Locally Advanced Gastrointestinal Stromal Tumor in a 33-Year-Old Woman Seeking to Conceive

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract. They commonly present with nonspecific symptoms and thus are often discovered incidentally. They are best identified by CT scan, and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. Several risk stratification classification systems have been developed based on tumor size, mitotic rate, location, and perforation. Traditional chemotherapy and radiation therapy have been very ineffective, making surgery the mainstay of treatment. The discovery of mutations associated with these tumors has revolutionized the treatment approach. Imatinib mesylate, a selective tyrosine kinase receptor inhibitor, used as adjuvant or neoadjuvant therapy, has greatly improved the morbidity and mortality associated with GISTs. As the survival of patients has increased with the long-term use of targeted therapies, quality-of-life issues now have become much more relevant and have come to the forefront of care. We present a young woman who was successfully treated for GIST but now faces associated long-term adverse effects of imatinib, including the challenge of preserving fertility and the potential for childbearing.

Mucinous Adenocarcinoma of the Appendix With Histologic Response to Neoadjuvant Chemotherapy: Review of Histologic and Clinical Spectrum of Epithelial Neoplastic Mucinous Lesions of the Appendix

Appendiceal mucinous neoplasms are a rare and heterogeneous group of diseases with challenging clinical management decisions. They account for less than 1% of all cancers but their incidence is on the rise. Treatment is based on their stage and histology. Appendiceal neoplasms frequently metastasize inside the abdomen; this leads to tumor cell growth in the abdominal cavity, known as peritoneal carcinomatosis, and buildup of mucinous material, known as pseudomyxoma peritonei. While low-grade, early-stage tumors can be effectively treated with limited surgical resection, patients with low-grade, advanced-stage disease require peritoneal debulking and hyperthermic intraperitoneal chemotherapy. Therapeutic options for high-grade, advanced-stage mucinous tumors of the appendix have not been well established. Debulking surgery with hyperthermic intraperitoneal chemotherapy preceded and/or followed by systemic chemotherapy has been utilized based on some prospective but not randomized data. We present a case of mucinous adenocarcinoma of the appendix treated with neoadjuvant chemotherapy followed by cytoreductive surgery/hyperthermic intraperitoneal chemotherapy and adjuvant chemotherapy. Preoperative chemotherapy provided a favorable histologic response by converting initial mucinous appendiceal adenocarcinoma histology to a high-grade mucinous appendiceal neoplasm.

Cellular Phenotypes in Cancer Patient Spleen and Peripheral Blood

Adoptive cellular therapy (ACT) has progressed; however, it remains ineffective for most solid tumors. Further, neoadjuvant patients frequently lack tumor tissue sufficient to isolate and expand tumor infiltrating lymphocytes (TIL’s) that are the primary source of T-cells for ACT. However, patients with tumors near the splenic vasculature often undergo a splenectomy, providing a cellular resource for ACT. We document herein that spleens provide a high frequency and number of CD8+ T-cells, with low expression of exhaustion markers (program death ligand-1 (PD-1), T-cell immunoglobulin and mucin domain containing-3 (TIM-3), and lymphocyte activation gene-3 (LAG-3)) relative to the peripheral blood (PB). The memory phenotypes of these CD8+ T-cells (predominantly central and transitional) support their potential for expansion and their high frequency of PD-1 expression indicates tumor specificity as PD-1, is a surrogate for tumor specificity. Further, spleens have a low frequency of myeloid derived suppressor cells (MDSCs) subsets vs. patient PB. Our preliminary studies with spleens from 19 abdominal tumor patients revealed that the spleens, relative to the PB from the same patients, have a significantly higher frequency of CD8+ and PD-1+CD8+ T-cells, including central and transitional memory T-cells. Further, the CD8+PD-1+ T-cells in the spleen also have a low expression of TIM-3 and LAG-3 suggesting minimal exhaustion as supported by ELISPOT analysis of tumor specific CD8+ T-cells responses. Based on our studies we suggest that resected spleens from cancer patients including pancreatic ductal adenocarcinoma (PDAC) patients can provide a valuable source for ACT due to their high frequency of CD8+PD-1+ T-cells.

