National Outcomes of Liver Transplantation for Model for End-Stage Liver Disease Score ≥40: The Impact of Share 35

In certain regions of the United States in which organ donor shortages are persistent and competition is high, recipients wait longer and are critically ill with Model for End-Stage Liver Disease (MELD) scores ≥40 when they undergo liver transplantation. Recent implementation of Share 35 has increased the percentage of recipients transplanted at these higher MELD scores. The purpose of our study was to examine national data of liver transplant recipients with MELD scores ≥40 and to identify risk factors that affect graft and recipient survival. During the 12-year study period, 5002 adult recipients underwent deceased donor whole-liver transplantation. The 1-, 3-, 5- and 10-year graft survival rates were 77%, 69%, 64% and 50%, respectively. The 1-, 3-, 5- and 10-year patient survival rates were 80%, 72%, 67% and 53%, respectively. Multivariable analysis identified previous transplant, ventilator dependence, diabetes, hepatitis C virus, age >60 years and prolonged hospitalization prior to transplant as recipient factors increasing the risk of graft failure and death. Donor age >30 years was associated with an incrementally increased risk of graft failure and death. Recipients after implementation of Share 35 had shorter waiting times and higher graft and patient survival compared with pre-Share 35 recipients, demonstrating that some risk factors can be mitigated by policy changes that increase organ accessibility.

In Vitro Flow Rates of Enteral Solutions through Nasoenteric Tubes

Enteral solutions must flow freely through nasoenteric tubes selected for gravity drip administration particularly in outpatients receiving nutritional support. This study determined in vitro flow rates of solutions with intact protein and hydrolyzed protein sources with various caloric densities. Each solution was infused through silicone rubber and polyurethane tubes of various lengths and bore sizes. Flow rates were measured five times at 25 degrees C using formula bags and drip sets hung at a uniform height and tubes uniformly positioned in a collecting vessel. Data are presented for tubes and formulas tested. Recommendations for selection of tubes for gravity drip administration are made based on flow rate data, patient comfort, administration convenience, and patient tolerance to osmolality.

National Outcomes of Liver Transplantation for Model for End-Stage Liver Disease Score ≥40: The Impact of Share 35

In certain regions of the United States in which organ donor shortages are persistent and competition is high, recipients wait longer and are critically ill with Model for End-Stage Liver Disease (MELD) scores ≥40 when they undergo liver transplantation. Recent implementation of Share 35 has increased the percentage of recipients transplanted at these higher MELD scores. The purpose of our study was to examine national data of liver transplant recipients with MELD scores ≥40 and to identify risk factors that affect graft and recipient survival. During the 12-year study period, 5002 adult recipients underwent deceased donor whole-liver transplantation. The 1-, 3-, 5- and 10-year graft survival rates were 77%, 69%, 64% and 50%, respectively. The 1-, 3-, 5- and 10-year patient survival rates were 80%, 72%, 67% and 53%, respectively. Multivariable analysis identified previous transplant, ventilator dependence, diabetes, hepatitis C virus, age >60 years and prolonged hospitalization prior to transplant as recipient factors increasing the risk of graft failure and death. Donor age >30 years was associated with an incrementally increased risk of graft failure and death. Recipients after implementation of Share 35 had shorter waiting times and higher graft and patient survival compared with pre-Share 35 recipients, demonstrating that some risk factors can be mitigated by policy changes that increase organ accessibility.

OC-14 - Baseline D-dimer levels are predictive of recurrent venous thromboembolism (VTE) at 6 months in cancer patients with VTE treated with tinzaparin

INTRODUCTION

VTE is a major complication in cancer patients. Despite treatment with low molecular weight heparin (LMWH), 9% will have recurrent VTE within 6 months. Measurement of plasma biomarkers in cancer patients receiving LMWH may be predictive of recurrent VTE or overall survival (OS).

AIM

We conducted a single arm phase 2 study to evaluate the efficacy and safety of once daily tinzaparin for the initial treatment and extended prophylaxis of VTE in cancer patients. The study included a prospective analysis of plasma biomarkers D-dimer and IL-6 to assess whether these were predictive of recurrent VTE or OS.

MATERIALS AND METHODS

Consecutive patients with active cancer diagnosed with a pulmonary embolism (PE) and/or proximal deep venous thrombosis (DVT) at the University of Southern California Norris Comprehensive Cancer Center, Los Angeles County Medical Center, or New York Presbyterian - Weill Cornell Medical Center were invited to participate in this study with a target enrollment of 100 patients. Key eligibility criteria included: age ≥18, ECOG score ≤2, adequate organ function, and ≥6 month estimated survival. Patients were treated with daily subcutaneously tinzaparin 175 U/kg for 6 months on study. Tinzaparin could be continued ≤1 year at the discretion of the treating physician. All patients who received ≥1 dose were evaluable for efficacy and safety. Primary study endpoints were recurrent VTE or major bleeding. Secondary outcome measures included OS and plasma biomarkers. Biomarkers were measured at baseline, 7 days, 1 month and 6 months after tinzaparin initiation. Patients who had baseline and 1 week or 1 month samples collected were included in the biomarker analysis.

RESULTS

97 patients were enrolled. 2 patients were ineligible. 8 patients did not have baseline or follow-up biomarkers completed. 87 patients were included in the analysis. 28 (32%) of patients completed≥6 months of tinzaparin. Major bleeding occurred in 2 patients. 11 patients had recurrent VTE at 6 months (3 PE, 7 DVT, 1 central venous thrombosis not associated with a catheter). Median baseline D-dimer level was 2759 ng/mL (range: 375-37,591). Median baseline IL-6 level was 9.4 pg/mL (range: 0.8-20.9). Baseline D-dimer>median was predictive of VTE recurrence at 6 months (p=.006). Baseline IL-6>median was not predictive of VTE recurrence at 6 months. Neither 1 month D-dimer or IL-6 levels were predictive of VTE recurrence at 6 months. D-dimer and IL-6 at baseline and at 1 month were not predictive of OS.

CONCLUSIONS

In patients with active cancer and VTE treated with tinzaparin, baseline D-dimer levels above the median value were predictive of VTE recurrence at 6 months.

