Treatment of Oligometastatic GI Cancers

Oligometastatic state is believed to potentially represent a transitional stage between early, locoregional state disease and widely metastatic disease. Historically, locoregional approaches, particularly in advanced colorectal cancers, have demonstrated efficacy in select patients with limited burden of metastatic disease. Recent strides in systemic therapies, including biomarker-based treatments and immunotherapy, alongside innovations in surgical techniques and novel locoregional approaches such as stereotactic radiotherapy and ablation, have ushered in a new era of therapeutic possibilities across all oligometastatic GI cancers. Despite these advancements, there remains a significant gap in high-quality prospective evidence guiding patient selection and treatment decisions across various disease types. Ongoing clinical trials are anticipated to provide crucial insights into oligometastatic states, fostering the refinement of disease-specific oligometastatic state definitions and treatment algorithms. This article reviews existing data on the management of oligometastatic GI cancer, summarizes current state of knowledge for each disease state, and provides updates on ongoing studies in this space.

Toxicity and Patient-Reported Quality-of-Life Outcomes After Prostate Stereotactic Body Radiation Therapy With Focal Boost to Magnetic Resonance Imaging-Identified Prostate Cancer Lesions: Results of a Phase 2 Trial

PURPOSE

In this prospective phase 2 trial, we investigated the toxicity and patient-reported quality-of-life outcomes in patients treated with stereotactic body radiation therapy (SBRT) to the prostate gland and a simultaneous focal boost to magnetic resonance imaging (MRI)-identified intraprostatic lesions while also de-escalating dose to the adjacent organs at risk.

METHODS AND MATERIALS

Eligible patients included low- or intermediate-risk prostate cancer (Gleason score ≤7, prostate specific antigen ≤20, T stage ≤2b). SBRT was prescribed to 40 Gy in 5 fractions delivered every other day to the prostate, with any areas of high disease burden (MRI-identified prostate imaging reporting and data system 4 or 5 lesions) simultaneously escalated to 42.5 to 45 Gy and areas overlapping organs at risk (within 2 mm of urethra, rectum, and bladder) constrained to 36.25 Gy (n = 100). Patients without a pretreatment MRI or without MRI-identified lesions were treated to dose of 37.5 Gy with no focal boost (n = 14).

RESULTS

From 2015 to 2022, a total of 114 patients were enrolled with a median follow-up of 42 months. No acute or late grade 3+ gastrointestinal (GI) toxicity was observed. One patient developed late grade 3 genitourinary (GU) toxicity at 16 months. In patients treated with focal boost (n = 100), acute grade 2 GU and GI toxicity was seen in 38% and 4% of patients, respectively. Cumulative late grade 2+ GU and GI toxicities at 24 months were 13% and 5% respectively. Patient-reported outcomes showed no significant long-term change from baseline in urinary, bowel, hormonal, or sexual quality-of-life scores after treatment.

CONCLUSIONS

SBRT to a dose of 40 Gy to the prostate gland with a simultaneous focal boost up to 45 Gy is well tolerated with similar rates of acute and late grade 2+ GI and GU toxicity as seen in other SBRT regimens without intraprostatic boost. Moreover, no significant long-term changes were seen in patient-reported urinary, bowel, or sexual outcomes from pretreatment baseline.

Phase I/II trial of perioperative avelumab in combination with chemoradiation (CRT) in the treatment of stage II/III resectable esophageal and gastroesophageal junction (E/GEJ) cancer

