Special populations in metastatic renal cell carcinoma

PURPOSE OF REVIEW

This review focuses on special populations poorly represented in current evidence-based practice for metastatic renal cell carcinoma (mRCC). This includes the elderly and frail, patients on immunosuppression or with autoimmune diseases, patients with brain, liver, and/or bone metastases, and RCC with sarcomatoid features.

RECENT FINDINGS

Certain populations are poorly represented in current trials for mRCC. Patients with central nervous system (CNS) metastases are often excluded from first-line therapy trials. Modern doublet systemic therapy appears to benefit patients with bone or liver metastases, but data supporting this conclusion is not robust. Post-hoc analyses on patients with sarcomatoid differentiation have shown improved response to modern doublet therapy over historical treatments. The elderly are underrepresented in current clinical trials, and most trials exclude all but high-performing (nonfrail) patients, though true frailty is likely poorly captured using the current widely adopted indices. It is difficult to make conclusions about the efficacy of modern therapy in these populations from subgroup analyses. Data from trials on other malignancies in patients with autoimmune diseases or solid organ transplant recipients on immunosuppression suggest that immune checkpoint inhibitors (ICIs) may still have benefit, though at the risk of disease flare or organ rejection. The efficacy of ICIs has not been demonstrated specifically for RCC in this group of patients.

SUMMARY

The elderly, frail, and immunosuppressed, those with tumors having aggressive histologic features, and patients with brain, bone, and/or liver metastases represent the populations least understood in the modern era of RCC treatment.

Advances in non-clear cell renal cell carcinoma management: From heterogeneous biology to treatment options

Non-clear cell renal cell carcinoma (nccRCC) makes up nearly one quarter of all RCC subtypes, commonly impacts younger patients, and is often metastatic at presentation. Compared to clear-cell RCC (ccRCC), nccRCC typically has a worse prognosis in the metastatic setting, with overall survival durations that are ~10 months shorter. The nccRCC consists of a wide range of different histological subtypes, the majority of which are composed of papillary, chromophobe, renal medullary carcinoma, translocation RCC, collecting duct carcinoma and unclassified RCC. Most clinical trials have either excluded or only included small numbers of patients with nccRCC; owing to the lack of prospective studies focusing on this population, data on response rates and survival outcomes are lacking. NccRCC treatment is a nascent field with various therapeutic modalities and combinations under investigation, often based on data extrapolated from therapeutic studies in ccRCC. We herein review the use and outcomes of cytotoxic chemotherapy, various combination modalities of tyrosine kinase inhibitors and immune checkpoint inhibitors, and targeted agents. We discuss active ongoing clinical trials for patients with nccRCC and future directions in the treatment of this rare disease. Historically, treatment for nccRCC has been adopted from the standard of care for patients with ccRCC, although these treatments are less effective in the nccRCC population. As we begin to understand the underlying biology of these tumors, clinical trials have been able to slowly accrue and include more patients with various subtypes of nccRCC. There remains much room for improvement in this area of need, but there is hope on the horizon.

The Prognostic and Functional Impact of Sprouty 2 Expression in Non-small Cell Lung Cancer

OBJECTIVE

We represent Sprouty 2 (Spry2) expression analysis and its association with key driver mutations and clinical features of patients with non-small cell lung cancer as the largest ex vivo data.

METHODS

The strength of Spry2 expression was evaluated using the immunoreactivity score (IRS), which was calculated using the following formula: IRS=(staining intensity score) SI×(percentage of positively stained cells) PP. The median IRS score was defined as the cutoff value. Patients were grouped as "weak immunoreactivity score" (IRS: 0 to 4) or "strong immunoreactivity score" (IRS: ≥4) with respect to the IRS score.

RESULTS

The intensity and percentage of Spry2 staining were significantly lower in tumor tissues than in normal lung tissues ( P <0.0001). Patients' characteristics were similar for both groups, except for smoking status and, brain and lymph node metastasis. Overall survival of patients with a strong immunoreactivity score was significantly lower than those with a weak immunoreactivity score among metastatic patients (6.9 mo vs. 13.6, P =0.023) and adenocarcinoma histology (7.0 mo vs. not reached, P =0.003).