3-Year Follow-Up of the Partial Breast Irradiation Trial for DCIS Using the MammoSite® Brachytherapy Balloon Catheter

Purpose: To report the 3-year median follow-up of a prospective Phase II partial breast irradiation (PBI) trial utilizing the MammoSite® interstitial balloon as the sole radiation therapy treatment after lumpectomy for ductal carcinoma in situ (DCIS).Materials and Methods: One hundred and thirty-three patients were enrolled from May 2003 through January 2006 to reach the 100-patient partial breast irradiation (PBI) target goal of 34 Gy in 10 fractions, 1 cm peripheral to the MammoSite® balloon surface, b.i.d. with Iridium192 HDR brachytherapy. The eligibility criteria were age 45, unicentric pure DCIS, mammographic size ≤3cm, negative margin of ≥1 mm, gross pathology size ≤5 cm, clinically node negative, post-lumpectomy mammogram absent of residual microcalcificaion. A USC/VNPI score was then calculated based on age, tumor size, margin width, and nuclear grade [ref: Silverstein MJ, Am J Surg 2003;186(4):337-343]. Placement of the balloon was performed at the time of lumpectomy or post-lumpectomy with a required minimum distance of the balloon surface to skin (skin bridge) of 5 mm. Data was collected at enrollment, at implant, 3 and 6-months, then yearly for local control, cosmesis (Harvard Scale), toxicity, adverse events, disease-free survival, cause-specific survival, and contralateral breast failure. Local recurrence is defined as either invasive or non-invasive within the target volume. Ipsilateral elsewhere recurrence (IER) is defined as invasive or non-invasive outside of the target volume.Results: Of the 133 patients enrolled, thirty-three were not treated for the following reasons: less than 5 mm skin bridge (n=13), poor cavity conformance (n=10), positive margin (n=3), microinvasion (n=3), MD decision (n=2), patient request (1), and other (1). The nuclear grade distribution of the tumors were: NG1(17%), NG2(44%), and NG3(39%). The mean age was 60.8 years. The mean tumor size was 10.6 mm; mean closest surgical margin was 6.8 mm (R=0.1-40mm); post-lumpectomy placement in 72%; mean skin bridge distance was 13 mm with 89% ≥7mm. No patients have been lost to follow-up, and at a median 3-year follow-up, the cosmetic results have been rated as excellent/good in 94 and fair in 6 patients. There have been only four recurrences, all non-invasive with the following histological patterns listed in the table below. One was an IER.Recurrence DetailsCase No.Months Since PlacementInvasiveUSC/VNPI ScoreOriginal Tumor GradeComedo Necrosis18No93Yes211No83No317No62Yes432No52Yes No serious adverse events were reported with an infection rate of 9% (7 breast infections; 2 cellulitis).Conclusion: This is the longest reported prospective Phase II study using a PBI technique for pure DCIS patients, and continues to demonstrate the efficacy of the MammoSite® balloon for treating pure DCIS breast tumors, with no new recurrences since our last report at SABCS 2007. All the recurrences were noninvasive, and had at least one or more risk factors of a high USC/VNPI score, high nuclear tumor grade, or had a comedo necrosis pattern. There have been no recurrences in nuclear grade 1 or 2 patients in the absence of a comedo necrosis pattern. The cosmesis also continues to be excellent or good long-term in 96% patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 952.

Genetic variations in angiogenesis pathway genes associated with clinical outcome in localized gastric adenocarcinoma

BACKGROUND

Angiogenesis has been attributed to be a well-recognized aspect of human cancer biology. As such, proteinase-activated receptor (PAR)-1, endostatin (ES) and interleukin-8 (IL-8) mediate the regulation of early-onset angiogenesis and in turn impact the process of tumor-growth and disease progression.

PATIENTS AND METHODS

Formalin-fixed paraffin-embedded tissues were obtained from 137 patients with localized gastric cancer at University of Southern California and Memorial Sloan-Kettering Cancer Center medical facilities. DNA was extracted and genotyping was carried out using PCR-restriction fragment length polymorphism-based protocols.

RESULTS

In false discovery rate-adjusted univariate analysis, PAR-1 -506 ins/del (P < 0.001), ES +4349 G>A (P = 0.004), and IL-8 -251 T>A (P < 0.0001) were associated with time to tumor recurrence (TTR). Further, PAR-1 -506 ins/del and IL-8 -251 were associated with overall survival (OS). After adjusting for covariates, IL-8 remained significantly associated with TTR (adjusted P = 0.003) and OS (adjusted P = 0.049), whereas ES was significantly associated with TTR (adjusted P = 0.026).

CONCLUSIONS

Polymorphisms in PAR-1, ES, and IL-8 may serve as independent molecular prognostic markers in patients with localized gastric adenocarcinoma. The assessment of the patients' individual risk on the basis of interindividual genotypes may therefore help to identify patient subgroups at high risk for poor clinical outcome.

A phase I study of zoledronic acid (ZA) and low-dose cyclophosphamide (CTX) in children with recurrent/refractory neuroblastoma (NB): A New Approaches to Neuroblastoma Therapy (NANT) study

