Phase II Trial Using a Combination of Oxaliplatin, Capecitabine, and Celecoxib with Concurrent Radiation for Newly Diagnosed Resectable Rectal Cancer

LESSONS LEARNED

Colorectal cancers exhibit a high level of cyclooxygenase-2 (COX-2) expression with strong preclinical rationale for improved clinical outcomes with COX-2 inhibition. Celecoxib is a COX-2 inhibitor and we have shown that it can be safely combined with capecitabine and oxaliplatin as part of neoadjuvant treatment with radiation therapy (RT) in rectal cancer.There was a significant improvement in skin toxicity with this combination as compared with historical data. Considering the field has moved on to single-agent capecitabine, we believe future trials with capecitabine and celecoxib hold potential.

BACKGROUND

Improved survival is seen among patients with rectal cancer who achieve pathologic complete response (pCR) after neoadjuvant therapy. Cyclooxygenase-2 (COX-2) expression is increased in gastrointestinal malignancies and it may serve as a target to enhance pathologic response. A trial combining chemoradiation and COX-2 inhibition was conducted to evaluate the pCR rate, surgical outcomes, survival, and treatment toxicity.

METHODS

Patients with resectable (T3-4, N1-2) rectal cancer within 12 cm of the anal verge were included in this phase II clinical trial. The neoadjuvant treatment consisted of capecitabine 850 mg/m² b.i.d. Monday through Friday for 5 weeks, weekly oxaliplatin 50 mg/m² intravenous (IV), celecoxib 200 mg b.i.d. daily, along with concurrent 45 gray radiation therapy in 25 fractions.

RESULTS

Thirty-two patients were included in the final analysis. The primary endpoint was pCR: 31% (95% confidence interval [CI]: 16%-50%). Secondary endpoints were surgical downstaging (SD): 75% (95% CI: 57%-89%) and sphincter-sparing surgery (SSS): 56% (95% CI: 38%-74%). Common grade >3 toxicities were diarrhea and abnormal liver function tests (9% each). Grade 0 and 1 toxicities included radiation dermatitis (59% and 34%, respectively) and proctitis (63% and 28%, respectively). At 3 years, disease-free survival and overall survival (OS) were 84% (95% CI: 65%-93%) and 94% (95% CI: 77%-98%), respectively.

CONCLUSION

Chemoradiation with celecoxib in rectal cancer was well tolerated and demonstrated high rates of pCR, SD, and SSS. Improvement in skin toxicity (34% grade 1 and no grade 3/4) as compared with historical results (43%-78% grade 3/4) seems to be a significant improvement with addition of celecoxib to neoadjuvant chemotherapy.

Disease-specific survival for patients with multiple myeloma: significant improvements over time in all age groups

This study analyzed the survival of patients with multiple myeloma. Surveillance, Epidemiology, and End Results (SEER) and Centers for Disease Control and Prevention (CDC) databases were queried to calculate myeloma cause-specific survival curves by the Kaplan and Meier product-limit method. The Cox proportional hazards model was used to assess univariate and multivariate predictors of myeloma cause-specific survival. The outcome of interest was death due to myeloma. Results from a Cox proportional hazards model restricted to age and time period at diagnosis demonstrated that the magnitude of improvement in survival by time period varied by age at diagnosis. Among patients under 60 years at diagnosis, hazard ratios for myeloma cause-specific death decreased by more 50% from the first interval of observation to the last. Hazard ratios decreased during the study period by 39% among patients 60-69 years of age and by 27% among patients who were 70 years of age and older. Survival is improving in patients with myeloma of all ages.

