Moderate dose serial therapy for aged and resistant patients with cholangiocarcinomas

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Background: Advanced (Adv) intrahepatic IH Cholangiocarcinoma BD trials found multi-drug, sequences (GFLIO) safely expand eligibility (El) for patients (pts) of all ages -/+ resistant Ca (R). Two series had response/survival (S) of 80% / > 2 years (yr) (Bruckner et al Anti Ca Res 16). Therapy reverses R to key drugs, improves the pts' many immune functions and exposure to neoantigens, (Caraglia RT et al Front Oncol 19.) A.L.A.N.(AS) blood tests (Ts) predict chances of S (Salati et al EuJCa 18). Methods: Kaplan-Meier analyses examine prognostic Ts as El criteria for real-world pts. El included poor risk pts: any adult age, +/- R (-/+ prior test drugs). El: Intent to treat; consent; adv measurable IHBD; active progression (pg); Performance 0-2 and expected 6 wks S. The inE have 2ary CNS, require IVs; are unable to reach office, or have gr3-4 toxicity. GFLIO every 2 wks in mg/M2: Gemcitabine 500; 5-Fluorouracil 1200 over 24 hrs; Leucovovorin 180 Irinotecan 80 and day (D)2, Oxaliplatin 40. On pg, drugs are added, none are discontinued: D2 docetaxel 20-25, -/+ Mitomycin C 4-6; on 2nd pg, D1 Cetuximab is added (KRAS wild), wkly, and replaced on 3rd pg with D1 bevacizumab 10 mg/kg every 2 wks. Baseline A.L.A.N. assays (AS) are in Salati ibid. Results: Survival of the 35 pts, 19 R, is: 84% at 1 yr and 64% (CI 50-78%) at 2 yrs, median S CI 22.5 - > 24 mos; S at 12, 18 and 24 mos: with no unfavorable (UF) AS0 Ts (12 pts), is 100, 100, and 90%; with 1-2 UF Ts (15pts), is 76, 66 and 66% (CI > 56%). With 3-4 UF Ts (8 pts) S is 67, 34, and 13%. The old, 14 > 70, and young S similarly (̃); 4/4 > 75 S in remission for > 2 yr. p. 0.36, HR 1.68. Pts, 19R/16 - prior therapy, S similarlỹ, p 0.96, HR 1.03; both groups have similar ̃ Ts AS. Females, 17, and males, in spite of a cluster with UF AS 3-4, have similar ̃ S, p 0.6, HR 1.4. GFLIO induction produced neither hospitalizations, neutropenic fevers nor severe neuropathy and no initial need for prophylactic or high dose granulocyte factors. Favorable (Fav) Ts include: low < 3.1 neutrophile-lymphocyte ratio, 57%of pts, 81% S 2yr, p 0.005 HR 9.4; 2-4/4 fav ALAN Ts, 77% of pts,78% S 2 yr, p 0.007, hr 6.3; low < 300,000 platelets 71%, 80% S 2 yr, p 0.01, HR 1.7, and high > 3.5 albumin,74% of pts,72% S 2yr, p 0.03, HR 3.9. Groups defined by single UF Ts (except low albumin, 33% S 2 yr) S > ̃ 50% at 2 yr. Conclusions: A real world, safe, survival of > 2yr, is confirmed in this 3rd series. This meets NCI criteria for: selective use, and development of GFLIO's elements (lowest effective dosages and sequential regimens), and prognostic tests (criteria and models). Therapy can, in theory, correct UF T's - pathology. When matched for AScore, GFLIO is ̃ effective, -/+, R and at all ages. Tests and GFLIO can change practice, improve El and survival for under treated pts, some half of all pts, the aged and the Resistant, told they have "only 6 or 12 mos to live." Clinical trial information: NCT01905150.

Blood tests to predict one- to two-year survival of patients with difficult cancers