10022

Background: ZA, a bisphosphonate, delays progression of bone metastases in adult malignancies. Bone metastases occur in 60% of children with advanced NB. A xenograft mouse model demonstrated ZA with low dose chemotherapy delayed progression of NB bone lesions prompting a phase I trial of ZA. Methods: Three dose levels of intravenous ZA (2, 3, or 4 mg/m2) administered every 28 days were evaluated with continuous daily oral CTX (25 mg/m2/day) in patients with recurrent/refractory NB and bone metastases. The primary objective was to determine a recommended dose of ZA for future trials. PKs with the first dose of ZA and serial serum IL-6 levels (stimulator of osteoclast activity) were evaluated. Results: 21 patients (14 male), median age 7.9 years (0.8–26.6 years), were enrolled at ZA dose levels 2 mg/m2 (n=4), 3 mg/m2 (n=3), and 4 mg/m2 (n=13). Seventy-five cycles were administered with median of 1 cycle per patient (range 1–18). Two DLT (Gr 3 hypophosphatemia) occurred at 4 mg/m2 ZA. Other Gr 3 or 4 toxicities included hypocalcemia (n = 2), elevated transaminases (n = 2), neutropenia (n = 2), anemia (n = 1), lymphopenia (n = 1), and hypokalemia (n = 1). A fracture related to osteosclerosis occurred after 18 cycles. There were no renal or dental complications. There was 1 complete response, 9 stable disease median 4.5 cycles (range 3–18), and 10 progressions (central review pending). At 4 mg/m2, mean serum IL-6 levels decreased from 3.9 pg/mL (95% CI: 2.8–5.2 pg/mL) (n = 11) to 2.9 pg/mL (95% CI: 1.8–4.4 pg/mL) after cycle 1 (n = 8). ZA PK were similar to adults. Conclusions: ZA with low dose CTX is well tolerated with evidence of clinical benefit in children with recurrent/refractory NB. The recommended ZA dose for future study is 4 mg/m2 every 28 days.

No significant financial relationships to disclose.

Phase I study of fenretinide (4-HPR) oral powder in patients with recurrent or resistant neuroblastoma: New Approaches to Neuroblastoma Therapy (NANT) Consortium trial

10009

Background: Fenretinide (4-HPR), a cytotoxic retinoid, achieved limited and variable plasma levels when tested in a corn oil-based capsule. 4HPR/Lym-X-Sorb (LXS) oral powder is a new formulation intended to increase bioavailability, especially in children. Methods: This trial sought to define the toxicities, dose limiting toxicities (DLTs), maximum tolerated dose (MTD), and pharmacokinetics of 4-HPR/LXS oral powder when given mixed in Slim-Fast nutritional shakes, twice a day for 7 days, every 21 days. Eligible patients had high-risk neuroblastoma with recurrent/progressive disease, or disease refractory or persistent after frontline therapy. Dose escalation was in 30% increments using the traditional 3 + 3 design. Plasma levels were measured by HPLC. Results: Thirty-two patients accrued to 8 Dose Levels (DL) (352 –2210 mg/m2/day); 30 patients were evaluable. No MTD was identified. There was a DLT elevation of alkaline phosphatase on DL1. No other DLT's were observed. Other toxicities included dry skin, elevated triglycerides, reversible nyctalopia, and transient transaminase elevation. Course 1 day 7 peak 4HPR plasma levels (Dose (mg/m2/day) - mean, (range)) were: 352 –6 μM (3.8–9.6); 458–11.5 μM (9.7–14.9); 595–17.6 μM (6–24.3); 774–15 μM (9.1–25.3); 1006–6.7 μM (5.2–9.2); 1308–13.9 μM (2.9–23.8); 1700–19.7 μM (17.3–24.3); and 2210–10.8 μM (4–16.5). Course 2 day 7 peak plasma levels trended higher than course 1 at DL5–8. Three patients with isolated bone marrow disease and one with MIBG avid bone lesions, had complete responses (DL4, DL4, DL7, DL8) receiving 10, 17, 18 and 10 courses of therapy, respectively. Six patients had stable disease for 4–27 courses (median 5.5) (DL3, DL4, DL4, DL5, DL6, DL8). Twenty patients had progressive disease. Central review of responses is pending. Conclusions: 4-HPR/LXS oral powder was well tolerated, obtained 2 - 5 fold higher 4HPR plasma levels than fenretinide capsules on the same dose and schedule (P < 0.01), and showed anti-tumor activity (complete responses in 4/15 patients at DL4–8). Based on pharmacokinetic data, a recommended Phase II dose and schedule is 1700 mg/m2/day × 7days every 3 weeks.

No significant financial relationships to disclose.

Randomized trial of p53 targeted adjuvant therapy for patients (pts) with organ- confined node-negative urothelial bladder cancer (UBC)

5017

Background: Retrospective studies suggest that p53 mutation and associated immunohistochemical (IHC) detectable expression are prognostic for recurrence in pts with organ confined UBC and may be predictive for benefit from MVAC adjuvant chemotherapy. Methods: Pts with pT1–2N0M0 UBC following radical cystectomy and bilateral pelvic lymph node dissection were eligible. IHC for p53 was centrally performed and pts with ≥10% nuclear reactivity were offered randomization to 3 cycles of adjuvant MVAC vs. observation. P53 negative and p53 positive pts who declined randomization were observed. Primary endpoint was recurrence-free survival (RFS) in the randomized population. Secondary endpoints were RFS in p53 negative versus p53 positive pts and overall survival in each of these groups. Using a one-sided log-rank test with α = 0.05 and β = 0.15, 190 p53 positive patients were planned to be randomized to detect an absolute improvement in RFS at 3 years (yrs) from 50% to 70% (corresponding hazards ratio of 0.51). Results: 521 pts were registered, 499 underwent successful p53 assessment (male: 80%, <65 yrs: 57%, Caucasian: 91%, pathologic stage P1/P2: 37%/63%, lymphovascular invasion: 20% yes/28% unknown), 272 (55%) were p53 positive and 114 were randomized (42%). Further accrual was halted based on data safety monitoring board review of futility analysis on the first 100 randomized pts. P53 positive tumors were higher grade (97% vs 93% grade 3/4, p = 0.04) and less likely to express p21 (59% vs 84%, p < 0.001). Overall 5-yr RFS was 80 ± 2% with no difference based on p53 status. P53 positive patients declining were older but otherwise similar to those accepting randomization. Only 67% of pts randomized to MVAC received all 3 cycles with 12 (21%) receiving none. There was no difference in RFS in the randomized population (overall 5 yr RFS 83 ± 4%, hazard ratio = 0.88, p = 0.78). Conclusions: The prognostic and predictive value of p53 IHC were not confirmed in this prospective study, but the lower than expected event rate and failures to receive assigned therapy severely compromised the study's power. The value of p53 mutations is being assessed.

No significant financial relationships to disclose.

