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Hartlapp I, Valta-Seufzer D, Siveke JT, Algül H, Goekkurt E, Siegler G, Martens UM, Waldschmidt D, Pelzer U, Fuchs M, Kullmann F, Boeck S, Ettrich TJ, Held S, Keller R, Anger F, Germer CT, Stang A, Kimmel B, Heinemann V, Kunzmann V. Corrigendum to "Prognostic and predictive value of CA 19-9 in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: results from a prospective, multicenter phase II trial (NEOLAP-AIO-PAK-0113)": [ESMO Open 7 (2024) 100552]. ESMO Open 2024; 9:103463. [PMID: 38703429 PMCID: PMC11087890 DOI: 10.1016/j.esmoop.2024.103463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Affiliation(s)
- I Hartlapp
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg
| | - D Valta-Seufzer
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg
| | - J T Siveke
- Department of Medical Oncology, Bridge Institute of Experimental Tumor Therapy, University Medicine Essen, Essen; Division of Solid Tumor Translational Oncology (DKTK Partner Site Essen, DKFZ Heidelberg), West German Cancer Center, University Medicine Essen, Essen
| | - H Algül
- Comprehensive Cancer Center München, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Bavaria, Germany
| | - E Goekkurt
- Hämatologisch-Onkologische Praxis Eppendorf (HOPE), Hamburg and University Cancer Center Hamburg (UCCH), Hamburg, Germany
| | - G Siegler
- Department of Internal Medicine 5, Hematology and Medical Oncology, Paracelsus Medical University, Nürnberg
| | - U M Martens
- Department of Internal Medicine III, SLK-Clinics Heilbronn GmbH, Heilbronn
| | - D Waldschmidt
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne
| | - U Pelzer
- Division of Oncology and Hematology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin
| | - M Fuchs
- Clinic for Gastroenterology, Hepatology and GI-Oncology, München Klinik Bogenhausen, Munich
| | - F Kullmann
- Department of Internal Medicine I, Kliniken Nordoberpfalz AG, Klinikum Weiden, Weiden
| | - S Boeck
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm
| | - S Held
- Department of Biometrics, ClinAssess GmbH, Leverkusen
| | - R Keller
- Clinical Research, AIO Studien gGmbH, Berlin
| | - F Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg
| | - A Stang
- Department of Haematology, Oncology and Palliative Care Medicine, Asklepios Hospital Barmbek, Hamburg, Germany
| | - B Kimmel
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg
| | - V Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich
| | - V Kunzmann
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg.
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Heinrich K, Heinemann V, Stintzing S, Müller L, Ettrich TJ, Buechner-Steudel P, Geißler M, Trojan J, Moosmann N, Folprecht G, Schmidt J, Kanzler S, Kullmann F, Moulin JC, Werner J, Angele MK, Probst V, Held S, Schulz C, Boukovala M. Adjuvant treatment with S-1 in patients after R0-resection of adenocarcinoma of the stomach and esophagogastric junction - A multicenter phase I/II feasibility study (GMBH-STO-0114). Oncol Res Treat 2024:000538143. [PMID: 38565089 DOI: 10.1159/000538143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION S-1 has been shown to be an effective adjuvant treatment option for East Asian patients who underwent gastrectomy for stage II/III gastric cancer. We conducted a phase I/II study to evaluate the feasibility, tolerability and efficacy of administering S-1 in the adjuvant setting after R0-resection of adenocarcinoma of the stomach and esophagogastric junction (EGJ) in Caucasian patients. METHODS In this single-cohort, open-label, phase I/II trial, we enrolled patients with locally advanced adenocarcinoma of the stomach or EGJ having undergone R0-resection with or without neoadjuvant treatment. One treatment cycle consisted of oral S-1 (30mg/m² bid) for 14 days. Cycles were repeated every 3 weeks for 18 cycles (54 weeks). Primary endpoint was feasibility and tolerability. Safety was evaluated according to the common toxicity criteria adverse events 4.0 criteria. Secondary endpoints were one-year relapse-free survival rate, relapse-free survival (RFS) and overall survival (OS). RESULTS Between 10/2015 and 02/2018, 32 patients were enrolled in 12 German centres and 30 started adjuvant study treatment. Seventeen patients completed all 18 cycles. Two patients terminated study treatment due to adverse events (AEs), 7 due to patient's or investigator's decision and 4 due to recurrence or distant metastasis during adjuvant therapy. Dose levels were reduced to 25 mg/m² in 9 patients, and to 20 mg/m² in 1 patient. Of patients completing all 18 cycles, 5 did so with reduced dosage of S-1. Documented grade ≥ 3 AEs were neutropenia, diarrhoea, vomiting, polyneuropathy, palmar-plantar erythrodysaesthesia and rash. Serious AEs were observed in 7 patients. Median RFS was 32.2 months. One-year relapse-free survival rate was 77%. Data on OS were still premature at the end of the study. CONCLUSION Adjuvant treatment with S-1 for one year is a feasible and safe treatment option for Caucasian patients diagnosed with gastric adenocarcinoma or cancer of the EGJ cancer after R0-resection.
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Goetze T, Gonzalez-Carmona MA, Kochen L, Agaoglu NB, Al-Batran SE, Habibzada T, Pons M, Brunner M, Ettrich TJ, Köhne CH, Roderburg C, Modest D. ADJUBIL: phase II study of adjuvant immunotherapy with STRIDE regimen with/without capecitabine in biliary tract cancers. Future Oncol 2024; 20:307-315. [PMID: 38410920 DOI: 10.2217/fon-2023-0961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Biliary tract cancer is a highly heterogeneous group of gastrointestinal cancers, and the only curative treatment is surgery, which is only applicable at early stages of the malignancy. ADJUBIL, a phase II trial (NCT05239169), aims to evaluate immunotherapy with durvalumab and tremelimumab with or without capecitabine in adjuvant situations for biliary tract cancers. A total of 40 prospective patients will be randomly assigned following surgery, consisting of a two-arm feasibility pilot part with a pick-the-winner design with durvalumab and tremelimumab in combination with or without capecitabine.
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Affiliation(s)
- Thorsten Goetze
- Krankenhaus Nordwest, University Cancer Center Frankfurt, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
- Frankfurter Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
| | | | - Lisa Kochen
- Frankfurter Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
| | - Nihat Bugra Agaoglu
- Frankfurter Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
| | - Salah-Eddin Al-Batran
- Krankenhaus Nordwest, University Cancer Center Frankfurt, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
- Frankfurter Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
| | - Timorshah Habibzada
- Krankenhaus Nordwest, University Cancer Center Frankfurt, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
| | - Miriam Pons
- Frankfurter Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
| | - Marius Brunner
- Universitätsklinikum Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Thomas J Ettrich
- Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Claus-Henning Köhne
- Department of Gynaekology,Klinikum Oldenburg AöR, Rahel-Straus-Straße 10, 26133 Oldenburg, Germany
| | | | - Dominik Modest
- Department of Hematology, Oncology, and Cancer Immunology (CVK)Charité Berlin, Augustenburger Platz 1 Ostring 1, 13353 Berlin, Germany
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4
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Vogele D, Mueller T, Wolf D, Otto S, Manoj S, Goetz M, Ettrich TJ, Beer M. Applicability of the CT Radiomics of Skeletal Muscle and Machine Learning for the Detection of Sarcopenia and Prognostic Assessment of Disease Progression in Patients with Gastric and Esophageal Tumors. Diagnostics (Basel) 2024; 14:198. [PMID: 38248074 PMCID: PMC10814393 DOI: 10.3390/diagnostics14020198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
PURPOSE Sarcopenia is considered a negative prognostic factor in patients with malignant tumors. Among other diagnostic options, computed tomography (CT), which is repeatedly performed on tumor patients, can be of further benefit. The present study aims to establish a framework for classifying the impact of sarcopenia on the prognosis of patients diagnosed with esophageal or gastric cancer. Additionally, it explores the significance of CT radiomics in both diagnostic and prognostic methodologies. MATERIALS AND METHODS CT scans of 83 patients with esophageal or gastric cancer taken at the time of diagnosis and during a follow-up period of one year were evaluated retrospectively. A total of 330 CT scans were analyzed. Seventy three of these patients received operative tumor resection after neoadjuvant chemotherapy, and 74% of the patients were male. The mean age was 64 years (31-83 years). Three time points (t) were defined as a basis for the statistical analysis in order to structure the course of the disease: t1 = initial diagnosis, t2 = following (neoadjuvant) chemotherapy and t3 = end of the first year after surgery in the "surgery" group or end of the first year after chemotherapy. Sarcopenia was determined using the psoas muscle index (PMI). The additional analysis included the analysis of selected radiomic features of the psoas major, quadratus lumborum, and erector spinae muscles at the L3 level. Disease progression was monitored according to the response evaluation criteria in solid tumors (RECIST 1.1). CT scans and radiomics were used to assess the likelihood of tumor progression and their correlation to sarcopenia. For machine learning, the established algorithms decision tree (DT), K-nearest neighbor (KNN), and random forest (RF) were applied. To evaluate the performance of each model, a 10-fold cross-validation as well as a calculation of Accuracy and Area Under the Curve (AUC) was used. RESULTS During the observation period of the study, there was a significant decrease in PMI. This was most evident in patients with surgical therapy in the comparison between diagnosis and after both neoadjuvant therapy and surgery (each p < 0.001). Tumor progression (PD) was not observed significantly more often in the patients with sarcopenia compared to those without sarcopenia at any time point (p = 0.277 to p = 0.465). On average, PD occurred after 271.69 ± 104.20 days. The time from initial diagnosis to PD in patients "with sarcopenia" was not significantly shorter than in patients "without sarcopenia" at any of the time points (p = 0.521 to p = 0.817). The CT radiomics of skeletal muscle could predict both sarcopenia and tumor progression, with the best results for the psoas major muscle using the RF algorithm. For the detection of sarcopenia, the Accuracy was 0.90 ± 0.03 and AUC was 0.96 ± 0.02. For the prediction of PD, the Accuracy was 0.88 ± 0.04 and the AUC was 0.93 ± 0.04. CONCLUSIONS In the present study, the CT radiomics of skeletal muscle together with machine learning correlated with the presence of sarcopenia, and this can additionally assist in predicting disease progression. These features can be classified as promising alternatives to conventional methods, with great potential for further research and future clinical application. However, when sarcopenia was diagnosed with PMI, no significant correlation between sarcopenia and PD could be observed.
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Affiliation(s)
- Daniel Vogele
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, 89081 Ulm, Germany; (T.M.); (D.W.); (S.M.); (M.G.); (M.B.)
| | - Teresa Mueller
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, 89081 Ulm, Germany; (T.M.); (D.W.); (S.M.); (M.G.); (M.B.)
| | - Daniel Wolf
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, 89081 Ulm, Germany; (T.M.); (D.W.); (S.M.); (M.G.); (M.B.)
- Visual Computing Group, Institute for Media Informatics, Ulm University, 89081 Ulm, Germany
- XAIRAD—Artificial Intelligence in Experimental Radiology, University Hospital of Ulm, 89081 Ulm, Germany
| | - Stephanie Otto
- Comprehensive Cancer Center Ulm (CCCU), Ulm University Medical Center, 89081 Ulm, Germany;
| | - Sabitha Manoj
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, 89081 Ulm, Germany; (T.M.); (D.W.); (S.M.); (M.G.); (M.B.)
- XAIRAD—Artificial Intelligence in Experimental Radiology, University Hospital of Ulm, 89081 Ulm, Germany
| | - Michael Goetz
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, 89081 Ulm, Germany; (T.M.); (D.W.); (S.M.); (M.G.); (M.B.)
- XAIRAD—Artificial Intelligence in Experimental Radiology, University Hospital of Ulm, 89081 Ulm, Germany
| | - Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University Medical Center, 89081 Ulm, Germany;
- i2SouI—Innovative Imaging in Surgical Oncology Ulm, University Hospital of Ulm, 89081 Ulm, Germany
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, 89081 Ulm, Germany; (T.M.); (D.W.); (S.M.); (M.G.); (M.B.)
- i2SouI—Innovative Imaging in Surgical Oncology Ulm, University Hospital of Ulm, 89081 Ulm, Germany
- MoMan—Center for Translational Imaging, Department of Internal Medicine II, University Hospital of Ulm, 89081 Ulm, Germany
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Vogele D, Schmidt SA, Gnutzmann D, Thaiss WM, Ettrich TJ, Kornmann M, Beer M, Juchems MS. Gastroenteropancreatic Neuroendocrine Tumors-Current Status and Advances in Diagnostic Imaging. Diagnostics (Basel) 2023; 13:2741. [PMID: 37685279 PMCID: PMC10486652 DOI: 10.3390/diagnostics13172741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasia (GEP-NEN) is a heterogeneous and complex group of tumors that are often difficult to classify due to their heterogeneity and varying locations. As standard radiological methods, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET/CT) are available for both localization and staging of NEN. Nuclear medical imaging methods with somatostatin analogs are of great importance since radioactively labeled receptor ligands make tumors visible with high sensitivity. CT and MRI have high detection rates for GEP-NEN and have been further improved by developments such as diffusion-weighted imaging. However, nuclear medical imaging methods are superior in detection, especially in gastrointestinal NEN. It is important for radiologists to be familiar with NEN, as it can occur ubiquitously in the abdomen and should be identified as such. Since GEP-NEN is predominantly hypervascularized, a biphasic examination technique is mandatory for contrast-enhanced cross-sectional imaging. PET/CT with somatostatin analogs should be used as the subsequent method.
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Affiliation(s)
- Daniel Vogele
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (S.A.S.); (W.M.T.); (M.B.)
| | - Stefan A. Schmidt
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (S.A.S.); (W.M.T.); (M.B.)
| | - Daniel Gnutzmann
- Department of Diagnostic and Interventional Radiology, Konstanz Hospital, Mainaustraße 35, 78464 Konstanz, Germany; (D.G.); (M.S.J.)
| | - Wolfgang M. Thaiss
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (S.A.S.); (W.M.T.); (M.B.)
- Department of Nuclear Medicine, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany;
- i2SouI—Innovative Imaging in Surgical Oncology Ulm, University Hospital of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany;
| | - Marko Kornmann
- i2SouI—Innovative Imaging in Surgical Oncology Ulm, University Hospital of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany;
- Department of General and Visceral Surgery, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (S.A.S.); (W.M.T.); (M.B.)
- i2SouI—Innovative Imaging in Surgical Oncology Ulm, University Hospital of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany;
| | - Markus S. Juchems
- Department of Diagnostic and Interventional Radiology, Konstanz Hospital, Mainaustraße 35, 78464 Konstanz, Germany; (D.G.); (M.S.J.)
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d’Almeida S, Markovic S, Hermann P, Bracht H, Peifer J, Ettrich TJ, Imhof A, Zhou S, Weiss M, Viardot A, Rottbauer W, Dahme T. Thromboembolism after Astra Zeneca COVID-19 vaccine: Not always PF4- antibody mediated. Hum Vaccin Immunother 2023; 19:2252239. [PMID: 37655367 PMCID: PMC10478733 DOI: 10.1080/21645515.2023.2252239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023] Open
Abstract
Cases of thromboembolic events in 2021 flared up the discussion about the safety of Astra Zeneca's AZD1222 vaccine. We hereby report three cases of pulmonary embolism (PE), one case of extended portal vein thrombosis, and one case of combined portal vein thrombosis and PE within 2 weeks after vaccination with the Astra Zeneca AZD1222 vaccine in a 60-year-old, a 50-year old, a 33-year-old, a 30-year old, and a 40-year-old male in that year. All patients were healthy before. In three patients, we observed thrombocytopenia and to some extent unusually low antibody levels for the Spike Protein (S-protein), while the other two had normal thrombocyte counts. Only one patient had anti-platelet factor 4 (PF4)-antibodies detectable as it has been described in the "heparin-induced thrombocytopenia (HIT)-like" disease of "vaccine-induced prothrombotic immune thrombocytopenia" (VIPIT) and we therefore assume that heterogeneous mechanisms led to PE. Therefore, we advise to collect and report more cases, in order to determine the age-related risks of vaccination balanced against the benefits of immunity to SARS-COV-2 for the AZD1222 vaccine in order to gain knowledge for the next pandemic.