CONCLUSION

Spry2 expression was lower in tumor tissues than in normal lung parenchyma. Increased expression of Spry2 is associated with poor prognosis. There were no significant associations between epidermal growth factor receptor, anaplastic lymphoma kinase, or c-ros oncogene 1 rearrangement and Spry2 expression. Despite the absence of KRAS mutational analysis, the clinical and epidemiological features of patients suggested that KRAS mutation might be an underlying determinant factor of the functional role of Spry2 in non-small cell lung cancer.

Treatment Outcomes and Prognostic Factors in N3 Stage Gastric Cancer After Curative Resection: A Real World Data

Purpose

N3 gastric cancer is characterized by a fairly high lymph node metastasis burden and poor outcome despite optimal therapy. Given the limitations of TNM classification, a comprehensive evaluation tool is necessary to predict the prognosis of patients with N3 gastric cancer who underwent curative surgery. This study aims to explore the outcomes and clinicopathologic prognostic factors affecting the overall survival (OS) of patients with N3 gastric cancer after surgery.

Methods

Data on patients with N3 gastric cancer who underwent (sub)total gastrectomy and regional lymph node dissection between November 2005 and September 2018 (n = 169) were analyzed by Cox regression to determine the independent prognostic factors for OS.

Results

The multivariable analysis established that gender, patient performance status, metastatic lymph node ratio (MLNR), tumor grade, and adjuvant chemotherapy are significantly associated with OS. The five-year OS of the study population was 15%. Adjuvant chemoradiotherapy was applied to 72% of the patients, which resulted in an improvement in recurrence-free survival but not OS. Recurrence occurred in 103 (75%) patients, in which the most frequent recurrence site was distant metastasis.

Conclusion

Male gender, poor performance status, grade 3 tumor, MLNR > 0.37, and not receiving adjuvant chemotherapy are predictors of poor prognosis in N3 gastric cancer after curative resection. Considering the high recurrence rates of this group, prospective studies are needed to optimize treatment strategies.

The effectiveness of adjuvant treatment approaches for resectable esophageal cancer: A single-center experience

AIMS AND BACKGROUND

In general, neoadjuvant treatment is the standard for clinical stage II/III esophageal cancer (EC), whereas the effect of adjuvant treatment on survival still remains controversial. The aim of this study was to investigate the efficacy of adjuvant treatment modalities on the survival of EC patients.

PATIENTS AND METHODS

A total of 63 patients with stage II-IVA EC who had undergone curative surgery between the years 2002 and 2020 were included in the study. Patients' data were retrospectively collected from oncologic follow-up files. Various treatment regimens were administered during this period, including chemotherapy and chemoradiotherapy.

RESULTS

The median age was 56 years (24-73), and the number of males was slightly higher than females (male/female: 33/30). While 32 (51%) patients received postoperative adjuvant treatment, the remaining 31 (49%) patients underwent surgery alone. The median overall survival (OS) was 45.9 months (95% confidence interval [CI]: 25.1-66.8) in patients receiving adjuvant therapy and 37.6 months (95% CI: 20.9-54.4) in patients not receiving adjuvant therapy. The 8.3-month survival difference was statistically insignificant (P = 0.54). The 1-, 3-, and 5-year OS rates were 87.5% versus 77.4%, 58.4% versus 51.6%, and 40.8% versus 27.6% for patients with and without adjuvant therapy, respectively. Pathological stage (P = 0.028) and lymph node status (P = 0.044) were significant prognostic factors for survival.

CONCLUSIONS

This study did not support the benefit of adjuvant treatment compared with surgery alone in completely resected EC patients. The reason for this result may be related to the small sample size and different treatment regimens due to the change in treatment options over time.

Simple and easily accessible prognostic markers in ewing sarcoma; neutrophil-lymphocyte ratio, neutrophil-platelet score and systemic-inflammation index

Background

Inflammation markers are the new point of view in cancer due to increasing data on the interaction of immune system with tumor cells and their prognostic and predictive importance were found in many different types of solid tumors. Therefore, we aimed to evaluate the prognostic value of neutrophil-lymphocyte ratio (NLR), neutrophil-platelet score (NPS), and systemic inflammation index (SII) in Ewing sarcoma patients in which risk groups are still not clearly defined.