A Phase I Protocol of Hydralazine and Valproic Acid in Advanced, Previously Treated Solid Cancers

Smokers experience aberrant gene promoter methylation in their bronchial cells, which may predispose to the development of neoplasia. Hydralazine is a DNA demethylating agent, and valproic acid is a histone deacetylase inhibitor, and both have modest but synergistic anticancer activity in vitro. We conducted a phase I trial combining valproic acid and hydralazine to determine the maximally tolerated dose (MTD) of hydralazine in combination with a therapeutic dose of valproic acid in patients with advanced, unresectable, and previously treated solid cancers. Twenty females and nine males were enrolled, with a median age of 57 years and a median ECOG performance status of 0. Grade 1 lymphopenia and fatigue were the most common adverse effects. Three subjects withdrew for treatment-related toxicities occurring after the DLT observation period, including testicular edema, rash, and an increase in serum lipase accompanied by hyponatremia in one subject each. A true MTD of hydralazine in combination with therapeutic doses of valproic acid was not reached in this trial, and the planned upper limit of hydralazine investigated in this combination was 400 mg/day without grade 3 or 4 toxicities. A median number of two treatment cycles were delivered. One partial response by Response Evaluation Criteria In Solid Tumors criteria was observed, and five subjects experienced stable disease for 3 to 6 months. The combination of hydralazine and valproic acid is simple, nontoxic, and might be appropriate for chemoprevention or combination with other cancer treatments. This trial supports further investigation of epigenetic modification as a new therapeutic strategy.

Phase II trial of sorafenib (S) and capecitabine (C) for hepatocellular carcinoma (HCC) in cirrhotic patients (pts)

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Background: S is the currently approved treatment for HCC. C has antitumor activity in HCC and biliary tree cancers. The combination of the two, if tolerated, could possibly improve antitumor response, and patient-overall survival (OS). Methods: This phase II trial of S and C accrued unresectable HCC pts. with histologically confirmed disease or radiological characteristics of HCC in cirrhotics with an elevated AFP of > 400 ng/mL. Eligibility criteria were: ECOG Performance status of ≤ 2, Child-Pugh (CP) class A or B-7 cirrhosis, hemoglobin ≥ 8.5 g/dL, platelets ≥ 50,000/µL, ANC ≥ 1500 cells/µL, and a serum creatinine of ≤ 2.0 mg/dL (creatinine clearance > 30 mL/minute). HIV+ patients were excluded. All subjects received a combination of S and C, on a 14-day treatment schedule. S dose was started at 400 mg BID daily with dose adjustments for hand foot syndrome. Starting C dose was 850 mg/m2BID for 7 days and a 7-day break; doses were adjusted as tolerated. The primary end point was assessment of safety and tolerability. OS and disease control rate (DCR) were also estimated. Results: 15/47 assessed pts. met inclusion criteria. One patient was never treated and excluded from analysis. Response data were available on 13 and safety data on all 14. Median pts.’ age was 64 years (56-79), and 75 % were male. Etiologies included viral hepatitis (64%), or viral hepatitis and alcohol in another 29%; 50% of pts. had CP class A (5-6) and 50% B-7 cirrhosis. With a median follow up of 12 months (M), median OS (mOS) was 11.3 (95% CI, 2.7-21.3) M. DCR was 54% (CR 8%, PR 15% and SD 31%). Grade 3-4 adverse events included: thrombocytopenia 9(64%), neutropenia 1(7%), anemia 2(14%); electrolyte imbalance, hypophosphatemia 3(21%), hypomagnesemia 2(14%), hypocalcaemia 1 and hyponatremia 1 (7%) each. Liver abnormalities included; hyperbilirubinemia 3(21%), increased AST 2(14%). Skin and mucosal abnormalities included hand-foot syndrome 3(21%), mucositis 1, alopecia 1 and skin rash 1 each. DVT occurred in 3 (21%). Conclusions: At tolerable doses, S and C seem active and safe palliative treatment for HCC in CP A & B-7 cirrhotics. It was associated with a DCR of 54% and mOS of 11.3 M. The small sample size does not allow comparison with single agent S. Clinical trial information: NCT01032850.

A phase II study of temsirolimus and erlotinib in patients with recurrent and/or metastatic, platinum-refractory head and neck squamous cell carcinoma

OBJECTIVES

The epidermal growth factor receptor (EGFR) is a validated target in head and neck squamous cell carcinoma (HNSCC). In recurrent and/or metastatic (R/M) HNSCC, resistance to anti-EGFR therapy inevitably occurs. Downstream activation of the PI3K/Akt/mTOR pathway is an established resistance mechanism. Concurrent mTOR blockade may improve efficacy of anti-EGFR therapy.

