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Carthon BC, Kim SE, McDermott DF, Dutcher JP, Puligandla M, Manola J, Pins M, Carducci MA, Plimack ER, Appleman LJ, MacVicar GR, Kohli M, Kuzel TM, DiPaola RS, Haas NB. Results From a Randomized Phase II Trial of Sunitinib and Gemcitabine or Sunitinib in Advanced Renal Cell Carcinoma with Sarcomatoid Features: ECOG-ACRIN E1808. Clin Genitourin Cancer 2023; 21:546-554. [PMID: 37455214 PMCID: PMC10543556 DOI: 10.1016/j.clgc.2023.06.012] [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] [Received: 06/07/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Sarcomatoid renal cancer (sRCC) patients have poor outcomes. EA1808 evaluated sunitinib and gemcitabine (SG) and sunitinib alone (S) in sRCC in a randomized cooperative group phase II trial (NCT01164228). PATIENTS AND METHODS Pts were aggregated 1:1 to SG (45 pts) or S (40 pts) using a 2-stage design. sRCC pts with ≤ 1 prior nonvascular endothelial growth factor tyrosine kinase inhibitor were stratified into prognostic groups: good (clear cell, < 20% sarcomatoid, PS 0), intermediate (20%-50% sarcomatoid, PS 0), and poor (nonclear cell or > 50% sarcomatoid or PS 1). The primary endpoint was response rate (RR). For SG, the null RR was 15% and a 30% RR was of interest. For S, a 20% RR was of interest vs. a 5% null rate. Secondary endpoints were progression-free survival, overall survival, and safety. RESULTS Both arms met protocol criteria for stage 2 of accrual. A total of 47 pts were randomized to SG and 40 to S. The SG arm had 9 of 45 evaluable patient responses (RR of 20%; CI = [13%-31%]) not meeting the predetermined threshold for success. The sunitinib arm met its endpoint with 6/37 (RR of 16%; CI = [9%-27%]) evaluable responses. Grade ≥ 3 events were experienced by 36 in the SG arm and 17 in the sunitinib arm CONCLUSIONS: EA1808 was the largest and first randomized cytotoxic trial for sarcomatoid RCC. Sunitinib alone but not the SG met the preset threshold of success. Cytotoxic chemotherapy is only useful in limited clinical scenarios for sRCC.
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Affiliation(s)
- Bradley C Carthon
- Department of Medicine, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Se Eun Kim
- Department of Statistics, Dana-Farber Cancer Institute, Boston, MA
| | - David F McDermott
- Division of Hematology/Oncology; Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | - Judith Manola
- Department of Statistics, Dana-Farber Cancer Institute, Boston, MA
| | - Michael Pins
- Department of Pathology; Advocate Lutheran General Hospital, Park Ridge, IL
| | - Michael A Carducci
- Division of Hematology /Oncology; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | - Leonard J Appleman
- Department of Medicine; University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Manish Kohli
- Department of Medicine; University of Utah, Salt Lake City, UT; Department of Medicine; Mayo Clinic, Rochester, MN
| | - Timothy M Kuzel
- Department of Medicine; Northwestern University, Chicago, IL
| | - Robert S DiPaola
- Department of Medicine; Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Naomi B Haas
- Department of Medicine; Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA.
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Karam JA, Puligandla M, Flaherty KT, Uzzo RG, Matin SF, Pins MR, Wood CG, Kane C, Jewett MAS, Kim SE, Dutcher JP, DiPaola RS, Haas NB. Adjuvant therapy in patients with sarcomatoid renal cell carcinoma: post hoc analysis from Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) E2805. BJU Int 2021; 129:718-722. [PMID: 34480522 DOI: 10.1111/bju.15587] [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] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To study the effects of adjuvant therapy in patients with sarcomatoid renal cell carcinoma (sRCC) enrolled in the randomised phase III clinical trial E2805. PATIENTS AND METHODS The original trial (E2805) was a randomised, double-blinded phase III clinical trial comparing outcomes in 1943 patients with RCC accrued between 2006 and 2010 and treated with up to 1 year of adjuvant placebo, sunitinib, or sorafenib. The present study analyses the cohort of patients with sRCC that participated in E2805. RESULTS A total of 171 patients (8.8%) had sarcomatoid features. Of these, 52 patients received sunitinib, 58 received sorafenib, and 61 received placebo. Most patients were pT3-4 (71.1%, 63.7%, and 70.5%, respectively); 17.3%, 19.0%, and 27.9% had pathologically positive lymph nodes; and 59.6%, 62.1%, and 62.3% of the patients were University of California Los Angeles (UCLA) Integrated Staging System (UISS) very-high risk. In 49% of patients with subsequent development of metastatic disease, recurrence occurred in the lung, followed by 30% in the lymph nodes, and 13% in the liver. There was a high local recurrence rate in the renal bed (16%, 29%, and 18%, respectively). The 5-year disease-free survival (DFS) rates were 33.6%, 36.0%, and 27.8%, for sunitinib, sorafenib and placebo, respectively (hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.45-1.20 for sunitinib vs placebo, and HR 0.82, 95% CI 0.53-1.28 for sorafenib vs placebo). CONCLUSIONS Adjuvant therapy with sunitinib or sorafenib did not show an improvement in DFS or OS in patients with sRCC.
