012). Patients with solitary tumors had significantly longer median OS from radioembolization than patients with multifocal disease (25 vs. 6.1 months, P = .006). The absence of extrahepatic metastasis was associated with significantly increased median OS (15.2 vs. 6.8 months, P = .003). Increased time from diagnosis to radioembolization was a negative predictor of OS. The morphology of the tumor (mass-forming or infiltrative, hyper- or hypo-enhancing) had no effect on survival. Post-treatment increased cancer antigen 19-9 level, increased international normalized ratio, decreased albumin, increased bilirubin, increased aspartate aminotransferase, and increased Model for End-Stage Liver Disease score were significant predictors of decreased OS.

CONCLUSIONS

These data support the therapeutic role of radioembolization for the treatment of unresectable ICC with good efficacy and an acceptable safety profile.

Adjuvant radiation provides survival benefit for resected pancreatic adenocarcinomas of the tail

BACKGROUND

The appropriate adjuvant treatment for resected pancreatic cancer remains a controversy. We sought to determine the effect of adjuvant treatment on overall survival (OS) in patients with pancreatic tail adenocarcinoma.

METHODS

Retrospective review of patients with upfront surgically resected pancreatic tail cancer treated at our institution between 2000-2012 was performed to determine outcomes of patients treated with and without adjuvant radiation therapy (RT). Survival curves were calculated according to the Kaplan-Meier method. Univariate analysis (UVA) and multivariate analysis (MVA) were performed using the Cox proportional hazards model.

RESULTS

Thirty-four patients met inclusion criteria. 79% received adjuvant chemotherapy, either concurrent with RT or alone. The groups were well matched, with the only significant difference being patient sex. On both UVA and MVA there was significantly worse survival in patients with a post-op CA19-9 >90 [hazard ratio (HR) 5.55; 95% confidence interval (CI): 1.20-25.7, P=0.03] and improved survival in patients treated with adjuvant RT (HR 0.15; 95% CI: 0.04-0.58, P=0.006). The median and 2-year OS were 21.6 months and 47% for patients treated with adjuvant RT compared with 11.3 months and 21% for those treated without RT.

CONCLUSIONS

Although few in patient numbers, this data suggests integration of adjuvant RT in resected pancreatic tail adenocarcinoma may improve OS.

Outcomes of adjuvant radiotherapy and lymph node resection in elderly patients with pancreatic cancer treated with surgery and chemotherapy

Background

We sought to determine the effects of post-operative radiation therapy (PORT) and lymph node resection (LNR) on survival in patients ≥70 years with pancreatic cancer treated with surgery and chemotherapy.

Methods

An analysis of patients ≥70 years with surgically resected pancreatic cancer who received chemotherapy from the SEER database between 2004-2008 was performed to determine association of PORT and LNR on survival.

Results

We identified 961 patients who met inclusion criteria. There was a trend towards increased survival associated with PORT in all patients (P=0.052) and N1 patients (P=0.060) but no benefit in N0 patients (P=0.161). There was no difference in OS based on number of lymph nodes removed in all (P=0.741), N0 (P=0.588), and N1 (P=0.070) patients. MVA for all patients revealed that higher T stage, N1, and high grade tumors were prognostic for increased mortality, while there was decreased mortality with PORT and mild benefit with increased lymph nodes resected (P=0.084).

Conclusions

PORT demonstrated no benefit in survival of pancreatic cancer patients ≥70 who are resected and treated with adjuvant chemotherapy. Future investigation will need to address age as a stratification factor for pancreatic cancer in the adjuvant setting.

Systematic Review and Case Series Report of Acinar Cell Carcinoma of the Pancreas

BACKGROUND

Acinar cell carcinoma of the pancreas is a rare malignancy representing less than 1% of all pancreatic malignancies.

METHODS

We report on a case series of 21 patients with acinar cell carcinoma of the pancreas treated at a high-volume quaternary center. A systematic review of the medical literature was performed that described typical therapeutic management approaches for acinar cell carcinoma of the pancreas and reported on disease control and survival rates. Data for the case series were obtained from a prospective database.

RESULTS

In our systematic review of 6 articles, study patients had a median age of 61 years, 66% were male, 52% had stage I/II disease, and 55% of lesions were located in the pancreatic head. The rates of median survival were approximately 47 months after resection with adjuvant therapy, 38 months for nonmetastatic, locally unresectable disease, and 17 months for metastatic disease treated with chemotherapy. Combination fluoropyrimidine-based chemotherapy regimens had better rates of disease control than other therapies. Our case series included 21 study patients, 14 of whom required resection and 7 who had metastatic disease. The rates of median survival were 40.2 ± 31.9 months in those who underwent surgery and were treated with adjuvant therapy and 13.8 ± 11.3 months for patients with metastatic disease.

CONCLUSIONS

Multidisciplinary treatment for acinar cell carcinoma of the pancreas should be considered due to the rarity of the disease and its lack of high-level therapeutic data. Progress in the molecular analysis of this tumor may improve outcomes through the use of personalized therapy based on underlying tumor mutations.

Predictors and survival for pathologic tumor response grade in borderline resectable and locally advanced pancreatic cancer treated with induction chemotherapy and neoadjuvant stereotactic body radiotherapy

BACKGROUND

Neoadjuvant therapy response correlates with survival in multiple gastrointestinal malignancies. To potentially augment neoadjuvant response for pancreas adenocarcinoma, we intensified treatment with stereotactic body radiotherapy (SBRT) following multi-agent chemotherapy. Using this regimen, we analyzed whether the College of American Pathology (CAP) tumor regression grade (TRG) at pancreatectomy correlated with established response biomarkers and survival.

MATERIALS AND METHODS

We identified borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer patients treated according to our institutional clinical pathway who underwent surgical resection with reported TRG (n = 81, median follow-up after surgery 24.2 months). Patients had baseline CA19-9, computed tomography (CT), endoscopic ultrasound, and FDG positron emission tomography (PET)/CT then underwent multi-agent chemotherapy (79% with three cycles of gemcitabine, docetaxel and capecitabine) followed by 5-fraction SBRT. They then underwent restaging CT, PET/CT and CA19-9. Overall (OS) and progression-free (PFS) survival were estimated and compared by Kaplan-Meier and log-rank methods. Univariate ordinal logistic regression correlated TRG with baseline, restaging and change in CA19-9 and the PET maximum standardized uptake value (SUVmax).

RESULTS

Restaging level and decrease in CA19-9 correlated with improved TRG (p = .02 for both) as did restaging SUVmax (p < .01), yet there was no TRG correlation with decrease in SUVmax (p = .10) or CT response (p = .30). The TRG groups had similar OS and PFS except the TRG 0 (complete response) group. Compared to partial response levels (TRG 1-3, median OS 33.9 months, median PFS 13.0 months), the six (7%) patients with TRG 0 had no deaths (p = .05) and only one progression (p = .03). A group of 10 (12%) TRG 1 patients with only residual isolated tumor cells had similar outcomes to the other TRG 1-3 patients.

CONCLUSION

Pre-operative PET-CT and CA19-9 response correlate with histopathologic tumor regression. Patients with complete pathologic response have superior outcomes, suggesting a rationale for intensification and personalization of neoadjuvant therapy in BRPC and LAPC.

Phase II study of first-line radioembolization with yttrium-90 glass microspheres for intrahepatic cholangiocarcinoma

482

Background: The standard of care for unresectable intrahepatic cholangiocarcinoma (ICC) is systemic chemotherapy. The role of liver directed therapy for ICC is controversial given the lack of level I data. We conducted a phase II study to determine the safety and effectiveness of first-line liver directed therapy with radioembolization with yttrium-90 (Y90) glass microspheres for ICC. Methods: Eligible patients were enrolled on an IRB-approved phase II study (NCT01253148). Patients were included if they had no evidence of extrahepatic metastases, Childs-Pugh A, without main portal vein thrombus, bilirubin < 2 mg/dL, ECOG performance status of 0-2, and no prior chemotherapy, liver embolization, or radiation therapy for ICC. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS) and toxicity. Results: Twenty-five patients were enrolled between 2010 and 2013 with a median followup of 13 months (9-20 months). The median age was 76 years. Twenty patients came off study due to progression or death. The overall response rate was 56%. Median PFS was 6 months (95% CI: 4-12 months). This was likely due to tumors appearing larger after treatment due to tumor inflammation despite a decrease in CA19-9 levels. Univariate (UVA) and multivariate analysis (MVA) failed to identify any prognostic factors associated with PFS. Despite the low median PFS, median OS was 22 months (95% CI: 10 months to upper limit not reached). However, UVA and MVA failed to identify and prognostic factors for OS. Treatment was well tolerated with no reported grade 3 gastrointestinal or general disorder toxicities. Grade 3 ALT, AST, and alkaline phosphatase increase were reported in 4%, 4%, and 8%, respectively. Grade 4 hyperbilirubinemia and thrombocytopenia were reported in 4% and 4%, respectively. There were 2 patient who developed sepsis one patient who died within 30 days of treatment. Conclusions: First-line liver directed therapy with radioembolization with Y90 glass microspheres is a safe and effective treatment for ICC. Further prospective clinical trials are needed to identify the proper sequencing of liver directed therapy and systemic chemotherapy. Clinical trial information: NCT01253148.

Survival analysis of yttrium-90 radioembolization for unresectable intrahepatic cholangiocarcinoma

383

Background: Intrahepatic cholangiocarcinoma (ICC) is a rapidly progressing malignancy that frequently presents at an advanced stage and is often chemorefractory. The median overall survival (OS) with best medical treatment is approximately 12 months. The current study examines survival and characterizes predictors of mortality for ICC patients treated with transarterial yttrium-90 radioembolization (TARE). Methods: All patients with unresectable ICC who underwent TARE between May 2009 and May 2016 at a single institution were included and clinicopathologic variables reviewed. Primary endpoint was OS from time of TARE. Secondary endpoints included OS from time of diagnosis, post procedure toxicities and predictors of mortality. Results: A total of 134 TARE were performed on 85 patients. Average age at treatment was 73.4 ± 9.3 years and most patients were female (52%). More than one third of patients had an ECOG of 2 and had no significant post procedure sequalae. Thirty-six patients (42%) had extrahepatic disease at time of treatment and 61 patients (72%) were treated with systemic chemotherapy prior to TARE. A majority of patients (92.9%) received treatment to one lobe with an average radiation dose of 180.1±127.1 Gy. The median OS from time of the first TARE was 12 months (95% CI 7.8–16.1). The median OS from time of diagnosis was 21.4 months (95% CI 14.9-27.8). 51.8% and 26% of treated patients were still alive at 1 and 3 years, respectively. On univariate analysis, age at treatment, ECOG score, presence of extrahepatic disease, baseline albumin, alkaline phosphatase and AST correlated with OS. On multivariate analysis only low ECOG score and higher baseline albumin predicted improved OS (p < 0.01). Conclusions: Y90 radioembolization demonstrates a survival benefit for patients with unresectable ICC compared to historic controls of best medical treatment and should be considered an effective therapy in select patients. A multi-institutional randomized control trial should be performed to evaluate efficacy of TARE in select patients as both 1st line and salvage therapy.