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Affiliation(s)
- Sascha d’Almeida
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Sinisa Markovic
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Patrick Hermann
- Department of Medicine I, Ulm University Medical Center, Ulm, Germany
| | - Hendrik Bracht
- Central Emergency Department, Ulm University Medical Center, Ulm, Germany
| | - Johannes Peifer
- Central Emergency Department, Ulm University Medical Center, Ulm, Germany
| | - Thomas J. Ettrich
- Department of Medicine I, Ulm University Medical Center, Ulm, Germany
| | - Armin Imhof
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Shaoxia Zhou
- Department of Laboratory Medicine, Ulm University Medical Center, Ulm, Germany
| | - Manfred Weiss
- Department of Anesthesiology and Intensive Care, Ulm University Medical Center, Ulm, Germany
| | - Andreas Viardot
- Department of Medicine III, Ulm University Medical Center, Ulm, Germany
| | | | - Tillman Dahme
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
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7
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Dorman K, Boeck S, Snijder RJ, Siveke JT, Schenk M, Mayerle J, Caca K, Freiberg-Richter J, Fischer von Weikersthal L, Kullmann F, Reinacher-Schick A, Fuchs M, Kanzler S, Kunzmann V, Ettrich TJ, Zhang D, Held S, Abdul-Ahad A, von Bergwelt-Baildon M, Heinemann V, Haas M. Integrated Analysis of the RASH Study with the Use of the "Burden of Therapy" (BOTh ®TM) Methodology-A Novel Tool for Assessing Adverse Events in Metastatic Pancreatic Cancer. Curr Oncol 2023; 30:5828-5834. [PMID: 37366919 DOI: 10.3390/curroncol30060436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
This analysis of the RASH trial (NCT01729481) aimed at gaining a better understanding of the "Burden of Therapy" (BOTh®TM) in pancreatic ductal adenocarcinoma (PDAC). In the RASH study, 150 patients with newly diagnosed metastatic PDAC were treated with gemcitabine plus erlotinib (gem/erlotinib) for four weeks. Patients who developed a skin rash during this four-week run-in phase continued with the gem/erlotinib treatment, while rash-negative patients were switched to FOLFIRINOX. The study demonstrated a 1-year survival rate of rash-positive patients who received gem/erlotinib as first-line treatment that was comparable to previous reports of patients receiving FOLFIRINOX. To understand whether these comparable survival rates may be accompanied by better tolerability of the gem/erlotinib treatment compared to FOLFIRINOX, the BOTh®TM methodology was used to continuously quantify and depict the burden of therapy generated by treatment emergent events (TEAEs). Sensory neuropathy was significantly more common in the FOLFIRINOX arm, and prevalence as well as severity increased over time. In both arms, the BOTh®TM associated with diarrhea decreased over the course of treatment. The BOTh®TM caused by neutropenia was comparable in both arms but decreased in the FOLFIRINOX arm over time, possibly due to chemotherapy dose reductions. Overall, gem/erlotinib was associated with a slightly higher overall BOTh®TM, but the difference was not statistically significant (p = 0.6735). In summary, the BOTh®TM analysis facilitates the evaluation of TEAEs. In patients fit for intense chemotherapeutic regimens, FOLFIRINOX is associated with a lower BOTh®TM than gem/erlotinib.
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Affiliation(s)
- Klara Dorman
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336 Munich, Germany
| | - Stefan Boeck
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336 Munich, Germany
| | | | - Jens T Siveke
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, 45147 Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, Partner site Essen) and German Cancer Research Center, DKFZ, 69120 Heidelberg, Germany
| | - Michael Schenk
- Department of Haematology and Oncology, Hospital Barmherzige Brüder, 93049 Regensburg, Germany
| | - Julia Mayerle
- Department of Internal Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Karel Caca
- Department of Internal Medicine I, Klinikum Ludwigsburg, 71640 Ludwigsburg, Germany
| | | | | | - Frank Kullmann
- Department of Medicine I, Klinikum Weiden, 92637 Weiden, Germany
| | - Anke Reinacher-Schick
- Department of Haematology and Oncology, St. Josef-Hospital, Ruhr University, 44791 Bochum, Germany
| | - Martin Fuchs
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Klinikum Bogenhausen, 81925 Munich, Germany
| | - Stephan Kanzler
- Department of Internal Medicine II, Leopoldina Krankenhaus Schweinfurt, 97422 Schweinfurt, Germany
| | - Volker Kunzmann
- Department of Medical Oncology, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, 89081 Ulm, Germany
| | - Danmei Zhang
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Swantje Held
- ClinAssess GmbH, Department of Biometry, 51379 Leverkusen, Germany
| | | | - Michael von Bergwelt-Baildon
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336 Munich, Germany
| | - Volker Heinemann
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336 Munich, Germany
| | - Michael Haas
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377 Munich, Germany
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8
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Ettrich TJ, Schuhbaur JS, Seufferlein T. [Metastatic colorectal cancer-Modern treatment strategies and sequences]. Inn Med (Heidelb) 2023:10.1007/s00108-023-01516-y. [PMID: 37222756 DOI: 10.1007/s00108-023-01516-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/25/2023]
Abstract
The treatment of metastatic colorectal cancer (mCRC) has been considerably expanded and relevantly improved in recent years with new strategies, such as resection of liver and/or lung metastases, induction and maintenance treatment, the establishment of targeted therapies and molecularly defined strategies in defined subgroups. This article presents evidence-based treatment options and algorithms, with a focus on systemic treatment.
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Affiliation(s)
- T J Ettrich
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - J S Schuhbaur
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - T Seufferlein
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
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Seufferlein T, Uhl W, Ettrich TJ. Reply to the Letter to the Editor 'The Neonax study' by M. W. Büchler and J. Neoptolemos. Ann Oncol 2023; 34:443-445. [PMID: 37061251 DOI: 10.1016/j.annonc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 04/17/2023] Open
Affiliation(s)
- T Seufferlein
- Department of Internal Medicine I, Ulm University, Ulm, Germany.
| | - W Uhl
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University, Ulm, Germany
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Seufferlein T, Uhl W, Kornmann M, Algül H, Friess H, König A, Ghadimi M, Gallmeier E, Bartsch DK, Lutz MP, Metzger R, Wille K, Gerdes B, Schimanski CC, Graupe F, Kunzmann V, Klein I, Geissler M, Staib L, Waldschmidt D, Bruns C, Wittel U, Fichtner-Feigl S, Daum S, Hinke A, Blome L, Tannapfel A, Kleger A, Berger AW, Kestler AMR, Schuhbaur JS, Perkhofer L, Tempero M, Reinacher-Schick AC, Ettrich TJ. Perioperative or only adjuvant gemcitabine plus nab-paclitaxel for resectable pancreatic cancer (NEONAX)-a randomized phase II trial of the AIO pancreatic cancer group. Ann Oncol 2023; 34:91-100. [PMID: 36209981 DOI: 10.1016/j.annonc.2022.09.161] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Data on perioperative chemotherapy in resectable pancreatic ductal adenocarcinoma (rPDAC) are limited. NEONAX examined perioperative or adjuvant chemotherapy with gemcitabine plus nab-paclitaxel in rPDAC (National Comprehensive Cancer Network criteria). PATIENTS AND METHODS NEONAX is a prospective, randomized phase II trial with two independent experimental arms. One hundred twenty-seven rPDAC patients in 22 German centers were randomized 1 : 1 to perioperative (two pre-operative and four post-operative cycles, arm A) or adjuvant (six cycles, arm B) gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2) on days 1, 8 and 15 of a 28-day cycle. RESULTS The primary endpoint was disease-free survival (DFS) at 18 months in the modified intention-to-treat (ITT) population [R0/R1-resected patients who started neoadjuvant chemotherapy (CTX) (A) or adjuvant CTX (B)]. The pre-defined DFS rate of 55% at 18 months was not reached in both arms [A: 33.3% (95% confidence interval [CI] 18.5% to 48.1%), B: 41.4% (95% CI 20.7% to 62.0%)]. Ninety percent of patients in arm A completed neoadjuvant treatment, and 42% of patients in arm B started adjuvant chemotherapy. R0 resection rate was 88% (arm A) and 67% (arm B), respectively. Median overall survival (mOS) (ITT population) as a secondary endpoint was 25.5 months (95% CI 19.7-29.7 months) in arm A and 16.7 months (95% CI 11.6-22.2 months) in the upfront surgery arm. This difference corresponds to a median DFS (mDFS) (ITT) of 11.5 months (95% CI 8.8-14.5 months) in arm A and 5.9 months (95% CI 3.6-11.5 months) in arm B. Treatment was safe and well tolerable in both arms. CONCLUSIONS The primary endpoint, DFS rate of 55% at 18 months (mITT population), was not reached in either arm of the trial and numerically favored the upfront surgery arm B. mOS (ITT population), a secondary endpoint, numerically favored the neoadjuvant arm A [25.5 months (95% CI 19.7-29.7months); arm B 16.7 months (95% CI 11.6-22.2 months)]. There was a difference in chemotherapy exposure with 90% of patients in arm A completing pre-operative chemotherapy and 58% of patients starting adjuvant chemotherapy in arm B. Neoadjuvant/perioperative treatment is a novel option for patients with resectable PDAC. However, the optimal treatment regimen has yet to be defined. The trial is registered with ClinicalTrials.gov (NCT02047513) and the European Clinical Trials Database (EudraCT 2013-005559-34).
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Affiliation(s)
- T Seufferlein
- Department of Internal Medicine I, Ulm University, Ulm, Germany.
| | - W Uhl
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - M Kornmann
- Department of General and Visceral Surgery, Ulm University, Ulm, Germany
| | - H Algül
- CCC Munich-TUM and Department of Internal Medicine II, TUM, Munich, Germany
| | - H Friess
- Department of General and Visceral Surgery, TUM, Munich, Germany
| | - A König
- Department of Gastroenterology, GI-Oncology and Endocrinology, University Medical Center, Göttingen, Germany
| | - M Ghadimi
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - E Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Marburg, Germany
| | - D K Bartsch
- Department of General and Visceral Surgery, University of Marburg, Marburg, Germany
| | - M P Lutz
- Department of Gastroenterology, Caritasklinik St. Theresia, Saarbrücken, Germany
| | - R Metzger
- Department of General and Visceral Surgery, Caritasklinik St. Theresia, Saarbrücken, Germany
| | - K Wille
- Department of Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, Ruhr-University Bochum, Bochum, Germany
| | - B Gerdes
- Department of General and Visceral Surgery Minden, Ruhr-University Bochum, Minden, Germany
| | - C C Schimanski
- Department of Internal Medicine and Gastroenterology, Darmstadt Hospital, Darmstadt, Germany
| | - F Graupe
- Department of General and Visceral Surgery, Darmstadt Hospital, Darmstadt, Germany
| | - V Kunzmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - I Klein
- Department of General, Visceral, Vascular and Pediatric Surgery, Julius Maximilians University, Würzburg, Germany
| | - M Geissler
- Department of Hematology and Oncology, Esslingen Hospital, Esslingen, Germany
| | - L Staib
- Department of Surgery, Esslingen Hospital, Esslingen, Germany
| | - D Waldschmidt
- Department of Gastroenterology and Hepatology, University of Cologne, Cologne, Germany
| | - C Bruns
- Department of Visceral Surgery, University of Cologne, Cologne, Germany
| | - U Wittel
- Department of General and Visceral Surgery, University of Freiburg, Freiburg, Germany
| | - S Fichtner-Feigl
- Department of General and Visceral Surgery, University of Freiburg, Freiburg, Germany
| | - S Daum
- Department for Gastroenterology, Rheumatology and Infectology, Charite University Hospital Berlin, Berlin, Germany
| | - A Hinke
- Biostatistics, CCRC Cancer Clinical Research Consulting, Düsseldorf, Germany
| | - L Blome
- Biometrics, ClinAssess Gesellschaft für klinische Forschung mbH, Leverkusen, Germany
| | - A Tannapfel
- Institute of Pathology, Ruhr-University Bochum, Bochum, Germany
| | - A Kleger
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - A W Berger
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - A M R Kestler
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - J S Schuhbaur
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - L Perkhofer
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - M Tempero
- UCSF Department of Medicine, University of California San Francisco, San Francisco, USA
| | - A C Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University, Ulm, Germany
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11
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Tintelnot J, Ristow I, Sauer M, Simnica D, Schultheiß C, Scholz R, Goekkurt E, von Wenserski L, Willscher E, Paschold L, Lorenzen S, Riera-Knorrenschild J, Depenbusch R, Ettrich TJ, Dörfel S, Al-Batran SE, Karthaus M, Pelzer U, Hinke A, Bauer M, Massa C, Seliger B, Wickenhauser C, Bokemeyer C, Hegewisch-Becker S, Binder M, Stein A. Translational analysis and final efficacy of the AVETUX trial - Avelumab, cetuximab and FOLFOX in metastatic colorectal cancer. Front Oncol 2022; 12:993611. [PMID: 36605436 PMCID: PMC9808039 DOI: 10.3389/fonc.2022.993611] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/02/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction In metastatic colorectal cancer (mCRC), the efficacy of immune checkpoint blockade (ICB) has so far been limited to patients with microsatellite instability high tumors (MSI-H). Unfortunately, most mCRC patients suffer from non-immunogenic microsatellite stable (MSS) tumors. Therefore, new combinatorial strategies are urgently needed to enhance the immunogenicity of MSS tumors to finally increase the number of patients benefiting from ICB. Methods The AVETUX trial aimed to combine the PD-L1 antibody avelumab with the standard of care chemotherapy combination FOLFOX and the anti-EGFR antibody cetuximab. Furthermore, we performed a central radiological review of the pre- and on-treatment computed tomography scans to better define the individual response to treatment. Results and Discussion In total, 43 patients were treated of which 39 patients were confirmed as RAS/BRAF wildtype in central tissue review and finally response evaluated. A final progression-free survival (PFS) of 11.1 (range: 0.8 to 22.3 months) and a herein updated final overall survival (OS) of 32.9 months (range: 0.8 to 47.1 months) was reached. We observed a strong median depth of response of 67.5% tumor shrinkage and deepness of response correlated significantly with survival. On the other hand, early tumor shrinkage was not an indicator of better outcome at a cut-off of 20% (median values). In a next step, we correlated the individual best radiological response with potential ICB response biomarkers and found that the clonality and diversity, but not frequency of tumor infiltrating lymphocytes (TiLs) and peripheral blood mononuclear cells (PBMCs), strongly correlated with response. In summary, we report the final overall survival of the AVETUX trial and propose T cell clonality and diversity as a potential marker to predict response to chemo-immunotherapy combinations in MSS mCRC by performing a central radiological review. Clinical Trial Registration ClinicalTrials.gov, identifier (NCT03174405).
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Affiliation(s)
- Joseph Tintelnot
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,*Correspondence: Joseph Tintelnot, ; Alexander Stein,
| | - Inka Ristow
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Sauer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Donjete Simnica
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Christoph Schultheiß
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Rebekka Scholz
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Eray Goekkurt
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Hämatologisch-Onkologische Praxis Eppendorf, Hamburg, Germany
| | - Lisa von Wenserski
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Edith Willscher
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Lisa Paschold
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Sylvie Lorenzen
- Department of Internal Medicine III (Haematology/Medical Oncology), Technical University of Munich Hospital Rechts der Isar, Munchen, Bayern, Germany
| | | | - Reinhard Depenbusch
- Private Practice Onkodoc GmbH Götersloh, Götersloh, Nordrhein-Westfalen, Germany
| | - Thomas J. Ettrich
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Baden-Wörttemberg, Germany
| | - Steffen Dörfel
- Private Practice Onkozentrum Dresden, Dresden, Sachsen, Germany
| | - Salah-Eddin Al-Batran
- Institute of Clinical Cancer Research Institut für Klinisch-Onkologische Forschung (IKF) at Northwest Hospital, Frankfurt, Hessen, Germany
| | - Meinolf Karthaus
- Department of Hematology and Oncology, Munich Hospital Neuperlach, Munchen, Bayern, Germany
| | - Uwe Pelzer
- Department of Hematology, Oncology and Tumorimmunology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Axel Hinke
- Clinical Cancer Research Consulting (CCRC), Dösseldorf, Germany
| | - Marcus Bauer
- Institute of Pathology, Martin Luther University Halle Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Chiara Massa
- Institute of Medical Immunology, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Barbara Seliger
- Institute of Medical Immunology, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | | | - Carsten Bokemeyer
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Mascha Binder
- Department of Internal Medicine IV – Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Alexander Stein
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Hämatologisch-Onkologische Praxis Eppendorf, Hamburg, Germany,*Correspondence: Joseph Tintelnot, ; Alexander Stein,
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. Z Gastroenterol 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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13
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Hartlapp I, Valta-Seufzer D, Siveke JT, Algül H, Goekkurt E, Siegler G, Martens UM, Waldschmidt D, Pelzer U, Fuchs M, Kullmann F, Boeck S, Ettrich TJ, Held S, Keller R, Anger F, Germer CT, Stang A, Kimmel B, Heinemann V, Kunzmann V. Prognostic and predictive value of CA 19-9 in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: results from a prospective, multicenter phase II trial (NEOLAP-AIO-PAK-0113). ESMO Open 2022; 7:100552. [PMID: 35970013 PMCID: PMC9434418 DOI: 10.1016/j.esmoop.2022.100552] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The prognostic and predictive value of carbohydrate antigen 19-9 (CA 19-9) in locally advanced pancreatic cancer (LAPC) has not yet been defined from prospective randomized controlled trials (RCTs). PATIENTS AND METHODS A total of 165 LAPC patients were treated within the NEOLAP RCT for 16 weeks with multiagent induction chemotherapy [ICT; either nab-paclitaxel/gemcitabine alone or nab-paclitaxel/gemcitabine followed by FOLFIRINOX (combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin)] followed by surgical exploration of all patients without evidence of disease progression. CA 19-9 was determined at baseline and after ICT and correlated with overall survival (OS) and secondary R0 resection rate. RESULTS From the NEOLAP study population (N = 165) 133 patients (81%) were evaluable for CA 19-9 at baseline and 81/88 patients (92%) for post-ICT CA 19-9 response. Median OS (mOS) in the CA 19-9 cohort (n = 133) was 16.2 months [95% confidence interval (CI) 13.0-19.4] and R0 resection (n = 31; 23%) was associated with a significant survival benefit [40.8 months (95% CI 21.7-59.8)], while R1 resected patients (n = 14; 11%) had no survival benefit [14.0 (95% CI 11.7-16.3) months, hazard ratio (HR) 0.27; P = 0.001]. After ICT most patients showed a CA 19-9 response (median change from baseline: -82%; relative decrease ≥55%: 83%; absolute decrease to ≤50 U/ml: 43%). Robust CA 19-9 response (decrease to ≤50U/ml) was significantly associated with mOS [27.8 (95% CI 18.4-37.2) versus 16.5 (95% CI 11.7-21.2) months, HR 0.49; P = 0.013], whereas CA 19-9 baseline levels were not prognostic for OS. Multivariate analysis demonstrated that a robust CA 19-9 response was an independent predictive factor for R0 resection. Using a CA 19-9 decrease to ≤61 U/ml as optimal cut-off (by receiver operating characteristic analysis) yielded 72% sensitivity and 62% specificity for successful R0 resection, whereas CA 19-9 nonresponders (<20% decrease or increase) had no chance for successful R0 resection. CONCLUSIONS CA 19-9 response after multiagent ICT provides relevant prognostic and predictive information and is useful in selecting LAPC patients for explorative surgery. CLINICAL TRIAL NUMBER ClinicalTrials.govNCT02125136; https://clinicaltrials.gov/ct2/show/NCT02125136; EudraCT 2013-004796-12; https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-004796-12/results.