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Affiliation(s)
- Jose A Karam
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maneka Puligandla
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | | | | | - Surena F Matin
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | - Se Eun Kim
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | | | | | - Naomi B Haas
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Fox Chase Cancer Center, Philadelphia, PA, USA
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Murphy CC, Fullington HM, Gerber DE, Bowman IA, Puligandla M, Dutcher JP, DiPaola RS, Haas NB. Adherence to oral therapies among patients with renal cell carcinoma: Post hoc analysis of the ECOG-ACRIN E2805 trial. Cancer Med 2021; 10:5917-5924. [PMID: 34405965 PMCID: PMC8419781 DOI: 10.1002/cam4.4140] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND As use of oral cancer therapies increases, patient adherence has become critical when evaluating the effectiveness of therapy. In a phase III trial for renal cell carcinoma, we: (a) characterized adherence to sorafenib, sunitinib, and/or placebo and (b) identified factors associated with non-adherence. METHODS ECOG-ACRIN E2805 was a double-blind, placebo-controlled, randomized trial comparing adjuvant sorafenib or sunitinib in patients with resected primary renal cell carcinoma at high risk for recurrence. We used patient-completed pill diaries to measure adherence as the number of pills taken divided by the number of pills prescribed. Log-binomial regression was used to identify correlates of non-adherence (<80% of prescribed pills reported as taken). RESULTS Mean adherence was 90.7% among those assigned to sunitinib (n = 613) and 84.8% among those assigned to sorafenib (n = 616). Among those assigned to placebo, mean adherence was 94.9% and 92.4% to sunitinib and sorafenib placebo, respectively. Non-adherence was associated with race/ethnicity (non-Hispanic Black: prevalence ratio [PR] 2.22, 95% CI 1.63, 3.01; Hispanic: PR 1.54, 95% CI 1.05, 2.26), high volume enrollment (≥10 patients: PR 1.30, 95% CI 1.03, 1.64), treatment group (sunitinib: PR 2.24, 95% CI 1.66, 3.02; sorafenib: PR 2.37, 95% CI 1.74, 3.22), and skin rash (PR 1.36, 95% CI 1.03, 1.80). CONCLUSION Among patients participating in a randomized clinical trial, adherence to oral cancer therapies was lower compared to placebo. Adherence was also worse in racial/ethnic minorities, those experiencing toxicities, and high volume enrolling sites. Our findings highlight several challenges to address in clinical practice as use of oral therapies continues to increase. CLINICAL TRIAL REGISTRATION NUMBER This trial is registered with ClinicalTrials.gov, number NCT00326898.
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Affiliation(s)
- Caitlin C Murphy
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Hannah M Fullington
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David E Gerber
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Maneka Puligandla
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Naomi B Haas
- Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Xu W, Puligandla M, Halbert B, Haas NB, Flaherty K, Uzzo RG, Dutcher JP, DiPaola RS, Sabbisetti V, Bhatt RS. Analysis of plasma KIM-1 as a biomarker for recurrence risk after resection for localized renal cell carcinoma. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.342] [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: 11/20/2022] Open
Abstract
342 Background: Recurrence is common after nephrectomy for renal cell carcinoma (RCC), but no circulating biomarkers are available to identify patients at highest risk of recurrence who may benefit from adjuvant therapy. Kidney injury molecule-1 (KIM-1) is overexpressed in RCC and its ectodomain circulates in plasma. We investigated whether plasma KIM-1 is a prognostic biomarker in patients with localized RCC after nephrectomy. Methods: Banked plasma samples were analyzed from the ECOG-ACRIN 2805 (ASSURE) trial evaluating adjuvant sunitinib, sorafenib, and placebo in resected high-risk RCC. KIM-1 levels were measured at trial enrollment 4-12 weeks post-nephrectomy (baseline) and on cycle 2 day 1 (C2D1) using a previously validated microbead assay. A lognormal accelerated failure time model was used to test for association between circulating KIM-1 and disease-free survival (DFS). Results: Plasma samples from 418 patients were analyzed. In univariable and multivariable analyses, higher post-nephrectomy KIM-1 was associated with worse DFS across all study arms. This association remained independently significant after adjustment for Fuhrman grade, T-stage, N-stage, and tumor histology (survival time ratio 0.56 for 75th vs 25th percentile of KIM-1, 95% CI 0.42-0.73, p < 0.001). The association between KIM-1 and DFS was stronger among patients with pathologic nodal involvement. The addition of baseline KIM-1 improved the concordance of both the SSIGN and UISS prognostic models (SSIGN concordance 0.57 vs 0.43, p = 0.05; UISS concordance 0.60 vs 0.40, p = 0.0005). C2D1 KIM-1 was not an independent predictor for DFS after adjusting for baseline KIM-1. Conclusions: Elevated plasma KIM-1 level at post-nephrectomy baseline is associated with worse DFS in RCC. This is consistent with the hypothesis that post-nephrectomy plasma KIM-1 may be a biomarker for microscopic residual disease. The model was additionally adjusted for papillary and chromophobe histology, sex, and ECOG performance status. [Table: see text]
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Affiliation(s)
- Wenxin Xu