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Background: Neoadjuvant CRT followed by surgery is the standard of care for patients (pts) with stage II/III E/GEJ cancer, yet recurrence rates remain high. Immunotherapy has demonstrated activity in advanced E/GEJ cancer and was recently approved for adjuvant treatment of early stage disease. This trial evaluated the safety and efficacy of avelumab with perioperative CRT in resectable E/GEJ cancer. Methods: This is a two part phase I/II trial. Phase I was a safety run-in of 6 pts. Phase II planned to enroll an additional 18 pts in an expansion cohort. Pts with E/GEJ adenocarcinoma or squamous cell cancer received CRT (41.4 Gy in 23 fractions) with weekly carboplatin and paclitaxel. Three doses of avelumab (10 mg/kg IV, q14 days) were administered starting on day 29 of treatment, to coincide with the last chemotherapy dose. Surgery was performed 8-10 weeks after CRT completion. Pts received 6 doses of avelumab after resection (10 mg/kg IV, q14 days). The primary endpoint of the Phase 1 was safety and tolerability. The primary endpoint of the Phase II was pathologic complete response (pathCR) rate, assessing patients from the safety run in and expansion cohorts. Results: Between 6/2018 and 10/2021, 22 pts (20 males, median age 64) enrolled in the study. Enrollment was stopped after 16 patients in the expansion cohort due to accrual delays and changes in standard treatment. 19/22 patients (86%) had adenocarcinoma; 15/22 (68%) had lymph node positive disease at diagnosis. 19 pts underwent successful resection while on study. 3 pts went off study before resection due to grade 3 avelumab-related infusion reaction (1), patient preference (1), and non-adherence (1). There were no unexpected surgical complications. 4 pts (21%) had R1 resection with 3/4 having positive radial margin and 1/4 positive proximal margin. At resection, 5 pts (26%) had pathCR (3/16 adenocarcinomas, 2/3 squamous cell), 4 ypT1N0 disease, and 14/19 were ypN0. 42% had tumor regression score of 0 or 1. The combination of CRT and avelumab had an acceptable toxicity profile. No grade ≥3 immune-related AEs were observed. Immune-related hypothyroiditis was seen in 2 patients (grade 2). Three patients had grade 2 infusion-related reaction, but were able to continue with treatment. 21/22 pts had reversible grade ≥3 lymphopenia; 13/22 grade ≥ 3 wbc decrease; 6/22 grade 3 neutropenia. As of data cutoff on 2/1/2022, 1 patient remains on study treatment, 15 in follow up, 5 expired, 1 off study. Additional efficacy data is being collected. Correlative studies are ongoing. Conclusions: Perioperative CRT with avelumab is well tolerated with no unexpected toxicities. Neoadjuvant chemoradiation with immunotherapy is a promising approach for patients with E/GEJ tumors. Additional safety, efficacy and correlative analysis from this study will be presented at the meeting. Clinical trial information: NCT03490292.

The State of the Science in Patient-Reported Outcomes for Patients with Lung Cancer

Traditionally, clinicians have assumed the primary responsibility for evaluating disease- and treatment-related outcomes. In the past few decades, however, a series of recommendations and standards promulgated by professional societies and regulatory agencies have resulted in increased use of patient-reported outcome (PRO) measures in cancer clinical trials. PROs, such as quality of life (QOL) measures, are important in establishing overall treatment effectiveness in cancer clinical trials, and they can inform clinical decision making. This article discusses the current state of the science in PRO research for patients with lung cancer, the cancer type with the highest incidence rate and the lowest survival rate worldwide. The discussion focuses on (1) PRO and survival; (2) electronic PRO reporting and interventions; (3) PROs and immunotherapy; (4) PRO, biomarkers, and precision health; (5) key issues in applying PROs in clinical trials; and (6) future directions for research.

An oncogenic activity of PDGF-C and its splice variant in human breast cancer

Despite strong evidence for the involvement of PDGF signaling in breast cancer, little is known about the PDGF ligand responsible for PDGFR activation during breast cancer progression. Here, we found PDGF-C to be highly expressed in breast carcinoma cell lines. Immunohistochemical analysis of invasive breast cancer revealed an association between increased PDGF-C expression and lymph node metastases, Ki-67 proliferation index, and poor disease-free survival. We also identified a PDGF-C splice variant encoding truncated PDGF-C (t-PDGF-C) isoform lacking the signal peptide and the N-terminal CUB domain. While t-PDGF C homodimer is retained intracellularly, it can be secreted as a heterodimer with full-length PDGF-C (FL-PDGF-C). PDGF-C downregulation reduced anchorage-independent growth and matrigel invasion of MDA-MB-231 cells. Conversely, ectopic expression of t-PDGF-C enhanced phenotypic transformation and invasion in BT-549 cells expressing endogenous FL-PDGF-C. The present study provides new insights into the functional significance of PDGF-C and its splice variant in human breast cancer.