Urinary tract infections and reduced risk of bladder cancer in Los Angeles

We investigated the association between urinary tract infections (UTIs) and transitional cell carcinoma of the bladder in a population-based case–control study in Los Angeles covering 1586 cases and age-, gender-, and race-matched neighbourhood controls. A history of bladder infection was associated with a reduced risk of bladder cancer among women (odds ratio (OR), 0.66; 95% confidence interval (CI), 0.46–0.96). No effect was found in men, perhaps due to power limitations. A greater reduction in bladder cancer risk was observed among women with multiple infections (OR, 0.37; 95% CI, 0.18–0.78). Exclusion of subjects with a history of diabetes, kidney or bladder stones did not change the inverse association. A history of kidney infections was not associated with bladder cancer risk, but there was a weak association between a history of other UTIs and slightly increased risk among men. Our results suggest that a history of bladder infection is associated with a reduced risk of bladder cancer among women. Cytotoxicity from antibiotics commonly used to treat bladder infections is proposed as one possible explanation.

Molecular profiling including epidermal growth factor receptor and p21 expression in high-risk breast cancer patients as indicators of outcome

BACKGROUND

Patients with high-risk primary breast cancer remain at high risk for relapse. More precise prognostic and predictive tools are needed to improve treatment of such patients.

PATIENTS AND METHODS

Formalin-fixed, paraffin-embedded tumors from 239 high-risk breast cancer patients were examined for expression of human epidermal growth factor receptor 2 (HER2), epidermal growth factor receptor (EGFR), estrogen receptor, progesterone receptor, Ki-67, p16, p21, p27, and p53 by immunohistochemistry. Gene expression of EGFR, HER2, glutathione S-transferase-Pi (GSTP1), excision repair cross complementation1 (ERCC1), p21, beta-tubulin-3, multidurg resistance (MDR1), cyclooxygenase2 (COX2), and cyclin-E was measured by RT-PCR.

RESULTS

Eighty percent of patients presented with locally advanced, or > or =10 axillary nodal metastasis, and 20% with inflammatory breast cancer. The median age was 46 years (26-62 years) and the median number of involved axillary lymph nodes was 12 (0-42). At a median follow-up of 86 months, relapse-free survival (RFS) and overall survival for the entire group were 50% (95% CI 43% to 57%) and 62% (95% CI 56% to 69%). Multivariate Cox stepwise analysis resulted in a simple model for RFS consisting only of p21 expression, EGFR expression assessed by RT-PCR, and number of axillary nodal metastases.

CONCLUSION

A prognostic model on the basis of the expression of a limited number of proteins and genes may help to guide target-specific therapies in patients with high-risk breast cancer.

Polymorphisms in VEGF and IL-8 predict tumor recurrence in stage III colon cancer

BACKGROUND

Identifying molecular markers for tumor recurrence is critical in successfully selecting patients with stage III colon cancer who are more likely to benefit from adjuvant chemotherapy. The present study analyzed a subset of 10 polymorphisms within eight genes involved in the tumor angiogenesis pathway and their impact on prognosis in stage III colon cancer patients treated with adjuvant chemotherapy.

PATIENTS AND METHODS

Blood samples were obtained from 125 patients with locally advanced colon cancer at University of Southern California medical facilities. DNA was extracted from peripheral blood and the genotypes were analyzed using PCR-restriction fragment length polymorphism and 5'-end [gamma-(33)P] ATP-labeled PCR protocols.

RESULTS

Polymorphisms in vascular endothelial growth factor (VEGF) (C+936T; P = 0.003, log-rank test) and interleukin-8 (IL-8) (T-251A; P = 0.04, log-rank test) were independently associated with risk of recurrence in stage III colon cancer patients. In combined analysis, grouping alleles into favorable versus nonfavorable alleles, high expression variants of VEGF C+936T and IL-8 T-251A were associated with a higher likelihood of developing tumor recurrence (P < 0.001).

CONCLUSION

High expression variants of VEGF C+936T and IL-8 T-251A were associated with shorter time to tumor recurrence, indicating that the analysis of angiogenesis-related gene polymorphisms may help to identify patient subgroups at high risk for tumor recurrence.

A phase I study of zoledronic acid and low dose cyclophosphamide in children with recurrent/refractory neuroblastoma: A New Approaches to Neuroblastoma Therapy (NANT) study

9572

Background: Zoledronic acid (ZA), is a new generation, highly potent bisphosphonate that delays progression of bone metastases in adult malignancies. Bone metastases occur in 60% of children with advanced neuroblastoma. Pre-clinical studies demonstrated ZA with low dose chemotherapy delayed progression of osteolytic neuroblastoma lesions in a xenograft mouse model, prompting a phase I trial of ZA in neuroblastoma. Methods: Three dose levels of intravenous ZA (2, 3 or 4 mg/m2) administered every 28 days were evaluated in combination with continuous daily oral cyclophosphamide (CTX) (25 mg/m2/day) in patients with recurrent/refractory neuroblastoma and cortical bone lesions. The primary objective was to determine a recommended dose of ZA for future trials. Serial blood and urine samples were collected for pharmacokinetics, markers of osteoclast activity, and immunologic assays. Results: 14 patients (9 male), median age 7.9 years (0.8 - 26.6 years), were enrolled at ZA dose levels 2 mg/m2 (n=4), 3 mg/m2 (n=3), and 4 mg/m2 (n=7). To date, 13 patients are evaluable for toxicity. Thirty-nine cycles were administered with a median of 1 cycle per patient (range 1 - 12). Treatment was well tolerated; one DLT (Grade 3 hypophosphatemia) occurred at 4 mg/m2 ZA. Other grade 3 or 4 toxicities attributable to the combination included hypocalcemia (n=2), elevated transaminases (n=2), neutropenia (n=2), anemia (n=1), lymphopenia (n=1), and hypokalemia (n=1). Hypocalcemia occurred in 69% of first cycles and 8% of subsequent cycles. There were no renal toxicities or dental complications. There have been 2 partial responses by MIBG (central review pending), 4 stable disease, and 7 progressive disease; one patient is too early for response. Pharmacokinetic and correlative biology study results are pending. Conclusions: ZA is well tolerated and had evidence of responses when given with low dose CTX to children with recurrent/refractory neuroblastoma. The recommended dose of ZA for subsequent study is 4 mg/m2. Future studies incorporating ZA into the regimen for children with NB and cortical bone lesions are planned.