MATERIALS AND METHODS

Erlotinib 150 mg daily and temsirolimus 15 mg weekly were administered to patients with platinum-refractory R/M HNSCC and ECOG performance status 0-2. The primary endpoint was progression-free survival (PFS). Correlative studies determined PIK3CA and HRAS mutation status; p16, EGFR, pS6K, pAkt and PTEN expression; and pre- and post-treatment plasma levels of 20 immunomodulatory cytokines.

RESULTS

Twelve patients enrolled; six withdrew within 6 weeks due to toxicity or death, prompting early closure of the trial. Grade ≥ 3 toxicities included fatigue, diarrhea, gastrostomy tube infection, peritonitis, pneumonia, dyspnea, and HN edema. Median PFS was 1.9 months. Median overall survival was 4.0 months. Six/12 tumors were p16(+), 9/11 lacked measurable PTEN expression, and 1/12 harbored a PIK3CA mutation. On exploratory analysis, high baseline plasma VEGF and interferon-gamma levels marginally associated with tumor progression.

CONCLUSIONS

The combination of erlotinib and temsirolimus was poorly tolerated. Low prevalence of PTEN expression and 8% incidence of PIK3CA mutations indicate biological relevance of this pathway in R/M disease. Investigation of more tolerable combinations of EGFR and PI3K/Akt/mTOR pathway inhibitors in selected HNSCC patients is warranted.

A phase II trial of combination oxaliplatin, capecitabine, and celecoxib with concurrent radiation for patients with newly diagnosed resectable rectal cancer

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Background: The goal of preoperative chemoradiation in rectal cancer is complete surgical resection without impairing sphincter function and to decrease local recurrence. The primary objective of the study was to determine complete pathological response rate (pCR) with capecitabine, oxaliplatin and celecoxib with concurrent radiation therapy. The secondary objectives were down staging rate, sphincter preservation rate, incidence and severity of adverse events. Methods: A total 37 out of 55 planned patients (pts) were enrolled by New Mexico cancer center consortium from 2005 to 2012. Inclusion criteria were: Resectable adenocarcinoma of the rectum within 12 cm of the anal verge, biopsy proven T3-4 N1-2 M0 based on endoscopic ultrasound, performance status of 0-2, adequate bone marrow reserve and liver functions. The neoadjuvant chemoradiation treatment was: capecitabine 850 mg/m2 bid Monday through Friday for 5 weeks, weekly oxaliplatin 50 mg/m2 IV, celecoxib 200 mg bid with concurrent 45 gray radiation therapy in 25 fractions over 5 weeks. Results: Only 21 of 37 pathology reports were assessable for the primary objective of pCR. 7/21 pts (33%, 95% CI, 0.14-0.56) had pCR and 4 had only microscopic residual disease. Thus, 11/21 pts (52%, 95% CI, 0.30-0.74) had an excellent response following chemoradiation. The secondary outcome analysis showed 19/21 pts (90%, 95% CI, 0.69-0.98) were down staged. Sphincter preservation rate was 71% (15/21) (95% CI, 0.47-0.88). Grade 3 and 4 toxicities were observed in 23% and included nausea, vomiting, diarrhea, dehydration, hypokalemia, lymphopenia and fatigue. Conclusions: We report the highest pathological CR so far in stage III rectal cancer with these early results. This could be due to anti-inflammatory activity of celecoxib leading to better tolerance of radiation therapy and possible synergistic anti-tumor activity. Final results will be reported upon completion of the trial. Clinical trial information: NCT00250835.