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Affiliation(s)
- I Hartlapp
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - D Valta-Seufzer
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - J T Siveke
- Department of Medical Oncology, Bridge Institute of Experimental Tumor Therapy, University Medicine Essen, Essen, Germany; Division of Solid Tumor Translational Oncology (DKTK Partner Site Essen, DKFZ Heidelberg), West German Cancer Center, University Medicine Essen, Essen, Germany
| | - H Algül
- Comprehensive Cancer Center Munich (CCCM(TUM)) at the Klinikum rechts der Isar, Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - E Goekkurt
- Hämatologisch-Onkologische Praxis Eppendorf (HOPE), Hamburg and University Cancer Center Hamburg (UCCH), Hamburg, Germany
| | - G Siegler
- Department of Internal Medicine 5, Hematology and Medical Oncology, Paracelsus Medical University, Nürnberg, Germany
| | - U M Martens
- Department of Internal Medicine III, SLK-Clinics Heilbronn GmbH, Heilbronn, Germany
| | - D Waldschmidt
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - U Pelzer
- Division of Oncology and Hematology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - M Fuchs
- Clinic for Gastroenterology, Hepatology and GI-Oncology, München Klinik Bogenhausen, Munich, Germany
| | - F Kullmann
- Department of Internal Medicine I, Kliniken Nordoberpfalz AG, Klinikum Weiden, Weiden, Germany
| | - S Boeck
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - S Held
- Department of Biometrics, ClinAssess GmbH, Leverkusen, Germany
| | - R Keller
- Clinical Research, AIO Studien gGmbH, Berlin, Germany
| | - F Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - A Stang
- Department of Haematology, Oncology and Palliative Care Medicine, Asklepios Hospital Barmbek, Hamburg, Germany
| | - B Kimmel
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - V Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich, Germany
| | - V Kunzmann
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany.
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14
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Sommerhäuser G, Kurreck A, Stintzing S, Heinemann V, von Weikersthal LF, Dechow T, Kaiser F, Karthaus M, Schwaner I, Fuchs M, König A, Roderburg C, Hoyer I, Quante M, Kiani A, Fruehauf S, Müller L, Reinacher-Schick A, Ettrich TJ, Stahler A, Modest DP. Study protocol of the FIRE-8 (AIO-KRK/YMO-0519) trial: a prospective, randomized, open-label, multicenter phase II trial investigating the efficacy of trifluridine/tipiracil plus panitumumab versus trifluridine/tipiracil plus bevacizumab as first-line treatment in patients with metastatic colorectal cancer. BMC Cancer 2022; 22:820. [PMID: 35897060 PMCID: PMC9327141 DOI: 10.1186/s12885-022-09892-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/13/2022] [Indexed: 01/05/2023] Open
Abstract
Background Initial systemic therapy for patients with metastatic colorectal cancer (mCRC) is usually based on two- or three-drug chemotherapy regimens with fluoropyrimidine (5-fluorouracil (5-FU) or capecitabine), oxaliplatin and/or irinotecan, combined with either anti-VEGF (bevacizumab) or, for RAS wild-type (WT) tumors, anti-EGFR antibodies (panitumumab or cetuximab). Recommendations for patients who are not eligible for intensive combination therapies are limited and include fluoropyrimidine plus bevacizumab or single agent anti-EGFR antibody treatment. The use of a monochemotherapy concept of trifluridine/ tipiracil in combination with monoclonal antibodies is not approved for first-line therapy, yet. Results from the phase II TASCO trial evaluating trifluridine/ tipiracil plus bevacicumab in first-line treatment of mCRC patients and from the phase I/II APOLLON trial investigating trifluridine/ tipiracil plus panitumumab in pre-treated mCRC patients suggest favourable activity and tolerability of these new therapeutic approaches. Methods FIRE-8 (NCT05007132) is a prospective, randomized, open-label, multicenter phase II study which aims to evaluate the efficacy of first-line treatment with trifluridine/tipiracil (35 mg/m2 body surface area (BSA), orally twice daily on days 1–5 and 8–12, q28 days) plus either the anti-EGFR antibody panitumumab (6 mg/kg body weight, intravenously on day 1 and 15, q28 days) [arm A] or (as control arm) the anti-VEGF antibody bevacizumab (5 mg/kg body weight, intravenously on day 1 and 15, q28 days) [arm B] in RAS WT mCRC patients. The primary objective is to demonstrate an improved objective response rate (ORR) according to RECIST 1.1 from 30% (control arm) to 55% with panitumumab. With a power of 80% and a two-sided significance level of 0.05, 138 evaluable patients are needed. Given an estimated drop-out rate of 10%, 153 patients will be enrolled. Discussion To the best of our knowledge, this is the first phase II trial to evaluate the efficacy of trifluridine/tipiracil plus panitumumab in first-line treatment of RAS WT mCRC patients. The administration of anti-EGFR antibodies rather than anti-VEGF antibodies in combination with trifluridine/tipiracil may result in an increased initial efficacy. Trial registration EU Clinical Trials Register (EudraCT) 2019-004223-20. Registered October 22, 2019, ClinicalTrials.govNCT05007132. Registered on August 12, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09892-8.
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Affiliation(s)
- G Sommerhäuser
- Department of Hematology, Oncology, and Cancer Immunology (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Kurreck
- Department of Hematology, Oncology, and Cancer Immunology (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - S Stintzing
- Department of Hematology, Oncology, and Cancer Immunology (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Cancer Consortium (DKTK), DKFZ, Heidelberg, Germany
| | - V Heinemann
- German Cancer Consortium (DKTK), DKFZ, Heidelberg, Germany.,Department of Hematology/Oncology, LMU Klinikum, University of Munich, Comprehensive Cancer Center Munich, Munich, Germany
| | | | - T Dechow
- Oncological Practice, Ravensburg, Germany
| | - F Kaiser
- Oncological Practice, Landshut, Germany
| | - M Karthaus
- Department of Hematology and Oncology, Klinikum Neuperlach/ Klinikum Harlaching, Munich, Germany
| | - I Schwaner
- Oncological Practice Kurfuerstendamm, Berlin, Germany
| | - M Fuchs
- Department of Gastroenterology, Hepatology, and Gastrointestinal Oncology, München Klinik Bogenhausen, Munich, Germany
| | - A König
- Department of Gastroenterology and Gastrointestinal Oncology Goettingen, University Medical Center Goettingen, Goettingen, Germany
| | - C Roderburg
- Department of Gastroenterology, Hepatology, and Infectiology, University Medical Center Duesseldorf, Duesseldorf, Germany
| | - I Hoyer
- Department of Hematology, Oncology, and Cancer Immunology (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - M Quante
- Department of Gastroenterology, Hepatology, Endocrinology, and Infectiology, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - A Kiani
- Department of Medicine IV, Klinikum Bayreuth GmbH, Bayreuth, Germany
| | - S Fruehauf
- Department of Hematology, Oncology, and Palliative Care, Klinik Dr. Hancken GmbH, Stade, Germany
| | - L Müller
- Onkologie UnterEms, Leer, Germany
| | - A Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, Ruhr-University Bochum, Bochum, Germany
| | - T J Ettrich
- Department of Internal Medicine, University Hospital Ulm, Ulm, Germany
| | - A Stahler
- Department of Hematology, Oncology, and Cancer Immunology (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - D P Modest
- Department of Hematology, Oncology, and Cancer Immunology (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany. .,German Cancer Consortium (DKTK), DKFZ, Heidelberg, Germany.
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. Z Gastroenterol 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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16
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Kruger SF, Lohneis A, Abendroth A, Berger AW, Ettrich TJ, Waidmann O, Kapp M, Steiner B, Kumbrink J, Reischer A, Haas M, Westphalen CB, Zhang D, Miller-Phillips L, Burger PJ, Kobold S, Werner J, Subklewe M, von Bergwelt-Baildon M, Kunzmann V, Seufferlein T, Siveke JT, Sinn M, Heinemann V, Ormanns S, Boeck S. Prognosis and tumor biology of pancreatic cancer patients with isolated lung metastases: translational results from the German multicenter AIO-YMO-PAK-0515 study. ESMO Open 2022; 7:100388. [PMID: 35121522 PMCID: PMC8818907 DOI: 10.1016/j.esmoop.2022.100388] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 12/25/2022] Open
Abstract
Background Pulmonary metastasis (M1-PUL) as first site of dissemination in pancreatic ductal adenocarcinoma (PDAC) is a rare event and may define a distinct biological subgroup. Patients and methods Arbeitsgemeinschaft Internistische Onkologie-Young Medical Oncologists-Pankreas-0515 study (AIO-YMO-PAK-0515) was a retrospective German multicenter study investigating clinical and molecular characteristics of M1-PUL PDAC patients; 115 M1-PUL PDAC patients from 7 participating centers were included. Clinical characteristics and potential prognostic factors were defined within the M1-PUL cohort. Archival tumor samples were analyzed for Her2/neu, HNF1A and KRT81 expression. Additionally, messenger RNA (mRNA) expression analysis (using a 770-gene immune profiling panel) was carried out in the M1-PUL and in a control cohort (M1-ANY). Results Median overall survival in the entire M1-PUL cohort was 20 months; the most favorable prognosis (median survival: 28 months) was observed in the subgroup of 66 PDAC patients with metachronous lung metastases after previous curative-intent surgery. The number of metastatic lesions, uni- or bilateral lung involvement as well as metastasectomy were identified as potential prognostic factors. Her2/neu expression and PDAC subtyping (by HNF1A and KRT81) did not differ between the M1-PUL and the M1-ANY cohort. mRNA expression analysis revealed significant differentially expressed genes between both cohorts: CD63 and LAMP1 were among the top 20 differentially expressed genes and were identified as potential mediators of organotropism and favorable survival outcome of M1-PUL patients. Conclusion M1-PUL represents a clinically favorable cohort in PDAC patients. Site of relapse might already be predetermined at the time of surgery and could potentially be predicted by gene expression profiling. The retrospective multicenter AIO-YMO-PAK-0515 study defines M1-PUL as a clinically favorable subgroup in PDAC. The number of metastatic lesions, bilateral lung involvement and surgical metastasectomy may serve as prognostic factors. Immune-related gene expression differs between patients with isolated pulmonary relapse versus other sites of relapse.
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Affiliation(s)
- S F Kruger
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany.
| | - A Lohneis
- Charité-Universitätsmedizin Berlin, Department of Medical Oncology and Hematology, Berlin, Germany; Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - A Abendroth
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - A W Berger
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - O Waidmann
- Department of Internal Medicine I, University Hospital Frankfurt, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany; University Cancer Centre Frankfurt, University Hospital Frankfurt, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - M Kapp
- Division of Medical Oncology, Department of Internal Medicine II, University Hospital Wuerzburg and Comprehensive Cancer Center Mainfranken, Wuerzburg, Germany
| | - B Steiner
- Department of Hematology and Oncology, University of Rostock, Rostock, Germany
| | - J Kumbrink
- Institute of Pathology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - A Reischer
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - M Haas
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - C B Westphalen
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - D Zhang
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - L Miller-Phillips
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - P J Burger
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - S Kobold
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; Center for Integrated Protein Science Munich and Division of Clinical Pharmacology, Department of Medicine IV, Klinikum der Ludwig-Maximilians-University of Munich, Munich, Germany
| | - J Werner
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - M Subklewe
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - M von Bergwelt-Baildon
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - V Kunzmann
- Division of Medical Oncology, Department of Internal Medicine II, University Hospital Wuerzburg and Comprehensive Cancer Center Mainfranken, Wuerzburg, Germany
| | - T Seufferlein
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - J T Siveke
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - M Sinn
- Charité-Universitätsmedizin Berlin, Department of Medical Oncology and Hematology, Berlin, Germany; Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - V Heinemann
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - S Ormanns
- Institute of Pathology, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - S Boeck
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
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Ettrich TJ, Sturm N, Güthle M, Hüttner FJ, Perkhofer L. Pancreatic Cancer: Current Multimodality Treatment Options and the Future Impact of Molecular Biological Profiling. Visc Med 2022; 38:20-29. [PMID: 35295894 PMCID: PMC8874237 DOI: 10.1159/000521631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/19/2021] [Indexed: 02/03/2023] Open
Abstract
Background Pancreatic cancer (PDAC) - even if deemed resectable - has still a dismal prognosis and is the seventh leading cause of global cancer-related death with rising incidence worldwide. Summary Surgical resection at best in combination with adjuvant systemic chemotherapy is the only potentially curative treatment. Surgical treatment has substantially improved over the last years with significantly reduced perioperative morbidity and mortality. Even when deemed radiologically resectable, the majority of PDAC is likely to have micrometastases, leaving most PDAC patients with an advanced stage. Recent 5-year overall survival was up to 46% in patients eligible for surgery with intensified adjuvant chemotherapy. Eligible for curative surgery are about one-third of the patients, and only 20% of these patients have the option for cure with surgery and adjuvant chemotherapy. Standards of care in treating PDAC patients include various mostly combinational chemotherapy approaches in the advanced and adjuvant setting. Moreover, first targeted therapies for individualizing treatment, e.g., specific subgroups like BRCA1/2 germline mutated patients, were established lately. Neoadjuvant concepts are currently part of research. This review focuses on current and future multimodal treatment options of PDAC and the impact of molecular profiling for individualizing treatment. Key Messages State of the art in pancreatic cancer therapy is multimodal and includes novel strategies to allow molecular defined subgroup-specific treatment.
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Affiliation(s)
- Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany,*Thomas J. Ettrich,
| | - Niklas Sturm
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Melanie Güthle
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Felix J. Hüttner
- Department of General and Visceral Surgery, Ulm University Hospital, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
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18
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Krug S, Kegel T, Gress TM, Rinke A, Apostolidis L, Jann H, König A, Hörsch D, Schrader J, Ettrich TJ, Richter M, Steighardt J, Michl P. Ramucirumab in combination with dacarbazine in patients with progressive well-differentiated metastatic pancreatic neuroendocrine tumors (RamuNET): study protocol for a multicenter single-arm trial. BMC Cancer 2021; 21:1206. [PMID: 34772353 PMCID: PMC8588662 DOI: 10.1186/s12885-021-08900-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cytotoxic chemotherapy combinations and targeted agents represent established treatment concepts in advanced pancreatic neuroendocrine tumors (PNETs). However, response rates, side effects and outcome data strongly vary among these therapeutic approaches. Head-to-head comparisons between chemo- and molecular therapies are missing and secondary resistances frequently occur. The RamuNET trial aims to identify the effectiveness of dual treatment with DTIC and ramucirumab in progressive advanced PNET patients. METHODS The RamuNET study is an investigator-initiated multicenter prospective single-arm trial to evaluate the efficacy of ramucirumab in combination with dacarbazine (DTIC) over a period of at least 6 months. Patients with progressive well-differentiated and metastatic pancreatic neuroendocrine tumors are eligible. The study aims to include 45 patients over a period of 24 months with a minimum follow-up of 24 months. The primary endpoint is disease control after 6 months. Secondary endpoints include progression-free survival, biochemical response, overall survival, quality of life and toxicity. Based on the hypothesis that 80% of the patients can achieve a disease control after 6 months, the sample size calculation follows an exact binomial single-stage design. H0: p < =p0 = 60% versus H1: p > =p1 = 80%, alpha = 0.05, beta = 0.1. DISCUSSION This study investigates a new therapeutic approach using the combination of cytotoxic and targeted antiangiogenic therapy in advanced PNET. If positive, this trial will be the basis for a randomized two-arm study to investigate the combination of ramucirumab and DTIC against other established therapies in PNET. TRIAL REGISTRATION EudraCT: 2017-001207-68 . Date of registration: 2018.01.03.
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Affiliation(s)
- Sebastian Krug
- Department of Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Thomas Kegel
- Department of Internal Medicine IV, Martin-Luther University Halle/Wittenberg, Halle, Germany
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology and Metabolism, Philipps-University Marburg, Marburg, Germany
| | - Anja Rinke
- Department of Gastroenterology, Endocrinology and Metabolism, Philipps-University Marburg, Marburg, Germany
| | - Leonidas Apostolidis
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Henning Jann
- Department of Gastroenterology and Hepatology, Charité University Hospital, Berlin, Germany
| | - Alexander König
- Department of Gastroenterology and gastrointestinal Oncology, Georg-August University, Göttingen, Germany
| | - Dieter Hörsch
- Department of Gastroenterology/Endocrinology, Center for Neuroendocrine Tumors Bad Berka, Bad Berka, Germany
| | - Jörg Schrader
- Department of Medicine - Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | - Michael Richter
- Coordination Centre for Clinical Trials, Faculty of Medicine, Martin-Luther University Halle/Wittenberg, Halle, Germany
| | - Jörg Steighardt
- Coordination Centre for Clinical Trials, Faculty of Medicine, Martin-Luther University Halle/Wittenberg, Halle, Germany
| | - Patrick Michl
- Department of Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
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Ettrich TJ, Hüttner FJ, Lisson C, Gani C, Prasad V, Seufferlein T. [Multimodal, interdisciplinary therapeutic concepts for liver metastasized colorectal cancer]. Dtsch Med Wochenschr 2021; 146:1468-1477. [PMID: 34741292 DOI: 10.1055/a-1391-5273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
About half of all patients with colorectal carcinoma (CRC) develop metastases mainly in the liver during the course of their disease. Metastatic disease is associated with a low 5-year overall survival rate of only 5-7 %, particularly when there is no possibility of local treatment. However, if there is an opportunity to resect the metastases, especially isolated liver metastases, the chance of long-term survival is approximately 15-27 % after both primary resection or secondary resection after neoadjuvant pretreatment. Overall, long-term survival of patients with metastatic CRC has improved significantly in recent years due to a combination of modern systemic therapies, advanced liver surgery and local ablative procedures.Of note, for the vast majority of patients, metastatic resection does not mean cure, but a significant prolongation of overall survival with a good quality of life. Chemotherapy-free intervals after metastasis resection maintain quality of life and can help to reduce toxicity.In this review, we would like to present the "toolbox" for the multidisciplinary treatment of metastatic CRC and give recommendations how the individual modalities should be optimally used, considering tumor-specific characteristics and patient preferences.