Longitudinal cohort study to determine effectiveness of a novel simulated case and feedback system to improve clinical pathway adherence in breast, lung and GI cancers

OBJECTIVES

This study examined whether a measurement and feedback system led to improvements in adherence to clinical pathways.

DESIGN

The M-QURE (Moffitt-Quality, Understanding, Research and Evidence) Initiative was introduced in 2012 to enhance and improve adherence to pathways at Moffitt Cancer Center (MCC) in three broad clinical areas: breast, lung and gastrointestinal (GI) cancers. M-QURE used simulated patient vignettes based on MCC's Clinical Pathways to benchmark clinician adherence and monitor change over three rounds of implementation.

SETTING

MCC, located in Tampa, Florida, a National Cancer Institute Comprehensive Cancer Center.

PARTICIPANTS

Three non-overlapping cohorts at MCC (one each in breast, lung and GI) totalling 48 providers participated in this study, with each member of the multidisciplinary team (composed of medical oncologists, radiation oncologists, surgeons and advanced practice providers) invited to participate.

INTERVENTIONS

Each participant was asked to complete a set of simulated patient vignettes over three rounds within their own cancer specialty. Participants were required to complete all assigned vignettes over each of the three rounds, or they would be excluded from this study.

PRIMARY OUTCOME MEASURE

Increased domain and overall provider care adherence to clinical pathways, as scored by blinded physician abstractors.

RESULTS

We found significant improvements in pathway adherence between the third and first rounds of data collection particularly for workup and treatment of cancer cases. By clinical grouping, breast improved by 13.6% (p<0.001), and lung improved by 12.1% (p<0.001) over baseline, whereas GI showed a decrease of 1.4% (p=0.68).

CONCLUSIONS

Clinical pathway adherence improved in a short timeframe for breast and lung cancers using group-level measurement and individual feedback. This suggests that a measurement and feedback programme may be a useful tool to improve clinical pathway adherence.

Favorable perioperative outcomes after resection of borderline resectable pancreatic cancer treated with neoadjuvant stereotactic radiation and chemotherapy compared with upfront pancreatectomy for resectable cancer

BACKGROUND

Neoadjuvant multi-agent chemotherapy and stereotactic body radiation therapy (SBRT) are utilized to increase margin negative (R0) resection rates in borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) patients. Concerns persist that these neoadjuvant therapies may worsen perioperative morbidities and mortality.

METHODS

Upfront resection patients (n=241) underwent resection without neoadjuvant treatment for resectable disease. They were compared to BRPC or LAPC patients (n=61) who underwent resection after chemotherapy and 5 fraction SBRT. Group comparisons were performed by Mann-Whitney U or Fisher's exact test. Overall Survival (OS) was estimated by Kaplan-Meier and compared by log-rank methods.

RESULTS

In the neoadjuvant therapy group, there was significantly higher T classification, N classification, and vascular resection/repair rate. Surgical positive margin rate was lower after neoadjuvant therapy (3.3% vs. 16.2%, P=0.006). Post-operative morbidities (39.3% vs. 31.1%, P=0.226) and 90-day mortality (2% vs. 4%, P=0.693) were similar between the groups. Median OS was 33.5 months in the neoadjuvant therapy group compared to 23.1 months in upfront resection patients who received adjuvant treatment (P=0.057).

CONCLUSIONS

Patients with BRPC or LAPC and sufficient response to neoadjuvant multi-agent chemotherapy and SBRT have similar or improved peri-operative and long-term survival outcomes compared to upfront resection patients.

Histopathologic tumor response after induction chemotherapy and stereotactic body radiation therapy for borderline resectable pancreatic cancer

BACKGROUND

While clinical outcomes following induction chemotherapy and stereotactic body radiation therapy (SBRT) have been reported for borderline resectable pancreatic cancer (BRPC) patients, pathologic response has not previously been described.

METHODS

This single-institution retrospective review evaluated BRPC patients who completed induction gemcitabine-based chemotherapy followed by SBRT and surgical resection. Each surgical specimen was assigned two tumor regression grades (TRG), one using the College of American Pathologists (CAP) criteria and one using the MD Anderson Cancer Center (MDACC) criteria. Overall survival (OS) and progression free survival (PFS) were correlated to TRG score.

RESULTS

We evaluated 36 patients with a median follow-up of 13.8 months (range, 6.1-24.8 months). The most common induction chemotherapy regimen (82%) was GTX (gemcitabine, docetaxel, capecitabine). A median SBRT dose of 35 Gy (range, 30-40 Gy) in 5 fractions was delivered to the region of vascular involvement. The margin-negative resection rate was 97.2%. Improved response according to MDACC grade trended towards superior PFS (P=061), but not OS. Any neoadjuvant treatment effect according to MDACC scoring (IIa-IV vs. I) was associated with improved OS and PFS (both P=0.019). We found no relationship between CAP score and OS or PFS.

CONCLUSIONS

These data suggest that the increased pathologic response after induction chemotherapy and SBRT is correlated with improved survival for BRPC patients.

A Phase I dose-escalation study of afatinib combined with nintedanib in patients with advanced solid tumors

AIMS

To evaluate the safety and maximum tolerated dose (MTD) of afatinib combined with nintedanib.

MATERIALS & METHODS

Patients received afatinib 10-20 mg daily plus nintedanib 150-200 mg twice daily (28-day cycle). Dose escalation followed a 3+3 design.

RESULTS

Patients received afatinib/nintedanib: 10/150 mg (n = 11); 10/200 mg (n = 13; MTD); 20/200 mg (n = 4). Four patients had dose-limiting toxicities (all grade 3): increased alanine aminotransferase (afatinib/nintedanib: 10/150 mg), diarrhea (10/200 mg), dehydration (20/200 mg), diarrhea with elevated liver enzymes (20/200 mg). Frequent treatment-related adverse events were diarrhea, nausea, anorexia, fatigue and vomiting. In total, 14 patients (46.2%) had objective responses at the MTD.

CONCLUSION

The MTD, afatinib 10 mg daily plus nintedanib 200 mg twice daily, had a manageable safety profile, but was considered subtherapeutic for Phase II evaluation.

A phase Ia/Ib trial of trametinib in combination with sorafenib in patients with advanced hepatocellular cancer

TPS469

Background: MEK inhibitors have demonstrated preclinical activity in hepatocellular carcinoma (HCC). More importantly, in xenograft models, this class of inhibitors acts synergistically with sorafenib to inhibit tumor growth, prevent metastatic spread and increase survival. In preclinical models, sorafenib leads to overactivation of the MAPK pathway, which can be counterbalanced by the use of MEK inhibitors. Trametinib is a reversible, highly selective, allosteric MEK inhibitor. Methods: This is an open label, single group, phase I study with cohort expansion that utilizes the standard 3+3 design for dose escalation. The primary objective of this study is to determine maximally tolerated dose (MTD) of trametinib in combination with sorafenib as first-line systemic treatment for patients with locally advanced or metastatic HCC. Secondary objectives are to explore and characterize the safety and tolerability of this combination at the established MTD and to explore its efficacy profile. Up to 24 patients will be enrolled in 4 dose levels. Once the MTD is reached and/or the recommended dose for expansion is determined, an additional cohort of 10 patients with advanced HCC will be accrued. Only patients with Child-Pugh score A will be included. Trametinib will be administered orally daily beginning day 8 of cycle 1. Sorafenib will be administered twice daily beginning day 1 of 28 days cycle. Patients will get restaging scans every 2 cycles. Correlative studies between various biomarkers and clinical outcomes will also be performed. Biomarkers will be assessed in archival tumor tissue. The pre- and post-dose expression level of biomarkers including pan and phospho-Mek and Erk will be measured on peripheral blood mononuclear cells during treatment. Pre and post treatment biopsies will be performed for patients participating in the dose expansion cohort for correlative studies including gene expression. As per September 2015, 3 patients have been enrolled in this trial. ClinicalTrials.gov identifier: NCT02292173 Clinical trial information: NCT02292173.

A phase I trial with cohort expansion of BYL719 in combination with gemcitabine and nab-paclitaxel in locally advanced and metastatic pancreatic cancer

TPS467

Background: The phosphatidylinositol 3-kinase (PI3K)/Akt/mTOR pathway which is aberrantly stimulated in many tumors has emerged as a potential target for anticancer therapy. Although several class I PI3K inhibitors are under development, there is considerable evidence suggesting that targeting a single isoform of PI3K (p110α) would have sufficient antitumor activity and improved therapeutic window. The PI3K pathway is frequently activated and plays an important role in pancreatic cancer. Further, PI3KCA mutations, the gene encoding isoform p110α, are observed in this disease. BYL719 is an oral class I α-specific PI3K inhibitor that showed anti-tumor activity in different preclinical models. Recently, the first in human phase 1 trial of BYL719 defined the maximum tolerated dose (MTD) at 400 mg once daily. Methods: This is a single institution, open label, single group, phase I study with cohort expansion that utilizes the standard 3+3 design for dose. The primary objective is to determine the MTD of BYL719 in combination with gemcitabine and nab-paclitaxel as frontline therapy in patients with locally advanced, recurrent or metastatic pancreatic adenocarcinoma. Up to 24 patients will be enrolled in 4 dose escalation levels. The MTD is defined as the highest dose level at which 1 or less of 6 patients experience a dose limiting toxicity (DLT). Once the MTD is reached and/or the recommended dose for expansion is determined, an additional dose expansion cohort of 15 patients will be included. Secondary endpoints include characterizing the safety profile at the MTD and DLTs associated with it as well as obtaining pharmacokinetic data. Peripheral blood and pre-treatment tumor samples will be collected for evaluation of biomarkers that could predict treatment response, including levels of pAKT, p4EBP1 and pS6. BYL719 will be administered daily. Standard doses of gemcitabine and nab-paclitaxel will be given on days 1, 8 and 15 of the 28 days cycle. Patients will get restaging scans every 2 cycles. As per September 2015, twelve patients have been included in this study which is currently enrolling patients on cohort 3. Clinical trial information: NCT02155088 Clinical trial information: NCT02155088.