Variation in the surgical management of locally advanced pancreatic cancer

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Background: Recent reports suggest patients with locally advanced pancreatic cancer (LAPC) may become candidates for curative resection following neoadjuvant therapy, with encouraging survival outcomes. Yet the optimal management approach for LAPC remains unclear. We sought to investigate surgeon preferences for the management of patients with LAPC. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included surgeon practice characteristics, preferences for staging and management, and 6 clinical vignettes (with detailed videos of post-neoadjuvant arterial and venous imaging) to assess attitudes regarding eligibility for surgical exploration. Results: A total of 150 eligible responses were received from 4 continents. Median duration in practice was 12 years (IQR 6-20) and 75% respondents work in a university setting. Most (84%) are considered high volume, 33% offer a minimally-invasive approach, and 48% offer arterial resection in selected patients. A majority (70%) always recommend neoadjuvant chemotherapy, and 62% prefer FOLFIRINOX. Preferences for duration of neoadjuvant therapy varied widely: 39% prefer ≥2 months, 41% prefer ≥4 months, and 11% prefer 6 months or more. Forty-one percent frequently recommend neoadjuvant radiation, and 51% prefer standard chemoradiotherapy. Age ≥80 years and CA 19-9 of ≥1000 U/mL were commonly considered contraindications to exploration. In 5 clinical vignettes of LAPC, the proportion of respondents that would offer exploration following neoadjuvant varied extensively, from 15% to 54%. In a vignette of oligometastatic pancreatic liver metastases, 32% would offer exploration if a favorable biochemical and imaging response to therapy is observed. Conclusions: In an international cohort of high volume pancreas surgeons, there is substantial variation in attitudes regarding staging preferences and surgical management of LAPC. These results underscore the importance of coordinated multi-disciplinary care, and suggest an evolving concept of “resectability.” Patients and their oncologists should have a low threshold to consider a second opinion for the surgical management of LAPC, if desired.

SAT-121 Immediate Dysglycemia After Pancreatic Resection: Prevalence and Risk Factors

Introduction: Postoperative hyper- and hypoglycemia are associated with increased morbidity and mortality following many types of surgical procedures. Long-term development of diabetes mellitus (DM) following pancreatic resection is well documented; however, less is known regarding glycemic control in the immediate postoperative period for patients undergoing pancreatic resection. Methods: We conducted a retrospective study investigating rates of hyperglycemia (blood glucose >140 mg/dL) and hypoglycemia (blood glucose ≤ 70 mg/dL) and associated risk factors in the 10-day postoperative period in patients undergoing pancreatic resection. Patients that underwent pancreaticoduodenectomy (PD), distal pancreatectomy (DP), or complete pancreatectomy (CP) from 7/1/12-7/1/18 were included. Patients with a functional tumor, end-stage renal disease, liver failure, deceased within 14 days of surgery, and solid-organ transplant recipients were excluded. Results: After applying exclusion criteria, 227 of 261 patients were included. Median age was 61 years and 50.2% were male. Preoperative DM was present in 46/227 (20.3%). A total of 130 patients (57.3%) had a pancreatic primary indication for surgery, with other abdominal malignancies accounting for most of the non-pancreatic indications. Most underwent DP (59.5%) followed by PD (40.1%) and CP (0.6%). A total of 162 (71.4%) patients had at least one hyperglycemic episode with 83 (36.6%) having a blood glucose >180 mg/dl. The type of surgical procedure was not a risk factor for hyperglycemia, even when stratified for pancreatic vs non-pancreatic indication. Rates of hyperglycemia were higher in patients with pancreatic cancer (78.5%) compared to those with a non-malignant pancreatic lesion (44.0%), p <0.05. A preoperative diagnosis of DM (p <0.01) and use of TPN or enteral feeds (p <0.01) were risk factors for having any hyperglycemic episode and a hyperglycemic episode >180 mg/dL. Peri-operative steroids and BMI were not associated with hyperglycemia. A total of 46 patients (20.3%) had at least one hypoglycemic episode, including 20 of 105 patients who received insulin. Hypoglycemia risk was higher in patients with BMI < 25 kg/m² compared to BMI >= 25 kg/m² (p <0.01). Most hypoglycemic episodes happened within 3 days postoperatively (73.0%) and while the patient’s diet order was NPO or ice chips without nutritional supplements (63.5%). Renal function was not associated with risk of hypoglycemia. Conclusions: Hyper- and hypoglycemia are both common after pancreatic resection. Hyperglycemia is especially common in patients with pancreatic cancer, preoperative DM, and/or on supplemental nutrition. Hypoglycemia after pancreatic resection may be largely explained by nutritional status. Understanding risk factors for hyper- and hypoglycemia can assist in targeted methods to reduce rates of dysglycemia after pancreatic resection.

Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in the Management of Colorectal Peritoneal Metastasis

Historically, patients with peritoneal carcinomatosis secondary to colorectal cancer have a poor overall prognosis. Recent data support the use of cytoreductive surgery and heated intraperitoneal chemotherapy (CRS + HIPEC) to specifically address the peritoneal disease. Retrospective studies on CRS + HIPEC have been promising, showing significant improvements in OS compared with systemic chemotherapy alone. However, CRS + HIPEC carries morbidity similar to other advance oncology procedures such as liver resection and pancreatoduonectomy. It is hoped that ongoing clinical trials will clarify its role in the treatment of patients with peritoneal metastatic colorectal cancer.