No significant financial relationships to disclose.

High plasma levels of fenretinide (4-HPR) were associated with improved outcome in a phase II study of recurrent ovarian cancer: A study by the California Cancer Consortium

5555

Background: 4-HPR is a synthetic retinoid with dose-dependent cytotoxicity in vitro for ovarian cancer cell lines, especially at concentrations > 10 μM. We previously reported preliminary results of a phase II trial (Garcia et al, Proc ASCO 2004: a5056) that showed encouraging stabilization of disease. Methods: 4-HPR capsules were given orally (900 mg/m2/bid for 7 days every 21-days) to women with recurrent ovarian cancer. Steady-state plasma concentrations of 4-HPR were determined by HPLC. Patients were required to have uni-dimensionally measurable disease, 0–2 chemotherapy regimens for recurrent disease, and performance status 0–2. The primary endpoint was response rate by RECIST criteria; secondary endpoints were progression-free survival (PFS) and overall survival (OS). Results: 31 patients were enrolled to the first stage; 28 patients were evaluable for response, with a median of 3 prior chemotherapy regimens (range: 1–3); 24 patients were evaluable for pharmacokinetics. A total of 172 4-HPR treatment cycles were given. Eleven patients experienced at least one grade 3 toxicity and one patient had grade 4 fatigue. No objective responses were observed, leading to study closure. Best response was stable disease in 13 patients (42%) with a median duration of 7.9 months (2.1–25.8 months). 4-HPR steady-state plasma levels ranged from 3.1–12.5 μM. PFS at 6 months was 26% (± 0.08 SE), 42 % (± 0.14 SE) for patients with 4-HPR plasma levels = 9 μM (n=12), and 17% (± 0.11 SE) for plasma levels < 9 μM (n=12). OS with plasma levels = 9 μM was significantly higher than for those with 4-HPR levels < 9 μM (66% vs. 13% at 18 months, adjusted p-value = 0.016). Conclusions: 4-HPR may provide clinical benefit to patients with recurrent ovarian cancer who obtain high 4-HPR plasma levels. Trials in ovarian cancer of 4-HPR focused on progression-free survival as an endpoint are justified using formulations with improved bioavailability. Supported by N01-CM-62209.

No significant financial relationships to disclose.

Phase I trial of fenretinide (4-HPR) intravenous emulsion for hematologic malignancies

13007

Background: 4-HPR is a retinoid cytotoxic for cancer cell lines. In clinical trials, oral capsule 4-HPR had limited bioavailability and activity. An intravenous intralipid emulsion formulation of 4-HPR (ILE 4-HPR) was developed to increase bioavailability. The objectives of this phase I trial were to determine a maximally tolerated dose (MTD) of ILE 4-HPR, and to assess toxicities, pharmacokinetics (PK), and preliminary response data. Methods: We used an accelerated titration Simon design 2 dose escalation schema with 100% increase in ILE 4-HPR per dose level tested until moderate toxicity was observed in 2 patients or DLT in one. Ten dose levels were planned with a starting dose of 80 mg/m2/day (continuous i.v. x 5 days q 3 weekly), increasing until Dose level 10 at 1,810 mg/m2. A De-escalation to 1,240 mg/m2/day Dose level 9 was added when DLT was observed in 2 patients at 1,810 mg/m2 dose level 10. Results: To date, 11 patients have been enrolled. At dose level 10 (1,810 mg/m2/day), 2 pts experienced a DLT of grade IV hypertriglyceridemia with grade 2 pancreatitis. A de-escalation to dose level 9 (1,280 mg/m2/day) has enrolled 4 pts, 1 had grade IV hypertriglyceridemia; enrollment is ongoing. We observed a transient response in a patient with NHL at 320 mg/m2 and a continued partial response in one patient with NHL on dose level 10 (1,810 mg/m2). PK showed a linear relationship of dose to plasma level, with steady-state levels of 54 μM (1,280 mg/m2)and 62 μM (1,810 mg/m2). Conclusions: ILE 4-HPR was given via continuous infusion to a dose of 1,810 mg/m2/day x 5 days. 1 patient with NHL had a transient partial response and a second patient with chemotherapy-refractory NHL had a partial response sustained on treatment for > 6 months. The DLT of hypertriglyceridemia is likely related to the intralipids delivered. Enrollment continues at a dose of 1,280 mg/m2/day. ILE 4- HPR can be safely administered and obtained plasma levels 6 to 7 times higher than previously obtained by oral capsule 4-HPR, with clinical activity in hematologic malignancies.

No significant financial relationships to disclose.

Phase I study of oral irinotecan and temozolomide in children with relapsed high-risk neuroblastoma: A New Approach to Neuroblastoma Therapy (NANT) Consortium study

9567

Background: Irinotecan (IRN) and temozolomide (TEM) have single-agent activity and schedule-dependent synergy against neuroblastoma. Because intravenous IRN is costly and inconvenient, especially with protracted scheduling common in pediatric trials, we sought to determine the maximum tolerated dose (MTD) of oral IRN combined with TEM in children with recurrent/resistant high-risk neuroblastoma, using the antibiotic cefixime to reduce IRN-associated diarrhea. Methods: Patients received oral TEM on days 1–5 and oral IRN on days 1–5 and 8–12, with courses repeated every 21 days. Oral cefixime 8 mg/kg (max 400 mg/day) was started on day -5 and continued daily. Results: Fifteen patients (median age 7 years, range 2–22) with a median of 3.5 previous treatment regimens were evaluable for toxicity and have to date received 71 courses (median 2, range 1–19+). Neutropenia and thrombocytopenia were dose-limiting in the first 6 patients, and TEM was reduced from 100 to 75 mg/m2/day for all subsequent patients. IRN was then escalated from 30 to 60 mg/m2/day. First-course grade 3 diarrhea was dose-limiting in 1 of 6 patients treated at the IRN MTD of 60 mg/m2/day. Other toxicities were mild and reversible. No grade 4 therapy-related toxicity occurred in 27 courses administered at the MTD. The median SN-38 lactone AUC at this dose was 72 ng*hr/ml, similar to that reported with protracted intravenous IRN at the single-agent MTD. Of 14 patients evaluable for response, one with measurable nodal disease had a very good partial response through 6 courses. Six additional patients had stable disease for a median of 7.5 courses (range 6–19+). Two patients remain on study after 10 and 19 courses. Conclusions: This combination was well tolerated in heavily-pretreated children with resistant neuroblastoma, and 7 (50%) of 14 evaluable patients had response/stable disease for 6 or more courses in this Phase I trial. This all-oral regimen was feasible and resulted in favorable SN-38-lactone exposures. The dose recommended for further study in this patient population is TEM 75 mg/m2/day plus IRN 60 mg/m2/day when given with cefixime.