Predictors and survival for pathologic tumor response grade (TRG) in borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) treated with induction chemotherapy and neoadjuvant stereotactic body radiotherapy (SBRT)

453

Background: Neoadjuvant therapy response correlates with survival in several gastrointestinal malignancies. Thus, we intensified our neoadjuvant approach to pancreas adenocarcinoma in part to induce greater response. Here we analyzed whether pre- and post- therapy CA19-9 or SUVmax correlated with College of American Pathology TRG at pancreatectomy and whether TRG associated with survival. Methods: After IRB approval, we identified BRPC and LAPC patients treated in our standardized pathway who underwent surgical resection with reported TRG (n = 81, median follow-up 30.8 months). Patients had baseline CA19-9, CT, endoscopic ultrasound, and FDG PET/CT then underwent multi-agent chemotherapy (79% with planned 3 cycles of GTX) followed by 5 fraction SBRT. They then underwent restaging CT, PET/CT, and CA19-9 prior to resection. Overall (OS) and progression free survival (PFS) were estimated and compared by Kaplan-Meier and log-rank methods. Univariate ordinal logistic regression correlated TRG with baseline, re-staging, and change in CA19-9 (16% with missing values or CA19-9 < 5 excluded) and SUVmax (14% with missing values or no hypermetabolism excluded). Results: Decrease in CA19-9 before and after neoadjuvant therapy correlated with improved TRG (p = 0.02) as did re-staging SUVmax (p < 0.01), though not decrease in SUVmax (p = 0.08). The TRG groupings had similar OS and PFS except the TRG 0 (complete response) group. Compared to TRG 1-3 patients (median OS 38.4 months, median PFS 17.8 months), the 6 patients with TRG 0 had no deaths (p = 0.05) and only 1 failure (p = 0.03). A group of 10 TRG 1 patients with only isolated tumor cells remaining had similar outcomes to the other TRG 1-3 patients. Conclusions: Pre-operative PET-CT and CA19-9 response correlate with neoadjuvant therapy response by TRG. Patients with complete pathologic response have superior outcomes. This provides rationale for further intensification of neoadjuvant therapy in BRPC and LAPC. Further work seeks to identify techniques to better select which BRPC and LAPC patients should undergo tumor resection.

Does metabolic tumor volume predict tumor regression grade after neoadjuvant therapy for borderline resectable pancreatic cancer?

214

Background: Metabolic tumor volume (MTV) based on FDG-PET has been shown to be prognostic for overall survival (OS) in patients with resectable, borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC). Tumor regression grade (TRG) following neoadjuvant therapy has also been shown to correlate with OS. No data currently exists evaluating whether metabolic response defined by MTV can predict pathologic response in BRPC. Methods: This IRB approved retrospective review evaluated 40 non-metastatic BRPC patients. All patients underwent staging imaging including FDG PET/CT. They then received induction multi-agent chemotherapy followed by five fraction stereotactic body radiation therapy (SBRT) with a median maximum dose of 35 Gy. Repeat pre-operative FDG PET/CT was performed for re-staging. Patients then underwent pancreatectomy. For this study, the diagnostic images were transferred to a software system that analyzed the pre-treatment, re-staging, and change in (differential) MTV values. We analyzed SUVmax and each of MTV2.5, MTV3.0, MTV4.0, and MTV5.0, as defined as the tumor volume with SUV above each threshold. At our center, each surgical specimen is assigned TRG using the College of American Pathology (CAP) criteria. The TRG scores regression from 0 – 3, with 0 indicating complete response and 3 indicating no response. Univariate ordinal logistic regression was used to correlate TRG with pre-, post-, absolute differential, and percent differential MTV 2.5-5.0 and SUVmax. Results: Of the sample population, TRG was as follows: TRG 0 n = 4, TRG 1 n = 17, TRG 2 n = 14, TRG 3 n = 5. TRG correlated with rradiologist reported re-staging SUVmax (p = 0.001) and percent differential SUVmax (p = 0.044). TRG did not correlate with pre-treatment SUVmax, absolute differential SUVmax, or any MTV measurements (all p > 0.05). Conclusions: We identified a correlation between SUVmax and percent change in SUVmax after neoadjuvant therapy with TRG (CAP scale). This analysis did not identify an association between any MTV threshold and TRG before or after neoadjuvant therapy. Future work seeks to identify alternate methods of neoadjuvant response assessment.

Interim results of a randomized phase II study of PEGPH20 added to nab-paclitaxel/gemcitabine in patients with stage IV previously untreated pancreatic cancer

439

Background: Poor outcome in pancreatic cancer (PDA) is associated partly with stromal hyaluronan (HA) accumulation, which compromises chemotherapy perfusion. PEGPH20, PEGylated recombinant human hyaluronidase, potentiates chemotherapy by depleting HA in tumors. Methods: In an ongoing, phase II, open-label, randomized study of PEGPH20+nab-paclitaxel (Nab)+Gemcitabine (Gem) (PAG) vs Nab+Gem (AG) in previously untreated stage IV PDA, pts receive PEGPH20 3 µg/kg twice weekly (C1), then weekly (C2+) with standard AG dosing. HA status was tested retrospectively. After a temporary clinical hold (Apr-Jul 2014) for an imbalance in thromboembolic (TE) events (29% PAG vs 15% AG), the protocol was amended to exclude high-TE-risk pts and add enoxaparin (LMWH) prophylaxis. Endpoints are PFS and TE events (primary); PFS and ORR by HA level and OS (secondary). Efficacy and safety data through Dec 2014 are for pts enrolled up to clinical hold (Stage 1); TE data are through Sep 2015 (Stage 2). Results: 135 pts were treated (74 PAG, 61 AG). PFS results are shown below (median follow-up 7 mo). In HA-high pts receiving PAG vs AG, ORR was 52% (1 CR) vs 24% (P=.038); ORR was 37% vs 38% in HA-low pts. OS was 12 mo vs 9 mo (HR=0.62) despite 12/23 PAG pts discontinuing PEGPH20 at clinical hold. Common ADRs (PAG vs AG) included peripheral edema (58% vs 31%), muscle spasms (55% vs 1.6%), and neutropenia (32% vs 18%). TE events were: Stage 1 42% vs 25% (no LMWH); Stage 2 (with LMWH; 40 mg/d or 40 mg/d increased to 1 mg/kg/d) 28% vs 29%; (1 mg/kg/d) 5% vs 6%; overall (40 mg/d or 1 mg/kg/d) 13% each arm (to be updated). Conclusions: Pts with HA-high tumors receiving PAG, vs AG, showed significant improvements in PFS and ORR and a trend toward improved OS. PAG was well tolerated, with TE events reduced with LMWH prophylaxis. A global phase III trial of PAG will initiate Q1 2016. Clinical Trial Information: NCT01839487. Clinical trial information: NCT01839487. [Table: see text]

Genomically adjusted radiation dose to predict for survival with adjuvant radiation in resectable pancreatic cancer

240

Background: The median survival of patients with resectable pancreatic cancer remains low at approximately 2 years. A major limitation of treating patients with postoperative radiation therapy (RT) is the close proximity of the small bowel, which confines the RT dose. We hypothesized that a subset of patients might exist who would benefit from an escalated RT dose based on their underlying tumor radiosensitivity. Methods: Genomically-profiled patients with pancreatic cancer were identified from an IRB-approved prospective observational protocol. Patients treated with upfront surgery and postoperative RT were included. Briefly, the radiosensitivity index (RSI) is derived from the expression of 10 specific genes and a linear regression algorithm modeled on SF2 of 48 cancer cells. The RSI was combined with the delivered RT dose to derive a genomically adjusted RT dose (GAD). The GAD patient subsets were split at the middle GAD value and rounded up to the nearest integer (27). Our primary endpoint was to assess whether the GAD would predict for survival. Results: Forty patients underwent surgery and postoperative RT with GAD and clinical outcome data available. The median RT dose was 50.4 Gy (range 45-54) and the median follow-up among surviving patients was 68 months (range 42-141). Eighteen patients with a GAD > 27 had a median survival of 32.1 months, while 22 patients with a GAD < 27 had a median survival of 17.9 months (p = 0.48). On Cox multivariate analysis, both high-risk pancreatic cancer patients (positive margins, positive lymph nodes or a postoperative CA 19-9 > 90) and patients with a GAD < 27 had significantly decreased survival (Hazard ratio [HR] 5.0 [95%CI 1.8,13.6], p = 0.002 and HR 2.6 [1.1-6.0], p = 0.03, respectively). Among patients with a GAD < 27, 3 of 22 (14%) would have exceeded a GAD of 27 with an escalated RT dose of 54 Gy, and 8 of 22 (36%) patients would have exceeded a GAD of 27 with an escalated dose of 56 Gy to the pancreatic bed. Conclusions: GAD is predictive of survival among patients with resectable pancreatic cancer when combined with known prognostic factors. The GAD provides a tool to determine who might benefit from dose-escalated RT based on the underlying tumor radiosensitivity.

Multi-institutional phase II trial of single agent regorafenib in refractory advanced biliary cancers

TPS468

Background: Currently, there is no standard second line treatment for patients with advanced biliary tract cancer (BC) who have failed prior systemic therapy. Aberrant activation of the Ras/Raf/MEK/ERK pathway occurs in more than 60% of BC indicating the importance of this pathway in biliary carcinogenesis. Furthermore anti-angiogenic agents such as the VEGF-antagonist bevacizumab, and the multikinase inhibitor sorafenib have been tested in BC in the first line setting with modest activity. Regorafenib is an oral multi-kinase inhibitor that targets multiple membrane-bound and intracellular kinases including VEGF, the Ras/Raf/MEK/ERK and PDGFR- ß pathways. Given the pivotal role of these pathways in biliary cancer biology, the clinical evaluation of regorafenib represents a novel and rational approach to treat this disease. Methods: This is a multi-institutional phase II single arm single-stage design trial using regorafenib as single agent. Patients with histologically or cytologically-proven locally advanced or metastatic biliary tract carcinomas that failed no more than 2 prior line of systemic chemotherapy are eligible for this study. Patients must have measurable disease per RECIST 1.1 criteria and never been treated with VEGF inhibitors. Patients will receive regorafenib 160 mg daily (21 days on and 7 days off) and will be evaluated for response every 2 cycles (1cycle = 28 days). The study’s primary endpoint is 6 month overall survival. Secondary endpoints are to define disease control, progression-free survival and toxicity related to treatment. Correlative biomarker studies using plasma samples will be performed to investigate levels of 40 relevant proteins associated with the above-mentioned pathways in the attempt to identify predictive markers of drug benefit. As per September 2015, twelve of the 39 planned patients have been accrued for the study. In addition to Moffitt Cancer Center, this trial will enroll patients at the UNC Lineberger Comprehensive Cancer Center and VCU Massey Cancer Center. Clinical trial information: NCT02115542.