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20
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Valle JW, Vogel A, Denlinger CS, He AR, Bai LY, Orlova R, Van Cutsem E, Adeva J, Chen LT, Obermannova R, Ettrich TJ, Chen JS, Wasan H, Girvan AC, Zhang W, Liu J, Tang C, Ebert PJ, Aggarwal A, McNeely SC, Moser BA, Oliveira JM, Carlesi R, Walgren RA, Oh DY. Addition of ramucirumab or merestinib to standard first-line chemotherapy for locally advanced or metastatic biliary tract cancer: a randomised, double-blind, multicentre, phase 2 study. Lancet Oncol 2021; 22:1468-1482. [PMID: 34592180 DOI: 10.1016/s1470-2045(21)00409-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary tract cancers are aggressive, rare, gastrointestinal malignancies with a poor prognosis; approximately half of patients with these cancers survive for less than 1 year after diagnosis with advanced disease. We aimed to evaluate the efficacy and safety of ramucirumab or merestinib in addition to first-line cisplatin-gemcitabine in patients with locally advanced or metastatic biliary tract cancer. METHODS We did a randomised, double-blind, phase 2 study at 81 hospitals across 18 countries. We enrolled patients with histologically or cytologically confirmed, non-resectable, recurrent, or metastatic biliary tract adenocarcinoma, who were treatment-naive, aged 18 years or older, with an Eastern Cooperative Oncology Group performance status of 0 or 1, estimated life expectancy of 3 months or more, and measurable disease per Response Evaluation Criteria in Solid Tumors version 1.1. Eligible participants were randomly assigned (2:1:2:1) to receive either intravenous ramucirumab 8 mg/kg or placebo (on days 1 and 8 in 21-day cycles) or oral merestinib 80 mg or placebo (once daily) until disease progression, unacceptable toxicity, death, or patient or investigator request for discontinuation. All participants received intravenous cisplatin 25 mg/m2 and gemcitabine 1000 mg/m2 (on days 1 and 8 in 21-day cycles), for a maximum of eight cycles. Randomisation was done by an interactive web response system using a permuted block method (blocks of six) and was stratified by primary tumour site, geographical region, and presence of metastatic disease. Participants, investigators, and the study funder were masked to treatment assignment within the intravenous and oral groups. The primary endpoint was investigator-assessed progression-free survival (in the intention-to-treat population). The safety analysis was done in all patients who received at least one dose of their assigned treatment. This trial is registered with ClinicalTrials.gov, NCT02711553, and long-term follow-up is ongoing. FINDINGS Between May 25, 2016, and Aug 8, 2017, 450 patients were assessed for eligibility and 309 (69%) were enrolled and randomly assigned to ramucirumab (n=106), merestinib (n=102), or pooled placebo (n=101); 306 received at least one dose of study treatment. The median follow-up time for progression-free survival at data cutoff (Feb 16, 2018) was 10·9 months (IQR 8·1-14·1). Median progression-free survival was 6·5 months (80% CI 5·7-7·1) in the ramucirumab group, 7·0 months (6·2-7·1) in the merestinib group, and 6·6 months (5·6-6·8) in the pooled placebo group (ramucirumab vs placebo hazard ratio 1·12 [80% CI 0·90-1·40], two-sided stratified p=0·48; merestinib vs placebo 0·92 [0·73-1·15], two-sided stratified p=0·64). The most common grade 3 or worse adverse events were neutropenia (51 [49%] of 104 patients in the ramucirumab group; 48 [47%] of 102 in the merestinib group; and 33 [33%] of 100 in the pooled placebo group), thrombocytopenia (36 [35%]; 19 [19%]; and 17 [17%]), and anaemia (28 [27%]; 16 [16%]; and 19 [19%]). Serious adverse events occurred in 53 (51%) patients in the ramucirumab group, 56 (55%) in the merestinib group, and 48 (48%) in the pooled placebo group. Treatment-related deaths (deemed related by the investigator) occurred in one (1%) of 104 patients in the ramucirumab group (cardiac arrest) and two (2%) of 102 patients in the merestinib group (pulmonary embolism [n=1] and sepsis [n=1]). INTERPRETATION Adding ramucirumab or merestinib to first-line cisplatin-gemcitabine was well tolerated, with no new safety signals, but neither improved progression-free survival in patients with molecularly unselected, locally advanced or metastatic biliary tract cancer. The role of these targeted inhibitors remains investigational, highlighting the need for further understanding of biliary tract malignancies and the contribution of molecular selection. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Juan W Valle
- Division of Cancer Sciences and Department of Medical Oncology, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK.
| | | | | | - Aiwu Ruth He
- Georgetown University Medical Center, Washington, DC, USA
| | - Li-Yuan Bai
- China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Rashida Orlova
- China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Eric Van Cutsem
- University Hospital Gasthuisberg and KU Leuven, Leuven, Belgium
| | - Jorge Adeva
- University Hospital 12 de Octubre, Madrid, Spain
| | | | | | | | - Jen-Shi Chen
- Linkou Chang Gung Memorial Hospital and Chang Gung University, Tao-Yuan, Taiwan
| | - Harpreet Wasan
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Wei Zhang
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | | | | | | | | | | | | | | | - Do-Youn Oh
- Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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Stein A, Simnica D, Schultheiß C, Scholz R, Tintelnot J, Gökkurt E, von Wenserski L, Willscher E, Paschold L, Sauer M, Lorenzen S, Riera-Knorrenschild J, Depenbusch R, Ettrich TJ, Dörfel S, Al-Batran SE, Karthaus M, Pelzer U, Waberer L, Hinke A, Bauer M, Massa C, Seliger B, Wickenhauser C, Bokemeyer C, Hegewisch-Becker S, Binder M. PD-L1 targeting and subclonal immune escape mediated by PD-L1 mutations in metastatic colorectal cancer. J Immunother Cancer 2021; 9:jitc-2021-002844. [PMID: 34315821 PMCID: PMC8317124 DOI: 10.1136/jitc-2021-002844] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with microsatellite stable (MSS) metastatic colorectal cancer (mCRC), immune checkpoint blockade is ineffective, and combinatorial approaches enhancing immunogenicity need exploration. METHODS We treated 43 patients with predominantly microsatellite stable RAS/BRAF wild-type mCRC on a phase II trial combining chemotherapy with the epidermal growth factor receptor antibody cetuximab and the programmed cell death ligand 1 (PD-L1) antibody avelumab. We performed next-generation gene panel sequencing for mutational typing of tumors and liquid biopsy monitoring as well as digital droplet PCR to confirm individual mutations. Translational analyses included tissue immunohistochemistry, multispectral imaging and repertoire sequencing of tumor-infiltrating T cells. Detected PD-L1 mutations were mechanistically validated in CRISPR/Cas9-generated cell models using qRT-PCR, immunoblotting, flow cytometry, complement-dependent cytotoxicity assay, antibody-dependent cytotoxicity by natural killer cell degranulation assay and LDH release assay as well as live cell imaging of T cell mediated tumor cell killing. RESULTS Circulating tumor DNA showed rapid clearance in the majority of patients mirroring a high rate of early tumor shrinkage. In 3 of 13 patients expressing the high-affinity Fcγ receptor 3a (FcγR3a), tumor subclones with PD-L1 mutations were selected that led to loss of tumor PD-L1 by nonsense-mediated RNA decay in PD-L1 K162fs and protein degradation in PD-L1 L88S. As a consequence, avelumab binding and antibody-dependent cytotoxicity were impaired, while T cell killing of these variant clones was increased. Interestingly, PD-L1 mutant subclones showed slow selection dynamics reversing on avelumab withdrawal and patients with such subclones had above-average treatment benefit. This suggested that the PD-L1 mutations mediated resistance to direct antitumor effects of avelumab, while at the same time loss of PD-L1 reduced biological fitness by enhanced T cell killing limiting subclonal expansion. CONCLUSION The addition of avelumab to standard treatment appeared feasible and safe. PD-L1 mutations mediate subclonal immune escape to avelumab in some patients with mCRC expressing high-affinity FcγR3a, which may be a subset experiencing most selective pressure. Future trials evaluating the addition of avelumab to standard treatment in MSS mCRC are warranted especially in this patient subpopulation. TRIAL REGISTRATION NUMBER NCT03174405.
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Affiliation(s)
- Alexander Stein
- Hämatologisch-Onkologische Praxis Eppendorf, Hamburg, Germany.,Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Donjete Simnica
- Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Christoph Schultheiß
- Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Rebekka Scholz
- Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Joseph Tintelnot
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eray Gökkurt
- Hämatologisch-Onkologische Praxis Eppendorf, Hamburg, Germany
| | - Lisa von Wenserski
- Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Edith Willscher
- Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Lisa Paschold
- Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Markus Sauer
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sylvie Lorenzen
- Department of Internal Medicine III (Haematology/Medical Oncology), Technical University of Munich Hospital Rechts der Isar, Munchen, Bayern, Germany
| | | | - Reinhard Depenbusch
- Private Practice Onkodoc GmbH Gütersloh, Gütersloh, Nordrhein-Westfalen, Germany
| | - Thomas J Ettrich
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Steffen Dörfel
- Private Practice Onkozentrum Dresden, Dresden, Sachsen, Germany
| | - Salah-Eddin Al-Batran
- Institute of Clinical Cancer Research IKF at Northwest hospital, Frankfurt, Hessen, Germany
| | - Meinolf Karthaus
- Department of Hematology and Oncology, Munich Hospital Neuperlach, Munchen, Bayern, Germany
| | - Uwe Pelzer
- Department of Hematology, Oncology and Tumorimmunology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Lisa Waberer
- IKF Klinische Krebsforschung GmbH at Krankenhaus Nordwest, Frankfurt, Hessen, Germany
| | - Axel Hinke
- Clinical Cancer Research Consulting (CCRC), Düsseldorf, Germany
| | - Marcus Bauer
- Institute of Pathology, Martin Luther University Halle Wittenberg, Halle, Sachsen-Anhalt, Germany
| | - Chiara Massa
- Institute of Medical Immunology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Germany
| | - Barbara Seliger
- Institute of Medical Immunology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Germany
| | | | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Penumology, Hubertus Wald University Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Mascha Binder
- Department of Oncology and Hematology, Bone Marrow Transplantation with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany .,Department of Internal Medicine IV - Oncology/Hematology, Martin-Luther-Universitat Halle-Wittenberg, Halle, Sachsen-Anhalt, Germany
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22
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Finkelmeier F, Scheiner B, Leyh C, Best J, Fründt TW, Czauderna C, Beutel A, Bettinger D, Weiß J, Meischl T, Kütting F, Waldschmidt DT, Radu P, Schultheiß M, Peiffer KH, Ettrich TJ, Weinmann A, Wege H, Venerito M, Dufour JF, Lange CM, Pinter M, Waidmann O. Cabozantinib in Advanced Hepatocellular Carcinoma: Efficacy and Safety Data from an International Multicenter Real-Life Cohort. Liver Cancer 2021; 10:360-369. [PMID: 34414123 PMCID: PMC8339523 DOI: 10.1159/000515490] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/20/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS The multikinase inhibitor cabozantinib has been approved for hepatocellular carcinoma (HCC) previously treated with sorafenib. We report safety and efficacy data of an international, multicenter, real-life cohort of patients with advanced HCC treated with cabozantinib. METHODS Patients with HCC who were treated with cabozantinib were retrospectively identified across 11 centers in Austria, Switzerland, and Germany. Patients' characteristics, adverse events, duration of treatment and overall survival (OS) data were analyzed until April 1, 2020. RESULTS Eighty-eight patients from 11 centers were included. The predominant underlying liver diseases were NAFLD/NASH in 26 (30%) and hepatitis C infection in 21 (24%) patients. Seventy-eight patients (89%) were classified as Barcelona clinic liver cancer (BCLC) stage C. Sixty patients (68%) were Child-Pugh A, whereas 22 (25%) were Child-Pugh B, respectively. Cabozantinib was used as systemic second- and third-line or later treatment in 41 (47%) and 46 (52%) patients, respectively. The following best responses under cabozantinib were documented: partial response in 6 (7%), stable disease in 28 (32%), and progressive disease in 28 (32%) patients, respectively. Fifty-two patients (59%) died during follow-up. The median OS from start of cabozantinib treatment was 7.0 months in the entire cohort and 9.7 months in Child-Pugh A patients, while Child-Pugh B patients had a median OS of 3.4 months, respectively. Thirty-seven (42%) patients fulfilled the CELESTIAL inclusion and exclusion criteria, showing a median OS of 11.1 months. Most common adverse events were fatigue (15.6%) and diarrhea (15.6%). CONCLUSION Cabozantinib treatment was effective, safe, and feasible in patients with advanced HCC in patients with compensated cirrhosis. Patients in the real-life setting had more advanced liver disease - in which 25% of patients were Child-Pugh B. However, OS in patients with Child-Pugh A cirrhosis was similar to that reported in the phase 3 trial (CELESTIAL).
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Affiliation(s)
- Fabian Finkelmeier
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt, Germany
- University Cancer Center Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
- Frankfurt Cancer Institute, Goethe University Frankfurt/Main, Frankfurt, Germany
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Catherine Leyh
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Jan Best
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-Von Guericke University Hospital, Magdeburg, Germany
| | - Thorben Wilhelm Fründt
- Department of Medicine, Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carolin Czauderna
- Department of Internal Medicine 1, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Clinical Registry Unit (CRU), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Medicine I, University Medical Center Schleswig Holstein-Campus Lübeck, Lübeck, Germany
| | - Alica Beutel
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta Ottenstein Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Weiß
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Meischl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Fabian Kütting
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dirk-Thomas Waldschmidt
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Pompilia Radu
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Michael Schultheiß
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kai-Henrik Peiffer
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt, Germany
| | - Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Arndt Weinmann
- Department of Internal Medicine 1, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Clinical Registry Unit (CRU), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Henning Wege
- Department of Medicine, Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-Von Guericke University Hospital, Magdeburg, Germany
| | - Jean-Francois Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Christian M. Lange
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Oliver Waidmann
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt, Germany
- University Cancer Center Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
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23
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Arnold F, Gout J, Wiese H, Weissinger SE, Roger E, Perkhofer L, Walter K, Scheible J, Prelli Bozzo C, Lechel A, Ettrich TJ, Azoitei N, Hao L, Fürstberger A, Kaminska EK, Sparrer KMJ, Rasche V, Wiese S, Kestler HA, Möller P, Seufferlein T, Frappart PO, Kleger A. RINT1 Regulates SUMOylation and the DNA Damage Response to Preserve Cellular Homeostasis in Pancreatic Cancer. Cancer Res 2021; 81:1758-1774. [PMID: 33531371 DOI: 10.1158/0008-5472.can-20-2633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/14/2020] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) still presents with a dismal prognosis despite intense research. Better understanding of cellular homeostasis could identify druggable targets to improve therapy. Here we propose RAD50-interacting protein 1 (RINT1) as an essential mediator of cellular homeostasis in PDAC. In a cohort of resected PDAC, low RINT1 protein expression correlated significantly with better survival. Accordingly, RINT1 depletion caused severe growth defects in vitro associated with accumulation of DNA double-strand breaks (DSB), G2 cell cycle arrest, disruption of Golgi-endoplasmic reticulum homeostasis, and cell death. Time-resolved transcriptomics corroborated by quantitative proteome and interactome analyses pointed toward defective SUMOylation after RINT1 loss, impairing nucleocytoplasmic transport and DSB response. Subcutaneous xenografts confirmed tumor response by RINT1 depletion, also resulting in a survival benefit when transferred to an orthotopic model. Primary human PDAC organoids licensed RINT1 relevance for cell viability. Taken together, our data indicate that RINT1 loss affects PDAC cell fate by disturbing SUMOylation pathways. Therefore, a RINT1 interference strategy may represent a new putative therapeutic approach. SIGNIFICANCE: These findings provide new insights into the aggressive behavior of PDAC, showing that RINT1 directly correlates with survival in patients with PDAC by disturbing the SUMOylation process, a crucial modification in carcinogenesis.
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Affiliation(s)
- Frank Arnold
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Johann Gout
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Heike Wiese
- Core Unit Mass Spectrometry and Proteomics, Medical Faculty, Ulm University, Ulm, Germany
| | | | - Elodie Roger
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Karolin Walter
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Jeanette Scheible
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | | | - André Lechel
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Thomas J Ettrich
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Ninel Azoitei
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | - Li Hao
- Center for Translational Imaging (MoMAN), Ulm University, Ulm, Germany
| | - Axel Fürstberger
- Institute of Medical Systems Biology, Ulm University, Ulm, Germany
| | - Ewa K Kaminska
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Volker Rasche
- Center for Translational Imaging (MoMAN), Ulm University, Ulm, Germany
| | - Sebastian Wiese
- Core Unit Mass Spectrometry and Proteomics, Medical Faculty, Ulm University, Ulm, Germany
| | - Hans A Kestler
- Institute of Medical Systems Biology, Ulm University, Ulm, Germany
| | - Peter Möller
- Institute of Pathology, University Medical Centre Ulm, Ulm, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany
| | | | - Alexander Kleger
- Department of Internal Medicine I, University Medical Centre Ulm, Ulm, Germany.