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Background: A sequence of drug combinations produces > 1 median (M) -strong 2-year (yr) survival (S) (Bruckner et al AACR 14 Antica Res (ACR) 16, 18 SIGO 19). Trials included high-risk patients (pts). Each initial series has 5-yr Ss, after pts were referred for hospice care. Prognostic ALAN blood tests (Ts) have been validated for stage IV (Adv) Cholangiocarcinoma (CCA) (Salati et al EuJCa18). Other Ts predict unexpected favorable (F) S of pts with gastric ca, PS 2-3. Bruckner et al JAMA, 82); but, there is little known about Ts for resistant (R) Ca. Methods: Planned Kaplan-Meier intent to treat analysis to find Ts that: expand eligibility (El) for therapy; identify biomarkers that predict therapy can prolong S and identify new hypotheses for therapy. El pts have:R to test drugs, Pancreatic (PC), Intrahepatic bile duct, CCA, Colon, CRC and new (N) APC. All series: -/+ high risk, -/+ aged, PS 0-2. El: Helsinki criteria- consent, recovered from severe (gr3) toxicity; able to reach office, -/+ help, and S > 6 wks. Inel: CNS involved, IV needed, F clinical factors predict 1 yr MST. Ts include A.L.A.N. scores, (AS) (Salati ibid) and other blood Ts (ACR ibid, Lavin et al CTR 82) Therapy GFLIO in mg/M2: gemcitabine 500, leucovorin 180, fluorouracil 1200, 24 hr infusion. Irinotecan 80 D2 Oxaliplatin 40. Then for progression (pg), add docetaxel 20-25, except CRC mitomycin C 4-6; next pg add cetuximab, except APC or KRAS-M, weekly, and next pg replace cetuximab with bevacizumab 10mg/kg ibid ACR 16. Results: At all ages, overall (O) S is > 1 yr for RCRC, and NAPC and sets with any 1 F or UnF T other than < 3.1 Albumin (Alb) or < 2.1 lymph/monocyte ratio (LMR) b For CCA, 17R/16N, OMS > 2 yrs 66% of pts and ≥ 2 yrs for all test sets except UnF, 26% of pts, MS 17 mos, with low Alb. For CRC: 50R OMS is 16.5 mos; 42% S 2 yrs, Fav Ts: MS > ̃ 2yrs, 39-82% of pts have FTs; Neutrophil Lymphocyte Ratio (NLR); < 3.1, 61% S 2 yrs, p < .02; Lymphs > 1.5, 53% S 2 yrs, p < .02; AS 0; 59% S 2 yrs, p < .06; Platelets < 300,000, 54% S 2 yrs, p < .06; Alb: ≥ 3.5, 48% S 2 yrs, p < .11. For N-APC: 53 pts, OS is 14.5 mos and > 12 mos in sets with any 1 UnF T other than Alb or LMR. FTs: MST 16.4-18 mos. 34-77% of pts have FTs; Alb ≥ 3.5, 34% S 2 yrs, p < 0.001; WBC < 10, 29% S 2 yrs, p < .06; AS 0-2, 35% S 2 yrs, p 2.7E-7. For R-PC: 53 pts, OS is 12 mos for 44% of pts, FTs: MST 13.6-17 mos, 21-70% of pts have FTs: Alb ≥ 3.5 30% S 2 yrs, p .0004; AS: 0, 41% S 2 yrs, p .0006; NLR < 3, 37% S 2 yrs, p < .02. GFLIO’s < 5% gr3 induction toxicity, is reversible, with no hospitalization, neutropenic fever or gr3 neuropathy. Conclusions: Robust Ts identify many difficult pts with median > 1 and testable prospective > 2 yr rates of S. Ts warrant development: validation with GFLIO and other therapy and other cancers; to improve Ts, models for eligibility and geriatric criteria; to identify false -/+ trials; and personalize trials to correct UnF Ts. FTs, with GFLIO, can change prognosis and practice for > 50% of pts now advised “against” any therapy due to a clinical estimate of “less than 6 -10 mos to live.” Clinical trial information: NCT01905150.

Survival and prognostic tests in a real-world phase II experience with a safe, moderate-dose, sequential chemotherapy (CT) algorithm (ALGO) for metastatic pancreatic adenocarcinoma (PANC)

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Background: Gemcitabine (G), 5-fluorouracil (F), leucovorin (L), irinotecan (I), and oxaliplatin (O), (GFLIO) is safe, employs moderate 1/2-1/3 dosages, offers expanded eligibility (0-2 ECOG PS; no age limit)). Each step reverse resistance (RR) to CT; drug synergism 4-6 simultaneous pairs) improve responses (Rs) and survival (S) (Bruckner ASCO 05, 08, 11, AntiCancer Res 2016; 36 (1), 2018; 38 (1) (ACR), and the immune system (Correale P: J. Immunother 2014; 37). M Caraglia: Front Oncol. 2019). Methods: Eligibility: intent to treat active metastatic PANC, no prior CT: any age: PS 0-2 and expected > 6 weeks S. IRB required safety < 1/10 severe events. ALGO in mg/m2: G 500, F 12-1500 over 24 hrs, L 180, I 80, day2 O (GFLIO) q2 wks, and on progression added in sequence, day 2, docetaxel 20-25 and good counts only mitomycin C 3-6 then bevacizumab 10mg/kg with prior monitoring and modifications (ACR). Median 12, 18, 24 mos Overall Survival (OS), Kaplan Meier estimates with 95% CI were evaluated with age, sex and normal nl and abnl baseline bloods: neutrophils N ANC; Lymphs Ly ALC; platelets; albumin (ALB); Alkaline phosphatase (Alk Ph) abn N alb 3.5 N/L; 2.1 L/monocyte ratios and the A.L.A.N (AS) composite prognostic score (M. Salati E.J.Ca. 2019; 117: 84-90). Results: OS @ 6, 12, 18 & 24 mos, for 53 pts, was 75; 57; 36; 26 % (+/- 8-10%). Median M S was 14.5 mo (CI 9-17mos); S @ all ages ≥ 60, 65 or 70, was not inferior. Women's M S 17 mo. was > men's 10.5: 95/65; 75/46; 48/29; 42/29%. AS for abnl tests was: 0 (18pts): 93: 81: 48; 34% & MS 17 mo vs 1-2 (23)90: 58;42;32% & MS 15.5mo vs 3-4 (12)MS 3 mo. Pts with best 17-14.5 mo MS had nl AS 0 > Alb > AS 1-2 > APh > ANC. Pts with worst 3-6 mo MS had abnl: AS 3-4 < Alb < ANC. No pt had severe infection, neuropathy or gastroenteritis. Pts -/+ 75-100gm ascorbic acid, 25, did not have inferior S in ALAN subsets (H.Bruckner AACR 17). Conclusions: The sequential moderate dose CT ALGO improves eligbility and provides pts with metastatic PANC of any age a well tolerated CT regimen with a high therapeutic index and strong, 12, 18, 24 mo, survival. Prognostic tests can identify subgroups ≥ 75% with favorable vs. unfavorable criteria and improve personalized choices and measures to remedy individual risk factors. Clinical trial information: NCT01905150 .