A Phase I Safety, Pharmacokinetic, and Pharmacodynamic Presurgical Trial of Vitamin E δ-tocotrienol in Patients with Pancreatic Ductal Neoplasia

Background

Vitamin E δ-tocotrienol (VEDT), a natural vitamin E from plants, has shown anti-neoplastic and chemoprevention activity in preclinical models of pancreatic cancer. Here, we investigated VEDT in patients with pancreatic ductal neoplasia in a window-of-opportunity preoperative clinical trial to assess its safety, tolerability, pharmacokinetics, and apoptotic activity.

Methods

Patients received oral VEDT at escalating doses (from 200 to 3200 mg) daily for 13 days before surgery and one dose on the day of surgery. Dose escalation followed a three-plus-three trial design. Our primary endpoints were safety, VEDT pharmacokinetics, and monitoring of VEDT-induced neoplastic cell apoptosis (ClinicalTrials.gov number NCT00985777).

Findings

In 25 treated patients, no dose-limiting toxicity was encountered; thus no maximum-tolerated dose was reached. One patient had a drug-related adverse event (diarrhea) at a 3200-mg daily dose level. The effective half-life of VEDT was ~ 4 h. VEDT concentrations in plasma and exposure profiles were quite variable but reached levels that are bioactive in preclinical models. Biological activity, defined as significant induction of apoptosis in neoplastic cells as measured by increased cleaved caspase-3 levels, was seen in the majority of patients at the 400-mg to 1600-mg daily dose levels.

Interpretation

VEDT from 200 to 1600 mg daily taken orally for 2 weeks before pancreatic surgery was well tolerated, reached bioactive levels in blood, and significantly induced apoptosis in the neoplastic cells of patients with pancreatic ductal neoplasia. These promising results warrant further clinical investigation of VEDT for chemoprevention and/or therapy of pancreatic cancer.

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Vitamin E δ-tocotrienol is the bioactive form of one of the natural vitamin E with activity against cancer cells

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Vitamin E δ-tocotrienol is safe in patients up to 3200 mg

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Vitamin E δ-tocotrienol selectively kills pancreatic tumor cells when compared with normal cells at 400, 600, and 800 mg/day

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The biomarker effect of vitamin E δ-tocotrienol suggest significant anticancer activity in patients, justifying further study

Vitamin E has been an intriguing vitamin to humans for its potential to promote human health. However, large-scale research with vitamin E to prevent cancer has had mixed results. Because recent laboratory studies have shown that the form of vitamin E used in previous interventions to reduce cancer risk have not been the active tocotrienol form of vitamin E, there is a question as to whether the lack of vitamin activity is due to the use of inactive forms of vitamin E in clinical trials. Based on our laboratory data, which showed that the vitamin E δ-tocotrienol (VEDT) form of vitamin E was active against pancreatic cancer, we tested the ability of VEDT to kill pancreatic tumor cells in patients using a window-of-opportunity design, with measurement of apoptosis as an intermediate endpoint. We found that VEDT was well tolerated at up to 3200 mg when taken for 2 weeks before surgery. We also found that, at doses of 400 to 800 mg, VEDT selectively killed pancreatic tumor cells.

Outcomes of resected pancreatic cancer in patients age ≥70

OBJECTIVE

To determine outcomes of patients ≥70 years with resected pancreatic cancer.

METHODS

A study was conducted to identify pancreatic cancer patients ≥70 years who underwent surgery for pancreatic carcinoma from 2000 to 2012. Patients were excluded if they had neoadjuvant therapy. The primary endpoint was overall survival (OS).

RESULTS

We identified 112 patients with a median follow-up of surviving patients of 36 months. The median patient age was 77 years. The median and 5 year OS was 20.5 months and 19%, respectively. Univariate analysis (UVA) showed a significant correlation for increased mortality with N1 (P=0.03) as well as post-op CA19-9 >90 (P<0.001), with a trend towards decreased mortality with adjuvant chemoradiation (P=0.08). Multivariate analysis (MVA) showed a statistically significant increased mortality associated with N1 (P=0.008), post-op CA19-9 >90 (P=0.002), while adjuvant chemoradiation (P=0.04) was associated with decreased mortality.

CONCLUSIONS

These data show that in patients ≥70, nodal status, post-op CA19-9, and adjuvant chemoradiation, were associated with OS. The data suggests that outcomes of patients ≥70 years who undergo upfront surgical resection are not inferior to younger patients.

Radiosensitivity index predicts for survival with adjuvant radiation in resectable pancreatic cancer

BACKGROUND AND PURPOSE

Adjuvant radiation therapy for resectable pancreatic cancer remains controversial. Sub-populations of radiosensitive tumors might exist given the genetic heterogeneity of pancreatic cancers. We evaluated whether RSI is predictive of survival in pancreatic cancer treated with radiation.

MATERIALS AND METHODS

We identified 73 genomically-profiled pancreas cancer patients treated with upfront surgery between 2000 and 2011 (48 radiation, 25 no radiation). Briefly, RSI score is derived from the expression of 10 specific genes and a linear regression algorithm modeled on SF2 of 48 cancer cells. The primary endpoint was to assess the association of RSI with overall survival.

RESULTS

Median follow-up was 67months for surviving patients. On multivariate analysis, patients with radioresistant tumors had a trend toward worse survival (Hazard ratio [HR] 2.1 [95% CI 1.0-4.3], p=0.054). Among high-risk, irradiated patients (positive margins, positive lymph nodes, or a post-operative CA19-9 >90; n=31), radiosensitive patients had significantly improved survival compared with radioresistant patients (median 31.2 vs. 13.2months; HR 0.42 [0.19, 0.94], p=0.04). Among irradiated patients (n=48), low-risk patients lived longer than both high-risk patients with radiosensitive tumors and radioresistant tumors (HR 2.7 [1.0, 7.2], p=0.04 and HR 6.3 [2.3, 17.0], p<0.001, respectively).

CONCLUSIONS

Integrating RSI with standard high-risk variables has the potential to refine the classification of high-risk resected pancreatic cancer patients treated with radiation therapy.

Phase I study of combination of pasireotide LAR + gemcitabine in locally advanced or metastatic pancreatic cancer

PURPOSE

Pasireotide LAR (SOM230 LAR) is a cyclohexapeptide engineered to bind to multiple somatostatin receptor subtypes to mimic the action of naturally occurring somatostatin with higher affinity to these receptors than octreotide and is a potent inhibitor of insulin-like growth factor-1 (IGF-1). Somatostatin receptors and IGF receptors are highly expressed in pancreatic cancer, thereby potentially making it a valuable target. This phase I study evaluated safety, tolerability and preliminary tumor response of pasireotide LAR in combination with gemcitabine in locally advanced or metastatic pancreatic cancer.

METHODS

Patients with previously untreated metastatic pancreatic cancer were included. A 3 + 3 dose-escalation design was used. Patients received gemcitabine on days 1, 8 and 15 and pasireotide LAR IM monthly in a 28-day cycle. Two dose levels of pasireotide LAR were planned: 40 mg IM and 60 mg. Cohort was expanded by ten more patients at the highest tested dose to further assess the safety and efficacy.

RESULTS

Twenty patients were consented on this trial, and 16 patients were evaluable for safety and efficacy. No dose-limiting toxicities were observed. Two out sixteen patients (12%) had partial response, and nine of sixteen (56%) had stable disease as best response. Median progression-free survival was 4.1 months (range 1-16 months), and median overall survival was 6.9 months (range 1-25 months). Most common grade 3 or 4 toxicities were hyperglycemia (n = 5), hyperbilirubinemia (n = 1) and thrombocytopenia (n = 2). Median baseline IGF-1 level was lower in patients with stable disease than in those with progressive disease (63 vs 71 ng/ml).

CONCLUSION

Pasireotide in combination with gemcitabine was well tolerated with disease control rate of 68%. Larger trials are needed in the future to establish its efficacy in the treatment of pancreatic cancer.

CLINICAL TRIAL

NCT01385956.

Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreatic adenocarcinoma

PURPOSE

Limited data are available to guide neoadjuvant treatment of borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer.

MATERIAL AND METHODS

We updated our institutional outcomes with a neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT) approach. An IRB-approved analysis was performed of all BRPC and LAPC patients treated with our departmental treatment protocol. After staging, medically fit patients underwent chemotherapy for 2-3 months, with regimen at the discretion of the treating medical oncologist. Patients then received SBRT delivered in five consecutive daily fractions with median total radiation doses of 30 Gy to tumor and 40 Gy dose painted to tumor-vessel interfaces. This was followed by restaging imaging for possible resection. Overall survival (OS), event free survival (EFS), and locoregional control (LRC) rates were estimated and compared by Kaplan-Meier and log-rank methods.

RESULTS

We identified 159 patients, 110 BRPC and 49 LAPC, with 14.0 months median overall follow-up. The resection and margin negative (R0) rate for BRPC patients who completed neoadjuvant therapy was 51% and 96%, respectively. Estimated median OS was 19.2 months for BRPC patients and 15.0 months for LAPC patients (p = 0.402). Median OS was 34.2 months for surgically resected patients versus 14.0 months for unresected patients (p < 0.001). Five of 21 (24%) LAPC patients receiving FOLFIRINOX chemotherapy underwent R0 resection. In LAPC, FOLFIRINOX recipients underwent R0 resection more often than other chemotherapy recipients (5 of 21 vs. 0 of 28, p = 0.011). There was a trend for improved survival in those resected LAPC patients (p = 0.09). For those not undergoing resection, one year LRC was 78%. Any grade ≥ 3 potentially radiation-related toxicity rate was 7%.

CONCLUSIONS

These data underscore the feasibility, safety, and effectiveness of neoadjuvant SBRT and chemotherapy for BRPC and LAPC.

Novel pancreatic cancer vaccines could unleash the army within

BACKGROUND

Despite recent progress with novel chemotherapy regimens, pancreatic ductal adenocarcinoma remains the fourth leading cause of cancer death in the United States. Innovative approaches to treatment of this disease are needed to accelerate progress.

METHODS

A review was conducted of the results of 2 pancreatic cancer vaccine programs with results that have shown promise in early-phase clinical trials.

RESULTS

In a phase 2 trial, a cell-based allogeneic pancreatic cancer vaccine exploiting the hyperacute rejection response targeted against alpha-1,3 galactosyl epitopes (algenpantucel-L) has shown improvement in disease-free and overall survival rates in the adjuvant setting compared with a historical control. This vaccine has advanced to ongoing phase 3 trials. Compared with GVAX alone, a second whole-cell vaccine employing GM-CSF-expressing pancreatic cancer cells (GVAX) to enhance the antigen presentation in a priming phase followed by a Listeria-based vaccine targeting mesothelin in a boost phase improved survival rates. This vaccine platform is undergoing additional phase 2 testing.