Methods and Results

A total of 64 patients were evaluated retrospectively. Receiver operating characteristic analysis was performed to find cut-off values for NLR and SII. Survival analysis was calculated by using Kaplan-Meier method. Cox regression analysis was performed to determine prognostic factors such as age, stage, and neoadjuvant chemotherapy were statistically significant prognostic factors for OS in multivariate analysis. While patients with low NLR and SII had longer OS (P = 0.003 and P = 0.018), patients with high NPS score had shorter OS (67.7 vs 21.7 months, P = 0.001).

Conclusion

Patients with lower NLR, NPS, and SII score have a better prognosis compared with those with higher NLR, NPS, and SII score and these simple parameters may be monitoring tools of the tumor microenvironment.

The prognostic value of Sprouty2 protein in nonsmall cell lung cancer

e20524

Background: We represent Sprouty 2 (Sprty2) protein expression analysis and its association with key pathological and clinical features of pts with NSCLC as the largest ex-vivo data series. Methods: All IHC stainings were performed using a fully automated IHC staining device (Ventana BenchMark XT, Ventana Medical Systems, Tucson, AZ). Sprouty2 (Clone: AB_2720609, Cat. Number: PA5-7688; Dilution:1/100, ThermoFisher-Invitrogen) primer antibodies were used in IHC examination. Lung alveolar epithelium and bronchial mucosa were used as positive controls. Staining intensity [0 (no reaction), 1+ (weak reaction), 2+ (moderate reaction), 3+ (strong reaction)] and percentage of positively (PP) stained cells [0 (0%), 1 (< 10%), 2 (11-50%), 3 (51-90%), 4 (> 90%)] were analyzed together to calculate immunreactivity score (IRS) values ranging from 0 to 12. Results: 41 pts' sample were analyzed in this study. Sprty2 staining intensity and percentage were statistically significantly lower in tumor tissue (p < 0.0001). The number of pts with positive Sprty2 expression was 17 (42%) and negative was 24 (58%). The ratio of smoking status, brain and lypmh node metastasis were higher in Sprty2 positive group (Table). OS for patients with Sprty2 positive was lower than those with Sprty2 negative in metastatic patients (6.9 mo vs 13.6 mo, p = 0.023). Sprty2 positive pts had inferior survival compared to Sprty2 negative pts among those with AC histology (7.0 mo vs NR, p = 0.003). Conclusions: Sprty2 expression was decreased in tumor tissue compared to normal lung parenchyma. Paradoxically, Sprty2 positive patients had lower survival in certain subgroups (metastatic disease, AC) compared to those with negative pts. Sprty2 protein may be a new target especially for pts without druggable targets. [Table: see text]

Predictive and prognostic effect of ABO blood group on immune checkpoint inhibitors

BACKGROUND

The relationship of the ABO blood group system with the immune response is known, but its relationship with immune checkpoint inhibitors (ICIs) has not been clearly investigated until now.

OBJECTIVE

In this study, the relationship between different blood groups and nivolumab treatment response in patients with advanced malignant melanoma was investigated.

METHODS

The data of patients who used nivolumab for advanced malignant melanoma between April 2018 and April 2021 were retrospectively reviewed.

RESULTS

A total of 73 patients were included in the study. In the progression-free survival (PFS) analysis according to blood groups, it was 3.9 months, 16.1 months, 20.0 months and 3.0 months for A, B, AB and O, respectively (p= 0.1). Overall survival (OS) analysis according to blood groups was 5.1 months, 25.0 months, 20.0 months and 9.3 months for A, B, AB and O, respectively (p= 0.1). The B antigen group (B or AB) had significantly longer PFS and OS than the non-B antigen group (A or O) (16.1 vs. 3.5 months for PFS, respectively, p= 0.03; 20.0 vs. 7.4 months for OS, respectively, p= 0.02).

CONCLUSIONS

The presence of B antigen provides a significant advantage in terms of survival in patients using ICIs for advanced melanoma.

A Comparison of Osseous and Extraosseous Ewing Sarcoma

OBJECTIVE

To compare the clinicopathological characteristics, treatment responses, survival analysis of osseous Ewing sarcoma (OES) and extraosseous ES (EES).