A Phase I-II Study Using Rexin-G Tumor-Targeted Retrovector Encoding a Dominant-Negative Cyclin G1 Inhibitor for Advanced Pancreatic Cancer

Rexin-G is a replication-incompetent retroviral vector displaying a cryptic SIG-binding peptide for targeting abnormal Signature (SIG) proteins in tumors and encoding a dominant-negative human cyclin G1 construct. Herein we report on the safety and antitumor activity of escalating doses of Rexin-G in gemcitabine-refractory pancreatic adenocarcinoma, with one 10-year survivor. For the safety analysis (n = 20), treatment-related grade 1 adverse events included fatigue (n = 6), chills (n = 2), and headache (n = 1), with no organ damage and no DLT. No patient tested positive for vector-neutralizing antibodies, antibodies to gp70, replication-competent retrovirus (RCR), or vector integration into genomic DNA of peripheral blood lymphocytes (PBLs). For the efficacy analysis (n = 15), one patient achieved a complete response (CR), two patients had a partial response (PR), and 12 had stable disease (SD). Median progression-free survival (PFS) was 2.7, 4.0, and 5.6 months at doses 0–I, II, and III, respectively. Median overall survival (OS) and 1-year OS rate at dose 0–I were 4.3 months and 0%, and at dose II–III they were 9.2 months and 33.3%. To date, one patient is still alive with no evidence of cancer 10 years after the start of Rexin-G treatment. Taken together, these data suggest that Rexin-G, the first targeted gene delivery system, is uniquely safe and exhibits significant antitumor activity, for which the FDA granted fast-track designation.

Broad safety impact of high-dose ascorbic acid and induction chemotherapy for high-risk pancreatic cancer

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Background: High dose ascorbic acid inhibits many tumors in vitro. It may reduce chemotherapy's adverse hematologic events and improve quality of life. Moderate dose gemcitabine, fluorouracil, leucovorin, irinotecan, oxaliplatin (GFLIP) is an effective regimen for patients with many cancers (Anticancer Research 17). High dose ascorbic acid may reverse half the preexisting and largely eliminate the predicted cumulative toxicity of GFLIP (ASCO 15). Methods: High dose ascorbic acid AA 75-100 grams IV was given 1-2 times per week with GFLIP every 2 weeks until progression with serial wkly and Q2wk blood tests and 3 month imaging. Eligibility: Unresectable, III, recurrent and metastatic, mod and high grade typical pancreatic ca; ECOG 0-2; +/- prior chemo; adults of any age with consent. Results: A prescheduled 2 yr analysis found 26 patients; 16 ≥ 65, (9 ≥ 70 years of age). 25 stage IV; Nine had failed at least one prior standard chemo (35%), 3 were PS 2, 9 had severe weight loss. Safety: Five had uncomplicated 3 (19%) and none had 4 neutropenia or neutropenic infection, one (4%) had a 3 anemia and thrombocytopenia without bleeding. Prophylactic growth factors were not used and limited to 1-2 as needed low doses used infrequently. There was no limiting diarrhea, enteritis, stomatitis, weight loss or coagulopathy due to GFLIP. GFLIP is on track to reproduce/retain prior response and survival benefit (ASCO 08). Conclusions: Ascorbic Acid-GFLIP can be exceptionally safe and well tolerated. It may avoid standard 20-40% rates of severe toxicities. It can be, otherwise unavailable, safe reduced cost, treatment for many elderly and prior resistant tumor patients. Given the broad multi-disease role of the GFLIP drugs, and available personalized medicine tests (Cancer Letters), further development is very attractive and feasible. Potential outcome can spare all, and especially high risk pancreatic ca patients, 20k severe toxicities every year toxicities as much as $100 million cost and make some ineligibility criteria unnecessary. Development of safe AA regimens may benefit quality of life and improve survival for many with a broad spectrum of cancers that otherwise go untreated. Clinical trial information: NCT01905150.

Stereotactic radiosurgery plays a critical role in enhancing long-term survival in a patient with pancreatic cancer metastatic to the brain

BACKGROUND

Pancreatic cancer is an aggressive disease which metastasizes readily. The presence of brain metastases from pancreatic cancer is rare and it carries a poor prognosis. Our approach to treating these lesions stresses extensive use of stereotactic radiosurgery (SRS), whereas other reports focus on surgical resection.

CASE REPORT

Information regarding the patient's clinical history was extracted from a retrospective review of the medical records and imaging studies. The patient survived seven years after his primary diagnosis of pancreatic cancer, and 36 months after diagnosis of metastatic disease to the brain. In addition to surgical resection and the use of multiple chemotherapeutic agents, the patient received six separate radiosurgery treatments.

CONCLUSION

We present a case of brain metastasis from pancreatic cancer that is remarkable for an unusually long survivorship and discuss the utility of SRS along with a multimodality treatment approach for dealing with these cases.