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Naomi B. Haas
- Abramson Cancer Center, University of Pennsylvania (ECOG-ACRIN), Philadelphia, PA
| | - Keith Flaherty
- Dana-Farber Cancer Institute/Harvard Medical School/Massachusetts General Hospital, Boston, MA
| | - Robert Guy Uzzo
- Fox Chase Cancer Center–Temple University Health System, Philadelphia, PA
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Carney BJ, Uhlmann EJ, Puligandla M, Mantia C, Weber GM, Neuberg DS, Zwicker JI. Anticoagulation after intracranial hemorrhage in brain tumors: Risk of recurrent hemorrhage and venous thromboembolism. Res Pract Thromb Haemost 2020; 4:860-865. [PMID: 32685895 PMCID: PMC7354400 DOI: 10.1002/rth2.12377] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a common and often devastating outcome in patients with brain tumors. Despite this, there is little evidence to guide anticoagulation management following an initial ICH event. OBJECTIVES To analyze the risk of recurrent hemorrhagic and thrombotic outcomes after an initial ICH event in patients with brain tumors and prior venous thromboembolism (VTE). PATIENTS AND METHODS A retrospective cohort study was performed. Radiographic images obtained after initial ICH were reviewed for the primary outcomes of recurrent ICH and VTE. RESULTS AND CONCLUSIONS A total of 79 patients with brain tumors who developed ICH on anticoagulation for VTE were analyzed. Fifty-four patients (68.4%) restarted anticoagulation following ICH. The cumulative incidence of recurrent ICH at 1 year was 6.1% (95% confidence interval [CI], 1.5-15.3) following reinitiation of anticoagulation. Following a major ICH (defined as an ICH >10 mL in size, causing symptoms, or requiring intervention), the rate of recurrent ICH upon reexposure to anticoagulation was 14.5% (95% CI, 2.1-38.35), whereas the rate of recurrent ICH following smaller ICH was 2.6% (95% CI, 0.2%-12.0%). Mortality following a recurrent ICH on anticoagulation was 67% at 30 days. The cumulative incidence of recurrent VTE was significantly lower in the restart cohort compared to patients who did not restart anticoagulation (8.1% vs 35.3%; P = .003). We conclude that resumption of anticoagulation is lowest among patients with metastatic brain tumors with small initial ICH. Following an initial major ICH, resumption of anticoagulation was associated with a high rate of recurrent ICH.
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Affiliation(s)
- Brian J. Carney
- Division of Hemostasis and ThrombosisBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Erik J. Uhlmann
- Department of NeurologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Maneka Puligandla
- Department of Data SciencesDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Charlene Mantia
- Division of Hematology and OncologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Griffin M. Weber
- Interdisciplinary Medicine and BiotechnologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Donna S. Neuberg
- Department of Data SciencesDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Jeffrey I. Zwicker
- Division of Hemostasis and ThrombosisBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
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Ladas EJ, Blonquist TM, Puligandla M, Orjuela M, Stevenson K, Cole PD, Athale UH, Clavell LA, Leclerc JM, Laverdiere C, Michon B, Schorin MA, Greene Welch J, Asselin BL, Sallan SE, Silverman LB, Kelly KM. Protective Effects of Dietary Intake of Antioxidants and Treatment-Related Toxicity in Childhood Leukemia: A Report From the DALLT Cohort. J Clin Oncol 2020; 38:2151-2159. [DOI: 10.1200/jco.19.02555] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The benefits and risks of supplementation with antioxidants during cancer therapy have been a controversial area. Few studies have systematically evaluated dietary intake of antioxidants with toxicity and survival in childhood cancer. We sought to determine the role of dietary intake of antioxidants on rates of infections, mucositis, relapse, and disease-free survival during induction and postinduction phases of therapy among children and adolescents with acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS We enrolled 794 children in a prospective clinical trial for treatment of ALL. Dietary intake was prospectively evaluated by a food frequency questionnaire. The association between dietary intake of antioxidants and treatment-related toxicities and survival were evaluated with the Benjamini-Hochberg false discovery rate (q) and logistic regression and the Kaplan-Meier method, respectively. RESULTS Dietary surveys were available for analysis from 614 (77%), and 561 (71%) participants at diagnosis and at end of induction, respectively. Of 513 participants who completed the dietary surveys at both time points, 120 (23%) and 87 (16%) experienced a bacterial infection and 22 (4%) and 55 (10%) experienced mucositis during the induction or postinduction phases of treatment, respectively. Increased intake of dietary antioxidants was associated with significantly lower rates of infection and mucositis. No association with relapse or disease-free survival was observed. Supplementation was not associated with toxicity, relapse, or survival. CONCLUSION Consumption of antioxidants through dietary intake was associated with reduced rates of infection or mucositis, with no increased risk of relapse or reduced survival. Dietary counseling on a well-balanced diet that includes an array of antioxidants from food sources alone may confer a benefit from infections and mucositis during treatment of childhood ALL.