STUDY DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Ankara City Hospital and Ankara Numune Training Research Hospital Medical Oncology Clinics from January 2005 to February 2020.

METHODOLOGY

Clinicopathological characteristics of histologically confirmed ES/PNET and followed up, and treatment modalities were recorded from patients' registration data-base of the hospital. Lactate dehydrogenase (LDH), alkaline phosphatase (ALP), hemoglobin were measured before chemotherapy or surgery. The patients with a second cancer, gall bladder/biliary tract diseases, viral hepatitis and other bone diseases were excluded.

RESULTS

Sixty seven patients evaluated retrospectively. Out of the total patients, 56.7% consisted of OES, and 43.3% consisted of EES. The median age of the EES group (26 years) was significantly higher than that of the OES group (22 years, p = 0.008). The most common metastasis region was lung in both the groups. Age, LDH levels and stage of the disease were found to be statistically significant prognostic factors in univariate and multivariate analysis. The median OS of patients who started with local treatment (surgical, surgical ± radiotherapy) and followed up with chemotherapy was 82.6 months (95% CI, 55.2-110.1), while the median OS of patients who received local treatment between or after chemotherapy was 43.4 months (95% CI, 13.2-73.6, p = 0.042).

CONCLUSION

Patients with extrosseus ES were significantly older. Age, LDH levels, stage of disease, local treatment followed by systemic therapy are important associated factors. Key Words: Osseous ewing sarcoma, Extraosseous ewing sarcoma, Chemotherapy, Local treatment.

The Comparison of mDCF and mFOLFOX-6 as First-Line Treatment in Metastatic Gastric Cancer

Introduction: Fluoropyrimidine and platinum-based chemotherapy regimens are widely accepted for metastatic gastric cancer (GC). Because of drug toxicity, a combined two-drug cytotoxic drug regimen is recommended for first-line therapy, while three-drug cytotoxic regimens are recommended for patients with medically fit and better performance status. In this study, it was aimed to compare modified FOLFOX-6 (mFOLFOX-6) and modified DCF (mDCF) regimens in terms of survival and side effects in first-line treatment in metastatic GC.

Methods: We retrospectively reviewed the clinical record of patients with metastatic gastric or gastro-esophageal junction cancer who had received mDCF or mFOLFOX-6 as the first-line treatment, and followed up in our center between February 2013 and December 2020. The data were collected from the patients' registration database of the hospital and oncologic follow-up files of our center. In the mDCF arm, docetaxel 60 mg/m² and cisplatin 60 mg/m² on day 1 intravenous (i.v.) infusion, and 600 mg/m² 5-fluorouracil (FU) as a continuous infusion for five days were administrated every three weeks for up to six cycles. In the mFOLFOX-6 arm, 85 mg/m² oxaliplatin and 400 mg/m² LV as an i.v. infusion over two hours and a 5-FU bolus of 400 mg/m² as a 10-minute infusion, followed by 2.400 mg/m² 5-FU as a 46-hour continuous infusion were administrated every two weeks for up to six cycles. Univariate and multivariate analyses for overall survival (OS) were performed by Cox proportional hazards regression model. Survival analysis was performed by the Kaplan-Meier method with the Long-rank test. P-value <0.05 was considered statistically significant.

Results: A total of 70 patients included into the study. Of those, 40 (57%) patients had received mDCF and 30 (43%) had received FOLFOX-6 regimens as first-line treatment. There were no complete responses in both groups. The partial response rate was 28% and 27% for mDCF and mFOLFOX-6, respectively. There was no statistically significant difference regarding treatment response for both groups (p=0.787). The median OS was 13.9 months (95% CI: 7.5-20.4) in the mDCF arm, and 10.4 months (95% CI: 6.4-14.4) in the mFOLFOX-6 arm (p=0.409). The median progression-free survival (PFS) was 5.2 months (95% CI: 3.6-6.9) in the mDCF arm, and 6.4 months (3.2-9.6) in the FOLFOX-6 arm (p=0.126). The ratio of dose reduction, treatment delay, and neutropenic fever were not statistically different between treatment arms.