An open-label trial of SMK treatment of advanced metastatic cancer

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Background: SMK is a novel therapy that creates alteration in defenses to oxidative stress and increases free radical availability to the cancer cell. SMK is designed to penetrate the living cancer cells and introduce multiple mechanisms to kill the cell. Inducing transfer of electrons in the cancer cells allow catalyzed external free radicals to react and stress the cell. SMK is a combination of low dose agents used for non-cancer treatment. Methods: IRB approved study for metastatic cancer. No additional chemotherapy allowed. First 30 subjects meeting criteria were consented. SMK given orally and SQ, 5 days/wk, 6 weeks (1 cycle). Eligible subjects had cycles 2 and 3. Results: Average age 57.5 (30-81); 70% female; 30% Male. 90% Caucasian, 3.3% each- Asian, Hispanic, Native American. Cancer type: 43% breast, 20% lung, 10% pancreatic, 6.6% each: bile duct and prostate with bone metastasis, 3.3% each: colon, tongue, appendix and thyroid. 100% Breast cancer subjects had metastasis: 15% each: bone, lung, bone/lymph 8% each: lung, lymph, bone/brain/lung, bone/brain/spine, bone/liver, bone/brain, liver/bones/lymph. 10% treated for 1 cycle, 90% 2 -3 cycles. 13.3% maintained same ECOG rating. 76.6% had 1 pt, 6.6% had 2 pt, and 3.3% had 3 pt improvement. 13.3% had 1 pt decrease, 23.3% maintained the same, 63.3% had 1-3 pt improvement in health on EORTC (1-7) rating. 13.3% had a 1 pt decrease, 20% maintained the same, 66.7% had 1-4 pt improvement in quality of life on EORTC (1-7) rating. 56.6% gained 1-13lbs. 16.6% same weight, 26.6% lost 1-4 lbs. 73.3% had 1-8 pt. pain reduction (scale 1-10). 19.9% had minimal or moderate pain and maintained. 6.6% had minimal pain and had a 1 pt increase. 46.6% were on pain medication. 43% no longer needed pain medication after study. 100% Health and quality of life significantly improved: 16.6% show no uptake on a PT scan; 16.6% have significant reduction in quantity and/or size of the tumor; 26.8% have reduction in quantity/size of the tumor; 40% have a stable disease; 90% -Alive, median survival 257 days to date. 10% died, median survival 163 days.Total median survival 247 days (from first day of treatment). 100% had hyperpigmentation. No SMK related adverse events reported. Conclusions: SMK is a very promising treatment for metastatic cancer.

Integration of neuropathy-sparing multimetronomic bevacizumab and multibiochemical modulation followed by regional consolidation and maintenance therapy for refractory ovarian cancer

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Background: In vitro disease models predicted advantages for use of 1/2-1/4 standard cytotoxic doses and selection of drugs each of which simultaneously interact with multiple drugs. Methods: Treatment (rx) combined 10mg/kg bevacizumab (B) q 2 weeks, cyclophosphamide (Cy) 400mg/m2 modified AC (Garcia Gyn Onc 05) with low dose GFLIP (carboplatin=P) P -/+ docetaxel (D) (Bruckner, ASCO 08). Regional therapy followed: +/- intraperitoneal, target directed or D+cisplatin, +/- or empirical HIPEC. To prevent further neuropathy, present in 8 of 10 pts, D was reserved for late addition (as needed) to create less than 0.5cm or otherwise “eligible for reduction surgery” tumors. Results: Overall S is 8/10 and 4/6 @ 6 and 12 mos. Two lead pts S at 18+ mos. 10/10 tumor marker responses (R); 9/10 objective R all with benefit. Patients (pts) had failed a median of 3 prior regimens and all had large rapidly worsening tumors during prior rx; 6/10 were considered “entirely untreatable.” There were no grade 4 complicated AEs, other than anemia. Epistaxis and HTN were minor, easily controlled AEs. Three deaths due to disease: One pt, PS3, refused surgery for a preexisting bowel obstruction and one, PS3, required weekly paracentesis and had sb obstruction. She relapsed after four mos OR. The third, PS4, pt was paracentesis and thorocentesis dependent and had a 6 mos OR. Median PFS is not yet reached. The lead pt, a 33yo third line, twice operated achieved a pCR in 4 mos, now stoma reversed, unmaintained for 14+ mos, following vaccine rx. Seven had OR without D; brief addition of D; brief addition of D produced 3/3 OR, a pCR, CR and PR. IRB provided prospective oversight of consent. Conclusions: This is an active multi-drug, in theory, anti BRCA rx, for very high risk and some otherwise “untreatable” pts. Simultaneous modulation of multiple drugs, both metronomically, six ways, (Cy-GFIC-D) and biochemically, up to five ways "each," 15 ways (5+4+3+2+1), is safe. Algorithms can offer cost savings (for B) by selecting a finite, short, “best” period for rx and then definitive, B free, consolidation rx. B driven response can create new windows of opportunity for test worthy multidisciplinary rxs.

Serial application and development of a new treatment paradigm for pancreatic cancer

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Background: New "paradigm driven" treatments (rx) “doubled” phase II survival (S) for 250 pts (ASCO, Bruckner 01, 04, 05, 08, 11). Addition or repartnering of drugs which failed trials or individual use (all in cost saving doses) produced synergism and reversed drug resistance. New rxs and safer doses were rapidly discovered by application of game theory to models of rxs, testing human pancreatic ca (PC) in vitro. Some measures of response (R) and extreme drug resistance as selection criteria were downgraded. Priority went to disease specific in vitro “R” rate (RR), increased number of simultaneously impacted drugs, activity at low doses and avoiding both duplication of targeting and antagonism. Clinical objectives now included wider eligibility, safety and 50% cost saving. Methods: With prospective registration and IRB consent rxs evolved: GFLIP>GFLIO>GFLIO -/+ docetaxel (D) -/+Mitoymcin-C (M). GFLIO and on progression GFLIO-D-M was the rx for 107 new tests (biopsy high risk ductal PC, PS 0-2, no active obstruction). Pts: unresectable (U) or metastatic (IV), G1; failing prior rx with some rx drugs, G2 or resected PC +/- margin G3 (G1, G2 all with progressive disease). Serial findings were compared (ASCO 05, 08). Results: OS for U/IV (G1 and G2) adding D-MMC to GFLIO was: n=70, at 24 mos 22/38 (S) (61%) alive; at 36 mos 8/20 (40%) vs prior 32 and 21%. Adjuvant, G3: n=37 at 18 mos 15, (50%) PFS, 28/30 S; alive S at 24 mos 10, (43%) PFS 20/23 S; at 36 mos 6, 40% PFS 14/15 S. Cumulative RR depending on R criteria meet models for 40-60% R per treatment with benefit rx (61-84%). Rxs were safe, no induction hospital AEs. Conclusions: This 350 pt prospective Phase II further supports testing of low dose rx; use of D-MMC as additions and adjuvant GFLIO rx (see Reni, Fine, Isakoff). The pts large N and long OS have testworthy practice changing: consent, reimbursement and trial (algorithm) “design” implications. Cost of drugs per unit of survival (S) can often be saved, safely while possibly improving QL and OS. Palliative applications of dose intensity, drug efficacy, tumor resistance and one drug at a time testing as rx concepts are (sometimes) questionable. improving QL and OS.