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Affiliation(s)
- Elena J. Ladas
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Medical Center, New York, NY
- Institute of Human Nutrition, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY
| | | | | | - Manuela Orjuela
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Medical Center, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY
| | | | - Peter D. Cole
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Uma H. Athale
- Division of Hematology/Oncology, McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Jean-Marie Leclerc
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, Quebec, Canada
| | | | - Bruno Michon
- Centre Hospitalier Universitaire de Quebec, Sainte-Foy, Quebec, Canada
| | | | - Jennifer Greene Welch
- Division of Pediatric Hematology/Oncology, Hasbro Children’s Hospital, Brown University, Providence, RI
| | - Barbara L. Asselin
- Department of Pediatrics, University of Rochester School of Medicine, Golisano Children’s Hospital at URMC, Rochester, NY
| | | | | | - Kara M. Kelly
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center and University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
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Zwicker JI, Roopkumar J, Puligandla M, Schlechter BL, Sharda AV, Peereboom D, Joyce R, Bockorny B, Neuberg D, Bauer KA, Khorana AA. Dose-adjusted enoxaparin thromboprophylaxis in hospitalized cancer patients: a randomized, double-blinded multicenter phase 2 trial. Blood Adv 2020; 4:2254-2260. [PMID: 32442298 PMCID: PMC7252540 DOI: 10.1182/bloodadvances.2020001804] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/15/2020] [Indexed: 11/20/2022] Open
Abstract
Hospitalized patients with cancer are at an increased risk of developing venous thromboembolism (VTE). The recommendation for routine pharmacologic thromboprophylaxis in hospitalized patients with cancer to prevent VTE is based on extrapolation of results from noncancer cohorts. There are limited data to support the efficacy and safety of fixed-dose low-molecular-weight heparin (LMWH) regimens in high-risk hospitalized patients with cancer. We conducted a randomized, double-blinded, phase 2 trial in hospitalized patients with active cancer at high risk of developing VTE based on Padua risk score. Patients were randomly assigned to fixed-dose enoxaparin (40 mg daily) vs weight-adjusted enoxaparin (1 mg/kg daily) during hospitalization. The primary objectives were to evaluate the safety of dose-adjusted enoxaparin and evaluate the incidence of VTE with fixed-dose enoxaparin. Blinded clinical assessments were performed at day 14, and patients randomly assigned to fixed-dose enoxaparin subsequently underwent a bilateral lower extremity ultrasound. A total of 50 patients were enrolled and randomized. The median weight of patients enrolled in weight-adjusted enoxaparin arm was 76 kg (range, 60.9-124.5 kg). There were no major hemorrhages or symptomatic VTE in either arm. At time of completion of the blinded clinical assessment, there was only 1 incidentally identified pulmonary embolus that occurred in the weight-adjusted arm. In the group randomly assigned to fixed-dose enoxaparin who subsequently underwent surveillance ultrasound, the cumulative incidence of DVT was 22% (90% binomial confidence interval, 0%-51.3%). This phase 2 trial confirms a high incidence of asymptomatic VTE among high-risk hospitalized patients with cancer and that weight-adjusted LMWH thromboprophylaxis is feasible and well-tolerated. This trial was registered at www.clinicaltrials.gov as #NCT02706249.