No significant financial relationships to disclose.

Tissue factor promoter polymorphism as a prognostic factor in patients with metastatic colon cancer

4108

Background: Tissue Factor (TF), a transmembrane glycoprotein, initiates the physiologic coagulation cascade. Cumulative evidence implies that TF plays a key role in tumor angiogenesis. Elevated TF expression has been reported to be associated with poor survival in patients in solid tumor. We investigated whether a functional TF promoter polymorphism -603 A/G is a prognostic factor in patients with advanced colon cancer because the G allele had been linked to high constitutive TF gene expression in human monocytes in healthy volunteers. Methods: 318 patients with metastatic colon cancer treated at the USC/Norris Comprehensive Cancer Center or the LA County/USC Medical Center during 1992 through 2003 were included in this study. Genomic DNA was extracted from white blood cells of peripheral blood samples using the QiaAmp kit (Qiagen, Valencia, CA). The TF polymorphism was genotyped by PCR-RFLP-based approach. The association between the TF polymorphism and overall survival was examined using the log-rank and trend test. The association between TF polymorphism and baseline demographic characteristics was tested using the χ2 test or Fisher’s exact test when appropriate. Results: There were 141 females and 177 males, with a median age of 58 years (range 25–86). The cohort comprised 234 whites, 43 Asians, 15 Blacks, 24 Hispanics, and 2 Native Americans. The median survival was 13.7 months with a median follow-up of 2.3 years. Asians were less likely to bear the G allele compared to other racial groups (P < 0.001, Fisher’s exact test). Patients who carried 1 or 2 G alleles were at higher risk of poor survival compared to patients with no G alleles (A/A) (P = 0.038, trend test). The median overall survival was 14.7 vs. 11.9 months for patients with A/A vs. patients with G/G or A/G, respectively. Conclusions: This study suggests that TF may be a prognostic factor for patients with metastatic colon cancer. The finding should be validated with future prospective clinical studies.

No significant financial relationships to disclose.

Intratumoral mRNA levels predict clinical outcome in patients with metastatic colorectal cancer treated in a prospective clinical trial with 5-FU and oxaliplatin

10010

Background: 5-flurouracil (5-FU) and Oxaliplatin-based therapy is one of the most frequently used combinations in the treatment of advanced colorectal cancer (CRC). There are no validated and established predictive factors for clinical outcome following 5-FU/Oxaliplatin treatment. We had shown an association between intratumoral mRNA levels of TS and ERCC1 involved in 5-FU metabolism and DNA repair, respectively, and survival to 5-FU/Oxaliplatin chemotherapy in advanced CRC in a retrospective study. Now we investigated whether intratumoral mRNA levels of these two genes and others involved in 5-FU metabolism (DPD, TP, dUTPase), DNA repair (ERCC2, XRCC1), angiogenesis (COX-2, EGFR, IL-8, PLA2), and drug detoxification (GSTP-1) predict the clinical outcome of patients with CRC in a prospectively designed biomarker study. Methods: 85 patients with metastatic CRC treated with second-line 5-FU/Oxaliplatin from the prospective trial were included. mRNA levels of 12 genes were assessed from paraffin- embedded tissue samples using laser capture microdissection and quantitative Real-time PCR. Overall survival (OS) was the primary endpoint. Progression-free survival (PFS), response, and toxicity were the secondary endpoints. Results: There were 40 women and 45 men (median age 60 years; range 29–87), median survival of 9.7 ms, median PFS of 4.2 ms, CR in 1 (1%) patient, PR in 15 (18%), SD in 36 (43%) and PD in 32 (38%) patients. High intratumoral mRNA levels of PLA2, TP, GSPTP-1 and low mRNA levels of COX-2 were each significantly associated with shorter OS (P≤0.05, log-rank test). There was a trend in the association between high mRNA levels of PLA2 and shorter PFS (P=0.08). In addition, high mRNA levels of XRCC1 and IL-8 were each significantly associated with high risk of cumulative grade 3+ toxicity (P≤0.05). No significant association was found between mRNA levels and response to 5-FU/Oxaliplatin. Conclusions: This study suggests that mRNA levels of PLA2, TP, GSTP-1, COX-2, XRCC1, and IL-8 may be useful to predict the outcome of patients with metastatic CRC with second-line 5-FU/Oxaliplatin chemotherapy. These findings should be validated with future basic sciences studies and prospective clinical trials.