Cumulative impact of algorithm-integrated multidisciplinary treatments for cholangiocarcinoma

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Background: Pancreatic Ca (PC) treatments (rxs) are often applied to patients (pts) with cholangioC (CC). Analyses support parallel "testing" of neoadjuvant (NeoA) and adjuvant (A) rx for CC pts. The rxs below “doubled” phase II objective response (OR) and survival (OS) vs PC. Methods: With pre-registration and IRB consent over ten years: GFLIP>GFLIO >GFLIO docetaxel (D) -/+mitomycin -C (MM-C) (Bruckner ASCO 01, 05, 08, 11) were applied to pts with PC and CC; stage adjusted, “possible best" choices for PC rxs were applied as NeoA and A rxs for high risk CC pts. Risk was defined by: margin, +; size, large; location, surgical difficulty, central; LNs, involved (or suspect), number of sites (and distance); pathology, atypical, high virulence and relapse (second surgery). These are the worst half of resected pts. Pts with unresectable (U) and metastatic (IV) CC were eligible with or without prior failure of some of the rx drugs. Targeted rx (TT) was briefly added, bevacizumab (B) 5mg/kg or cetuximab (C), as needed, to convert stable disease (SD) to NeoA eligible OR. Gallbladder Ca (GBC) pts were also treated. The algorithm's goal was to both optimize surgery for tumor reduction to improve rx and to select “timely” drug partners to reduce tumor size and allow further surgery. Results: No fatal AEs; Of 16 high risk, Adjuvant, resected pts, at 18 mos, 14 are alive, 10/11at 2 yrs, 6/7 (86%) at 3 yrs, 1 lost contact CC U/ IV, N=28, 4 lost contact 16/19 (84%) alive at 18 mos; 12/16 alive at 2yrs; 8/12 alive at 3 yrs. This vs. 50% (18mo) MST (ASCO 11). Of 7 NeoA, 4/4 were alive at 3 yrs, 3 others alive < 3 yrs. (3 had best R with TT). *RR GFLIO ~ 60% add DMM-C ~ 60% € ~84% add TT ~20% €~ 87%. Conclusions: Rxs are safe, economical and well tolerated. € RR and OS adding (FI, D, D-MMC and selectively TT) are testworthy. Both 12 mos OS and NeoA/A are testworthy for GBC pts. B and C are individually active, safe and cost effective in brief NeoA usage applications. Low dose multi drug rxs are ideal safe platforms for TT. High serial € RR encourage 1° and 2° attempts at both debulking - strategic palliative and definitive surgery, ideally in trials to optimize (pt conditioning, eligibility) and compare NeoA vs A rxs.

Adjuvant and Neoadjuvant Therapies of Pancreatic Cancer: A Review

The survival of patients diagnosed with pancreatic cancer is dismal. Few patients on initial presentation aresuitable for surgical resection. This has prompted clinical studies with chemotherapy and/or radiotherapydesigned either to increase the number of patients eligible for surgery (neoadjuvant therapy) or to prolong thesurvival of patients who had undergone surgery (adjuvant therapy). None of these studies may at this time beconsidered definitive. Wherever possible, patients felt eligible for neoadjuvant or adjuvant therapy should beentered on clinical trials. Where this is not possible, clinicians should exercise their best judgment in offeringthis type of treatment to pancreatic cancer patients under their care.

Self-incompatibility in passionfruit: evidence of gametophytic-sporophytic control

Self-incompatibility in passionfruit was studied in families originated from crosses among plants that presented differences in reciprocal crosses. The three families, obtained by crossing S(3) plants, exhibited one incompatible group; no reciprocal differences were observed. The phenotype of the families was the same as the parent plants, S(3). These results suggest the presence of a gene ( G), gametophytic in its action, associated to the sporophytic gene S, modifying the incompatibility reaction in passionfruit. The reciprocal difference exhibited in the crosses among the parents could be explained as a matching between plants homozygous for S, but homozygous and heterozygous for G. Actually this would be a partially compatible cross, not detectable when the evaluation is done based on fruit set data. As the family originated from this kind of cross is homozygous for S and heterozygous for G, no reciprocal differences are expected, and the phenotype should be the same as the parental plants, as observed in the present work.

Irinotecan plus gemcitabine induces both radiographic and CA 19-9 tumor marker responses in patients with previously untreated advanced pancreatic cancer

PURPOSE

This phase II, multicenter, open-label, single-arm study evaluated the efficacy and safety of irinotecan and gemcitabine as combination chemotherapy for previously untreated patients with unresectable or metastatic pancreatic cancer.