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24
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Kunzmann V, Siveke JT, Algül H, Goekkurt E, Siegler G, Martens U, Waldschmidt D, Pelzer U, Fuchs M, Kullmann F, Boeck S, Ettrich TJ, Held S, Keller R, Klein I, Germer CT, Stein H, Friess H, Bahra M, Jakobs R, Hartlapp I, Heinemann V. Nab-paclitaxel plus gemcitabine versus nab-paclitaxel plus gemcitabine followed by FOLFIRINOX induction chemotherapy in locally advanced pancreatic cancer (NEOLAP-AIO-PAK-0113): a multicentre, randomised, phase 2 trial. Lancet Gastroenterol Hepatol 2020; 6:128-138. [PMID: 33338442 DOI: 10.1016/s2468-1253(20)30330-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal preoperative treatment for locally advanced pancreatic cancer is unknown. We aimed to compare the efficacy and safety of nab-paclitaxel plus gemcitabine with nab-paclitaxel plus gemcitabine followed by fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) as multidrug induction chemotherapy regimens in locally advanced pancreatic cancer. METHODS In this open-label, multicentre, randomised phase 2 study, done at 28 centres in Germany, eligible patients were adults (aged 18-75 years) with an Eastern Cooperative Oncology Group performance status of 0 or 1 and histologically or cytologically confirmed, treatment-naive locally advanced pancreatic adenocarcinoma, as determined by local multidisciplinary team review. After two cycles of nab-paclitaxel 125 mg/m2 plus gemcitabine 1000 mg/m2 (administered intravenously on days 1, 8, and 15 of each 28-day cycle), patients without progressive disease or unacceptable adverse events were randomly assigned (1:1) to receive either two additional cycles of nab-paclitaxel plus gemcitabine (nab-paclitaxel plus gemcitabine group) or four cycles of sequential FOLFIRINOX (oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 180 mg/m2, fluorouracil 400 mg/m2 by intravenous bolus followed by a continuous intravenous infusion of 2400 mg/m2 for 46 h on day 1 of each 14-day cycle; sequential FOLFIRINOX group). Randomisation was done by the clinical research organisation on request of the trial centre using a permuted block design (block size 2 and 4). Patients, investigators, and study team members were not masked to treatment allocation. The primary endpoint was surgical conversion rate (complete macroscopic tumour resection) in the randomised population by intention-to-treat analysis, which was assessed by surgical exploration in all patients with at least stable disease after completion of induction chemotherapy. This trial is registered with ClinicalTrials.gov, NCT02125136. FINDINGS Between Nov 18, 2014, and April 27, 2018, 168 patients were registered and 130 were randomly assigned to either the nab-paclitaxel plus gemcitabine group (64 patients) or the sequential FOLFIRINOX group (66 patients). Surgical exploration after completed induction chemotherapy was done in 40 (63%) of 64 patients in the nab-paclitaxel plus gemcitabine group and 42 (64%) of 66 patients in the sequential FOLFIRINOX group. 23 patients in the nab-paclitaxel plus gemcitabine group and 29 in the sequential FOLFIRINOX group had complete macroscopic tumour resection, yielding a surgical conversion rate of 35·9% (95% CI 24·3-48·9) in the nab-paclitaxel plus gemcitabine group and 43·9% (31·7-56·7) in the sequential FOLFIRINOX group (odds ratio 0·72 [95% CI 0·35-1·45]; p=0·38). At a median follow-up of 24·9 months (95% CI 21·8-27·6), median overall survival was 18·5 months (95% CI 14·4-21·5) in the nab-paclitaxel plus gemcitabine group and 20·7 months (13·9-28·7) in the sequential FOLFIRINOX group (hazard ratio 0·86 [95% CI 0·55-1·36]; p=0·53). All other secondary efficacy endpoints, such as investigator-assessed progression-free survival, radiographic response rate, CA 19-9 response rate, and R0 resection rate, were not significantly different between the two treatment groups except for improved histopathological downstaging in evaluable resection specimens from the sequential FOLFIRINOX group (ypT1/2 stage: 20 [69%] of 29 patients in the sequential FOLFIRINOX group vs four [17%] of 23 patients in the nab-paclitaxel plus gemcitabine group, p=0·0003; ypN0 stage: 15 [52%] of 29 patients in the sequential FOLFIRINOX group vs four [17%] of 23 patients in the nab-paclitaxel plus gemcitabine group, p=0·02). Grade 3 or higher treatment-emergent adverse events during induction chemotherapy occurred in 35 (55%) of 64 patients in nab-paclitaxel plus gemcitabine group and in 35 (53%) of 66 patients in the sequential FOLFIRINOX group. The most common of which were neutropenia (18 [28%] in nab-paclitaxel plus gemcitabine group, 16 [24%] in the sequential FOLFIRINOX group), nausea and vomiting (two [3%] in nab-paclitaxel plus gemcitabine group, eight [12%] in the sequential FOLFIRINOX group), and bile duct obstruction with cholangitis (six [9%] in nab-paclitaxel plus gemcitabine group, seven [11%] in the sequential FOLFIRINOX group). No deaths were caused by treatment-related adverse events during the induction chemotherapy phase. INTERPRETATION Our findings suggest that nab-paclitaxel plus gemcitabine is similarly active and safe as nab-paclitaxel plus gemcitabine followed by FOLFIRINOX as multidrug induction chemotherapy regimens for locally advanced pancreatic cancer. Although conversion to resectability was achieved in about a third of patients, additional evidence is required to determine whether this translates into improved overall survival. FUNDING Celgene.
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Affiliation(s)
- Volker Kunzmann
- Department of Internal Medicine II, Medical Oncology, Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany.
| | - Jens T Siveke
- Department of Medical Oncology and Division of Solid Tumour Translational Oncology, West German Cancer Center, University Medicine Essen, Essen, Germany
| | - Hana Algül
- Comprehensive Cancer Center Munich, Klinikum rechts der Isar, Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Eray Goekkurt
- North-German Trial Center for Innovative Oncology, Hematology-Oncology Practice Eppendorf, Hamburg, Germany
| | - Gabriele Siegler
- Department of Internal Medicine 5, Hematology and Medical Oncology, Paracelsus Medical University, Nürnberg, Germany
| | - Uwe Martens
- Department of Internal Medicine III, SLK-Clinics Heilbronn, Heilbronn, Germany
| | - Dirk Waldschmidt
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Uwe Pelzer
- Division of Oncology and Hematology, Charite Campus Mitte and Charite Campus Virchow Klinikum, Freie Universität Berlin, Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin Germany
| | - Martin Fuchs
- Clinic for Gastroenterology, Hepatology and Gastrointestinal-Oncology, München Klinik Bogenhausen, Munich, Germany
| | - Frank Kullmann
- Department of Internal Medicine I, Kliniken Nordoberpfalz, Klinikum Weiden, Weiden, Germany
| | - Stefan Boeck
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University - Grosshadern, Munich, Germany
| | - Thomas J Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Swantje Held
- Department of Biometrics, ClinAssess, Leverkusen, Germany
| | - Ralph Keller
- Clinical Research, Arbeitsgemeinschaft für Internistische Onkologie Studien, Berlin, Germany
| | - Ingo Klein
- Department of Surgery I, Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of Surgery I, Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Hubert Stein
- Department of Surgery, Paracelsus Medical University, Nürnberg, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Technical University Munich, Munich, Germany
| | - Marcus Bahra
- Department of Surgery, Charite Campus Mitte and Charite Campus Virchow Klinikum, Freie Universität Berlin, Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin Germany
| | - Ralf Jakobs
- Department of Internal Medicine C, Gastroenterology and Gastrointestinal Oncology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Ingo Hartlapp
- Department of Internal Medicine II, Medical Oncology, Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Volker Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University - Grosshadern, Munich, Germany
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25
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Al-Batran SE, Hofheinz RD, Reichart A, Pauligk C, Schönherr C, Schlag R, Siegler G, Dörfel S, Koenigsmann M, Zahn MO, Schubert J, Aldaoud A, Höffkes HG, Schulz H, Hahn L, Uhlig J, Blau W, Stauch M, Weniger J, Wolf M, Jacobasch L, Bildat S, Wehmeyer J, Homann N, Trojan J, Waidmann O, Fietz T, Feustel HP, Groschek M, Wierecky J, Waibel K, Mahlmann S, Schwindel U, Peters U, Schuch G, Pink D, Eschenburg H, Wörns MA, Harich HD, von Weikersthal LF, Däßler KU, Behringer DM, Messmann H, Kretzschmar A, Gallmeier E, Forstbauer H, Kunzmann V, Papke J, Büchner-Steudel P, Vehling-Kaiser U, Springfeld C, Vogel A, Ettrich TJ, Schaaf M, Hausen GZ, Götze TO. Quality of life and outcome of patients with metastatic pancreatic cancer receiving first-line chemotherapy with nab-paclitaxel and gemcitabine: Real-life results from the prospective QOLIXANE trial of the Platform for Outcome, Quality of Life and Translational Research on Pancreatic Cancer registry. Int J Cancer 2020; 148:1478-1488. [PMID: 33038277 DOI: 10.1002/ijc.33336] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/07/2020] [Accepted: 08/21/2020] [Indexed: 01/05/2023]
Abstract
Few data exist on health-related quality of life (QoL) in patients with metastatic pancreatic cancer (mPC) receiving first-line chemotherapy (Awad L ZE, Mesbah M Boston, MA. Applying survival data methodology to analyze quality of life data, in Mesbah M, Cole BF, Ting Lee M-L (eds): Statistical Methods for Quality of Life Studies: Design, Measurements and Analysis. Kluwer Academic Publishers 2002). The QOLIXANE study is a prospective, noninterventional, multicenter substudy of the Platform for Outcome, Quality of Life and Translational Research on Pancreatic Cancer (PARAGON) registry, which evaluated QoL in patients with mPC receiving first-line gemcitabine and nab-paclitaxel chemotherapy in real-life setting. QoL was prospectively measured via EORTC QLQ-C30 questionnaires at baseline and every month thereafter. Therapy and efficacy parameters were prospectively collected. Main objectives were the rate of patients without deterioration of Global Health Status/QoL (GHS/QoL) at 3 and 6 months. Six hundred patients were enrolled in 95 German study sites. Median progression-free survival was 5.9 months (95% confidence interval [CI], 5.2-6.3). Median overall survival (OS) was 8.9 months (95% CI, 7.9-10.2), while median time to deterioration of GHS/QoL was 4.7 months (95% CI, 4.0-5.6). With a baseline GHS/QoL score of 46 (SD, 22.8), baseline QoL of the patients was severely impaired, in most cases due to loss in role functioning and fatigue. In the Kaplan-Meier analysis, 61% and 41% of patients had maintained GHS/QoL after 3 and 6 months, respectively. However, in the QoL response analysis, 35% and 19% of patients had maintained (improved or stable) GHS/QoL after 3 and 6 months, respectively, while 14% and 9% had deteriorated GHS/QoL with the remaining patients being nonevaluable. In the Cox regression analysis, GHS/QoL scores strongly predicted survival with a hazard ratio of 0.86 (P < .0001). Patients with mPC have poor QoL at baseline that deteriorates within a median of 4.7 months. Treatment with gemcitabine and nab-paclitaxel is associated with maintained QoL in relevant proportions of patients. However, overall, results remain poor, reflecting the aggressive nature of the disease.
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Affiliation(s)
- Salah-Eddin Al-Batran
- Krankenhaus Nordwest, UCT-University Cancer Center, Frankfurt, Germany.,Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
| | | | - Alexander Reichart
- Krankenhaus Nordwest, UCT-University Cancer Center, Frankfurt, Germany.,Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
| | - Claudia Pauligk
- Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
| | - Caroline Schönherr
- Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
| | - Rudolf Schlag
- Gemeinschaftspraxis Schlag/Schöttker, Würzburg, Germany
| | | | | | | | | | | | - Ali Aldaoud
- HELIOS Park-Klinikum, Pankreaszentrum Leipzig, Leipzig, Germany
| | - Heinz-Gert Höffkes
- Universitätsmedizin Marburg, Klinikum Fulda, Fulda, Germany.,MVZ Osthessen GmbH, Fulda, Germany
| | - Holger Schulz
- Pioh Frechen-Köln Praxis Internistischer Onkologie und Hämatologie, Frechen, Germany
| | - Lars Hahn
- Dokusan Gesellschaft für med. Studien GmbH und Co. KG, Herne, Germany
| | - Jens Uhlig
- Hämatologisch-Onkologische Schwerpunktpraxis, Naunhof, Germany
| | - Wolfgang Blau
- Medizinische Klinik IV/V des Universitätsklinikums Gießen und Marburg, Gießen, Germany
| | - Martina Stauch
- Schwerpunktpraxis für Hämatologie/Onkologie, Kronach, Germany
| | - Jörg Weniger
- Gemeinschaftspraxis für Hämatologie und Onkologie Dres. Weniger/Bittrich/Schütze, Erfurt, Germany
| | - Martin Wolf
- Klinikum Kassel GmbH, Klinik für Hämatologie und Onkologie, Kassel, Germany
| | - Lutz Jacobasch
- Onkologische Gemeinschaftspraxis Dr. med. Lutz Jacobasch, Dresden, Germany
| | - Stephan Bildat
- Klinikum Herford, Medizinische Klinik II & MVZ für Onkologie, Onkologisches Zentrum, Herford, Germany
| | - Jürgen Wehmeyer
- Gemeinschaftspraxis für Hämatologie und Onkologie, Münster, Germany
| | - Nils Homann
- Med. Klinik II Klinikum Wolfsburg, Wolfsburg, Germany
| | - Jörg Trojan
- Klinikum der J. W. Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Oliver Waidmann
- Klinikum der J. W. Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Thomas Fietz
- Schwerpunktpraxis für Hämatologie, Onkologie und Gastroenterologie Dres Banhardt/Fietz/Hertkorn, Singen, Germany
| | | | | | - Jan Wierecky
- Überörtliche Gemeinschaftspraxis, Schwerpunkt Hämatologie, Onkologie und Palliativmedizin, Hamburg, Germany
| | - Karin Waibel
- medius Kliniken gGmbH, medius Klinik Ostfildern-Ruit, Ostfildern-Ruit, Germany
| | | | - Uwe Schwindel
- GPR Gesundheits- und Pflegezentrum gGmbH, I. Medizinische Klinik, Rüsselsheim, Germany
| | - Uwe Peters
- Ambulantes Tumorzentrum Spandau Dres. Peters und Saeuberlich-Knigge, Berlin, Germany
| | - Gunter Schuch
- Hämatologisch-Onkologische Praxis Altona (HOPA), Hamburg, Germany
| | - Daniel Pink
- Klinik und Poliklinik für Innere Medizin C, Hämatologie und Onkologie, Transplantationszentrum, Palliativmedizin, Universität Greifswald, Greifswald, Germany.,Klinik für Hämatologie, Onkologie und Palliativmedizin, Sarkomzentrum Berlin-Brandenburg, HELIOS Klinikum Bad-Saarow, Brandenburg, Germany
| | | | - Marcus-A Wörns
- I. Med. Klinik und Poliklinik, Universitätsmedizin Mainz, Germany
| | | | | | | | | | - Helmut Messmann
- Universitätsklinikum Augsburg, III. Medizinische Klinik, Augsburg, Germany
| | | | - Eike Gallmeier
- Universitätsklinikum Gießen und Marburg GmbH, Klinik für Innere Medizin, Marburg, Germany
| | | | - Volker Kunzmann
- Universitätsklinik Würzburg, Zentrum Innere Medizin, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | - Jens Papke
- Praxis Prof. Dr. med. Jens Papke, Neustadt/Sa, Germany
| | - Petra Büchner-Steudel
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Innere Medizin I, Halle, Germany
| | | | - Christoph Springfeld
- Nationales Centrum für Tumorerkrankungen (NCT), Abt. Medizinische Onkologie Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Arndt Vogel
- Medizinische Hochschule Hannover, Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Hannover, Germany
| | - Thomas J Ettrich
- Universitätsklinikum Ulm, Klinik für Innere Medizin I, Ulm, Germany
| | - Marina Schaaf
- Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
| | - Gerrit Zur Hausen
- Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
| | - Thorsten Oliver Götze
- Krankenhaus Nordwest, UCT-University Cancer Center, Frankfurt, Germany.,Institut für Klinische Krebsforschung IKF GmbH am Krankenhaus Nordwest, Frankfurt, Germany
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Ettrich TJ, Perkhofer L, Decker T, Hofheinz RD, Heinemann V, Hoffmann T, Hebart HF, Herrmann T, Hannig CV, Büchner-Steudel P, Güthle M, Hermann PC, Berger AW, Seufferlein T. Nintedanib plus mFOLFOX6 as second-line treatment of metastatic, chemorefractory colorectal cancer: The randomised, placebo-controlled, phase II TRICC-C study (AIO-KRK-0111). Int J Cancer 2020; 148:1428-1437. [PMID: 32930387 DOI: 10.1002/ijc.33296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022]
Abstract
Nintedanib is a triple angiokinase inhibitor of vascular endothelial growth factor receptor 1-3, fibroblast growth factor receptor 1-3 and platelet-derived growth factor receptor-a/-b. Thereby, it targets angiogenic escape mechanisms. The trial TyRosine kinase Inhibitor for the treatment of Chemorefractory Colorectal Cancer (TRICC-C) trial evaluates the addition of nintedanib to mFOLFOX6 (fluorouracil, folinic acid and oxaliplatin) in patients with metastatic colorectal cancer (mCRC). TRICC-C is a randomised controlled, double-blinded, phase II trial in mCRC patients that received a first-line non-oxaliplatin containing chemotherapy. Patients received mFOLFOX6 + nintedanib (F + N) (2 × 200 mg p.o./d, d1-d14) or mFOLFOX6 + placebo (F + P), in a 1:1 ratio. Primary endpoint was median progression free survival (mPFS) and secondary overall response rate (ORR), overall survival (OS) and safety. Fifty-three patients (27 F + N; 26 F + P) were randomised between 12/2012 and 5/2016 (scheduled n = 180). The trial was terminated prematurely due to slow accrual. The trial did not reach its primary endpoint but mPFS, median overall survival (mOS) and disease control rate (DCR) were numerically higher in the F + N arm compared to the F + P arm; however, the difference was not significant (mPFS: F + P: 4.6 months vs F + N: 8.1 months; HR 0.65; 95% CI 0.32-1.30; P = .2156; mOS: F + P: 9.9 months vs F + N: 17.1 months; HR 1.03, 95% CI 0.48-2.23; P = .9387; DCR: F + P: 50% vs F + N: 66,7%; P = .2709). Toxicity was moderate and only different for neutropenia (F + P: 11.5%, F + N: 19.2%) and gastrointestinal disorders (F + P: 65.4%, F + N: 84.6%). Final results show safety and a nonsignificant trend towards improved PFS and DCR for the combination of mFOLFOX6 + nintedanib in the second-line therapy of mCRC.