Conclusion: The present study demonstrated that proper patient selection for metastatic GC may give rise to comparable survival rates without increased toxicity. mFOLFOX-6 and mDCF had similar response rates, OS, PFS, and side effect profiles.

Is there any clinical or laboratory predictive factor for cetuximab-induced skin toxicity?

BACKGROUND: We aim to explore the predictive role of clinical and hematological parameters for cetuximab-induced skin toxicity (CI-ST) and survival outcomes in patients according to risk categories.RESEARCH DESIGN AND METHODS: The optimal cut-off values for hematological parameters were assessed by the Receiver Operating Characteristic (ROC) analysis. Patients were classified as High risk, Intermediate risk and Low risk subgroups with respect to platelet to lymphocyte ratio (PLR) and red blood cell count (RBC) values. Kaplan-Meier test was used for survival analysis, and outcomes were analyzed by Log-rank test. P-value <0.05 considered as statistically significant.RESULTS: Among hematological parameters, only PLR and RBC were statistically significant prognostic factors.Optimal cut-off value for PLR was 196.2 (82.9% sensitivity and 61.1% specificity), and 4.610x106/µL for RBC count (65.9% sensitivity and 81.1% specificity). Patients in high risk group had increased risk with an OR:69.34 (p<0.0001), and in the intermediate risk group had an OR:28.73 (p=0.002) for CI-ST. De novo metastatic patients had 9.11-fold increased risk for CI-ST compared to recurrent metastatic patients (p=0.028).CONCLUSION: Our study indicates that risk categories based on PLR and RBC can predict CI-ST and de novo metastatic patients had higher risk for CI-ST.

"Swords and Shields" against COVID-19 for patients with cancer at "clean" and "pandemic" hospitals: are we ready for the second wave?

Purpose

COVID-19 will continue to disrupt the diagnosis-treatment process of cancer patients. Dr. Abdurrahman Yurtaslan Ankara Oncology Hospital has been considered as a ‘non-pandemic’ center (‘clean’) in Ankara, the capital city of Turkey. The other state hospitals that also take care of cancer patients in Ankara were defined as ‘pandemic’ centers. This study aimed to evaluate hospital admission changes and the precautionary measures in clean and pandemic centers during the pandemic. The effect of these measures and changes on COVID-19 spreading among cancer patients was also evaluated.

Methods

The patients admitted to the medical oncology follow-up, new diagnosis, or chemotherapy (CT) outpatient clinics during the first quarter of pandemic period (March 15–June 1, 2020) of each center were determined and compared with the admissions of the same frame of previous year (March 15–June 1, 2019). COVID-19 PCR test results in clean and pandemic centers were compared with each other. Telemedicine was preffered in the clean hospital to keep on follow-up of the cancer patients as ‘noninfected’.

Results

In the clean hospital, COVID-19-infected patients that needed to be hospitalized were referred to pandemic hospitals. COVID-19 test positivity rate was eight-fold higher for outpatient clinic admissions in pandemic hospitals (p < 0.001). The number of patients admitted new diagnosis outpatient clinics in both clean and pandemic hospitals decreased significantly during the pandemic compared with the previous year.

Conclusion

We consider that local strategic modifications and defining ‘clean’ hospital model during infectious pandemic may contribute to protect and treat cancer patients during pandemic.

Systemic treatment options for growing teratoma syndrome: A single-center experience with a comprehensive review of the literature

Background

Growing teratoma syndrome (GTS) is a very uncommon phenomena. Given its lower prevalence, there is little data about clinichopathological features and management of GTS. Literature about disease mostly composed of case reports. In this study, we aimed to report patients characteristics and treatment modalities in our center within a relatively large cohort.

Patients and Methods

We retrospectively reviewed the clinical records 21 patients who fulfilled criteria of GTS. Survival analysis was performed by using the Kaplan-Meier method with the Long-rank test. p<0.05 was considered statistically significant.

Results

The median age at diagnosis was 25 (range 17-51). A total of 12 patients could have undergone surgery. Of patients who underwent surgery, 5 patients remained fully disease free, and 7 patients had experienced disease recurrences. Nine patients had unresectable disease, and treated with either platin-based chemotherapy or interferone α2b. Of those, 5 patients eventually had undergone autologous stem cell transplantation (ASCT) with surprisingly promising response rates. One patient had complete response and three patients had partial response. One patient died soon after ASCT due to infectious complication.