Enhancing melanoma treatment with resveratrol

BACKGROUND

Resveratrol (RESV) is a naturally occurring compound that possesses anti-cancer capabilities. The goal of this study was to evaluate the potential of RESV as an adjunct to chemotherapy in melanoma treatment.

METHODS

The in vitro and in vivo cytotoxic activity of RESV with or without chemotherapy was tested using cellular assays and a xenograft model. Two Duke melanoma cell lines (DM738, DM443) were used for both in vivo and in vitro experiments, and two nonmalignant human fibroblast lines (NHDF, HS68) were used for in vitro cellular assays. Xenografts were randomized to treatment arms and tumors measured to evaluate response. Results were analyzed using a Student's t-test and ANOVA. Western blots were performed on in vivo tissue.

RESULTS

In vitro RESV significantly decreased melanoma cell viability in all lines tested (all P < 0.0001). Treatment of fibroblast cell lines revealed that RESV selectively spared NHDF and HS68 cells compared with its cytotoxic effects on melanoma cells (P < 0.0001). Treatment of malignant cells with 50 μM RESV and temozolomide (TMZ) for 72 h significantly enhanced cytotoxicity compared with treatment with TMZ alone (P < 0.0001). In vivo, however, there was no significant difference between any treatment arms (P = 0.65).

CONCLUSION

RESV shows promise as a novel therapeutic in the management of melanoma for its selective anti-tumor activity in vitro. Translating in vitro results to in vivo models has proven difficult. Barriers thought to prevent such translation are identified, and a rationale for overcoming them is discussed.

Sorafenib, a multikinase inhibitor, enhances the response of melanoma to regional chemotherapy

Melanoma responds poorly to standard chemotherapy due to its intrinsic chemoresistance. Multiple genetic and molecular defects, including an activating mutation in the BRaf kinase gene, are associated with melanoma, and the resulting alterations in signal transduction pathways regulating proliferation and apoptosis are thought to contribute to its chemoresistance. Sorafenib, a multikinase inhibitor that targets BRaf kinase, is Food and Drug Administration approved for use in advanced renal cell and hepatocellular carcinomas. Although sorafenib has shown little promise as a single agent in melanoma patients, recent clinical trials suggest that, when combined with chemotherapy, it may have more benefit. We evaluated the ability of sorafenib to augment the cytotoxic effects of melphalan, a regional chemotherapeutic agent, and temozolomide, used in systemic and regional treatment of melanoma, on a panel of 24 human melanoma-derived cell lines and in an animal model of melanoma. Marked differences in response to 10 micromol/L sorafenib alone were observed in vitro across cell lines. Response to sorafenib significantly correlated with extracellular signal-regulated kinase (ERK) downregulation and loss of Mcl-1 expression (P < 0.05). Experiments with the mitogen-activated protein kinase/ERK kinase inhibitor U0126 suggest a unique role for ERK downregulation in the observed effects. Sorafenib in combination with melphalan or temozolomide led to significantly improved responses in vitro (P < 0.05). In the animal model of melanoma, sorafenib in combination with regional melphalan or regional temozolomide was more effective than either treatment alone in slowing tumor growth. These results show that sorafenib in combination with chemotherapy provides a novel approach to enhance chemotherapeutic efficacy in the regional treatment of in-transit melanoma.

A phase I study of systemic sorafenib in combination with isolated limb infusion with melphalan (ILI-M) in patients (pts) with locally advanced in-transit melanoma

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Background: Sorafenib is a multi-kinase inhibitor that may also enhance the cytotoxicity of concurrently administered chemotherapy. In a preclinical model of regionally advanced melanoma, the combination of systemic Sorafenib and regional melphalan led to augmented tumor responses. Methods: A Phase I multicenter study was performed to evaluate the safety and pharmacokinetics (PK) of systemic Sorafenib in combination with ILI-M in patients with measurable in-transit melanoma of the extremity. Sorafenib dose escalation cohorts consisted of 200mg, 300mg, and 400mg administered systemically twice daily for one week prior and one week after a standard dose ILI-M corrected for ideal body weight. Tumor biopsies pre-therapy and pre-ILI were obtained to assess molecular changes associated with Sorafenib pretreatment. Response was defined at 3 months using RECIST. Results: Nine pts with high disease burden, including 7 previous ILI-M alone failures, have been treated; 3 in the first cohort and 6 in the second cohort. There were no grade 5 toxicities. Four patients had CTCAE Grade 4 toxicities including neutropenia (2), CPK elevation (1), and skin ulceration (1). In the remaining 5 patients, there were no >grade 3 toxicities. The maximally tolerated dose (MTD) has not yet been defined. Initial in field response determination in 6 of the 9 patients out at least 3 months includes 2 partial responses and 4 disease progressions. Conclusions: Systemic Sorafenib administered pre and post ILI-M is a well tolerated, novel targeted therapy approach to regionally advanced melanoma. An additional 10 patients will be enrolled to define the MTD. Correlation of response with drug PK, Sorafenib downregulation of pErk and Mcl1, and a melphalan resistance signature is in progress.