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Lukas Perkhofer
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Thomas Decker
- Private Practice, Onkologie Ravensburg, Ravensburg, Germany
| | | | - Volker Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University, Munich, Germany
| | | | - Holger F Hebart
- Medizinische Klinik, Klinikum Schwäbisch Gmünd, Stauferklinik, Mutlangen, Baden-Württemberg, Germany
| | - Thomas Herrmann
- Medizinische Klinik, Westküstenklinikum Heide, Heide, Schleswig-Holstein, Germany
| | - Carla V Hannig
- Private Practice, Schwerpunktpraxis Hämatologie/Onkologie, Bottrop, Germany
| | | | - Melanie Güthle
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Patrick C Hermann
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
| | - Andreas W Berger
- Department of Internal Medicine I, Ulm University, Ulm, Delaware, USA
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27
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Lorenzen S, Lordick F, Loosen SH, Tacke F, Trautwein C, Roderburg C, Ettrich TJ, Perkhofer L, Reinacher-Schick A, Stein A. Current status of immunotherapy in gastrointestinal malignancies. Z Gastroenterol 2020; 58:542-555. [PMID: 32018315 DOI: 10.1055/a-1071-8322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Gastrointestinal (GI) malignant neoplasms have a high global incidence and a huge impact on cancer-associated mortality. In the past years, excitement was growing among oncologists and patients alike for the use of immunotherapy, specifically immune checkpoint inhibitors. The approval of several PD-1/PD-L1 and CTLA-4 inhibitors radically changed the treatment landscape in many cancer types and established immune-oncology as a new treatment strategy against cancer. Despite major breakthrough reports, shortcomings of immune checkpoint inhibitors (ICI) have been observed, including primary and acquired treatment resistance, especially in patients receiving ICIs as a single treatment. Several immunotherapies for the treatment of GI tumors have recently emerged; however, checkpoint inhibition has not yet shown similar success in GI malignancies compared to other solid tumors. Various phase I-III trials focusing on immunotherapies for GI tumors have found only moderate to unsatisfactory objective response rates (ORR), ranging between 10 % and 25 %. In particular, negative studies have been reported in gastric and pancreatic cancer. Nevertheless, small subsets of cancers, such as DNA mismatch repair deficient (dMMR)/microsatellite instable (MSI) cancers, among others, seem to benefit from treatment with immune checkpoint inhibition. Routine testing for the rare molecular features that can predict response should be implemented in clinical routine for all GI tumors, and large scale clinical trials to identify predictive biomarkers are needed. This article will address the current use and evidence for immunotherapy in GI malignancies and future trends in this area for clinical practice.
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Affiliation(s)
- Sylvie Lorenzen
- Department of Hematology and Oncology, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Florian Lordick
- University Cancer Center, University Clinic Leipzig, Germany
| | - Sven Heiko Loosen
- University Hospital Aachen, Department of Medicin III, Aachen, Germany
| | - Frank Tacke
- Charité University Medicine Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany
| | | | - Christoph Roderburg
- Charité University Medicine Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany
| | | | - Lukas Perkhofer
- Department of Internal Medicine I, University of Ulm, Germany
| | | | - Alexander Stein
- Hämatologisch-Onkologische Praxis Eppendorf, University Cancer Center Hamburg, Germany
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28
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Moehler M, Maderer A, Thuss-Patience PC, Brenner B, Meiler J, Ettrich TJ, Hofheinz RD, Al-Batran SE, Vogel A, Mueller L, Lutz MP, Lordick F, Alsina M, Borchert K, Greil R, Eisterer W, Schad A, Slotta-Huspenina J, Van Cutsem E, Lorenzen S. Cisplatin and 5-fluorouracil with or without epidermal growth factor receptor inhibition panitumumab for patients with non-resectable, advanced or metastatic oesophageal squamous cell cancer: a prospective, open-label, randomised phase III AIO/EORTC trial (POWER). Ann Oncol 2019; 31:228-235. [PMID: 31959339 DOI: 10.1016/j.annonc.2019.10.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/10/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Palliative chemotherapy of advanced oesophageal squamous cell cancer (ESCC) consists of cisplatin/5-fluorouracil (CF) to target epidermal growth factor receptor (EGFR) with panitumumab (P); chemotherapy enhanced overall survival (OS) in advanced colorectal or squamous cell head and neck cancers. With prospective serum and tumour biomarkers, we tested if P added to CF (CFP) improved OS in advanced ESCC. PATIENTS AND METHODS Eligible patients with confirmed ESCC that was not curatively resectable or did not qualify for definitive radiochemotherapy, were randomised 1 : 1 to receive CF [cisplatin (C) 100 mg/m2 i.v., day 1; 5-fluorouracil (F) 1000 mg/m2 i.v., days 1-4] or CF plus P (9 mg/kg, i.v., day 1, each q3-week cycle) until progressive disease or unacceptable toxicity. Safety was reviewed by the Data Safety Monitoring Board after 40, 70 and 100 patients who completed at least one cycle. After 53 enrolled patients, cisplatin was reduced from 100 mg/m2 to 80 mg/m2. RESULTS The trial was stopped early based on interim efficacy results triggered by the third safety analysis: median OS (mOS) favoured CF over CFP, regardless of cisplatin dose [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.06-2.98; P = 0.028]. In the final analysis, mOS was 10.2 versus 9.4 months for CF versus CFP, respectively (HR 1.17, 95% CI 0.79-1.75; P = 0.43). One hundred (70.4%) of 142 patients in the safety population died, 51 (51.0%) with CFP. Most deaths were related to disease progression [44/49 (90%) deaths in CF versus 34/51 (67%) deaths in CFP]; objective responses [27/73 (37.0%)] were identical. The most common serious adverse events were kidney injury [3 (4.3%) versus 7 (9.7%)], general health deterioration [5 (7.1%) versus 5 (6.9%)] and dysphagia [4 (5.7%) versus 4 (5.6%)] in CF versus CFP, respectively. There were three (4.3%) and 17 (23.6%) common terminology criteria for adverse events (CTCAE) grade 5 events in CF versus CFP, respectively. Low soluble (s)EGFR levels were associated with better progression-free survival; sEGFR was induced under CFP. CONCLUSION EGFR inhibition added to CF did not improve survival in unselected advanced ESCC patients. The results support further liquid biopsy studies. TRIAL REGISTRATION ClinicalTrials.gov (NCT01627379) and EudraCT (2010-020606-15).
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Affiliation(s)
- M Moehler
- 1st Department of Internal Medicine, Johannes Gutenberg-University Mainz, Mainz, Germany.
| | - A Maderer
- 1st Department of Internal Medicine, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - P C Thuss-Patience
- Medical Department, Division of Hematology, Oncology and Tumor Immunology, Charité - University Medicine Berlin, Berlin, Germany
| | - B Brenner
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Meiler
- Department of Internal Medicine, University Hospital Essen, Essen, Germany
| | - T J Ettrich
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - R-D Hofheinz
- Medical Department III, University Hospital Mannheim, Mannheim, Germany
| | - S E Al-Batran
- Institute of Clinical Cancer Research, Hospital North-West, Frankfurt, Germany
| | - A Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - L Mueller
- Oncology Leer-Emden-Papenburg, Leer, Germany
| | - M P Lutz
- Gastroenterology, Caritas Hospital, Saarbrücken, Germany
| | - F Lordick
- 1st Medical Department and University Cancer Center Leipzig, University of Leipzig Medical Center, Leipzig, Germany
| | - M Alsina
- Department of Medical Oncology, Hospital Universitari Vall d'Hebron and Vall d'Hebron Institute of Oncology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - K Borchert
- Medical Department III, University Hospital Rostock, Rostock, Germany
| | - R Greil
- 3rd Medical Department, Cancer Research Institute, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - W Eisterer
- Department of Internal Medicine V, Medical University Innsbruck, Innsbruck, Austria
| | - A Schad
- Institute of Pathology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - J Slotta-Huspenina
- Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
| | - E Van Cutsem
- University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven, Belgium
| | - S Lorenzen
- Medical Department III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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29
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Perkhofer L, Berger AW, Beutel AK, Gallmeier E, Angermeier S, Fischer von Weikersthal L, Goetze TO, Muche R, Seufferlein T, Ettrich TJ. Nal-IRI with 5-fluorouracil (5-FU) and leucovorin or gemcitabine plus cisplatin in advanced biliary tract cancer - the NIFE trial (AIO-YMO HEP-0315) an open label, non-comparative, randomized, multicenter phase II study. BMC Cancer 2019; 19:990. [PMID: 31646981 PMCID: PMC6813114 DOI: 10.1186/s12885-019-6142-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Biliary tract cancer (BTC) has a high mortality. Primary diagnosis is frequently delayed due to mostly unspecific symptoms, resulting in a high number of advanced cases at the time of diagnosis. Advanced BTCs are in principle chemotherapy sensitive as determined by improved disease control, survival and quality of life (QoL). However, median OS does not exceed 11.7 months with the current standard of care gemcitabine plus cisplatin. Thereby, novel drug formulations like nanoliposomal-irinotecan (nal-IRI) in combination with 5- fluorouracil (5-FU)/leucovorin may have the potential to improve therapeutic outcomes in this disease. Methods NIFE is an interventional, prospective, randomized, controlled, open label, two-sided phase II study. Within the study, 2 × 46 patients with locally advanced, non-resectable or metastatic BTC are to be enrolled by two stage design of Simon. Data analysis will be done unconnected for both arms. Patients are allocated in two arms: Arm A (experimental intervention) nal-IRI mg/m2, 46 h infusion)/5-FU (2400 mg/m2, 46 h infusion)/leucovorin (400 mg/m2, 0.5 h infusion) d1 on 14 day-cycles; Arm B (standard of care) cisplatin (25 mg/m2, 1 h infusion)/gemcitabine (1000 mg/m2, 0.5 h infusion) d1 and d8 on 21 day-cycles. The randomization (1:1) is stratified for tumor site (intrahepatic vs. extrahepatic biliary tract), disease stage (advanced vs. metastatic), age (≤70 vs. > 70 years), sex (male vs. female) and WHO performance score (ECOG 0 vs. ECOG 1). Primary endpoint of the study is the progression free survival (PFS) rate at 4 months after randomization by an intention-to-treat analysis in each of the groups. Secondary endpoints are the overall PFS rate, the 3-year overall survival rate, the disease control rate after 2 months, safety and patient related outcome with quality of life. The initial assessment of tumor resectability for locally advanced BTCs is planned to be reviewed retrospectively by a central surgical board. Exploratory objectives aim at establishing novel biomarkers and molecular signatures to predict response. The study was initiated January 2018 in Germany. Discussion The NIFE trial evaluates the potential of a nanoliposomal-irinotecan/5-FU/leucovorin combination in the first line therapy of advanced BTCs and additionally offers a unique chance for translational research. Trial registration Clinicaltrials.gov NCT03044587. Registration Date February 7th 2017.
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Affiliation(s)
- L Perkhofer
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - A W Berger
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany.,Department of Internal Medicine and Gastroenterology, Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Germany
| | - A K Beutel
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - E Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - S Angermeier
- Internal Medicine I, Klinikum Ludwigsburg, Posilipostraße 4, 71640, Ludwigsburg, Germany
| | | | - T O Goetze
- Institute of Clinical Cancer Research (IKF) at Krankenhaus Nordwest, UCT-University Cancer Center, Steinbacher Hohl 2-26, 60488, Frankfurt, Germany
| | - R Muche
- Institute of Epidemiology and Medical Biometry, Ulm University, Schwabstraße 13, 89081, Ulm, Germany
| | - T Seufferlein
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
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30
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Ettrich TJ, Schwerdel D, Dolnik A, Beuter F, Blätte TJ, Schmidt SA, Stanescu-Siegmund N, Steinacker J, Marienfeld R, Kleger A, Bullinger L, Seufferlein T, Berger AW. Genotyping of circulating tumor DNA in cholangiocarcinoma reveals diagnostic and prognostic information. Sci Rep 2019; 9:13261. [PMID: 31519967 PMCID: PMC6744511 DOI: 10.1038/s41598-019-49860-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/29/2019] [Indexed: 12/13/2022] Open
Abstract
Diagnosis of Cholangiocarcinoma (CCA) is difficult, thus a noninvasive approach towards (i) assessing and (ii) monitoring the tumor-specific mutational profile is desirable to improve diagnosis and tailor treatment. Tumor tissue and corresponding ctDNA samples were collected from patients with CCA prior to and during chemotherapy and were subjected to deep sequencing of 15 genes frequently mutated in CCA. A set of ctDNA samples was also submitted for 710 gene oncopanel sequencing to identify progression signatures. The blood/tissue concordance was 74% overall and 92% for intrahepatic tumors only. Variant allele frequency (VAF) in ctDNA correlated with tumor load and in the group of intrahepatic CCA with PFS. 63% of therapy naive patients had their mutational profile changed during chemotherapy. A set of 76 potential progression driver genes was identified among 710 candidates. The molecular landscape of CCA is accessible via ctDNA. This could be helpful to facilitate diagnosis and personalize and adapt therapeutic strategies.
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Affiliation(s)
- T J Ettrich
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | - D Schwerdel
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | - A Dolnik
- Charité University Medical Center Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - F Beuter
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | - T J Blätte
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - S A Schmidt
- University Medical Center Ulm, Department of Diagnostic and Interventional Radiology, University of Ulm, Ulm, Germany
| | - N Stanescu-Siegmund
- University Medical Center Ulm, Department of Diagnostic and Interventional Radiology, University of Ulm, Ulm, Germany
| | - J Steinacker
- University Medical Center Ulm, Department of Diagnostic and Interventional Radiology, University of Ulm, Ulm, Germany
| | - R Marienfeld
- University Medical Center Ulm, Institute of Pathology, University of Ulm, Ulm, Germany
| | - A Kleger
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | - L Bullinger
- Charité University Medical Center Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - T Seufferlein
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine I, University of Ulm, Ulm, Germany.
| | - A W Berger
- University Medical Center Ulm, Center for Internal Medicine, Department of Internal Medicine I, University of Ulm, Ulm, Germany.,Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Vivantes Klinikum im Friedrichshain, Teaching Hospital of Charité - University Medical Center Berlin, Berlin, Germany
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31
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Seufferlein T, Simões C, Kude F, Ettrich TJ. Molecular Approaches to Metastatic Colorectal Cancer: Better Diagnosis - Better Treatment? Visc Med 2019; 35:259-264. [PMID: 31602389 PMCID: PMC6738174 DOI: 10.1159/000500617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/26/2019] [Indexed: 12/15/2022] Open
Abstract
Molecular diagnostics of metastatic colorectal cancer (mCRC) are coming of age. Whereas for many years RAS mutations were the only relevant molecular alterations examined in mCRC, nowadays the BRAF, HER2, and microsatellite instability status of a given tumor is gaining importance, since it has not only prognostic relevance but opens new avenues for therapeutic approaches. This review summarizes the recent advances in molecular approaches to mCRC and their therapeutic consequences and discusses novel approaches for molecular diagnostics in mCRC.
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Affiliation(s)
- Thomas Seufferlein
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Carolina Simões
- Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, Lisbon, Portugal
| | - Fernando Kude
- Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
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32
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Gaiser MR, Lorenzen S, Merx K, Trojan J, Ocvirk J, Ettrich TJ, Al-Batran SE, Schulz H, Homann N, Feustel HP, Schatz M, Kripp M, Schulte N, Heeger S, Vlassak S, Koch W, Hofheinz RD. Evaluation of EGFR inhibitor-mediated acneiform skin toxicity within the double-blind randomized EVITA trial: A thorough gender-specific analysis using the WoMo score. Cancer Med 2019; 8:4169-4175. [PMID: 31199595 PMCID: PMC6675717 DOI: 10.1002/cam4.2132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 12/16/2022] Open
Abstract
Acne‐like skin reactions frequently occur in patients undergoing treatment with drugs inhibiting the epidermal growth factor receptor. Recently, the effects of vitamin K1 containing cream (Reconval K1) as prophylactic skin treatment in addition to doxycycline were explored in a double‐blind randomized phase II trial (EVITA) in patients with metastatic colorectal cancer receiving cetuximab. EVITA demonstrated a trend towards less severe skin rash in Reconval K1‐treated patients using the tripartite WoMo skin reaction grading score as a thorough tool for quantification of drug related skin reactions. This gender‐specific analysis of the EVITA trial evaluated the application of the WoMo score for assessment of epidermal growth factor receptor (EGFR)‐related skin toxicities according to treatment arm and gender. To show the robustness of results parametric and non‐parametric statistical analyses were conducted. All three parts of the WoMo score independently demonstrated the superiority of the treatment arm (Reconval K1) regarding a significant reduction in acneiform skin reactions in women. Men did not benefit from Reconval K1 cream at any time point in none of the WoMo score analyses. The treatment effect in women was confirmed by the use of skin rash categories based on the final WoMo overall score and mixed effect longitudinal multiple linear regression analysis. The WoMo score represents a sensitive tool for studies exploiting treatments against EGFR mediated acne‐like skin rash. Part C of the WoMo score seems to be sufficient for quantification of drug related skin toxicities in further studies. Standard WoMo skin reaction score values for future studies are provided.