PATIENTS AND METHODS

Patients received repeated 21-day cycles at starting doses of gemcitabine 1,000 mg/m(2) over 30 minutes followed immediately by irinotecan 100 mg/m(2) over 90 minutes, both given intravenously on days 1 and 8. Patients were evaluated for objective tumor response, changes in the serum tumor marker CA 19-9, time to tumor progression (TTP), survival, and safety.

RESULTS

Forty-five patients were treated. Eleven patients (24%) had 50% or greater reductions in tumor area. These were confirmed one cycle later in nine patients (response rate, 20%; 95% confidence interval, 8% to 32%). Among 44 patients with baseline CA 19-9 determinations, CA 19-9 decreased during therapy in 22 patients (50%) and was reduced by 50% or more in 13 patients (30%). Median TTP was 2.8 months (range, 0.3 to 10.8 months). There were significant (P <.001) correlations between proportional changes in CA 19-9 and radiographic changes in tumor area with regard to extent of change (r =.67), timing of minimum on-study values (r =.85), and tumor progression (r =.89). Median survival was 5.7 months (range, 0.4 to 19.4+ months), and the 1-year survival rate was 27%. Severe toxicities were uncommon and primarily limited to grade 4 neutropenia (2%), grade 4 vomiting (2%), and grade 3 diarrhea (7%).

CONCLUSION

Irinotecan/gemcitabine is a new combination that offers encouraging activity in terms of radiographic and CA 19-9 response and notable 1-year survival in pancreatic cancer. The regimen was well tolerated, with minimal grade 3 and 4 toxicities and excellent maintenance of planned dose-intensity.

Irinotecan plus gemcitabine induces both radiographic and CA 19-9 tumor marker responses in patients with previously untreated advanced pancreatic cancer

PURPOSE

This phase II, multicenter, open-label, single-arm study evaluated the efficacy and safety of irinotecan and gemcitabine as combination chemotherapy for previously untreated patients with unresectable or metastatic pancreatic cancer.

PATIENTS AND METHODS

Patients received repeated 21-day cycles at starting doses of gemcitabine 1,000 mg/m(2) over 30 minutes followed immediately by irinotecan 100 mg/m(2) over 90 minutes, both given intravenously on days 1 and 8. Patients were evaluated for objective tumor response, changes in the serum tumor marker CA 19-9, time to tumor progression (TTP), survival, and safety.

RESULTS

Forty-five patients were treated. Eleven patients (24%) had 50% or greater reductions in tumor area. These were confirmed one cycle later in nine patients (response rate, 20%; 95% confidence interval, 8% to 32%). Among 44 patients with baseline CA 19-9 determinations, CA 19-9 decreased during therapy in 22 patients (50%) and was reduced by 50% or more in 13 patients (30%). Median TTP was 2.8 months (range, 0.3 to 10.8 months). There were significant (P <.001) correlations between proportional changes in CA 19-9 and radiographic changes in tumor area with regard to extent of change (r =.67), timing of minimum on-study values (r =.85), and tumor progression (r =.89). Median survival was 5.7 months (range, 0.4 to 19.4+ months), and the 1-year survival rate was 27%. Severe toxicities were uncommon and primarily limited to grade 4 neutropenia (2%), grade 4 vomiting (2%), and grade 3 diarrhea (7%).

CONCLUSION

Irinotecan/gemcitabine is a new combination that offers encouraging activity in terms of radiographic and CA 19-9 response and notable 1-year survival in pancreatic cancer. The regimen was well tolerated, with minimal grade 3 and 4 toxicities and excellent maintenance of planned dose-intensity.

Adjuvant and neoadjuvant therapies of pancreatic cancer: a review

The survival of patients diagnosed with pancreatic cancer is dismal. Few patients on initial presentation are suitable for surgical resection. This has prompted clinical studies with chemotherapy and/or radiotherapy designed either to increase the number of patients eligible for surgery (neoadjuvant therapy) or to prolong the survival of patients who had undergone surgery (adjuvant therapy). None of these studies may at this time be considered definitive. Wherever possible, patients felt eligible for neoadjuvant or adjuvant therapy should be entered on clinical trials. Where this is not possible, clinicians should exercise their best judgment in offering this type of treatment to pancreatic cancer patients under their care.

Current surgical therapy for carcinoma of the pancreas

Despite progress in treating many solid tumors, pancreatic cancer continues to be a grave illness. Each year, >29,000 new cases of adenocarcinoma of the pancreas are diagnosed in the United States. Of these patients, only 10-20% have resectable tumors and 25,000 patients (83%) die within 12 months of diagnosis. Until recently, surgery has been the only "effective" therapy available for select patients. Historically, the operative mortality after radical pancreatic resection has been variable, ranging 1-30%, and is both operator- and institution-dependent. Even with a safe and complete surgical resection, the actual 5-year survival after surgery alone is essentially zero, although rates up to 5% have been reported. Despite what would appear to be a dismal outlook, slow progress has occurred in the operative and postoperative care of patients with pancreatic cancer. Advanced imaging techniques and laparoscopy have limited the number of unnecessary laparotomies, and novel adjuvant and neoadjuvant chemotherapy approaches have yielded promising results. This review will summarize the recent literature concerning the surgical therapy and trends in the treatment of carcinoma of the pancreas from 1990 to 1999.

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma. An outcomes trial

BACKGROUND

Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

METHODS

Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2).

RESULTS

Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment.

CONCLUSIONS

Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP.

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma. An outcomes trial

BACKGROUND

Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

METHODS

Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2).

RESULTS

Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment.

CONCLUSIONS

Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP.