No significant financial relationships to disclose.

A multi-institutional experience of isolated limb infusion: defining response and toxicity in the US

BACKGROUND

Isolated limb infusion (ILI) is a minimally invasive approach for treating in-transit extremity melanoma, with only two US single-center studies reported. Establishing response and toxicity to ILI as compared with hyperthermic isolated limb perfusion is important for optimizing future regional chemotherapeutic strategies in melanoma.

STUDY DESIGN

Patient characteristics and procedural variables were collected retrospectively from 162 ILIs performed at 8 institutions (2001 to 2008) and compared using chi-square and Student's t-test. ILIs were performed for 30 minutes in patients with in-transit melanoma. Melphalan dose was corrected for ideal body weight (IBW) in 42% (n = 68) of procedures. Response was determined at 3 months by Response Evaluation Criteria in Solid Tumors; toxicity was assessed using the Wieberdink Limb Toxicity Scale.

RESULTS

In 128 evaluable patients, complete response rate was 31%, partial response rate was 33%, and there was no response in 36% of patients. For all patients (n = 162), 36% had Wieberdink toxicity grade >or=3 with one toxicity-related amputation. On multivariate analysis, smaller limb volumes were associated with better overall response (p = 0.021). Use of papaverine in the circuit to achieve cutaneous vasodilation was associated with better response (p < 0.001) but higher risk of grade >or=3 toxicity (p = 0.001). Correction of melphalan dose for ideal body weight did not alter complete response (p = 0.345), but did lead to marked reduction in toxicity (p < 0.001).

CONCLUSIONS

In the first multi-institutional analysis of ILI, a complete response rate of 31% was achieved with acceptable toxicity demonstrating this procedure to be a reasonable alternative to hyperthermic isolated limb perfusion in the management of advanced extremity melanoma.

Tissue compression is not necessary for needle-localized lesion identification

BACKGROUND

Tissue compression to enhance lesion visibility on radiography of needle-localized breast biopsy specimens is widely used. We hypothesized that compression is not necessary for detection of lesions on specimen radiography.

METHODS

Forty-nine consecutive patients underwent needle-localization biopsies of 59 mammographic targets. All specimens were radiographed without and with compression. The films were later independently reviewed and compared with preoperative mammograms by 2 surgeons and a breast-imaging radiologist. The primary end point was identification of mammographic targets in noncompressed specimen radiographs.

RESULTS

Twenty-nine targets were masses, 36 contained calcifications, and 14 contained previously placed clips. All mammographically localized lesions were identified on noncompressed views. Overall concordance for the 2 images was 100% for all 3 reviewers and 98% among reviewers.

CONCLUSIONS

Tissue compression before specimen radiography is not routinely necessary for target lesion identification.

Minimally Invasive Management of Obstructive Gastroduodenal Tuberculosis

Pulmonary tuberculosis (TB) is prevalent in Western urban centers, especially among immuno-compromised patients and immigrants. However, TB enteritis is a rare sequela, occurring in less than 1 per cent of this population. Tuberculosis may affect any portion of the gastrointestinal (GI) tract, and 85 per cent of cases manifest in the ileocecal region. However, the stomach and duodenum are involved in just 0.3–2.3% of TB cases that affect the gut. Gastric outlet obstruction due to TB has been traditionally treated by a surgical bypass operation, followed by anti-TB chemotherapy. In a recent review of 17 cases of TB-related gastric outlet obstruction, gastrojejunostomy or duodenojejunostomy was performed in all patients. We present a case of gastric outlet obstruction due to TB that was treated successfully with a minimally invasive approach, without the need for a gastric bypass.

Minimally invasive management of obstructive gastroduodenal tuberculosis

Pulmonary tuberculosis (TB) is prevalent in Western urban centers, especially among immunocompromised patients and immigrants. However, TB enteritis is a rare sequela, occurring in less than 1 per cent of this population. Tuberculosis may affect any portion of the gastrointestinal (GI) tract, and 85 per cent of cases manifest in the ileocecal region. However, the stomach and duodenum are involved in just 0.3-2.3% of TB cases that affect the gut. Gastric outlet obstruction due to TB has been traditionally treated by a surgical bypass operation, followed by anti-TB chemotherapy. In a recent review of 17 cases of TB-related gastric outlet obstruction, gastrojejunostomy or duodenojejunostomy was performed in all patients. We present a case of gastric outlet obstruction due to TB that was treated successfully with a minimally invasive approach, without the need for a gastric bypass.