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Functional heterogeneity of prostatic intra-epithelial neoplasia: Length of hormonal therapy influences response

4648

Background: Prostatic intraepithelial neoplasia (PIN) is a premalignant lesion of the prostate etiologically linked to prostate cancer. While androgen deprivation therapy (ADT) has been used to reduce prostate cancer, there are controversial data regarding the effect of ADT on PIN. We hypothesized that PIN is a heterogeneous entity with respect to hormone responsiveness, that this may explain aspects of the heterogeneity in the natural history of this disease, and have used the clinical model of ADT followed by radical prostatectomy as a test of this hypothesis. Methods: We performed a retrospective study on a cohort of patients who underwent prostatectomy with biopsy proven prostate cancer. Study patients were those who must have received at least 3 months of ADT at the discretion of their surgeons. Patients from the same cohort who did not undergo ADT were used as controls. Patients were randomly selected from the database and their pathology slides were reviewed by a blinded pathologist looking for presence of PIN with an independent observer. Fisher’s exact test was used to compare the proportions of subjects who had residual PIN in the study group and the control group. Exact logistic regression was used to evaluate the duration of ADT in PIN regression. Results: Eighteen patients initially diagnosed with PIN who did not receive hormonal therapy were identified; 28 patients with PIN who underwent hormonal therapy were also studied. All patients who did not receive hormonal therapy had residual PIN whereas 7 of 28 patients undergoing ADT had no residual PIN (p = 0.043). Evaluation of hormonal therapy between responders and non-responders showed statistically significant association between PIN regression and hormone therapy duration (p < 0.001). However PIN response to ADT was not uniform as 16% of patients with ADT longer than 6 months had residual PIN, suggesting variable sensitivity of PIN to ADT. Conclusions: Our results demonstrate that ADT does cause PIN regression, and that there is heterogeneity in this effect with respect to hormonal duration. We propose for future prospective, multi-centered, randomized trials in which ADT impact on PIN is characterized further.

No significant financial relationships to disclose.

Phase I dose and schedule finding study of pegylated liposomal doxorubicin (D) and weekly docetaxel (T)

12012

Background: The combination of D and T has many potential applications, particularly in breast and ovarian cancers. A phase 3 trial is examining D + T versus T in first-line metastatic breast cancer ( NCT00091442 ). D has better tumor localization and penetration in solid tumors than conventional doxorubicin. In previous studies, the maximum tolerated dose (MTD) of the combination was identified as D 30 mg/m2 and T 75 mg/m2 q4 weeks (wks), with a recommended dose and schedule of D 30 mg/m2 and T 60 mg/m2 q3wks without G-CSF. We conducted a phase I study to determine the MTD of D with weekly T. Our hypothesis was that the lower incidence of myelosuppression with weekly T would allow for higher doses of both drugs. Methods: There were 2 schedules. Arm A: D q4wks starting at 25 mg/m2 with weekly T for 3 wks starting at 30 mg/m2. Arm B: D q2wks starting at 15 mg/m2 with weekly T for 3 wks starting at 30 mg/m2. One cycle was 28 days. Standard 3+3 design was used with MTD defined as the highest dose level causing dose limiting toxicity (DLT) in ≥ 2/6 patients (pts). Results: 32 pts were treated; 13 females, 19 males, median age of 60 years. Median number of cycles administered was 2 (1–13) with a median follow-up of 11.5 months. Tumor types included lung (16%), thyroid (9%), esophagus (9%), nasopharynx, breast, colorectal, stomach and kidney (6% each). Arm A (13 pts) was closed after 2/7 evaluable pts at dose level 2 (D 33mg/m2; T 30 mg/m2) experienced DLT in the form of grade 3 stomatitis. The most common grade 3/4 toxicities were neutropenia (3/13), stomatitis (3/13) and fatigue (3/13). Arm B accrued 19 pts. The trial was closed at the highest planned dose in Arm B (D 20mg/m2 q2wks and T 35 mg/m2 weekly) with only 1/6 evaluable pts experiencing DLT in the form of grade 4 fatigue and weakness. The most common grade 3/4 toxicities in Arm B included neutropenia (5/19 pts), fatigue (5/19 pts) and stomatitis (2/19 pts). There was no grade 3/4 hand-foot syndrome or cardiotoxicity. 2 partial responses were observed in nasopharyngeal and salivary gland carcinomas, with 13 pts achieving stable disease. Conclusions: The combination of D q2 wks and T weekly for 3/4 wks is well tolerated and results in a higher dose intensity of both drugs than in previously evaluated regimens.

[Table: see text]

131I-Metaiodobenzylguanidine (131I-MIBG) double infusion with autologous stem cell transplant for neuroblastoma: A New Approaches to Neuroblastoma Therapy (NANT) study

9011

Background: 131I-MIBG provides targeted radiotherapy with >30% response in refractory neuroblastoma, but the activity infused is limited by radiation safety and hematologic toxicity. The goal was to determine the maximum tolerated dose of 131I-MIBG in two consecutive infusions at a 2-week interval, supported by autologous stem cell transplant (ASCT) 2 weeks after the second dose. Methods: The 131I-MIBG was escalated in a 3+3 Phase I trial design, with levels calculated by total red marrow radiation index (RMI) from the double infusion. The first infusion of 131I-MIBG was 12, 15, 18 and 21 mCi/kg for levels 1, 2, 3 and 4 respectively. Using detailed dosimetry, the second infusion was adjusted to achieve the target RMI, except at Level 4, where the second infusion was capped at 21 mCi/kg. Results: Twenty-one patients were enrolled at Level 1–4, with 18 evaluable for toxicity. Median age at enrollment was 7 years, all were heavily pretreated, including 12 with prior high dose therapy and ASCT, and 12 patients had bone marrow tumor. Cumulative 131I-MIBG given to achieve the target RMI ranged from 18 mci/kg to 49 mCi/kg. RMI delivered per mCi of MIBG decreased in 15/19 patients by mean of 0.21 cGy/mCi with the second infusion. Hematologic toxicity was acceptable, with median time to ANC>500 after ASCT of 13 (4–27) days. Platelet transfusion was required in 15/18 patients, with median time to platelet independence of 18 (6–47) days after ASCT. There were no non-hematologic toxicities above grade 2 attributed to therapy, though 9 patients had grade 1–2 elevations of transaminase, and 1 had grade 2 hypothyroidism. Responses in 17 evaluable patients included 1 PR, 4 MR, 6 SD, and 6 PD. Eleven patients are alive at median of 361 days (46–483); 5 died of PD and 1 of unrelated toxicity. Conclusion: The lack of toxicity with this approach allowed dramatic dose intensification of 131I-MIBG, with minimal toxicity and the possibility of improved response.

[Table: see text]

No significant financial relationships to disclose.