CONCLUSIONS

Allogenic whole-cell pancreatic adenocarcinoma vaccines show promise in early-phase trials and have the potential to improve survival rates by unleashing antitumor immunity.

Comparative long-term outcomes of upfront resected pancreatic cancer after preoperative biliary drainage

BACKGROUND

We evaluated whether preoperative biliary drainage was predictive of recurrence and survival among patients with resectable pancreatic cancer.

METHODS

Patients with pancreatic cancer who were treated with upfront surgery between 2000 and 2012 were identified and stratified by preoperative percutaneous transhepatic cholangiogram-guided drainage (PTBD), placement of endoscopic stents (ERCP), or no biliary drainage (NBD). The primary endpoint was overall survival.

RESULTS

We identified 193 patients with resectable pancreatic head cancer (33 PTBD; 96 ERCP; and 64 NBD). Key differences between the three groups were more patients who underwent >1 preoperative biliary procedures (p = 0.004) in the PTBD cohort. PTBD patients had a significant increase in hepatic recurrence rate compared with patients who did not undergo PTBD (44.8 vs. 23.3 %, p = 0.02). PTBD patients also had worse overall survival. Median and 5-year survival for PTBD, ERCP, and NBD patients were 17.5 months and 3 %, 22.4 months and 24 %, and 28.9 months and 32 %, respectively (p = 0.002). MVA revealed that percutaneous drainage was an independent predictor of worse overall survival [HR 1.76, 95 % CI (1.05-2.99), p = 0.03].

CONCLUSIONS

Patients with resectable pancreatic cancer who receive PTBD have more advanced disease, higher hepatic recurrence, and worse survival.

A genome-wide investigation of microRNA expression identifies biologically-meaningful microRNAs that distinguish between high-risk and low-risk intraductal papillary mucinous neoplasms of the pancreas

BACKGROUND

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic ductal adenocarcinoma (PDAC) precursors. Differentiating between high-risk IPMNs that warrant surgical resection and low-risk IPMNs that can be monitored is a significant clinical problem, and we sought to discover a panel of mi(cro)RNAs that accurately classify IPMN risk status.

METHODOLOGY/PRINCIPAL FINDINGS

In a discovery phase, genome-wide miRNA expression profiling was performed on 28 surgically-resected, pathologically-confirmed IPMNs (19 high-risk, 9 low-risk) using Taqman MicroRNA Arrays. A validation phase was performed in 21 independent IPMNs (13 high-risk, 8 low-risk). We also explored associations between miRNA expression level and various clinical and pathological factors and examined genes and pathways regulated by the identified miRNAs by integrating data from bioinformatic analyses and microarray analysis of miRNA gene targets. Six miRNAs (miR-100, miR-99b, miR-99a, miR-342-3p, miR-126, miR-130a) were down-regulated in high-risk versus low-risk IPMNs and distinguished between groups (P<10-3, area underneath the curve (AUC) = 87%). The same trend was observed in the validation phase (AUC = 74%). Low miR-99b expression was associated with main pancreatic duct involvement (P = 0.021), and serum albumin levels were positively correlated with miR-99a (r = 0.52, P = 0.004) and miR-100 expression (r = 0.49, P = 0.008). Literature, validated miRNA:target gene interactions, and pathway enrichment analysis supported the candidate miRNAs as tumor suppressors and regulators of PDAC development. Microarray analysis revealed that oncogenic targets of miR-130a (ATG2B, MEOX2), miR-342-3p (DNMT1), and miR-126 (IRS-1) were up-regulated in high- versus low-risk IPMNs (P<0.10).

CONCLUSIONS

This pilot study highlights miRNAs that may aid in preoperative risk stratification of IPMNs and provides novel insights into miRNA-mediated progression to pancreatic malignancy. The miRNAs identified here and in other recent investigations warrant evaluation in biofluids in a well-powered prospective cohort of individuals newly-diagnosed with IPMNs and other pancreatic cysts and those at increased genetic risk for these lesions.

Radiosensensitivity index prognostic for survival with adjuvant radiation in resectable pancreatic cancer

398

Background: Adjuvant radiation therapy (RT) for resectable pancreatic cancer remains controversial. We evaluated whether a previously validated molecular signature of tumor radiosensitivity (RSI) is prognostic for survival in pancreatic cancer. Methods: We identified patients treated with upfront surgery between 2006 and 2012. Briefly, RSI score is derived from the expression of 10 specific genes and a linear regression algorithm modeled on SF2 of 48 cancer cells (RSI, high index = radioresistant). We assessed the relative radiosensitivity of pancreatic cancers compared with other common cancers and then tested the association of RSI with overall survival (OS). Results: Compared with other common cancers such as lung, breast, and prostate, pancreatic cancers were more radioresistant as a group (p<0.0001). We identified 80 patients who underwent upfront surgery with both RSI and clinical outcome available (49 RT, 31 no RT). Median follow-up among surviving patients was 4.1 years. Median OS for radiosensitive tumors (RS), defined by lower ½ RSI, was 2.7 years compared with 1.5 years for radioresistant (RR) tumors (p=0.35). Among the high-risk pancreatic cohort, (positive margins, positive lymph nodes, or a post-operative CA 19-9 >90), irradiated patients with RS tumors had a trend toward improved OS (3y OS: 38% vs. 8%; p=0.07), while there was no difference in OS between RS and RR patients who weren’t treated with RT (p=0.79). When RSI was integrated, high-risk-RS patients had similar OS compared with low-risk-RR patients (3y OS: 38% vs. 50%; p=0.29). When low-risk-RR and high-risk-RS were combined into a single intermediate-risk group, RSI score added substantial prognostic value to OS outcomes on univariate (3 y OS: 78%, 42%, and 8%, for low-risk-RS, intermediate-risk group, and high-risk-RR, respectively; p=0.001) and multivariate analysis (intermediate-risk HR: 4.3, 1.0-18.6; p=0.053; high-risk HR: 9.9, 2.2-45.1; p=0.003). Conclusions: Patients with pancreatic tumors have relatively radioresistant tumors. Integrating RSI with standard prognostic variables refines the classification of resected pancreatic cancer patients.

Outcomes of a clinical pathway for borderline resectable pancreatic cancer

374

Background: While multimodality therapy for borderline resectable pancreatic adenocarcinoma (BPA) is advocated, treatment regimens vary by institution without a standardized approach supported by prospective randomized data. We implemented a multidisciplinary multimodality clinical pathway (CP) for the management of BPA and examined outcomes to investigate optimal therapy. Methods: From January 1, 2006, to December 31, 2013, BPA cases as defined by the NCCN and AHPBA consensus guidelines were managed prospectively along CP. Resection rates, margin status, pathologic response, and overall survival were retrospectively examined. Standard statistical and survival analysis were used. Results: 121 patients were classified as BPA and 101 entered the CP. The neoadjuvant chemoradiation (NT) completion rate was 93.1%. Of those who entered the CP, 55 patients (54.5%) underwent pancreatectomy. R0, R1 and R2 margin rates were 96.3%, 3.7% and 0%, respectively. Of the 55 patients who underwent resection, 22 (40%) required vascular reconstruction, with R0, R1 and R2 margin rates of 95.2%, 4.8%, and 0%, respectively. Pathologic response to treatment was found in 70.8%, with a complete response rate of 15.9%. Median overall survival in the resected group versus the non-resected group was 34.2 months versus 14.7 months, p<0.001. Conclusions: Our series represents one of the largest reports of BPA in the literature and implementation of our CP resulted in a high NT completion rate and pancreatectomy with negative margin rate. Although 41.4% of cases were not resectable after NT, there was a high rate of negative margin resection with >70% pathologic response rate and a favorable median survival.

Surgery and adjuvant therapy in gallbladder cancer: A single-institution experience

405

Background: Gallbladder cancer is a highly fatal disease with a high rate of recurrence even when diagnosed at an early stage. Because of its relative rarity, there are currently no established algorithms to guide therapy after cholecystectomy. To explore the value of adjuvant therapy with chemotherapy and radiation, we evaluated patients with resected gallbladder cancer treated at our institution. Methods: Patients diagnosed with gallbladder cancer who underwent cholecystectomy (simple or radical) between 2000 and 2010 were identified using our cancer registry. Retrospective chart review was performed for clinicopathologic data, including age, stage, grade, type of surgery, margin status, and type and duration of adjuvant therapy. The primary endpoint was overall survival (OS). Univariate (UVA) and multivariate (MVA) analysis was performed with Cox logistic regression analyses. Results: We identified 73 patients with a median followup for all patients of 28.2 months. The majority of patients were female (74%) and underwent radical cholecystectomy (64%). Positive margins and adjuvant radiation therapy were documented in 21% and 37%, respectively. The majority of patients did not receive any adjuvant therapy (53.4%). Median OS for all patients was 41.3 months. There was a survival benefit associated with patients undergoing radical cholecystectomy followed by adjuvant radiation (median OS 48.4 months vs. 22.3 months; HR 0.35; 95% CI: 0.13–0.98; p=0.0448) compared to simple cholecystectomy alone. On UVA, increasing age and positive margins were significantly associated with worse OS, while radical cholecystectomy was associated with improved OS. On MVA, increasing age, male gender, poorly differentiated tumor, and positive margins were associated with worse OS, while adjuvant radiation was associated with improved OS (p=0.0113). Conclusions: Our analysis supports the role for adjuvant radiation therapy in resected gallbladder cancer. Multi-institutional prospective studies should be performed to evaluate the optimal treatment strategy. Biomarker analysis might also help determine the subset of patients who would benefit from combined chemoradiation.