Phase II study of temsirolimus and erlotinib in patients (pts) with recurrent/metastatic (R/M), platinum-refractory head and neck squamous cell carcinoma (HNSCC)

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Background: The Epidermal Growth Factor Receptor (EGFR) is a validated target in HNSCC. In R/M disease, primary or acquired resistance to anti-EGFR therapy inevitably occurs. Downstream activation of the PI3K/Akt/mTOR pathway is an established resistance mechanism. We hypothesized that concurrent mTOR blockade may improve efficacy of anti-EGFR therapy and conducted this phase II study. Methods: We evaluated the combination of erlotinib 150 mg po daily and temsirolimus 15 mg IV weekly in pts with platinum-refractory R/M HNSCC and ECOG PS 0-2. The exact, single-stage phase II design had 80% power (5% significance level) to detect improvement in progression-free survival (PFS) from 2.3 to 4.4 mos with 35 evaluable pts. Correlatives included determination of PIK3CA mutation (mut) status; p16, EGFR and PTEN expression; and immunomodulatory cytokine levels. Results: From Dec 2009 – Mar 2011, 12 pts enrolled. Six pts withdrew prior to first planned response assessment, due to toxicity (5) or death (1), prompting referral to the Data Safety and Monitoring Committee and early closure. Grade ≥ 3 toxicities included fatigue (5), diarrhea (2), GI infection/peritonitis (2), dyspnea (2), HN edema (2), and neutropenia (1). Among 8 progression-evaluable pt, median PFS was 1.9 mos. Median OS was 4.1 mos. 4/12 tumors were p16(+); 4/10 were EGFR(+); 11/11 showed no PTEN expression. PIK3CA mut was present in 1/11; the mut(+) pt withdrew after 3 wk for diarrhea/peritonitis with minor response. There were no associations between tumor p16, EGFR or PTEN status and oncologic outcomes. Five of 6 toxicity-related withdrawals occurred in p16(-) pts. Immunomodulatory cytokine levels in pre- and post-temsirolimus plasma did not significantly differ or associate with toxicity. Two pts with ≥ 4.4 mos PFS were p16(-) and PIK3CA mut(-). Conclusions: The combination of erlotinib and temsirolimus was poorly tolerated in this population, with toxicities predominant in p16(-) pts. Although the sample size was small, this R/M cohort demonstrated lack of PTEN expression and 9% PIK3CA mut, justifying further investigation of PI3K/Akt/mTOR pathway inhibitors in selected HNSCC pts.

Phase II trial of sorafenib and capecitabine for hepatocellular carcinoma in cirrhotic patients

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Background: Sorafenib (sorf.) has become the standard treatment for Hepatocellular Carcinoma (HCC), demonstrating an increase in patients (pts) median survival from 7.9 to 10.7 months (m) (Llovett, NEJM 2008). Abou-Alfa added doxorubicin to sorf. observing a median survival of 13.7 m vs 6.7 m. for doxorubicin + placebo, (JAMA. 2010). Since most of our HCC pts were cirrhotic and 8/12 HCV +, and 2/12 HBV only +, with cirrhosis and thrombopenia we chose to add capecitabine (cap) to sorf in a phase II trial, anticipating better tolerance. Primary objectives were to assess safety and tolerability of the combination while secondary objectives included estimations of PFS, OST and documentation of disease control rate (DCR = CR+PR+SD). With relaxation of eligibility criteria C-P B-7 pts and ≥ 50,000 platelets were allowed.

Methods: Sorf dose was 400 mg BID with dose adjustments for sorf related hand foot syndrome (HFS). Starting cap dose was 850mg/m2 BID x 7 Q 14 and adjusted as tolerated to 650mg/m2 BID or to 500 mg/m2 BID x 7 Q 14.. The lowest dose used was 250 mg/m2; BID (500 mg BID) for 5 days Q14. Patients: Only 12 of about 30 assessed patients met eligibility criteria, and were recruited between Nov. 2, 2009 and Sep. 13, 2011.The protocol was reviewed and approved by the WIRB and all participants signed an IRB approved consent form.