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Affiliation(s)
- Jeffrey I Zwicker
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Joanna Roopkumar
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Maneka Puligandla
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Benjamin L Schlechter
- Gastrointestinal Cancer Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and
| | - Anish V Sharda
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Peereboom
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Robin Joyce
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Bruno Bockorny
- Division of Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Kenneth A Bauer
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alok A Khorana
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Haas NB, Puligandla M, Allaf ME, McDermott DF, Drake CG, Signoretti S, Cella D, Gupta RT, Shuch BM, Lara P, Kapoor A, Heng DYC, Leibovich BC, Michaelson MD, Choueiri TK, Jewett MA, Maskens D, Harshman LC, Master VA, Carducci MA. PROSPER: Phase III randomized study comparing perioperative nivolumab versus observation in patients with renal cell carcinoma (RCC) undergoing nephrectomy (ECOG-ACRIN EA8143). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.tps5101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS5101 Background: There is no standard adjuvant systemic therapy that increases overall survival (OS) over surgery alone for non-metastatic RCC. Anti-PD-1 nivolumab (nivo) improves OS in metastatic RCC and is well tolerated. In mouse models, priming the immune system prior to surgery with anti-PD-1 results in superior OS compared to adjuvant dosing. Remarkable pathologic responses have been seen with neoadjuvant PD-1 in multiple ph 2 studies in bladder, lung and breast cancers. Phase 2 neoadjuvant RCC trials of nivo show preliminary feasibility and safety with no surgical delays. PROSPER RCC seeks to improve clinical outcomes by priming the immune system with neoadjuvant nivo prior to nephrectomy followed by continued immune system engagement with adjuvant blockade in patients (pts) with high risk RCC compared to standard of care surgery alone. Methods: This global, unblinded, phase 3 National Clinical Trials Network study is accruing pts with clinical stage ≥T2 or TanyN+ RCC of any histology planned for radical or partial nephrectomy. Select oligometastatic disease is permitted if the pt can be rendered ‘no evidence of disease’ within 12 weeks of nephrectomy (≤3 metastases; no brain, bone or liver). In the investigational arm, nivo is administered 480mg IV q4 weeks with 1 dose prior to surgery followed by 9 adjuvant doses. The control arm is nephrectomy followed by standard of care surveillance. There is no placebo. Baseline tumor biopsy is required only in the nivo arm but encouraged in both. Randomized pts are stratified by clinical T stage, node positivity, and M stage. 805 pts provide 84.2% power to detect a 14.4% absolute benefit in recurrence-free survival at 5 years assuming the ASSURE historical control of ~56% to 70% (HR = 0.70). The study is powered to evaluate a significant increase in OS (HR 0.67). Critical perioperative therapy considerations such as safety, feasibility, and quality of life metrics are integrated. PROSPER RCC embeds a wealth of translational studies to examine the contribution of the baseline immune milieu and neoadjuvant priming with anti-PD-1 on clinical outcomes. As of February 2020, 396 patients have been enrolled. Clinical trial information: NCT03055013 .
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Affiliation(s)
| | | | - Mohamad E. Allaf
- James Buchanan Brady Urological Institute, Dept. of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David F. McDermott
- Beth Israel Deaconess Medical Center, Dana-Farber/Harvard Cancer Center, Boston, MA
| | | | | | - David Cella
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | - Brian M. Shuch
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Primo Lara
- University of California, Sacramento, CA
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Daniel Yick Chin Heng
- Department of Medical Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada
| | | | | | - Toni K. Choueiri
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Harshman LC, Puligandla M, Allaf ME, McDermott DF, Drake CG, Signoretti S, Cella D, Gupta RT, Shuch BM, Lara P, Kapoor A, Heng DYC, Leibovich B, Michaelson MD, Choueiri TK, Master VA, Jewett MA, Maskens D, Haas NB, Carducci MA. PROSPER: Phase III randomized study comparing perioperative nivolumab versus observation in patients with renal cell carcinoma (RCC) undergoing nephrectomy (ECOG-ACRIN EA8143). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.tps765] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS765 Background: There is no standard adjuvant systemic therapy that increases overall survival (OS) over surgery alone for non-metastatic RCC. Anti-PD-1 nivolumab (nivo) improves OS in metastatic RCC and is well tolerated. In mouse models, priming the immune system prior to surgery with anti-PD-1 results in superior OS compared to adjuvant dosing. Remarkable pathologic responses have been seen with neoadjuvant PD-1 in multiple ph 2 studies in bladder, lung and breast cancers. Phase 2 neoadjuvant RCC trials of nivo show preliminary feasibility and safety with no surgical delays. PROSPER RCC seeks to improve clinical outcomes by priming the immune system with neoadjuvant nivo prior to nephrectomy followed by continued immune system engagement with adjuvant blockade in patients (pts) with high risk RCC compared to standard of care surgery alone. Methods: This global, unblinded, phase 3 National Clinical Trials Network study is accruing pts with clinical stage ≥T2 or TanyN+ RCC of any histology planned for radical or partial nephrectomy. Select oligometastatic disease is permitted if the pt can be rendered ‘no evidence of disease’ within 12 weeks of nephrectomy (≤3 metastases; no brain, bone or liver). In the investigational arm, nivo is administered 480mg IV q4 weeks with 1 dose prior to surgery followed by 9 adjuvant doses. The control arm is nephrectomy followed by standard of care surveillance. There is no placebo. Baseline tumor biopsy is required only in the nivo arm but encouraged in both. Randomized pts are stratified by clinical T stage, node positivity, and M stage. 805 pts provide 84.2% power to detect a 14.4% absolute benefit in recurrence-free survival at 5 years assuming the ASSURE historical control of ~56% to 70% (HR = 0.70). The study is powered to evaluate a significant increase in OS (HR 0.67). Critical perioperative therapy considerations such as safety, feasibility, and quality of life metrics are integrated. PROSPER RCC embeds a wealth of translational studies to examine the contribution of the baseline immune milieu and neoadjuvant priming with anti-PD-1 on clinical outcomes. As of October 18, 2019, 317 patients have been enrolled. Clinical trial information: NCT03055013.