Population Modeling of Selexipag Pharmacokinetics and Clinical Response Parameters in Patients With Pulmonary Arterial Hypertension

Selexipag (Uptravi) is an oral selective IP prostacyclin receptor agonist approved for the treatment of pulmonary arterial hypertension (PAH). The pivotal GRIPHON study was the largest clinical study ever conducted in PAH patients, providing long‐term data from 1,156 patients. PAH comedication did not affect exposure to selexipag, while exposure to its active metabolite ACT‐333679 was reduced by 30% when taken in combination, clinically not relevant in the context of individual dose up‐titration. Using log‐linear regression models linking model‐predicted steady‐state exposure to pharmacodynamics (PD), exposure to selexipag and ACT‐333679 showed some statistically significant, albeit not clinically relevant, effects on exercise capacity, laboratory values, and the occurrence of prostacyclin‐related adverse events, but not on vital signs or adverse events denoting hemorrhage. Using suitable modeling techniques, the GRIPHON study yielded clinically relevant data with limited burden of pharmacokinetics (PK) blood sampling, demonstrating that PK/PD modeling enables firm conclusions even with sparse PK and PD sampling.

The effect of DXA scanning on clinical decision making by general practitioners: a randomized, prospective trial of direct access versus referral to a hospital consultant

The objective of the study was to assess the impact of direct access DXA scanning (DADS) upon GPs' management decisions in patients considered to be at risk of osteoporosis. It was designed as a randomized, prospective, parallel group trial, set within the primary care environment and a university teaching hospital. The participants were 330 patients aged 31 to 89 years from 18 general practices in Edinburgh. Patients were randomized to either DADS or to the current system of specialist referral (controls). The primary outcome measure was frequency of change of management after DXA scanning. Secondary outcome measures were: change in health status, adherence to therapy, clinical events and resource use at one-year follow-up. The primary outcome was that 60% each of DADS patients (98/165) and controls (99/165) had changes in management following DXA scanning. In 30% of patients (12/41) in whom GPs had proposed changing management even in the absence of a scan, different therapy was chosen after the scan (no difference between DADS and control groups). There was an improvement in health utility (p =0.014 for both groups combined), differing slightly between the two groups even after age correction (p =0.014). 68% of the DADS group and 70% of controls were adherent to therapy after one year. In terms of clinical events, at one year there was one major adverse event (control group patient), 5 new fractures in the DADS group and 3 in controls - there were no hip fractures in this study. With regard to resource use, there were 24 referrals to hospital specialist after DXA scanning among the DADS group, vs 12 among controls (p < 0.05). The total number of visits to health professionals was 525 in DADS and 585 in controls (p=ns); mean waiting time from randomization to receipt of report/clinic letter was 4 weeks for DADS vs 13 weeks for controls( p < 0.0001). In conclusion, DXA scanning resulted in management change in at least 60% of cases. Direct access does not result in a clinical outcome significantly different from a consultant led service, and is more economically efficient than the current model of hospital referral.

Inhibition of human monocyte respiratory burst, degranulation, phospholipid methylation and bactericidal activity by pneumolysin

The interaction between the pneumococcal toxin pneumolysin and human monocytes was examined. At non-cytotoxic concentrations (0.5-2.5 HU/10(6) cells) pneumolysin depressed the oxygen-dependent respiratory burst in monocytes, induced by opsonized zymosan or phorbol myristate acetate (PMA). This included depressed hexose-monophosphate shunt activity and hydrogen peroxide production. The toxin also depressed the ability of monocytes to degranulate (measured by release of lysozyme) in response to the above stimuli. Phospholipid transmethylation was also markedly decreased by pretreating monocytes with pneumolysin. These effects on monocyte functions were accompanied by a decreased ability of pneumolysin-treated monocytes to kill Streptococcus pneumoniae, the organism that produces the toxin. Cholesterol, which inhibits the haemolytic activity of the toxin, was shown to abrogate the effects of pneumolysin on monocytes.

A short, retarded child with a deletion of the short arm of chromosome 18 (18p-)

A small black girl with a deletion of chromosome 18 is described. She is mentally retarded and small for her age, and has severe dental decay, hypertelorism, and epicanthic folds. Her IgA is normal. Her bone age is retarded.