Radiotherapy in locally advanced pancreatic cancer: SEER experience

364

Background: Pancreatic cancer is the fourth most common cause of cancer deaths in the US. Despite the fact that the radiotherapy in addition to chemotherapy is frequently employed, the role of radiation therapy in the treatment of locally advanced pancreatic cancer (LAPC) remains controversial. The majority of the data evaluating the efficacy of this approach is derived from small randomized trials. Methods: The Surveillance, Epidemiology and End Results (SEER) registry dataset from 2004-2011 was queried to identify patients with locally advanced pancreatic adenocarcinoma. Pts with survival <2 months, unknown radiation status and those who received post-operative radiation were excluded. Multivariate analysis of prognostic factors related to survival was performed using a Cox proportional hazard regression model. Results: We identified 4,460 patients that met the inclusion criteria; 59% of pts received radiation and 41% did not. The two groups were similar with respect to gender, race and tumor differentiation. Pts in the radiation group were younger (ages<65: 49% vs. 38%), had smaller tumor size (largest dimension <4.5 cm: 80% vs. 75%), lesser lymph node involvement (33% vs. 36%) and lower rate of surgical resection (4% vs. 9%). Radiation treatment, age, tumor grade and surgical resection were significantly associated with survival on univariate analysis. Patients who received radiation therapy had better survival (median OS: 11 vs. 7 months; HR: 0.77; 95% CI 0.69-0.78). On the multivariate analysis, radiation was independently associated with improved survival (Table). Conclusions: In this population-based registry, radiation therapy was associated with improved survival in patients with LAPC in both univariate and multivariate analysis. Larger randomized trials are needed to confirm these findings. The optimal schedule and type of radiation therapy remains unknown. [Table: see text]

Phase I trial of enzalutamide in combination with gemcitabine and nab-paclitaxel for the treatment of advanced pancreatic cancer

467

Background: Despite recent advances, patients with metastatic pancreatic cancer have a very poor prognosis with a median survival of less than 1 year. Sex steroid hormones may play an important role in the growth and progression of pancreatic cancer. Anti-androgen drugs have demonstrated to have activity in pre-clinical pancreatic cancer models. In this Phase 1a/Ib trial, we evaluated the safety and tolerability of the combination of enzalutamide, a novel androgen receptor (AR) antagonist with gemcitabine and nab-paclitaxel. Methods: Pts with histologically confirmed metastatic pancreatic adenocarcinoma were included in this trial as a first-line treatment. Standard 3+3 dose escalation design was used to evaluate 2 dose levels of enzalutamide: 80 mg and 160 mg daily. Gemcitabine 1,000 mg/m2 was administered IV on days 1, 8 and 15 of 28-day cycle. The dose of nab-paclitaxel was 125 mg/m2 IV on days 1, 8 and 15. The DLT period was 28-days or until the beginning of the second cycle. Imaging studies were performed every 2 cycles. Results: Eight pts with stage IV pancreatic cancer have been enrolled in this trial, 5 pts at the first dose level and 3 pts at the second dose level. The median age was 64 years (50-80 years). All pts were male with an ECOG performance status of 1. Five pts had liver metastases. One patient was non-evaluable for DLT. No DLTs have been observed. Grade 3 treatment related AEs include febrile neutropenia (n=1), Neutropenia (n=1), ALT elevation (n=1). Grade 2 anemia and thrombocytopenia was seen in one patient. Grade 1 AEs included anemia (n=2), neutropenia (n=4), thrombocytopenia (n=3), diarrhea (n=1), fatigue (n=2), pruritis (n=1), nausea (n=1), hyponatremia (n=1) and AST elevation (n=1). Three pts had restaging studies performed and all had stable disease by RECIST criteria. There were decreases in size of target lesions in all the 3 patients along with a decrease in CA 19-9 levels. Conclusions: Enzalutamide at the dose of 160 mg daily is safe to administer in combination with gemcitabine and nab-paclitaxel. No unexpected toxicity has been observed. Cytopenias secondary to chemotherapy is common. Preliminary signals of efficacy were observed with this combination. Clinical trial information: NCT02138383.

Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreatic adenocarcinoma

360

Background: Limited data is available for neoadjuvant treatment of borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer. We update our institutional outcomes with a neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT) approach. Methods: We performed an IRB-approved analysis of all BRPC and LAPC patients treated with our departmental treatment protocol. After staging, medically fit patients underwent chemotherapy for 2-3 months, with regimen at the discretion of the treating medical oncologist (FOLFIRINOX, GTX, gem/abraxane, or gemcitabine alone). Patients then received SBRT delivered in 5 consecutive daily fractions with median radiation doses of 30 Gy to tumor and 40 Gy dose painted to tumor-vessel interfaces. This was followed by restaging imaging for possible resection. Overall survival (OS), event free survival (EFS), and locoregional control (LRC) rates were estimated and compared by Kaplan-Meier and log-rank methods. Results: We identified 159 patients, 110 BRPC and 49 LAPC, with 14.0 months median overall follow-up. The resection and margin negative (R0) rate for BRPC patients who completed neoadjuvant therapy was 50.9% and 96.4%, respectively. Estimated median OS was 14.4 months for BRPC patients and 11.3 months for LAPC patients (p=0.402). Median OS was 34.2 months for surgically resected patients vs 14.0 months for unresected patients (p<0.001). Five of 21 (23.8%) LAPC patients receiving FOLFIRINOX chemotherapy underwent R0 resection. In LAPC, FOLFIRINOX recipients underwent R0 resection more often than other chemotherapy recipients (5 of 21 vs. 0 of 28, p=0.011). There was a trend for improved survival in those resected LAPC patients (p=0.09). For those not undergoing resection, one year LRC was 78.4%. Grade ≥3 potentially radiation related toxicity rate was 6.9%. Conclusions: This data underscores the feasibility, safety, and effectiveness of neoadjuvant SBRT and chemotherapy for BRPC and LAPC. Compared with other chemotherapies, FOLFIRINOX induced greater tumor response in LAPC, permitting for R0 resection in a subset of LAPC patients and trend towards improved OS.

Resected pancreatic cancer outcomes in the elderly

OBJECTIVE

To determine if age affects outcome in patients with resected pancreatic head cancer.

MATERIALS AND METHODS

An IRB-approved pancreatic cancer database was queried for patients with upfront resected pancreatic head cancer treated at our institution between 2000 and 2012. Overall survival (OS) curves were calculated according to the Kaplan-Meier method and log-rank analysis. Multivariate analysis was performed using the Cox proportional hazard model.

RESULTS

We identified 193 patients. Patients ≥70 years were less likely to receive adjuvant treatment (p = 0.002); however there were no other significant differences between age groups. There was a trend towards increased pancreatic leaks in the elderly group (p = 0.06), but no difference in post-operative complications or mortality. There was no difference in overall survival based on age. Median and 5-year OS were 23 months and 26.7% in patients <70 years, 23.4 months and 23% in those 70-75, 16.1 months and 0% in those 76-80, and 18.7 months and 15.4% in those >80 years (p = 0.62). On univariate analysis, there was increased OS in patients with lower T stage, N0 status, post-operative CA19-9 level <90, and use of chemoradiotherapy (p< 0.05). Multivariate analysis revealed that lower tumor stage, N0, post-operative CA19-9 level <90, and use of any adjuvant therapy predicted decreased mortality (p < 0.05). Age, gender, tumor site, tumor grade, and positive margins were not prognostic on multivariate analysis.

CONCLUSIONS

There is no difference in outcomes when comparing elderly patients with resected pancreatic cancer to those patients <70 years of age.

Overall survival with preoperative biliary drainage in patients with resectable pancreatic cancer

314

Background: Resectable pancreatic cancer patients often present with obstructive jaundice necessitating the placement of biliary stents or percutaneouse drainage catheters. We sought to evaluate whether preoperative biliary drainage affects recurrence and survival. Methods: An IRB-approved study was conducted on our institutional tumor registry to identify pancreatic cancer patients who were treated with upfront surgery between 2000 and 2012. Patients were then stratified by preoperative use of endoscopically placed stents (ERCP), percutaneous catheters (PTC), or no biliary drainage (NBD). The primary endpoint was overall survival (OS). Survival curves were calculated using the Kaplan-Meier method and the log-rank test. Multivariate analysis (MVA) was performed with a Cox regression model. Results: We identified 202 patients for the study (21 PTC; 89 ERCP; 92 NBD). Key differences between the 3 groups were mean pathologic tumor size (p=0.005), pathologic T3/4 (p =0.01), and pathologic N1 (p=0.007) status, with more aggressive pathologic features in PTC patients. PTC patients had a non-significant increase in rate of hepatic recurrences compared with ERCP and NBD patients (47.4% vs. 26.6% vs. 28.7%, respectively; p=0.20). PTC patients also had worse median and 3 year survival (21 months and 16%) compared to ERCP (23.3 months and 39%) and NBD patients (29 months and 45%, p=0.02). MVA revealed that PTC was an independent predictor of worse overall survival (HR 2.3[95% CI 1.3-4.0], p=0.005), along with pathologic tumor size (HR 1.1[1.0-1.3], p=0.008), nodes positive (HR 1.1[1.1-1.2], p=0.001), and post-operative CA19-9 >90 (HR 2.6[1.5-4.4], p=0.001). Conclusions: Patients with resectable pancreatic cancer who require a pre-operative PTC drain had a non-significant increase in hepatic recurrence rate and worse overall survival than patients who either had an ERCP stent placed or no biliary decompression prior to surgery. Given their worse prognosis, patients who require PTC placement might also benefit from neoadjuvant treatment with restaging prior to surgery.

Utility of PET/CT as initial staging work up for early pancreatic cancer

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Background: In pancreatic cancer, early detection and complete surgical resection with negative margins offers the only cure for the disease. Work up to evaluate resectability includes triple phase helical scan CT of the pancreas and endoscopic ultrasound (EUS). A paucity of data exists in using PET/CT scan as staging work up in early resectable pancreatic cancer. The objective of our study was to determine if PET/CT prevents futile laparotomy by detecting occult metastatic disease in patients with resectable/borderline pancreatic cancer. Methods: We looked at our institutional PET/CT data base incorporating National Oncologic PET Registry (NOPR) with diagnosis of resectable or borderline pancreatic cancer from 2005-2012. Clinical, radiographic, and pathologic follow-up was evaluated, including age, gender, evidence of metastatic disease, and initial CA 19–9 levels. The impact of PET/CT on patient management was estimated by calculating the percentage of patients whose treatment plan was altered due to PET/CT. The confidence interval was computed using the exact binomial distribution. The effect on the change was evaluated by the multiple logistic regression model. The final model was selected using the backward elimination method. Results: 287 patients with early stage (resectable or borderline) pancreatic cancer who received PET/CT as part of initial staging workup were identified. Upon initial work up (CT + EUS), 62% of patients were considered resectable and 38% were borderline resectable. However, PET/CT findings changed the management in 11.9% (n=34) of patients (95% CI: 0.084 – 0.162). 33 patients were upstaged to stage IV and 1 patient was upstaged to stage III. Median time from CT to PET/CT was 5 days. Metastatic lesions were confirmed with biopsy in 21 patients. The proportion in the change in treatment plan is significantly higher in patients who were borderline resectable (p=0.005; OR=2.94; 95% CI: 1.38 – 6.26). In 204 patients who were taken to surgery, 17.7% (n=36) were found to have metastatic disease intraoperatively. Conclusions: PET/CT helped improve detection of occult metastases, ultimately sparing these patients a potentially unnecessary operation. The role of PET/CT scan should be validated in prospective study.