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Affiliation(s)
| | | | - Mohamad E. Allaf
- James Buchanan Brady Urological Institute, Dept. of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David F. McDermott
- Beth Israel Deaconess Medical Center, Dana-Farber/Harvard Cancer Center, Boston, MA
| | | | | | - David Cella
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | | | - Primo Lara
- University of California, Davis, Sacramento, CA
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | | | - Toni K. Choueiri
- Dana-Farber Cancer Institute/Brigham and Women’s Hospital and Harvard University School of Medicine, Boston, MA
| | | | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
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Nze C, Fortin B, Freedman R, Mandell E, Puligandla M, Neuberg D, Achebe M. Sudden death in sickle cell disease: current experience. Br J Haematol 2019; 188:e43-e45. [PMID: 31804704 DOI: 10.1111/bjh.16314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Chijioke Nze
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brooke Fortin
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
| | - Revital Freedman
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elyse Mandell
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maneka Puligandla
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maureen Achebe
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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11
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Gupta N, Goumnerova LC, Manley P, Chi SN, Neuberg D, Puligandla M, Fangusaro J, Goldman S, Tomita T, Alden T, DiPatri A, Rubin JB, Gauvain K, Limbrick D, Leonard J, Geyer JR, Leary S, Browd S, Wang Z, Sood S, Bendel A, Nagib M, Gardner S, Karajannis MA, Harter D, Ayyanar K, Gump W, Bowers DC, Weprin B, MacDonald TJ, Aguilera D, Brahma B, Robison NJ, Kiehna E, Krieger M, Sandler E, Aldana P, Khatib Z, Ragheb J, Bhatia S, Mueller S, Banerjee A, Bredlau AL, Gururangan S, Fuchs H, Cohen KJ, Jallo G, Dorris K, Handler M, Comito M, Dias M, Nazemi K, Baird L, Murray J, Lindeman N, Hornick JL, Malkin H, Sinai C, Greenspan L, Wright KD, Prados M, Bandopadhayay P, Ligon KL, Kieran MW. Prospective feasibility and safety assessment of surgical biopsy for patients with newly diagnosed diffuse intrinsic pontine glioma. Neuro Oncol 2019; 20:1547-1555. [PMID: 29741745 DOI: 10.1093/neuonc/noy070] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Diagnosis of diffuse intrinsic pontine glioma (DIPG) has relied on imaging studies, since the appearance is pathognomonic, and surgical risk was felt to be high and unlikely to affect therapy. The DIPG Biology and Treatment Study (DIPG-BATS) reported here incorporated a surgical biopsy at presentation and stratified subjects to receive FDA-approved agents chosen on the basis of specific biologic targets. Methods Subjects were eligible for the trial if the clinical features and imaging appearance of a newly diagnosed tumor were consistent with a DIPG. Surgical biopsies were performed after enrollment and prior to definitive treatment. All subjects were treated with conventional external beam radiotherapy with bevacizumab, and then stratified to receive bevacizumab with erlotinib or temozolomide, both agents, or neither agent, based on O6-methylguanine-DNA methyltransferase status and epidermal growth factor receptor expression. Whole-genome sequencing and RNA sequencing were performed but not used for treatment assignment. Results Fifty-three patients were enrolled at 23 institutions, and 50 underwent biopsy. The median age was 6.4 years, with 24 male and 29 female subjects. Surgical biopsies were performed with a specified technique and no deaths were attributed to the procedure. Two subjects experienced grade 3 toxicities during the procedure (apnea, n = 1; hypertension, n = 1). One subject experienced a neurologic deficit (left hemiparesis) that did not fully recover. Of the 50 tumors biopsied, 46 provided sufficient tissue to perform the study assays (92%, two-stage exact binomial 90% CI: 83%-97%). Conclusions Surgical biopsy of DIPGs is technically feasible, associated with acceptable risks, and can provide biologic data that can inform treatment decisions.