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Affiliation(s)
- Maria R Gaiser
- Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany.,Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Kirsten Merx
- Interdisciplinary Tumor Center Mannheim, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Jörg Trojan
- Medical Clinic I, University Hospital Frankfurt, Frankfurt, Germany
| | | | | | - Salah-Eddin Al-Batran
- Institute of Clinical Cancer Research (IKF) at Nordwest Hospital, UCT-University Cancer Center, Frankfurt, Germany
| | | | - Nils Homann
- Medical Clinic II Wolfsburg, Wolfsburg, Germany
| | | | - Michael Schatz
- Medizinische Klinik II, ViDia Christliche Kliniken Karlsruhe, Karlsruhe, Germany
| | - Melanie Kripp
- Interdisciplinary Tumor Center Mannheim, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Nadine Schulte
- Interdisciplinary Tumor Center Mannheim, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | | | | | | | - Ralf-Dieter Hofheinz
- Interdisciplinary Tumor Center Mannheim, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
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Seufferlein T, Ettrich TJ. Treatment of pancreatic cancer-neoadjuvant treatment in resectable pancreatic cancer (PDAC). Transl Gastroenterol Hepatol 2019; 4:21. [PMID: 30976724 PMCID: PMC6458347 DOI: 10.21037/tgh.2019.03.05] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/18/2019] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers. Curative-intended resection and adjuvant chemotherapy represents the current standard of care. Despite substantial improvements in surgical treatment and intensified adjuvant treatment with more powerful regimens over the last years even clearly resectable pancreatic cancer still has an unfavorable prognosis with a high risk of relapse. Neoadjuvant or perioperative multimodal therapies have substantially improved the outcome of other resectable gastrointestinal (GI) cancers such as esophagus and gastric cancer. It is reasonable to assume that efficient chemotherapy and or radiochemotherapy may have a similar impact on the outcome of resectable PDAC. This review is focused on neoadjuvant and perioperative treatment of resectable PDAC (no borderline resectable or locally advanced PDAC), summarizes the pros and cons for neoadjuvant treatment in the context of the current literature, and also provides an overview over the landscape of ongoing clinical trials in this up-and-coming field of PDAC therapy.
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Berger AW, Schwerdel D, Reinacher-Schick A, Uhl W, Algül H, Friess H, Janssen KP, König A, Ghadimi M, Gallmeier E, Bartsch DK, Geissler M, Staib L, Tannapfel A, Kleger A, Beutel A, Schulte LA, Kornmann M, Ettrich TJ, Seufferlein T. A Blood-Based Multi Marker Assay Supports the Differential Diagnosis of Early-Stage Pancreatic Cancer. Theranostics 2019; 9:1280-1287. [PMID: 30867830 PMCID: PMC6401492 DOI: 10.7150/thno.29247] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 01/10/2019] [Indexed: 12/24/2022] Open
Abstract
The most frequent malignancy of the pancreas is the pancreatic ductal adenocarcinoma (PDAC). Despite many efforts PDAC has still a dismal prognosis. Biomarkers for early disease stage diagnosis as a prerequisite for a potentially curative treatment are still missing. Novel blood-based markers may help to overcome this limitation. Methods: Prior to surgery plasma levels of thrombospondin-2 (THBS2), which was recently published as a novel biomarker, and CA19-9 from 52 patients with histologically proven PDAC were determined, circulating cell-free (cfDNA) was quantified. 15 patients with side-branch IPMNs without worrisome features and 32 patients with chronic pancreatitis served for comparison. Logit (logistic regression) models were used to test the performance of single biomarkers and biomarker combinations. Results: CA19-9 and THBS2 alone showed comparable c-statistics of 0.80 and 0.73, respectively, improving to 0.87 when combining these two markers. The c-statistic was further increased to 0.94 when combining CA19-9 and THBS2 with cfDNA quantification. This marker combination performed best for all PDAC stages but also for PDACs grouped by stage. The greatest improvement over CA19-9 was seen in the group of stage I PDAC, from 0.69 to 0.90 for the three marker combination. Conclusion:These data establish the combination of CA19-9, THBS2 and cfDNA as a composite liquid biomarker for non-invasive diagnosis of early-stage PDAC.
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Perkhofer L, Beutel AK, Ettrich TJ. Immunotherapy: Pancreatic Cancer and Extrahepatic Biliary Tract Cancer. Visc Med 2019; 35:28-37. [PMID: 31312647 DOI: 10.1159/000497291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 12/13/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) and extrahepatic biliary tract cancer (BTC) are among the malignancies with the highest morbidity and mortality. Despite increasing knowledge on biology and novel therapies, outcome remains poor in these patients. Recent progress in immunotherapies created new hopes in the treatment of PDAC and extrahepatic BTC. Several trials tested immunotherapies in various therapeutic situations as monotherapies or in combinations. Although responses were seen in some of the trials, the value of immunotherapy in PDAC and extrahepatic BTC remains unclear in the current situation, especially regarding the complex biological characteristics with a high stroma component, intrinsic resistance mechanisms and an immunosuppressive, hypoxic microenvironment. These major hurdles have to be taken into account and overcome if immunotherapies should be successful in these tumor entities. Thereby, combinational approaches that allow on the one hand targeted therapy and on the other restore or boost the function of immune cells are promising.
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Affiliation(s)
- Lukas Perkhofer
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
| | - Alica K Beutel
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
| | - Thomas J Ettrich
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
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Ettrich TJ, Berger AW, Perkhofer L, Daum S, König A, Dickhut A, Wittel U, Wille K, Geissler M, Algül H, Gallmeier E, Atzpodien J, Kornmann M, Muche R, Prasnikar N, Tannapfel A, Reinacher-Schick A, Uhl W, Seufferlein T. Neoadjuvant plus adjuvant or only adjuvant nab-paclitaxel plus gemcitabine for resectable pancreatic cancer - the NEONAX trial (AIO-PAK-0313), a prospective, randomized, controlled, phase II study of the AIO pancreatic cancer group. BMC Cancer 2018; 18:1298. [PMID: 30594153 PMCID: PMC6311014 DOI: 10.1186/s12885-018-5183-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Even clearly resectable pancreatic cancer still has an unfavorable prognosis. Neoadjuvant or perioperative therapies might improve the prognosis of these patients. Thus, evaluation of perioperative chemotherapy in resectable pancreatic cancer in a prospective, randomized trial is warranted. A substantial improvement in overall survival of patients with metastatic pancreatic cancer with FOLFIRINOX and nab-paclitaxel/gemcitabine vs standard gemcitabine has been demonstrated in phase III-trials. Indeed nab-paclitaxel/gemcitabine has a more favorable toxicity profile compared to the FOLFIRINOX protocol and appears applicable in a perioperative setting. Methods NEONAX is an interventional, prospective, randomized, controlled, open label, two sided phase II study with an unconnected analysis of the results in both experimental arms against a fixed survival probability (38% at 18 months with adjuvant gemcitabine), NCT02047513. NEONAX will enroll 166 patients with resectable pancreatic ductal adenocarcinoma (≤ cT3, N0 or N1, cM0) in two arms: Arm A (perioperative arm): 2 cycles nab-paclitaxel (125 mg/m2)/gemcitabine (1000 mg/m2, d1, 8 and 15 of an 28 day-cycle) followed by tumor surgery followed by 4 cycles nab-paclitaxel/gemcitabine, Arm B (adjuvant arm): tumor surgery followed by 6 cycles nab-paclitaxel/gemcitabine. The randomization (1:1) is eminent to avoid allocation bias between the groups. Randomization is stratified for tumor stage (ct1/2 vs. cT3) and lymph node status (cN0 vs. cN1). Primary objective is disease free survival (DFS) at 18 months after randomization. Key secondary objectives are 3-year overall survival (OS) rate and DFS rate, progression during neoadjuvant therapy, R0 and R1 resection rate, quality of life and correlation of DFS, OS and tumor regression with pharmacogenomic markers, tumor biomarkers and molecular analyses (ctDNA, transcriptome, miRNA-arrays). In addition, circulating tumor-DNA will be analyzed in patients with the best and the worst responses to the neoadjuvant treatment. The study was initiated in March 2015 in 26 centers for pancreatic surgery in Germany. Discussion The NEONAX trial is an innovative study on resectable pancreatic cancer and currently one of the largest trials in this field of research. It addresses the question of the role of intensified perioperative treatment with nab-paclitaxel plus gemcitabine in resectable pancreatic cancers to improve disease-free survival and offers a unique potential for translational research. Trial registration ClinicalTrials.gov: NCT02047513, 08/13/2014. Electronic supplementary material The online version of this article (10.1186/s12885-018-5183-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Andreas W Berger
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Severin Daum
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité University Medicine Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Alexander König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Andreas Dickhut
- Department of Oncology/Hematology, Fulda Hospital, Pacelliallee 4, 36043, Fulda, Germany
| | - Uwe Wittel
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Kai Wille
- Department of Hematology and medical oncology, Johannes-Wesling-Klinikum Minden, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Michael Geissler
- Department of Internal Medicine, Oncology/Hematology, Gastroenterology, Esslingen Hospital, Hirschlandstr. 97, 73730 Esslingen, Esslingen, Germany
| | - Hana Algül
- Department of Internal Medicine II, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Eike Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Jens Atzpodien
- Department of Medical Oncology and Hematology, Niels-Stensen-Kliniken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Marko Kornmann
- Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89081, Ulm, Germany
| | - Nicole Prasnikar
- Department of Oncologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Germany
| | - Andrea Tannapfel
- Department of Pathology, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Internal Medicine, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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Finkelmeier F, Czauderna C, Perkhofer L, Ettrich TJ, Trojan J, Weinmann A, Marquardt JU, Vermehren J, Waidmann O. Feasibility and safety of nivolumab in advanced hepatocellular carcinoma: real-life experience from three German centers. J Cancer Res Clin Oncol 2018; 145:253-259. [DOI: 10.1007/s00432-018-2780-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/24/2018] [Indexed: 12/18/2022]
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Haas M, Siveke JT, Schenk M, Lerch MM, Caca K, Freiberg-Richter J, Fischer von Weikersthal L, Kullmann F, Reinacher-Schick A, Fuchs M, Kanzler S, Kunzmann V, Ettrich TJ, Kruger S, Westphalen CB, Held S, Heinemann V, Boeck S. Efficacy of gemcitabine plus erlotinib in rash-positive patients with metastatic pancreatic cancer selected according to eligibility for FOLFIRINOX: A prospective phase II study of the 'Arbeitsgemeinschaft Internistische Onkologie'. Eur J Cancer 2018; 94:95-103. [PMID: 29549862 DOI: 10.1016/j.ejca.2018.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/13/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In metastatic pancreatic ductal adenocarcinoma (mPDAC) treatment, erlotinib is known to be more effective in patients developing skin rash. Treatment with the FOLFIRINOX regimen is only performed in fit patients following defined inclusion criteria. The present study investigates the efficacy of gemcitabine plus erlotinib (gem/erlotinib) in rash-positive patients fit for FOLFIRINOX. PATIENTS AND METHODS For this prospective phase II study, 150 patients were recruited in 20 centres. All patients received gem/erlotinib for 4 weeks (run-in phase); the subsequent treatment was determined by the development of skin rash: patients with rash grades 1-4 continued with gem/erlotinib, rash-negative patients were switched to FOLFIRINOX. Primary study end-point was to achieve a 1-year survival rate in rash-positive patients ≥40%. RESULTS Ninety patients were deemed positive for skin rash by the end of the run-in phase, showing a 1-year survival rate of 40.0% (95% confidence interval [CI] 29.8-50.9). Median overall survival (OS) was 10.1 months, progression-free survival (PFS) was 3.8 months and overall response rate (ORR) was 23.3%. Patients switched to FOLFIRINOX (n = 27) had a 1-year survival rate of 48.1% (95% CI 28.7-68.1), a median OS of 10.9 months, a median PFS of 6.6 months and an ORR of 33.3%. Rash-negative patients had a lower quality of life at baseline but seemed to experience an improved control of pain during FOLFIRINOX. CONCLUSIONS First-line treatment with gem/erlotinib was effective in fit, rash-positive mPDAC patients achieving a 1-year survival rate comparable to previous reports for FOLFIRINOX. The study was registered at clinicaltrials.gov (NCT0172948) and Eudra-CT (2011-005471-17).
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Affiliation(s)
- M Haas
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany.
| | - J T Siveke
- 2nd Medical Department, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany; Division of Solid Tumor Translational Oncology (DKTK, Partner Site Essen), West German Cancer Center, University Hospital Essen, Essen, Germany
| | - M Schenk
- Department of Haematology and Oncology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - M M Lerch
- Department of Medicine A, Universitätsmedizin Greifswald, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - K Caca
- Department of Internal Medicine I, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | | | - F Kullmann
- Department of Medicine I, Klinikum Weiden, Weiden, Germany
| | - A Reinacher-Schick
- Department of Haematology and Oncology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - M Fuchs
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Klinikum Bogenhausen, Munich, Germany
| | - S Kanzler
- Department of Internal Medicine II, Leopoldina Krankenhaus Schweinfurt, Schweinfurt, Germany
| | - V Kunzmann
- Department of Medical Oncology, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - T J Ettrich
- Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | - S Kruger
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - C B Westphalen
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - S Held
- ClinAssess GmbH, Leverkusen, Germany
| | - V Heinemann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - S Boeck
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
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Manzini G, Ettrich TJ, Kremer M, Kornmann M, Henne-Bruns D, Eikema DA, Schlattmann P, de Wreede LC. Advantages of a multi-state approach in surgical research: how intermediate events and risk factor profile affect the prognosis of a patient with locally advanced rectal cancer. BMC Med Res Methodol 2018; 18:23. [PMID: 29439652 PMCID: PMC5811976 DOI: 10.1186/s12874-018-0476-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/16/2018] [Indexed: 01/07/2023] Open
Abstract
Background Standard survival analysis fails to give insight into what happens to a patient after a first outcome event (like first relapse of a disease). Multi-state models are a useful tool for analyzing survival data when different treatments and results (intermediate events) can occur. Aim of this study was to implement a multi-state model on data of patients with rectal cancer to illustrate the advantages of multi-state analysis in comparison to standard survival analysis. Methods We re-analyzed data from the RCT FOGT-2 study by using a multi-state model. Based on the results we defined a high and low risk reference patient. Using dynamic prediction, we estimated how the survival probability changes as more information about the clinical history of the patient becomes available. Results A patient with stage UICC IIIc (vs UICC II) has a higher risk to develop distant metastasis (DM) or both DM and local recurrence (LR) if he/she discontinues chemotherapy within 6 months or between 6 and 12 months, as well as after the completion of 12 months CTx with HR 3.55 (p = 0.026), 5.33 (p = 0.001) and 3.37 (p < 0.001), respectively. He/she also has a higher risk to die after the development of DM (HR 1.72, p = 0.023). Anterior resection vs. abdominoperineal amputation means 63% risk reduction to develop DM or both DM and LR (HR 0.37, p = 0.003) after discontinuation of chemotherapy between 6 and 12 months. After development of LR, a woman has a 4.62 times higher risk to die (p = 0.006). A high risk reference patient has an estimated 43% 5-year survival probability at start of CTx, whereas for a low risk patient this is 79%. After the development of DM 1 year later, the high risk patient has an estimated 5-year survival probability of 11% and the low risk patient one of 21%. Conclusions Multi-state models help to gain additional insight into the complex events after start of treatment. Dynamic prediction shows how survival probabilities change by progression of the clinical history. Electronic supplementary material The online version of this article (10.1186/s12874-018-0476-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G Manzini
- Department of General and Visceral Surgery, University Hospital of Ulm, Albert-Einstein-Allee 23, 89073, Ulm, Germany.
| | - T J Ettrich
- Department of Internal Medicine, University Hospital of Ulm, Ulm, Germany
| | - M Kremer
- Department of General and Visceral Surgery, University Hospital of Ulm, Albert-Einstein-Allee 23, 89073, Ulm, Germany
| | - M Kornmann
- Department of General and Visceral Surgery, University Hospital of Ulm, Albert-Einstein-Allee 23, 89073, Ulm, Germany
| | - D Henne-Bruns
- Department of General and Visceral Surgery, University Hospital of Ulm, Albert-Einstein-Allee 23, 89073, Ulm, Germany
| | - D A Eikema
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - P Schlattmann
- Department of Medical Statistics, Informatics and Documentation, University of Jena, Jena, Germany
| | - L C de Wreede
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center (LUMC), Leiden, Netherlands
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Berger AW, Schwerdel D, Ettrich TJ, Hann A, Schmidt SA, Kleger A, Marienfeld R, Seufferlein T. Targeted deep sequencing of circulating tumor DNA in metastatic pancreatic cancer. Oncotarget 2017; 9:2076-2085. [PMID: 29416754 PMCID: PMC5788622 DOI: 10.18632/oncotarget.23330] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 12/08/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose Precision medicine in pancreatic ductal adenocarcinoma (PDAC) could be substantially supported by tools that allow to establish and monitor the molecular setup of the tumor. In particular, noninvasive approaches are desirable, but not validated. Characterization of circulating tumor DNA (ctDNA) may help to achieve this goal. Experimental Design Blood samples from patients with metastatic PDAC prior to and during palliative treatment were collected. ctDNA and corresponding tumor tissue were analyzed by targeted next generation sequencing and droplet digital PCR for the 7 most frequently mutated genes in PDAC (TP53, SMAD4, CDKN2A, KRAS, APC, ATM, and FBXW7). Findings were correlated with clinical and imaging data. Results A total of 20 patients (therapy naïve n = 11; pretreated n = 9) were included. All therapy naïve patients (n = 11/11) presented with detectable ctDNA at baseline. In pretreated patients, 3/7 (prior to 2nd line treatment) and 2/2 (prior to 3rd line chemotherapy) had detectable ctDNA. The combined mutational allele frequency (CMAF) of KRAS and TP53 was chosen to reflect the amount of ctDNA. The median CMAF level significantly decreased during treatment (P = 0.0027) and increased at progression (P = 0.0104). CA19-9 analyses did not show significant differences. In treatment naïve patients, the CMAF levels during therapy significantly correlated with progression-free survival (Spearman, r = -0.8609, P = 0.0013). Conclusions Monitoring of ctDNA and its changes during treatment may enable to adapt therapeutic strategies to the specific molecular changes present at a certain time during treatment of mPDAC.