Conclusion

GTS is an unique entity with regard to its clinicopathological features and available treatment options as we mentioned in the text. Despite various agents reported to have efficacy in case reports, surgery remains as the mainstay of treatment. According to result of our study, ASCT and platin-based chemotherapy regimens may be feasible options for patients with unresectable disease.

Albumin-to-Alkaline Phosphatase Ratio: Does It Predict Survival in Grade 1 and Grade 2 Neuroendocrine Tumors?

OBJECTIVES

Neuroendocrine tumors (NETs) are very heterogeneous tumors. This study aimed to evaluate prognostic value of an albumin-to-alkaline phosphatase (ALP) ratio (AAPR) in well-differentiated NETs.

METHODS

A total of 110 patients were included in this study. Albumin-to-alkaline phosphatase ratio was calculated by dividing albumin concentration (g/dL) to ALP level (U/L). Cutoff value for AAPR was determined by receiver operating characteristic analysis. Survival analysis was performed by Kaplan-Meier method with the log-rank test. A P value of less than 0.05 was considered statistically significant.

RESULTS

The optimum cutoff value for AAPR was 0.028. Patients were divided into 2 groups as patients with AAPR of 0.028 or less (n = 22, 20%) and with AAPR of greater than 0.028 (n = 88, 80%). Patients with AAPR of greater than 0.028 had statistically longer overall survival compared with patients with 0.028 or less (not reached vs 96.8 months, P = 0.001). In addition, AAPR has been shown to be an independent prognostic factor for overall survival in multivariate analysis (hazard ratio, 3.99; 95% confidence interval, 1.26-12.61, P = 0.018).

CONCLUSIONS

Patients with higher AAPR had more favorable prognosis compared with patients with lower AAPR. We demonstrated that AAPR can be of prognostic value in well-differentiated NETs.

Prognostic and Predictive Value of NAR Score in Gastric Cancer

INTRODUCTION

Neoadjuvant treatment is a widely accepted approach for locally advanced rectum cancer. Efforts to explore a surrogate endpoint for clinical trials revealed a new prognostic scoring system which is named as neoadjuvant rectal score (NAR) in patients who received neoadjuvant treatment for rectal cancer.

MATERIAL AND METHODS

88 patients who met inclusion criteria were included in the study. The optimal cutoff value of the NAR score was 17.6 with 71% sensitivity and 63% specificity. Patients with NAR score > 17.6 (n: 48, 54%) were defined as the high-risk group and those with NAR score ≤ 17.6 (n: 40, 56%) as the low-risk group.

RESULT

Survival analysis according to the NAR score group (low-risk vs high-risk) revealed that there was a statistically significant difference between groups regarding OS and DFS. The median OS for high-risk patients was 27.3 months (95% CI, 15.0-39.6); it was 76.6 months (47.3-106.0) for low-risk patients (p < 0.0001). The median DFS was 15.1 months (11.8-18.4) for high-risk patients; it was 44.3 months (95% CI, 4.1-84.6) in the low-risk group (p = 0.002).

DISCUSSION

As a result, we interpreted our findings as supporting data about the utility of NAR score not only as a surrogate endpoint for the clinical trial of rectal cancer but also as a prognostic marker in patients with gastric cancer who received neoadjuvant treatment.

Prognostic and predictive value of KRAS mutation number in metastatic colorectal cancer

Colorectal cancer (CRC) is the third most common cancer in the world and is the second leading cause of cancer-related deaths. Several mutations are involved in the development of CRC. The prognostic significance of the KRAS mutation has been discussed in many studies. We aimed to investigate the prognostic significance of the number of KRAS mutations in metastatic CRC (mCRC).Patients with mutations in the KRAS gene were included in the study. They were divided into 2 groups as single mutation and multiple mutations in the KRAS gene.For the study, 425 CRC patients were screened. KRAS mutation was positive in 191 patients (45%). One hundred ninety-one patients were included in the study, 171 patients (90%) had single mutations and 20 patients (10%) had multiple mutations. Median progression-free survival was 12.8 months in patients with multiple mutations, while it was 8.8 months in patients with single mutations (P: .05). The median overall survival of patients with multiple mutations was 40.7 months, while it was 22.7 months for patients with single mutations (P = .01)We found that the presence of multiple mutations in KRAS mutant patients was associated with better overall survival and progression-free survival than a single mutation.