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Affiliation(s)
- Nalin Gupta
- UCSF Benioff Children's Hospital & University of California San Francisco, San Francisco, California
| | - Liliana C Goumnerova
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Peter Manley
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Susan N Chi
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Jason Fangusaro
- Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University, Chicago, Illinois
| | - Stewart Goldman
- Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University, Chicago, Illinois
| | - Tadanori Tomita
- Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University, Chicago, Illinois
| | - Tord Alden
- Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University, Chicago, Illinois
| | - Arthur DiPatri
- Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University, Chicago, Illinois
| | - Joshua B Rubin
- Washington University Medical Center & St. Louis Children's Hospital, St. Louis, Missouri
| | - Karen Gauvain
- Washington University Medical Center & St. Louis Children's Hospital, St. Louis, Missouri
| | - David Limbrick
- Washington University Medical Center & St. Louis Children's Hospital, St. Louis, Missouri
| | - Jeffrey Leonard
- Washington University Medical Center & St. Louis Children's Hospital, St. Louis, Missouri
| | - J Russel Geyer
- Seattle Children's Hospital & University of Washington, Seattle, Washington
| | - Sarah Leary
- Seattle Children's Hospital & University of Washington, Seattle, Washington
| | - Samuel Browd
- Seattle Children's Hospital & University of Washington, Seattle, Washington
| | - Zhihong Wang
- Children's Hospital of Michigan & Wayne State University, Detroit, Michigan
| | - Sandeep Sood
- Children's Hospital of Michigan & Wayne State University, Detroit, Michigan
| | - Anne Bendel
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Mahmoud Nagib
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | | | | | | | | | - William Gump
- University of Louisville & Norton's Children's Hospital, Louisville, Kentucky
| | - Daniel C Bowers
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bradley Weprin
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tobey J MacDonald
- Children's Healthcare of Atlanta & Emory University, Atlanta, Georgia
| | - Dolly Aguilera
- Children's Healthcare of Atlanta & Emory University, Atlanta, Georgia
| | | | | | - Erin Kiehna
- Children's Hospital Los Angeles, Los Angeles, California
| | - Mark Krieger
- Children's Hospital Los Angeles, Los Angeles, California
| | - Eric Sandler
- Nemours Children's Clinic, Wolfson's Children's Hospital & University of Florida, Jacksonville, Florida
| | - Philipp Aldana
- Nemours Children's Clinic, Wolfson's Children's Hospital & University of Florida, Jacksonville, Florida
| | - Ziad Khatib
- Nicklaus Children's Hospital, Miami, Florida
| | - John Ragheb
- Nicklaus Children's Hospital, Miami, Florida
| | | | - Sabine Mueller
- UCSF Benioff Children's Hospital & University of California San Francisco, San Francisco, California
| | - Anu Banerjee
- UCSF Benioff Children's Hospital & University of California San Francisco, San Francisco, California
| | - Amy-Lee Bredlau
- Medical University of South Carolina, South Carolina, Charleston, South Carolina
| | - Sri Gururangan
- Preston Robert Tisch Brain Tumor Center & Duke University Medical Center, Durham, North Carolina
| | - Herbert Fuchs
- Preston Robert Tisch Brain Tumor Center & Duke University Medical Center, Durham, North Carolina
| | | | | | - Kathleen Dorris
- Children's Hospital of Colorado & University of Colorado School of Medicine, Denver, Colorado
| | - Michael Handler
- Children's Hospital of Colorado & University of Colorado School of Medicine, Denver, Colorado
| | - Melanie Comito
- Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Mark Dias
- Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Kellie Nazemi
- Oregon Health & Science University & Doernbecher Children's Hospital, Portland, Oregon
| | - Lissa Baird
- Oregon Health & Science University & Doernbecher Children's Hospital, Portland, Oregon
| | - Jeff Murray
- Cook Children's Medical Center, Fort Worth, Texas
| | | | | | | | - Claire Sinai
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Karen D Wright
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Michael Prados
- UCSF Benioff Children's Hospital & University of California San Francisco, San Francisco, California
| | - Pratiti Bandopadhayay
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts.,Broad Institute, Cambridge, Massachusetts
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | - Mark W Kieran
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
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12
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Xu W, Puligandla M, Haas N, Flaherty K, Uzzo R, Sabbisetti V, Dutcher J, DiPaola R, Bhatt R. Plasma KIM-1 is associated with clinical outcomes after resection for localized renal cell carcinoma: A trial of the ECOG-ACRIN Research Group (E2805). Ann Oncol 2019. [DOI: 10.1093/annonc/mdz239.066] [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: 11/12/2022] Open
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13