Results: Preliminary Results: Eight of 12 patients are alive, survivals ranging from 2.5 to 23 m. One patient has an unmaintained radiological CR continuing for 23 months with an AFP decrease from 139 to 2.9. Another patient had a PR and an AFP decrease from 355 to 3.2 ng/mL. She died in PR at 13 months from an UGI bleed. Grade 3 and 4 toxicities were limited to the skin, and included HFS, in 4/12, skin ulcers at sites of prior osteomyelitis (1/12); requiring treatment cessation, and fatigue in 4 /12.

Conclusions: With meticulous attention to cap dose adjustments as dictated by HFS this combination can be tolerated longitudinally in these frail pts that are not candidates for adding more aggressive agents to sorf. The objective radiological responses corroborated by AFP decreases in this very small cohort suggest that the findings are real, and warrant expansion of the trial.

Clinicopathologic features of agranulocytosis in the setting of levamisole-tainted cocaine

Levamisole is a known contaminant of cocaine and, via this route, has been associated with otherwise unexplained agranulocytosis. Levamisole is currently present in the majority of cocaine samples seized by the US Drug Enforcement Agency. We identified 20 cases of unexplained agranulocytosis in our practice locations of Albuquerque, NM, and Vancouver, Canada. Epidemiologic investigation revealed recent or ongoing cocaine use in 14 cases (70%). Certain morphologic features, including circulating plasmacytoid lymphocytes, increased bone marrow plasma cells, and mild megakaryocytic hyperplasia, were associated with the cocaine-exposed group. Of 5 patients tested, 3 (60%) were HLA-B27+ and showed antineutrophil antibodies, consistent with known associations of levamisole-induced agranulocytosis. One patient, who was positive for cocaine and levamisole by toxicology testing, died of infectious complications. Inadvertent consumption of levamisole via cocaine is a severely under-appreciated risk factor for agranulocytosis, and specific laboratory features are suggestive of this etiology.

Treatment of venous thromboembolism: guidelines translated for the clinician

Venous thromboembolism is a major cause of morbidity and mortality affecting over 2 million people in the United States each year. The American College of Chest Physicians (ACCP) published their first consensus statement on antithrombotic therapy in 1986, and the most recent guidelines from the ACCP on this topic were released in 2008. We aim to summarize the most recent ACCP guidelines on therapy for venous thromboembolism with practical application and interpretation for the practicing physician. We will briefly review the rating system used in the guidelines for the level of evidence and the strength of the recommendation. We will then discuss the recommendations for initial anticoagulant therapies including low molecular weight heparin, unfractionated heparin, and fondaparinux for patients with both deep vein thrombosis (DVT) and pulmonary embolism (PE). A discussion of the guidelines on duration of anticoagulant therapy with a vitamin K antagonist is also included. In addition, we will address the use of thrombolytic therapy and inferior vena cava filter placement for DVT and PE. Prevention of postphlebitic syndrome is discussed as well. We will conclude with a brief discussion of future directions including several novel therapeutic anticoagulants.

Epstein-Barr virus-associated inflammatory pseudotumor of the spleen: report of two cases and review of the literature

We report two rare examples of Epstein–Barr virus (EBV)-associated inflammatory pseudotumor of the spleen. One patient presented with night sweats, abdominal pain, and weight loss and was found to have a splenic mass on CT scan suspected of lymphoma. The splenic mass in second patient was found incidentally at the time of work up for kidney stones. The pathologic examination of these splenectomy specimens showed similar histologic features. However, the spindle cells were composed of EBV-infected follicular dendritic cells in one case whereas the second case lacked significant follicular dendritic cell proliferation and showed only focal EBV-infected cells suggesting that these proliferations are heterogenous in nature.

Breast disease: benign and malignant

Breast diseases, both benign and malignant, are common. Typically, young women present with more benign pathologies; however, breast malignancies can occur in young women, especially in those harboring mutations in the BRCA genes, other inherited genetic syndromes associated with increased risk of breast cancer, or familial predisposition for breast cancer. In all women aged 40 and over presenting with abnormalities of the breast, a primary breast cancer should be ruled out because it is the leading cancer among women in developed countries.