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Affiliation(s)
- Andreas W Berger
- Department of Internal Medicine I, Ulm University, 89081 Ulm, Germany
| | - Daniel Schwerdel
- Department of Internal Medicine I, Ulm University, 89081 Ulm, Germany
| | - Thomas J Ettrich
- Department of Internal Medicine I, Ulm University, 89081 Ulm, Germany
| | - Alexander Hann
- Department of Internal Medicine I, Ulm University, 89081 Ulm, Germany
| | - Stefan A Schmidt
- Department of Diagnostic and Interventional Radiology, Ulm University, 89081 Ulm, Germany
| | - Alexander Kleger
- Department of Internal Medicine I, Ulm University, 89081 Ulm, Germany
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Ettrich TJ, Schulte LA, Eitel N, Ettrich K, Berger AW, Perkhofer L, Seufferlein T. Surveillance after resection of pancreatic ductal adenocarcinoma with curative intent - a multicenter survey in Germany and review of the literature. Z Gastroenterol 2017; 55:657-666. [PMID: 28437802 DOI: 10.1055/s-0043-105502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers with high risk of relapse even after curative-intended resection. There are no evidence-based recommendations for surveillance in actual guidelines. Given this situation and as a basis for prospective studies, we wanted to determine the current practice of surveillance after pancreatic cancer resection in German institutions. Methods A web-based questionnaire was sent in 2015 to 300 German institutions (hospitals, outpatient clinics, and private practices) experienced in the care of patients with PDAC. The questionnaire comprised 23 items including the respective institution, the level of care, the annual case load of pancreatic cancer surgery, the surveillance algorithms used, and the most frequently used means for surveillance as well as their evaluation by the users with respect to the effectiveness of these means. Additionally, we perform a review of the literature. Results The final analysis comprised 161 questionnaires (response rate 53.7 %). Mainly high-volume centers (82.5 % with > 300 hospital beds) participated. In 46.6 % of centers, more than 80 % of patients received adjuvant chemotherapy after surgery. Between 60 - 80 % of these patients completed the recommended 6 months of adjuvant treatment, and 47 % of the patients received the whole treatment (surgery, adjuvant therapy) and surveillance in the same center. Upon completion of adjuvant treatment, 96 % of centers survey their patients, and 82 % of these centers already employ diagnostic means during the course of adjuvant chemotherapy. The most commonly used diagnostic means were taking patient history, conducting physical examination, performing laboratory tests including CA19 - 9, and imaging. Of those employed, CA19 - 9 and imaging followed by patient history were considered the most efficient to detect disease relapse by the centers. Half of the institutions perform surveillance for 5 years after surgery. Conclusion This is the first systematic analysis of self-reported surveillance strategies used in Germany after resection of PDAC with curative intent. Surveillance after resection of PDAC with curative intent is common in Germany. Alterations of CA19 - 9 levels as well as imaging and taking patient history are considered the most efficient means to detect relapse of disease by the physicians participating in our survey.
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Berger AW, Schwerdel D, Welz H, Marienfeld R, Schmidt SA, Kleger A, Ettrich TJ, Seufferlein T. Treatment monitoring in metastatic colorectal cancer patients by quantification and KRAS genotyping of circulating cell-free DNA. PLoS One 2017; 12:e0174308. [PMID: 28328955 PMCID: PMC5362218 DOI: 10.1371/journal.pone.0174308] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 03/07/2017] [Indexed: 01/06/2023] Open
Abstract
Treatment of metastatic colorectal cancer (CRC) has continuously improved over the last decade. However, disease monitoring remains underdeveloped and mostly dependent on imaging e.g. RECIST 1.1 criteria. The genetic landscape of individual cancers and subsequently occurring treatment-induced evolution remain neglected in current surveillance strategies. Novel biomarkers demand minimally invasive and repetitive tracking of the cancer mutagenome for therapy stratification and to make prognostic predictions. Carcinoembryonic antigen (CEA), a routinely used tumor marker for CRC, does not meet these goals and thus prevents its use as a reliable monitoring tool. A tumor-derived fraction of circulating cell-free DNA (cfDNA), isolated from blood samples, may bypass the limitations of currently available biomarkers and could be a tool for noninvasive disease monitoring. Here, total cfDNA levels differentiated a cohort of metastatic CRC patients from healthy controls. Furthermore, we correlated cfDNA during chemotherapy of 27 stage IV patients with clinical parameters to establish its prognostic and predictive value. Indeed, cfDNA levels in chemotherapy naive patients correlate with the tumor burden and CEA values at diagnosis and increase upon disease progression during 1st and 2nd line treatment. Moreover, we confirm the possibility of cfDNA-based genotyping of KRAS to early detect the emergence of resistance during chemotherapy. These data indicate that repetitive quantitative and mutational analysis of cfDNA might complement current treatment standards but may have also limited value in some patients.
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Affiliation(s)
- Andreas W. Berger
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Daniel Schwerdel
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Hanna Welz
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Ralf Marienfeld
- Institute of Pathology, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Stefan A. Schmidt
- Department of Diagnostic and Interventional Radiology, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Alexander Kleger
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Thomas J. Ettrich
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, Ulm, Germany
- * E-mail:
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Perkhofer L, Ettrich TJ, Kleger A. S-1: changing the facets of adjuvant chemotherapy in pancreatic cancer? Transl Cancer Res 2016. [DOI: 10.21037/tcr.2016.10.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ettrich TJ, Perkhofer L, von Wichert G, Gress TM, Michl P, Hebart HF, Büchner-Steudel P, Geissler M, Muche R, Danner B, Kächele V, Berger AW, Güthle M, Seufferlein T. DocOx (AIO-PK0106): a phase II trial of docetaxel and oxaliplatin as a second line systemic therapy in patients with advanced pancreatic ductal adenocarcinoma. BMC Cancer 2016; 16:21. [PMID: 26772812 PMCID: PMC4714522 DOI: 10.1186/s12885-016-2052-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/06/2016] [Indexed: 12/18/2022] Open
Abstract
Background The current study was conducted to examine the activity of a docetaxel/oxaliplatin (DocOx) combination as second line treatment for advanced pancreatic ductal adenocarcinoma (Trial registration: NCT00690300. Registered June 2, 2008) Methods DocOx is a prospective, multi-center, single arm, phase II trial using docetaxel (75 mg/m2, 60 min, d 1) and oxaliplatin (80 mg/m2, 120 min, d 2) in 21-day cycles. The treatment period was scheduled for up to 8 cycles. Primary endpoint was tumor response according to RECIST 1.0. Secondary endpoints were progression free survival, overall survival, safety/toxicity, quality of life and clinical benefit. Results Data represent the intention to treat analysis of 44 patients with chemorefractory pancreatic cancer enrolled between 2008 and 2012 at five institutions in Germany. The primary endpoint of tumor response was achieved in 15.9 % of the patients (7 partial remissions, no complete remission), with a disease control rate of 48 % after the first two treatment cycles. Median progression free survival (PFS) was 1.82 months (CI 95 % 1.5–3.96 months) and median overall survival (OS) was 10.1 months (CI 95 % 5.1–14.1 months). Conclusions This single-arm trial demonstrates that the combination of docetaxel and oxaliplatin yields promising results for the treatment of advanced pancreatic ductal adenocarcinoma patients. Selected patients had particular benefit from this treatment as indicated by long PFS and OS times. Even after 8 cycles of treatment with DocOx a partial response was observed in 2 patients and stable disease was observed in another 6 patients. The data obtained with the DocOx protocol compare well with other second line protocols such as OFF (oxaliplatin, 5-FU, leucovorin). The DocOx regimen could be an interesting option for patients who received gemcitabine as first line treatment for metastatic pancreatic cancer. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2052-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Goetz von Wichert
- Department of Internal Medicine, Schön-Klinik Hamburg-Eilbeck, Hamburg, Germany.
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Philipps University of Marburg, Marburg, Germany.
| | - Patrick Michl
- Department of Internal Medicine I, Martin-Luther-University, Halle (Saale), Germany.
| | - Holger F Hebart
- Department of Internal Medicine, Stauferklinikum Schwaebisch-Gmuend, Mutlangen, Germany.
| | - Petra Büchner-Steudel
- Department of Internal Medicine I, Martin-Luther-University, Halle (Saale), Germany.
| | - Michael Geissler
- Department of Internal Medicine, Oncology/Hematology, Gastroenterology, Esslingen Hospital, Esslingen, Germany.
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
| | - Bettina Danner
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
| | | | - Andreas W Berger
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
| | - Melanie Güthle
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
| | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
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Abstract
According to predictions pancreatic ductal adenocarcinoma will be the third most common cancer-related cause of death in 2030 due to its growing incidence and advances in prevention and treatment of other tumor entities. Pancreatic cancer is usually a (too) late diagnosed disease. Already at time of primary diagnosis nearly 80 % of patients have palliative disease due to local irresectability or distant metastases. Even after R0 resection of the primary tumor followed by adjuvant chemotherapy the 5-year overall survival rate does not exceed 20 %. Recently the treatment landscape has significanty changed in metastatic pancreatic cancer. For the first time, we have the opportunity to personalize our therapies in the field of pancreatic cancer. In addition, the range of therapeutic options after failure of first-line treatment expands more and more. After years of stagnation and negative results in clinical trials these advances inspire and dynamize the landscape of new clinical trials in this entity.
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Affiliation(s)
- Thomas J Ettrich
- Zentrum Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm
| | - Lukas Perkhofer
- Zentrum Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm
| | - Thomas Seufferlein
- Zentrum Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm
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Guthoff I, Ettrich TJ, Leithäuser F, Merk J. Pulmonale Spätmetastase eines Gallengangskarzinoms als seltene Differentialdiagnose zum Pleuramesotheliom. Zentralbl Chir 2014. [DOI: 10.1055/s-0034-1389358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related deaths in the Western world. Due to lack of specific symptoms and no accessible precursor lesions, primary diagnosis is commonly delayed, resulting in the identification of only 15-20% of patients with potentially curable disease. The major limiting factor is an already locally advanced or metastatic disease at the time of diagnosis. Consequently, systemic therapy forms the backbone of treatment strategy for the majority of patients. SUMMARY A deeper understanding of the molecular characteristics of pancreatic cancer has led to the identification of several potential therapeutic targets. A variety of targeted therapies are currently under clinical evaluation as single agents or in combination with chemotherapy for PDAC. This review highlights the current state of chemotherapy in pancreatic cancer and provides an outlook on its future perspectives. KEY MESSAGE This review focuses on the current chemotherapy regimens for the systemic treatment of PDAC. PRACTICAL IMPLICATIONS Various neoadjuvant approaches have been explored, including chemoradiation, chemotherapy followed by chemoradiation or intensified chemotherapy without defining a standard of care so far. The standard of care is gemcitabine or 5-fluorouracil. The oral fluoropyrimidine S-1 may be a promising new agent in this setting. For first-line treatment of metastatic pancreatic cancer, no targeted therapy has yet demonstrated clinical benefit apart from the combination of the tyrosine kinase inhibitor erlotinib plus gemcitabine. Recently, novel chemotherapeutic regimens such as FOLFIRINOX and gemcitabine plus nanoparticle albumin-bound paclitaxel have been introduced. Both combinations have proved to be superior to the standard gemcitabine regimen. For second-line treatment the combination of 5-fluorouracil/leucovorin and oxaliplatin yields improved results compared to best supportive care.
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Affiliation(s)
| | | | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
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Abstract
Regorafenib (BAY 73-4506, Stivarga®) is an oral diphenylurea multikinase inhibitor that targets angiogenic (VEGFR1-3, TIE2), stromal (PDGFR-β, FGFR), and oncogenic receptor tyrosine kinases (KIT, RET, and RAF). Regorafenib is the first small-molecule multikinase inhibitor to achieve survival benefits in metastatic colorectal cancer that has progressed after all standard therapies. Consequently, regorafenib was FDA approved for this indication. In addition, regorafenib treatment resulted in a significant improvement in progression-free survival (PFS) compared with placebo in patients with metastatic gastrointestinal stromal tumors (GIST) after progression on standard treatments and is also an FDA approved indication. Currently, regorafenib is examined in several clinical trials (mostly phase II) in different tumor entities, including renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and soft tissue sarcoma (STS).
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany,
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Berger AW, Ettrich TJ, Dollinger MM. [Colon Polypectomy - And Then?]. Zentralbl Chir 2013; 140:426-34. [PMID: 23846540 DOI: 10.1055/s-0032-1328567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Colorectal cancer (CRC) is the most frequent gastrointestinal tumour. Most CRC appear to arise from adenomas of the colon in a period of 10 or 15 years. The ultimately progression of benign adenomas to malignant CRC is known as the adenoma-carcinoma sequence. In addition, the description of the "serrated pathway" has shifted the focus of interest also towards to sessile serrated adenomas and traditional serrated adenomas in the development of CRC. It has been proven that the screening colonoscopy might prevent CRC by early detection of adenomatous polyps as precursors for colorectal cancer and polypectomy. Thus, disease-associated mortality of CRC could be reduced. Colonoscopy, the gold standard in CRC diagnosis, is recommended to men and women from the age of 55. On the one hand, there are requirements to the endoscopists. On the other hand there are also essential requirements to pathologists' findings. After polypectomy a risk stratification for aftercare based on endoscopic and histological findings is necessary. Endoscopic follow-up of high-risk patients (≥ 3 tubular adenomas, ≥ 1 adenoma ≥ 1 cm, tubulovillous or villous adenoma, ≥ 1 adenoma with high-grade intraepithelial neoplasia, ≥ 10 adenoma no matter what size or histological findings) should be done sooner (< 3 years). In contrast, colonoscopy in low-risk patients (1 or 2 [tubular] adenomas, size < 1 cm) should be performed later rather than sooner (> 5 years). Colonoscopic surveys under 12 months should be done only in exceptional and very serious situations. Pharmaceutical chemoprevention of adenomas or CRC are still part of clinical trails. More data are necessary.
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Affiliation(s)
- A W Berger
- Zentrum für Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Deutschland
| | - T J Ettrich
- Zentrum für Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Deutschland
| | - M M Dollinger
- Zentrum für Innere Medizin, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Deutschland
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Lübbert C, Wilhelms D, Worlitzsch D, Ettrich TJ, Behl S, Seufferlein T. [Antibiotic treatment of enterococcal infections in gastroenterology with daptomycin - first experiences from the EU-CORE registry study (European Cubicin® Outcomes Registry and Experience)]. Z Gastroenterol 2012; 50:373-81. [PMID: 22430297 DOI: 10.1055/s-0031-1282031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Enterococci are a frequent cause of nosocomial infections in gastroenterology. The increase of Enterococcus faecium infections with development of resistance to gentamicin and vancomycin as well as possible linezolid resistance require alternative antibiotic therapies. Study data show that daptomycin, a highly bactericidal antibiotic is effective in enterococcal infections. However, in Germany daptomycin is so far only approved for the treatment of complicated skin and soft tissue infections, bacteremia and infective endocarditis caused by Staphylococcus aureus. In the Department of Internal Medicine I, University Hospital Halle (Saale) from May 2 009 to April 2 010 all gastroenterological patients with evidence of invasive enterococcal infection received intravenous daptomycin treatment at inclusion in the European Cubicin® Outcomes Registry and Experience (EU-CORE). Gastroenterological diseases treated were necrotising pancreatitis, infected pancreatic pseudocysts, abscesses, obstructive cholangitis and sepsis. The clinical outcome was retrospectively detected by protocol-defined criteria. A total of 13 patients (8 male, 5 female, median age 59 years) with microbiologically assured enterococcal infections (10 × E. faecium, including 1 × VRE, 6 × E. faecalis, including double infections) were treated with intravenous daptomycin (6 mg per kg body weight). In the presence of polymicrobial infections (10 of 13 patients), an additional anti-infective therapy was initiated according to sensitivity testing. Concomitantly a direct focus approach with stenting, puncture or drainage was performed. The clinical cure rate was 92 % (12 of 13 patients). One patient died from a non-surgically uncontrollable malignancy (Klatskin tumour Bismuth IIIb). There were no adverse events. These results allow us to conclude that antibiotic therapy with daptomycin in invasive or bacteraemic enterococcal infections leads to high cure rates (up to 90 % and more) when concomitant and adequate focus relief is performed. Larger clinical studies to obtain an extended drug approval are desirable.
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Affiliation(s)
- C Lübbert
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Halle.
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