A phase 2, randomized trial of GVAX pancreas and CRS-207 immunotherapy versus GVAX alone in patients with metastatic pancreatic adenocarcinoma: Updated results

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Background: Immunotherapy for pancreatic ductal adenocarcinoma (PDA) is likely to require synergistic combinations. One approach is to use heterologous prime boost vaccinations to capitalize on immunostimulatory features of distinct vectors. GVAX is irradiated, GM-CSF-secreting allogeneic pancreatic cell lines given intradermally to elicit a broad antigenic response. Low-dose cyclophosphamide (CY) is given prior to GVAX to inhibit regulatory T-cells. CRS-207 is live-attenuated Listeria monocytogenes (Lm) which expresses mesothelin and stimulates innate and adaptive immunity. In mouse tumor models, Lm/GVAX vaccines are synergistic and in the Phase 1 study of CRS-207, 3 PDA patients who had received prior GVAX lived ≥15 months (mos). Methods: Metastatic PDA patients (ECOG 0-1; adequate organ function) who received or refused ≥1 prior chemotherapy were randomized 2:1 to receive either 2 doses of CY/GVAX followed by 4 doses of CRS-207 (Arm A) or 6 doses of CY/GVAX (Arm B) every 3 weeks. Courses could be repeated. The primary endpoint was to compare overall survival (OS) between the arms. Secondary endpoints were safety, clinical and immune responses. One-sided p-values are reported. Results: 90 patients (Full Analysis Set [FAS]; A: 61, B: 29), of which 51% had received ≥2 chemotherapy regimens for metastatic PDA, were treated. After a median follow-up of 7.8 mos, median OS in FAS was 6.1 vs 3.9 mos (A vs B; HR=0.54, p=0.011). Median OS in patients who received ≥3 doses (per protocol [PP] set: 2 doses of CY/GVAX and ≥1 dose of CRS-207 in A or ≥3 doses of CY/GVAX in B) was 9.7 vs 4.6 mos (A vs B; HR=0.44, p=0.0074). The treatment effect was particularly evident in patients who received ≥2 prior regimens for metastatic PDA with median OS of 5.1 vs 3.7 mos (A vs B; HR=0.34, p=0.001). OS in the PP set was 8.2 vs 4.0 mos (A vs B; HR=0.23, p=0.0003). CA19-9 stabilization was seen in 32% vs 13% of patients (A vs B; p=0.06). Toxicities included local reactions after GVAX and transient fevers, rigors and lymphopenia after CRS-207. Conclusions: CY/GVAX followed by CRS-207 shows extended survival with manageable toxicity in previously-treated metastatic PDA and warrants further study. Clinical trial information: NCT01417000.

Final result of a phase I study of combination of pasireotide (SOM 230) LAR plus gemcitabine in metastatic pancreatic cancer (MPC)

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Background: Pasireotide is a cyclohexapeptide engineered to bind to multiple somatostatin (SST) receptor subtypes (SST 1, 2, 3, and 5) to mimic the action of natural somatostatin with 40-times higher affinity for SST1 and SST5 and 5-times higher affinity for SST3 compared to octreotide and is potent inhibitor of insulin-like growth factor-1 (IGF-1). SST receptors and IGF receptors are highly expressed in pancreatic cancer, therefore potentially making it a valuable target. Methods: A 3+3 dose escalation design was used; patients with previously untreated MPC were eligible for the trial. Patients received GEM 1000 mg/m2(30-min, once-weekly IV infusion for 3 out of 4 weeks) and SOM 230 LAR according to dose escalation. Two dose levels were planned, 40mg IM and 60 mg IM once a month. Cohort was expanded to 10 more patients at the highest tested dose to further access safety and efficacy. IGF-1, IGFBP (insulin-like growth factor binding protein)-1, and IGFBP-3 were measured at baseline and with each restaging. Results: 20 patients enrolled with this study were treated and 16 patients (median age 65.5 years; male/female 6:10) were evaluable for safety and efficacy. No dose limiting toxicities were observed with the two used doses, therefore cohort at 60mg was expanded to 10 patients to assess efficacy. 12 % (2/16) of patients had partial responses (PR), 56% (9/16) had stable disease (SD) as best response. Median PFS was 4.1 months (range 1 to 16 months) and median overall survival was 6.8 months. Most common grade 3 or 4 toxicities were hyperglycemia (n=5), increased bilirubin (n=2), neutropenia (n=1), thrombocytopenia (n=1) and fatigue (n=1). Median baseline IGF-1 level was lower in Pts with stable disease than in progressive disease (63 vs.71 ng/mL), the median drop in the level of IGF-1 between the first cycle and the last cycle was more prominent in the stable disease than progressive disease (16 vs. 28 ng/mL). Conclusions: Pasireotide in combination with gemcitabine was well-tolerated. The disease control rate (56% SD + 12% PR) in patients with MPC. Baseline IGF-1 level may potentially be a prognostic and predictive biomarker for pasireotide. These results are promising and warrant further evaluation. Clinical trial information: NCT01385956.

Survival benefits of adjuvant radiotherapy and lymph node dissection in pancreatic cancer treated with surgery and chemotherapy

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Background: Prior SEER analyses of the benefit of radiotherapy in surgically resected pancreatic cancer could not analyze chemotherapy recipients due to limited database information. Recent updates permit us to determine the effects of postoperative radiation therapy (PORT) and lymph node resection (LNR) on overall survival (OS) in pancreatic cancer among patients treated with both surgery and chemotherapy. Methods: An analysis of surgically resected pancreatic cancer patients receiving chemotherapy from the SEER database between 2004-2008 was performed. Survival was calculated by Kaplan-Meier method and log-rank analysis. Multivariate analysis (MVA) was by the Cox proportional hazard model. Results: We identified 2,966 patients who met inclusion criteria. PORT significantly improved OS in pancreatic cancer patients treated with surgery and chemotherapy (p=0.02). Median survival (MS), 1-year OS, and 3-year OS was 21 months, 77%, and 28% with PORT (n=1842) versus 20 months, 70%, and 25% without radiation (n=1124). On subset analysis, the benefit of PORT was limited to node positive patients. In N1 patients (n=2043) MS, 1-year OS, and 3-year OS was 19 months, 73%, and 25% with PORT versus 18 months, 67%, and 20% without PORT (p<0.01). For N0 patients (n=923) MS, 1-year OS, and 3-year OS was 26 months, 85%, and 36% with PORT versus 25 months, 79%, and 38% without PORT (p=0.87). Increasing nodal count on LNR correlated with improved OS on MVA for all and N1 patients (each p<0.001). Significant cut points for OS based on LNR in N1 patients were found for greater than 8, 10, 12, 15, 20, and 30 nodes resected (p<0.05 for all). Prognostic factors on MVA include receipt of radiation, age, female sex, well differentiated grade, N0 status, and disease contained within the pancreas (p < 0.03 for all). In N1 patients (n=2043), these factors remained significant except patient age. In N0 patients (n=923), only pancreas-confined disease and less than high grade tumor were associated with survival benefit. Conclusions: PORT and degree of LNR are both correlated with improved OS in pancreatic cancer patients treated with surgery and chemotherapy. Benefit of PORT and LNR seems limited to node positive patients.

Outcomes of adjuvant radiotherapy and lymph node dissection in elderly patients with pancreatic cancer treated with surgery and chemotherapy

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Background: To determine the effects of postoperative radiation therapy (PORT) and lymph node resection (LNR) on survival in patients age ≥ 70 with pancreatic cancer treated with surgery and chemotherapy. Methods: An analysis of patients with surgically resected pancreatic cancer who received chemotherapy from the SEER database from 2004-2008 was performed to determine association of PORT and LNR on survival. Survival curves were calculated according to the Kaplan-Meier method and log-rank analysis. Multivariate analysis (MVA) was performed by the Cox proportional hazard model. Results: We identified 961 patients who met inclusion criteria. The only significant difference between PORT patients and no PORT patients was age, median 75 and 76 years, respectively (p=0.007). Overall survival (OS) in PORT versus no PORT was not statistically different in the whole cohort (p=0.064), N0 (p=0.803) or N1 (p=0.0501). On univariate analysis (UVA) there was increased OS in patients with lower T stage (p<0.001), N0 status (p<0.001), lower AJCC stage (p<0.001) and lower grade (p<0.001). No OS difference was seen based on gender, location, or PORT. There was no difference in OS based on number of lymph nodes removed in all patients (p=0.74), N0 (p=0.59), and N1 (p=0.07). MVA for all patients revealed higher T stage, N1, and high grade were prognostic for worse mortality, while there was a trend for decreased mortality with PORT (p=0.052). In N0 patients, increased T-stage and grade were prognostic for worse survival, while PORT and number of lymph nodes removed were not. In N1 patients, higher T-stage and grade were prognostic for increased mortality, while increasing number of lymph nodes removed was associated with decreased mortality. PORT trended towards improved survival in N1 patients (p=0.06). Age, gender and tumor location were not prognostic for survival. Conclusions: Adjuvant radiation therapy and number of lymph nodes removed in patients age ≥70 does not seem to correlate with increased OS in surgically resected pancreatic cancer treated with chemotherapy. Future clinical trials will need to address age as a stratification factor for pancreatic cancer in the adjuvant setting.

Adjuvant radiotherapy and lymph node dissection in pancreatic cancer treated with surgery and chemotherapy

BACKGROUND

The objective of this study was to determine the effects of postoperative radiation therapy (PORT) and lymph node dissection (LND) on survival in patients with pancreatic cancer.

METHODS

The 2004 to 2008 Surveillance, Epidemiology, and End Results (SEER) database was analyzed to identify patients with pancreatic cancer who underwent surgery and received chemotherapy and to evaluate the correlation between overall survival (OS), PORT, and LND.

RESULTS

In total, 2966 patients were identified who underwent pancreatic resection (1842 PORT, 1124 no PORT). Median survival, 1-year OS, and 3-year OS were 21 months, 77%, and 28%, respectively, with PORT versus 20 months, 70%, and 25%, respectively, without PORT (P = .02). Subset analysis revealed that the benefit of PORT was limited to lymph node-positive (N1) patients. Median survival, 1-year OS, and 3-year OS for patients with N1 disease were 19 months, 73%, and 25%, respectively, for those who received PORT versus 18 months, 67%, and 20%, respectively, for those who did not receive PORT (P < .01). An increasing lymph node count was associated with increased survival on multivariate analysis in all patients and in patients with N1 disease (both P < .001). Significant cutoff points for OS based on LND in patients with N1 disease were identified for those who had ≥8, ≥10, ≥12, ≥15, and ≥20 lymph nodes resected. Multivariate analysis for OS revealed that increasing age, T3 and T4 tumors, N1 stage, and moderately and poorly differentiated grade were prognostic for increased mortality, while female gender, PORT, and LND were prognostic for decreased mortality. In patients with N1 disease, other than patient age, all of these factors remained significant. In patients with N0 disease, only T1 and T2 tumor classification and having a tumor that was less than high grade were associated with survival benefit.