Sunitinib or Pazopanib: Is There Any Difference Between Tyrosine Kinase Inhibitors in the Pre-Nivolumab Setting in Metastatic Renal Cell Carcinoma?

Introduction

Treatment options for metastatic renal cell carcinoma disease have been improved in recent years. However, there is still no optimal treatment sequence or combination for metastatic disease. We aimed to investigate whether patients differed in terms of disease outcomes regarding pre-nivolumab tyrosine kinase inhibitors (TKIs).

Material and methods

The analysis of patients was performed after all cohorts were sub-grouped into two groups according to pre-nivolumab TKIs as following the sunitinib arm and the pazopanib arm.

Result

A total of 75 patients were included in this study. The median follow-up time was eight months for all cohorts. The objective response rate was statistically significantly higher in the pazopanib arm as compared to the sunitinib arm (56% vs 30%, p=0.02). Progression-free survival was significantly higher in pazopanib than sunitinib (10.3 months vs 5.3 months, p=0.02). Multivariate analysis revealed that pazopanib treatment was associated with better progression-free survival (HR: 0.44, 95 CI; 0.22-0.91, p=0.02). While the median overall survival for patients who had received sunitinib was 11.0 months, it has not been reached the median in the pazopanib arm (11.0 months vs NR, p=0.051).

Discussion

We demonstrated significantly better progression-free survival and a higher objective response rate with nivolumab treatment in patients who had received pazopanib as compared with patients who received sunitinib in the pre-nivolumab period.

Is there any correlation among MKK4 (mitogen-activated protein kinase kinase 4) expression, clinicopathological features, and KRAS/NRAS mutation in colorectal cancer

BACKGROUND

We aimed to evaluate the correlation between MKK4 expression and clinicopathological features, KRAS/NRAS mutation in colorectal cancer.

METHODS

MKK4 expression was assessed by immunoreactivity score (IRS). Staining intensity(SI) and percentage of positively stained cells (PP) were used for IRS (IRS = SI×PP). Cutoffs were explored with ROC analysis. Patients were grouped as WIR ('weak immunoreactive'; IRS:0-2) and SIR ('strong immunoreactive'; IRS: >3).

RESULTS

We enrolled 95 patients. 63.2% had metastasis. Median follow-up was 31.4 months. KRAS/NRAS mutation rate was 45.2%. Median values for OS, DFS, and PFS were as 31.6, 17.2, and 10.3 months. WIR group had longer OS (p = 0.03). Recurrence rate was 36.8%. Median DFS was longer for recurrent patients in WIR group (p = 0.055). KRAS or NRAS wild-type patients and those with left-sided tumors in WIR group had longer OS (p = 0.029, p = 0.024, p = 0.03). There was no PFS difference (p: 0.15). In correlation analysis, there was a negative correlation between MKK4 expression and KRAS mutation, NRAS mutation, OS, PFS, DFS (r: -0,06; r: -0,02; r: -0,10; r: -0,06; r: -0,34). Only the correlation for MKK4 expression and DFS was significant (p = 0.04).

CONCLUSION

MKK4 expression inversely correlates with survival outcomes. Patients with KRAS/NRAS wild-type, left-sided tumors with WIR had longer OS.

The prognostic value of the prognostic nutritional index in patients with metastatic colorectal cancer

OBJECTIVE

The prognostic nutritional index (PNI) has been shown to be prognostic value for many types of cancer of the gastrointestinal system. However, there are limited data on its value for metastatic colorectal cancer (mCRC). This study aimed to evaluate the prognostic value of PNI in newly diagnosed mCRC patients.

METHODS

The data of 468 patients who had been admitted to our center upon being diagnosed with mCRC between January 2010 and December 2017 were reviewed retrospectively, whereby satisfying the inclusion criteria were included in the study. Receiver operating characteristic (ROC) analysis was used for PNI's optimum cut-off value for overall survival (OS). The Cox regression model was used in the single-variable analysis in order to test whether or not variables with prognostic properties were independent prognostic factors.