Chemotherapy in advanced ovarian cancer: four systematic meta-analyses of individual patient data from 37 randomized trials. Advanced Ovarian Cancer Trialists' Group

The purpose of this systematic study was to provide an up to date and reliable quantitative summary of the relative benefits of various types of chemotherapy (non-platinum vs platinum, single-agent vs combination and carboplatin vs cisplatin) in the treatment of advanced ovarian cancer. Also, to investigate whether well-defined patient subgroups benefit more or less from cisplatin- or carboplatin-based therapy. Meta-analyses were based on updated individual patient data from all available randomized controlled trials (published and unpublished), including 37 trials, 5667 patients and 4664 deaths. The results suggest that platinum-based chemotherapy is better than non-platinum therapy, show a trend in favour of platinum combinations over single-agent platinum, and suggest that cisplatin and carboplatin are equally effective. There is no good evidence that cisplatin is more or less effective than carboplatin in any particular subgroup of patients.

Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors

Endoscopic ultrasonography was used to examine 38 patients with a pancreatic neoplasm (mean size, 2.8 cm; range, 1 to 5 cm). Three EUS signs appear to be reliable criteria for the identification of tumor invasion of major veins forming the portal confluence: (1) peri-pancreatic venous collaterals in the area of a mass that obliterates the normal anatomic location of a major portal confluence vessel; (2) tumor within the vessel lumen; and (3) abnormal vessel contour with loss of the vessel-parenchymal sonographic interface. At least one of these signs was present in each of the 21 patients with vascular invasion; none of them was present in the 17 patients without vascular invasion. Findings were confirmed by laparotomy plus biopsy (33 patients), autopsy (1 patient), or angiography plus biopsy (4 patients). Arterial involvement was identified by alteration of vessel course and caliber. All 7 patients with arterial involvement also had venous involvement. These signs provide reliable criteria for endoscopic ultrasonographic definition of unresectable tumors in patients with a pancreatic neoplasm that appears to be resectable on standard radiologic tests.

Mucin-associated sialosyl-Tn antigen expression in gastric cancer correlates with an adverse outcome

The expression of sialosyl-Tn (STn) antigen was evaluated by immunohistochemistry in primary gastric cancers. Twenty-one of 31 (68%) gastric cancers expressed STn, regardless of tumour location, stage or histological type. Eighty-one per cent of patients with STn-positive tumours died of their disease or had recurrent cancer, compared with 20% of patients with STn-negative tumours (P < 0.002). STn may be a useful prognostic marker in patients with gastric cancer.

Hypertensive crises induced by treatment of malignant pheochromocytoma with a combination of cyclophosphamide, vincristine, and dacarbazine

Combination chemotherapy with cyclophosphamide, vincristine, and dacarbazine (CVD) is an effective treatment regimen for malignant pheochromocytoma. There have not been any significant acute cardiovascular effects reported following CVD treatment. Among seven patients with malignant pheochromocytoma treated with CVD at our institution, two patients with labile hypertension developed hypertensive crisis following CVD treatment. The marked increase in blood pressure correlated with an increase in urinary excretion of catecholamine metabolites in one patient. Further hypertensive crises following subsequent CVD treatments were avoided by optimizing each patient's antiadrenergic therapy. Similar to the approach used preoperatively for patients with resectable pheochromocytoma, maximal antiadrenergic therapy is essential in preventing hypertensive crises in patients with malignant pheochromocytoma undergoing CVD treatment.

Management of hypocalcemic effects of WR2721 administered on a daily times five schedule with cisplatin and radiation therapy. The New York Gynecologic Oncology Group

PURPOSE

To determine the effects of the chemoprotective agent, WR2721, administered on a daily x 5 schedule with cisplatin and radiation therapy, on calcium and parathyroid hormone (PTH) levels.

PATIENTS AND METHODS

Twenty women with cervical cancer were enrolled in a clinical trial to determine the maximal safe dose of WR2721 plus radiation therapy and cisplatin on a novel daily x 5 schedule. Detailed studies of the effects of WR2721 on calcium and PTH levels were initiated after a patient developed symptomatic hypocalcemia.

RESULTS

Treatment with WR2721 resulted in a rapid decline in serum PTH levels within 4 hours, which fell below the lower limits of normal at 24 hours, then returned to within normal limits at 48 hours. In contrast, serum levels of ionized calcium were not affected acutely, and declined by only 7% within 24 hours. However, this small decrease persisted for the 5 days of treatment. Hypocalcemic effects were successfully managed with oral calcium carbonate and calcitriol supplements. In one patient, particularly sensitive to the effects of WR2721, serum levels of ionized calcium decreased to less than 3.0 mg/dL despite oral calcium supplements.

CONCLUSION

The effects of WR2721 on serum ionized calcium levels are mediated by direct inhibition of PTH activity; other effects such as inhibition of renal tubular calcium reabsorption cannot be excluded. We recommend that patients treated with WR2721, cisplatin, and radiation therapy receive routine oral calcium and calcitriol supplementation and that serum ionized calcium levels be monitored frequently.

A GC cluster repeat is a hotspot for mit- macro-deletions in yeast mitochondrial DNA

In a random collection of mit- mutations of the yeast strain 777-3A we find that deletions are exceptionally frequent in the OXI3 gene, a large mosaic gene coding for subunit I of cytochrome oxidase. About 10% of all oxi3-mutants carry the same macro-deletion, del-A, extending from the 5' non-translated leader of OXI3 to intron 5b of this gene. Determination of the respective wild-type sequences and of the del-A junction sequence revealed that the end-points of the deletion are in two GC clusters with 31 bp sequence identity which are located at a distance of 11.3 kb. We speculate that not only the sequence identity of the two GC clusters but also the palindromic structure of these putatively mobile elements of yeast mitochondrial DNA (mtDNA) plays a role in deletion formation.