POMB-ACE therapy for patients with international germ cell cancer collaborative group (IGCCCG) poor risk germ cell tumors (GCT): The USC experience

4591

Background: Patients with poor-risk GCT have low rates of cure with standard therapy, with 3 year overall survival (OS) reported at 50% (IGCCCG, JCO 1997). POMB-ACE is a rapidly alternating, dose dense chemotherapy regimen developed to improve outcomes in this population, with reported 3 year OS of 75% (Bower et al, Ann Oncol 1997). We report our experience with this regimen, including analysis of acute and long-term toxicity. Methods: Subjects with poor-risk GCT, defined by IGCCCG criteria as AFP >10,000, bHCG >50,000, LDH > 10 × ULN, non-testicular primary, or non-pulmonary visceral metastases, who were diagnosed at Los Angeles County General Hospital and USC/Norris Cancer Center between 1998 and 2005 were identified using pathology and admission records. All clinical notes and laboratory data were reviewed. Results: Of 23 poor-risk GCT patients identified, 21 received POMB-ACE; 16 were treated at the county facility. 15 patients were Hispanic. 5 had primary mediastinal tumors. 16 were stage IIIC, 4 stage IIIB, and 1 stage IIIA. The median number of cycles was 8 (range 4–12), with a median interval between treatment cycles of 14 days (range 10–39). There were no treatment-related deaths. Febrile neutropenia occurred in 5.9% of treatment cycles, grade 3/4 hematologic toxicity in 19%, and other Grade 3/4 non-hematologic toxicities in 9.8%. G-CSF support was used with 24% of cycles. Nineteen patients (90%) had a partial response, of whom 8 underwent surgery for residual disease; only 1 had residual active tumor, 4 teratoma. Marker-negative status was achieved in 5 patients (23.8%). With median follow-up of 28 months, 9 subjects have recurred (43%) and 4 have died of disease progression. The estimated 2 year disease-free survival is 54%, and 3 year OS 75%. At the end of treatment, residual neuropathy persisted in 2 patients (9.5%), renal compromise in 2 (9.5%), pulmonary toxicity in 3 (14%), and otoxicity in 1 patient (4.7%). Conclusions: In our modern North American experience, POMB-ACE is feasible to administer, even in an uninsured population. This is an effective option in poor-risk GCT patients, with 3 year OS exceeding that achieved with standard therapy. Acute toxicity is modest, however persistent adverse sequelae are common.

No significant financial relationships to disclose.

Lack of association with epidermal growth factor receptor gene polymorphisms with clinical outcome in patients with advanced colorectal cancer treated with platinum-based chemotherapy

3079

Background: We had previously shown an association between functional polymorphisms of the epidermal growth factor receptor gene and clinical outcome to platinum-based chemotherapy in advanced colorectal cancer in a retrospective study. Specifically, patients with <20 CA repeats in intron-1 of the EGFR gene were shown to have increased risk of disease progression. Here in, we report our findings of a confirmatory prospective study. Methods: Between September 2001 and August 2004, 173 patients with advanced refractory colorectal cancer were enrolled. Patients received 5-FU 200 mg/m2/day as continuous infusion and oxaliplatin 130 mg/m2, in three week cycles. Blood samples for genomic analysis were available for 152 patients. EGFR intron 1 CA-repeat and HER1- R497K polymorphisms and their relationship with clinical response, time-to-progression, overall survival, and toxicity, either alone or in combination were assessed prospectively. In addition, we were able to perform quantitative gene expression analysis of EGFR through RT-PCR in a subset of 58 patients. Results: Our cohort of 152 patients comprised 78 males and 74 females, with a median age of 60. There were 105 Caucasians, 24 Asians, 5 Blacks, and 18 Hispanics. The median number of cycles received was 5. The median survival was 10.3 months with a median follow-up of 18.6 months. There were 28 responders (19%). Asians were more likely to possess longer CA repeats and the HER1- 497K variant (Fisher’s exact test p<0.05). Neither EGFR intron-1 CA repeat nor the HER1- R497K polymorphisms were associated with clinical response, time-to-progression, overall survival, toxicity (p>0.10). EGFR gene expression was not associated with clinical outcome (p>0.10). Shorter EGFR intron-1 CA repeats (<20) was associated with higher EGFR gene expression (Kruskal-Wallis t test p=0.013)Conclusion: We were not able to confirm prospectively a previously reported association between functional EGFR gene polymorphisms and clinical outcome to platinum-based therapy in patients with advanced colorectal cancer. In-vitro studies assessing differential oxaliplatin sensitivity with respect to EGFR expression are on-going.

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Increased late toxicity in 12–20 year survivors of germ cell tumors (GCT)

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Background: There is extensive literature on occurrence of late effects of cisplatin-based chemotherapy, but it comes from centers of excellence and may reflect case selection or ascertainment biases. Funded by the NIH SEER Program and the Lance Armstrong Foundation, we studied community-based late outcomes via identification of cases from the Los Angeles SEER Tumor Registry and comparison with a control group. Methods: We identified 951 patients treated in Los Angeles County through the records of the L.A. SEER Cancer Registry/Cancer Surveillance Program (CSP) for 1983–1987, giving a minimum follow-up of 12 years. Consent was obtained from physician of record and forms sent to the patients, requesting information about a broad range of demographic, treatment-related and psycho-social issues. In addition, patients were asked to provide a “control”, a friend of approximately the same age at time of diagnosis, known to the patient before diagnosis and known not to have a history of testis cancer. Questionnaires were also sent to controls, to allow data comparison with patients. Anticipated initial difficulties included mobility of young males and invalid addresses. This occurred in > 50% of cases, and we used a planned strategy for acquisition through State agencies, Department of Motor Vehicles, etc. Results: Surveys were returned by 298 cases and 67 control subjects, and 35 patients refused. In 1983–87, success rates were lower, and 142 patients had died. An unexpected problem was reluctance or inability of subjects to identify friends of comparable age to provide a control population. Differences in groups are summarized in the Table. Conclusions: Long term survivors with GCT have an excess of late toxicity, including cardiovascular, neurological, hematologic, musculoskeletal and neoplastic problems, which increase with time. These data should assist in design of surveillance protocols.

[Table: see text]

No significant financial relationships to disclose.