FINDINGS

A total of 308 patients were included in the study. Sixty-two percent (n = 192) of the patients were males, and the median age was 57.5 years (range: 25-83). Forty-five percent (n = 137) of the patients had KRAS mutation. Tumors localized in the colon accounted for 63% (n = 193) of the patients. The liver was the most common region of metastasis at 69%. According to the ROC curve, the optimal cut-off value for PNI was 46 (sensitivity 74%, specificity 47%, AUC 0.615, 95% confidence interval [CI]: 0.54-0.68, P = .002). One hundred and eighty-two patients (59%) fell into the PNI-High (> 46) group, while 126 patients (41%) fell into the PNI-Low (≤ 46) group. The rectum localization was higher, whereas the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were lower in the PNI-High group. There was no difference in terms of other patient characteristics. The median OS was significantly longer in the PNI-High group compared to the PNI-Low group (28.4 vs 19.1 months, P < .001). The Cox regression analysis showed that a high PNI was an independent positive prognostic factor (hazard ratio: 0.61, 95% CI: 0.42-0.87, P = .007).

DISCUSSION

We found PNI to be an independent prognostic factor in mCRC. We think that PNI, which can be calculated by a simple formula, may provide clinicians important clues in order to make desicion for individual treatment.

Does primary tumor resection contribute to overall survival in unresectable synchronous metastatic colorectal cancer?

BACKGROUND

Primary tumor resection (PTR) in metastatic colorectal cancer (mCRC) has not been suggested by guidelines, since new systemic chemotherapy options have improved overall survival. However, the effect of PTR is still controversial in mCRC. In this study, we aimed to evaluate the effect of PTR on survival in unresectable mCRC.

MATERIALS AND METHODS

Two hundred and fifty-two patients with unresectable mCRC were screened retrospectively between January 2007 and December 2017 and a total of 147 patients who met inclusion criteria were included. The patients with emergency or elective PTR and the patients without surgery were compared for baseline features and overall survival.

RESULTS

The median follow-up time was 15.6 months (range; 1.2-78.9) in whole patients. There were 91 patients in nonsurgical (NS) group and 56 patients in PTR group. The median overall survival was significantly longer in PTR group compared NS group (21.8 vs. 17.0 months, P = 0.01), but it was not associated to better overall survival in multivariate Cox analysis (hazard ratio: 0.65, 95% confidence interval: 0.41-1.02, P = 0.06). There was no significant difference in overall survival between emergency and elective surgery subgroups (22.9 vs. 16.1 months, respectively, P = 0.9).

CONCLUSION

PTR did not offer an overall survival benefit in this study. Although it is debated, we think that it is better to start treatment with chemotherapy and biological agent combinations in patients with asymptomatic mCRC. Thus, the patients can be protected from the morbidity and mortality of the surgery.

KRAS codon 12 and 13 mutations may guide the selection of irinotecan or oxaliplatin in first-line treatment of metastatic colorectal cancer

Background: In this study, we aimed to investigate the frequency, prognostic effect of codon, and amino acid-specific KRAS mutations in patients with metastatic colorectal cancer (mCRC) and their predictive effect on irinotecan and oxaliplatin during first-line treatment.Methods: The data of 304 mCRC patients were retrospectively evaluated between 2010 and 2018. Patients were categorized according to the most prominent codon and amino acid mutation and their prognostic features were analyzed.Results: In total, 274 patients were included in the study and 128 patients (47%) revealed KRAS mutation. Median follow-up time was 19.8 months (range; 1.6-96). The median overall survival rates for patients with codons 12 and 13 mutations were 25.4 and 22.2 months, respectively (p = 0.4). Moreover, the median overall survival for the codon 12 mutant patients who received irinotecan-based chemotherapy in the first-line treatment was 42.7 months, whereas for the codon 13 mutant and KRAS wild-type patients, it was 18.3 and 23.9 months, respectively (codon 12 vs. codon 13; HR: 0.31, p = 0.03, codon 12 vs. wild-type; HR: 0.45, p = 0.03).Conclusion: The significant survival advantage was observed in patients with codon 12 mutations who received irinotecan-based chemotherapy as a first-line treatment.