Phase II evaluation of dibromodulcitol and actinomycin D, hydroxyurea, and cyclophosphamide in previously untreated patients with malignant melanoma

In this Eastern Cooperative Oncology Group (ECOG) phase II study, dibromodulcitol (DBD) and a combination of actinomycin D, hydroxyurea, and cyclophosphamide (AHC) were compared with methyl-CCNU, the current ECOG standard, in patients who had received no prior chemotherapy for disseminated malignant melanoma. The response rates were 6% (3/50) for AHC, 9% (3/34) for DBD, and 14% (7/49) for methyl-CCNU. Median survival times were 4, 5, and 6 months, respectively. Neither regimen appears to offer any advantage over methyl-CCNU as front-line therapy for patients with disseminated melanoma.

Treatment of primary undifferentiated sarcoma of the liver with surgery and chemotherapy

Primary undifferentiated sarcoma of the liver is a rare tumor with survival reliant on total excision of the tumor. The authors report such a tumor, initially nonresectable, in a 7-year-old girl whose tumor was successfully excised following treatment with cisplatin and Adriamycin (doxorubicin). The light and electron microscopic details of this patient's tumor are presented.

CEA monitoring among patients in multi-institutional adjuvant G.I. therapy protocols

The Gastrointestinal Tumor Study Group (GITSG) has since 1975 included protocols for monitoring carcinoembryonic antigen (CEA) levels in its colorectal cancer adjuvant trials. Among the 563 patients on the colon cancer study (GI 6175) and the 207 patients on the rectal cancer study (GI 7175), one third had preoperative CEA determinations and more than 90% had some postoperative CEA monitoring. Colon cancer patients whose preoperative CEA was greater than 5 ng/ml had a greater probability of recurring than those whose values were lower (33% versus 18% recurrence with 21 months minimum follow-up; p < 0.05). The prognostic value of preoperative CEA was apparent only in patients with Dukes' C1 colon tumors. Preoperative CEA values were not of prognostic significance among the rectal adenocarcinoma patients. Although elevated levels of CEA after resection of either colon or rectum cancers were strongly associated with subsequent tumor recurrence, no single CEA value, arbitrarily defined as "elevated", provided an adequate screening test with both high sensitivity and high specificity. Postoperative CEA elevations were more strongly predictive of recurrence when part of a steadily rising trend. In the colon cancer study, the median monthly increase in CEA for disease-free patients was estimated to be zero, and for the relapsed patients 5.8%. The corresponding estimates for patients on the rectal cancer protocol were zero and 7.8%. Only 36 of the 344 disease-free patients on the colon protocol and 14 of the 94 disease-free patients on the rectal protocol (15%) exhibited a rate of increase of CEA as high as 3% per month over the entire period of observation. Two thirds of the relapsed patients on both studies showed a rate of increase this high or higher. The patterns of CEA rise in individual patients were quite varied, however, and monthly rates of increase as established in our study are not to be used as guidelines in patient management.

Portable infusion pumps in ambulatory cancer chemotherapy

Fifty-seven adult patients receiving chemotherapy were treated with a total of 133 infusions using portable user-worn infusion pumps, the Autosyringe AS*2F Cormed ML6-4, and two earlier versions of the latter, the Sigmamotor ML6-2 and ML6-3. Ninety-eight infusions were given on an ambulatory basis. Fourteen infusions were given through peripheral venous catheters, 115 through central venous catheters, and four intra-arterially. Of 127 evaluable infusions, 65 were completed within 5% and 87 within 10% of the planned rate; results are similar for both inpatient and outpatient infusions. The Cormed ML6-4 pump was equal to the Autosyringe AS*2F in reliability but superior to the latter in patient preference. There were no instances of dangerously rapid administration of the drug. The only serious catheter complications were a pneumothorax after insertion of a subclavian catheter in one patient and cellulitis in a leukopenic patient with a Broviac catheter. All but three patients preferred outpatient therapy to hospitalization. Outpatient therapy costs about $300 per day less than in-hospital treatment.

Methyl-GAG in patients with malignant neoplasms: a phase I re-evaluation

Methyl-GAG was given to 71 patients with advanced malignancies as a weekly brief infusion (30-120 minutes) or as a biweekly 24- or 120-hour infusion. Mucositis (stomatitis, pharyngitis, esophagitis, and, rarely, inflammation of other mucous membranes) was dose-limiting in all three schedules. Generalized fatigue, malaise, myalgia, dysesthesias, nausea, and vomiting were more frequent in the brief-infusion schedule. Myelosuppression was mild and not dose-related. Fever, ventricular arrhythmias, skin rash, tender swelling of the palms, neuropathy, and paralytic ileus were rare. Toxicity was increased in patients with renal insufficiency or "third-space" fluid but was not increased by hepatic dysfunction. Cumulative and overlapping toxicity was evident only in the weekly schedule. Higher doses of methyl-GAG were tolerated when the duration of infusion was increased. The recommended doses for phase II trials are 700 mg/m2 weekly as a 1-2 hour infusion, 850 mg/m2/24 hours biweekly, and 1500 mg/m2/120 hours biweekly. Therapeutic effects were seen in all schedules and included objective responses in colon carcinoma (one of 13 patients), renal cell carcinoma (one of nine), and Hodgkin's lymphoma (one of two) and objective improvements in esophageal carcinoma (one of three), endometrial carcinoma (two of two), and leiomyosarcoma (one of three).