CONCLUSIONS

This SEER analysis demonstrated an associated survival benefit of PORT and LND in patients with N1, surgically resected pancreatic cancer who received chemotherapy.

Lysophosphatidic acid acyltransferase beta regulates mTOR signaling

Lysophosphatidic acid acyltransferase (LPAAT-β) is a phosphatidic acid (PA) generating enzyme that plays an essential role in triglyceride synthesis. However, LPAAT-β is now being studied as an important regulator of cell growth and differentiation and as a potential therapeutic target in cancer since PA is necessary for the activity of key proteins such as Raf, PKC-ζ and mTOR. In this report we determine the effect of LPAAT-β silencing with siRNA in pancreatic adenocarcinoma cell lines. We show for the first time that LPAAT-β knockdown inhibits proliferation and anchorage-independent growth of pancreatic cancer cells. This is associated with inhibition of signaling by mTOR as determined by levels of mTORC1- and mTORC2-specific phosphorylation sites on 4E-BP1, S6K and Akt. Since PA regulates the activity of mTOR by modulating its binding to FKBP38, we explored the possibility that LPAAT-β might regulate mTOR by affecting its association with FKBP38. Coimmunoprecipitation studies of FKBP38 with mTOR show increased levels of FKBP38 associated with mTOR when LPAAT-β protein levels are knocked down. Furthermore, depletion of LPAAT-β results in increased Lipin 1 nuclear localization which is associated with increased nuclear eccentricity, a nuclear shape change that is dependent on mTOR, further confirming the ability of LPAAT-β to regulate mTOR function. Our results provide support for the hypothesis that PA generated by LPAAT-β regulates mTOR signaling. We discuss the implications of these findings for using LPAAT-β as a therapeutic target.

Phase I study of combination of pasireotide (SOM 230) plus gemcitabine in metastatic pancreatic cancer (MPC)

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Background: For the past decade, gemcitabine (GEM) has been considered the standard chemotherapeutic agent in the treatment of MPC. SOM-230 is a multi-targeted somatostatin (SST) receptor (sst1,2,3 and 5) analog with five times the affinity of other SST receptor analogs and a potent inhibitor of insulin growth factor -1(IGF-1). SST receptors and IGF receptors are highly expressed in pancreatic cancer therefore potentially making it a valuable target. Methods: Patients with previously untreated MPC and ECOG PS 0-1 were eligible for the trial. A 3+3 dose escalation design was used. Patients with MPC received GEM 1000 mg/m2 (30-min, once-weekly IV infusion for 3 out of 4 weeks) and SOM 230 according to dose escalation. 2 dose levels (DL) were planned. (40mg and 60 mg IM once a month). Following MTD determination the plan was to expand the cohort to 10 more patients to assess efficacy. In the expanded cohort plasma levels of IGF-I, IGFBP (insulin growth factor binding protein)-1, and IGFBP-3 were measured at baseline and with each restaging CT scan. Results: 20 patients were enrolled with 16 patients evaluable for safety and efficacy. 3 patients were each enrolled in DL1 and DL2. No dose limiting toxicities related to SOM 230 were observed at any dose level. MTD was not reached. Therefore cohort at 60mg was expanded to 10 patients to assess efficacy. Median age was 65.5 years; 6 males and 10 females. Most common grade 3 or 4 toxicities were hyperglycemia (n=5), increased bilirubin (n=2), neutropenia (n=1), thrombocytopenia (n=1) and fatigue (n=1). Two of 16 evaluable pts (12%) had confirmed partial responses (PR), and 9 had stable disease (56%) as best response. Median PFS for all pts was 4.1 months and overall survival was 8.0 months. As of Feb 2nd2013 there are 3 patients who are still actively receiving treatment on the trial. One patient still has stable disease after 11 months. Plasma levels of IGF-I, IGFBP-1, and IGFBP-3 were measured and will be presented. Conclusions: SOM 230 (60 mg IM monthly) plus gemcitabine was well tolerated in pts with MPC. Preliminary efficacy in a cohort of 16 pts with MPC looks promising and warrants further evaluation Clinical trial information: NCT01385956.

Interim safety and efficacy analysis of a phase II, randomized study of GVAX pancreas and CRS-207 immunotherapy in patients with metastatic pancreatic cancer

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Background: GVAX is composed of GM-CSF-secreting allogeneic pancreas cancer cell lines and administered with low-dose cyclophosphamide (CY) to inhibit regulatory T cells. In prior studies, GVAX induced mesothelin-specific T cell responses that correlated with survival. CRS-207 is a live-attenuated Listeria monocytogenes engineered to express human mesothelin. CRS-207 stimulates potent innate and adaptive immunity and has shown synergy with GVAX in mouse tumor models. Anecdotal survival benefit was observed in the CRS-207 phase I study in patients who received prior GVAX. Methods: Patients were enrolled with metastatic pancreatic ductal adenocarcinoma (PDA) who received or refused ≥ 1 prior chemotherapy, had ECOG ≤ 1 and adequate organ function. Patients were randomized 2:1 to receive 2 doses of CY/GVAX followed by 4 doses of CRS-207 (Arm A) or 6 doses of CY/GVAX (Arm B) every 3 weeks. Clinically stable patients were offered additional 20-week courses. The primary endpoint was comparison of OS between treatment arms. Secondary endpoints were to evaluate safety, clinical and immune responses. Results: 90 patients were treated (Arm A: 61, Arm B: 29). As of Jan 2013, 27 patients completed 1 course (A: 24, B: 3) and 17 patients (A: 15, B: 2) initiated a 2nd course. Median age was 63. Median number of prior regimens was 3. No treatment-related serious adverse events (SAEs) or unexpected toxicities were observed. The most frequent Grade (G) 3/4 related toxicities were fever, lymphopenia, hypophosphatemia, elevated liver enzymes, and fatigue following CRS-207 in <5% of subjects. Of 51 patients evaluated post-treatment, 34% had stable disease in Arm A vs. 19% in Arm B. OS for all patients treated was 6 months in Arm A vs. 3.4 months in Arm B (two-sided, p=0.0114). Conclusions: Combined CY/GVAX pancreas and CRS-207 was generally well-tolerated with no treatment-related SAEs or unexpected G3/4 toxicities. The significant difference in OS between treatment arms met the criteria for early stopping. This indicates that the combination immunotherapy may extend OS for metastatic PDA patients with minimal toxicity and should continue to be developed as an effective therapy. Clinical trial information: NCT01417000.

Stereotactic body radiation therapy for locally advanced and borderline resectable pancreatic cancer is effective and well tolerated

PURPOSE

Stereotactic body radiation therapy (SBRT) provides high rates of local control (LC) and margin-negative (R0) resections for locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC), respectively, with minimal toxicity.

METHODS AND MATERIALS

A single-institution retrospective review was performed for patients with nonmetastatic pancreatic cancer treated with induction chemotherapy followed by SBRT. SBRT was delivered over 5 consecutive fractions using a dose painting technique including 7-10 Gy/fraction to the region of vessel abutment or encasement and 5-6 Gy/fraction to the remainder of the tumor. Restaging scans were performed at 4 weeks, and resectable patients were considered for resection. The primary endpoints were overall survival (OS) and progression-free survival (PFS).

RESULTS

Seventy-three patients were evaluated, with a median follow-up time of 10.5 months. Median doses of 35 Gy and 25 Gy were delivered to the region of vessel involvement and the remainder of the tumor, respectively. Thirty-two BRPC patients (56.1%) underwent surgery, with 31 undergoing an R0 resection (96.9%). The median OS, 1-year OS, median PFS, and 1-year PFS for BRPC versus LAPC patients was 16.4 months versus 15 months, 72.2% versus 68.1%, 9.7 versus 9.8 months, and 42.8% versus 41%, respectively (all P>.10). BRPC patients who underwent R0 resection had improved median OS (19.3 vs 12.3 months; P=.03), 1-year OS (84.2% vs 58.3%; P=.03), and 1-year PFS (56.5% vs 25.0%; P<.0001), respectively, compared with all nonsurgical patients. The 1-year LC in nonsurgical patients was 81%. We did not observe acute grade ≥3 toxicity, and late grade ≥3 toxicity was minimal (5.3%).

CONCLUSIONS

SBRT safely facilitates margin-negative resection in patients with BRPC pancreatic cancer while maintaining a high rate of LC in unresectable patients. These data support the expanded implementation of SBRT for pancreatic cancer.

Efficacy and feasibility of chemotherapy and radiation therapy for borderline resectable pancreatic cancer in elderly patients

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Background: To date there have been few studies evaluating the efficacy and tolerability of aggressive neoadjuvant chemotherapy and radiation therapy (RT) for patients ≥70 years of age with borderline resectable pancreatic cancer (BRPC). Methods: We performed a retrospective review of our institutional experience treating BRPC from 2006 to June 2012. All patients were staged with a pancreas protocol CT scan, endoscopic ultrasound, and PET/CT scan. The diagnosis of BRPC was confirmed by our GI Tumor Board prior to treatment. Our institutional preference for preoperative chemotherapy included gemcitabine, paclitaxel and capecitabine (GTX). RT techniques included intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT). Restaging scans were performed after RT completion and patients were then considered for surgical resection. The data was analyzed using Kaplan-Meier and Cox regression analysis. Results: This study included 72 BRPC patients with a median age of 65 years (range 36-87). 24 patients (33%) were ≥70 years old. Median follow up for all patients was 12.7 months. 56 patients (77%) received preoperative GTX. Of the patients ≥70 years, 7 were treated with IMRT and 17 with SBRT, compared to 8 who were treated with IMRT and 40 with SBRT in the younger cohort. In the older group, 11 patients (46%) underwent surgery with all attaining microscopically negative margins (R0), compared with 32 patients that underwent surgery in the younger cohort (61.7%), 29 of which received R0 margins (90.6%). Median survival for patients ≥70 years old was 12.6 months compared to 12.8 months for the younger patients. There was no difference in overall survival (p =.606) or progression free survival (p = .312) between the two groups. Multivariate analysis showed that surgery in the entire group was significantly associated with an improvement in overall survival (p = .011). Conclusions: Our data indicates that aggressive neoadjuvant chemotherapy and RT is equally effective for older patients. Neoadjuvant therapy for BRPC should not be withheld basely solely on patient age.