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Najjar YG, Puligandla M, Lee SJ, Kirkwood JM. An updated analysis of 4 randomized ECOG trials of high-dose interferon in the adjuvant treatment of melanoma. Cancer 2019; 125:3013-3024. [PMID: 31067358 PMCID: PMC7428054 DOI: 10.1002/cncr.32162] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Received: 05/16/2018] [Revised: 03/04/2019] [Accepted: 03/11/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND The pivotal E1684, E1690, E1694, and E2696 trials of adjuvant high-dose interferon-α (HDI) enrolled nearly 2000 patients, and established HDI as the standard of care in adjuvant therapy for patients with resected high-risk melanoma. Herein, the authors present an updated analysis of these 4 trials. METHODS Survival and disease status were updated in September 2016. These data represent a median follow-up of 17.9 years for the E1684 trial, 12.2 years for the E1690 trial, 16.0 years for the E1694 trial, and 16.5 years for the E2696 trial. RESULTS The current analysis confirmed the benefit to recurrence-free survival (RFS) of HDI in the E1684 trial at a median follow-up of 17.9 years. The RFS benefit in the E1694 trial remained evident at a median follow-up of 16 years. Furthermore, the results of the current study confirmed the RFS benefit of adjuvant HDI compared with observation in a pooled analysis of the E1684 and E1690 trials. No overall survival benefit was apparent in this pooled analysis. Updated results for the E1690 and E2696 trials did not differ from those previously reported. In addition, to the authors' knowledge, the current study is the first to report a significant difference in melanoma-specific survival (MSS) between patients treated with HDI compared with the ganglioside GM2/keyhole limpet hemocyanin (GMK) vaccine in the E1694 trial. CONCLUSIONS In patients with resected high-risk melanoma, adjuvant HDI demonstrated improved RFS in the E1684 and E1694 trials, and improved MSS in a pooled analysis of HDI in the E1694 trial. To the authors' knowledge, these findings represent the most mature level of evidence for the benefit of HDI with respect to RFS and MSS. HDI is the only approved adjuvant treatment for which there are data available in patients with resected stage IIB/IIC melanoma, and remains a reasonable treatment option in this population.
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Affiliation(s)
- Yana G. Najjar
- Department of Medicine, Division of Hematology-Oncology, University of Pittsburgh, UPMC-Hillman Cancer Center. 5117 Centre Ave, 1.32 E, Pittsburgh, PA 15213
| | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute
| | - Sandra J. Lee
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School
| | - John M. Kirkwood
- Department of Medicine, Division of Hematology-Oncology, University of Pittsburgh, UPMC-Hillman Cancer Center
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14
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Xu W, Puligandla M, Manola J, Bullock AJ, Tamasauskas D, McDermott DF, Atkins MB, Haas NB, Flaherty K, Uzzo RG, Dutcher JP, DiPaola RS, Bhatt RS. Angiogenic Factor and Cytokine Analysis among Patients Treated with Adjuvant VEGFR TKIs in Resected Renal Cell Carcinoma. Clin Cancer Res 2019; 25:6098-6106. [PMID: 31471309 DOI: 10.1158/1078-0432.ccr-19-0818] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/06/2019] [Accepted: 07/09/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE The use of VEGFR TKIs for the adjuvant treatment of renal cell carcinoma (RCC) remains controversial. We investigated the effects of adjuvant VEGFR TKIs on circulating cytokines in the ECOG-ACRIN 2805 (ASSURE) trial. EXPERIMENTAL DESIGN Patients with resected high-risk RCC were randomized to sunitinib, sorafenib, or placebo. Plasma from 413 patients was analyzed from post-nephrectomy baseline, 4 weeks, and 6 weeks after treatment initiation. Mixed effects and Cox proportional hazards models were used to test for changes in circulating cytokines and associations between disease-free survival (DFS) and cytokine levels. RESULTS VEGF and PlGF increased after 4 weeks on sunitinib or sorafenib (P < 0.0001 for both) and returned to baseline at 6 weeks on sunitinib (corresponding to the break in the sunitinib schedule) but not sorafenib (which was administered continuously). sFLT-1 decreased after 4 weeks on sunitinib and 6 weeks on sorafenib (P < 0.0001). sVEGFR-2 decreased after both 4 and 6 weeks of treatment on sunitinib or sorafenib (P < 0.0001). Patients receiving placebo had no significant changes in cytokine levels. CXCL10 was elevated at 4 and 6 weeks on sunitinib and sorafenib but not on placebo. Higher baseline CXCL10 was associated with worse DFS (HR 1.41 per log increase in CXCL10, Bonferroni-adjusted P = 0.003). This remained significant after adjustment for T-stage, Fuhrman grade, and ECOG performance status. CONCLUSIONS Among patients treated with adjuvant VEGFR TKIs for RCC, drug-host interactions mediate changes in circulating cytokines. Elevated baseline CXCL10 was associated with worse DFS. Studies to understand functional consequences of these changes are under way.
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Affiliation(s)
- Wenxin Xu
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Maneka Puligandla
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | - Judith Manola
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | | | | | | | - Michael B Atkins
- MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Naomi B Haas
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Rupal S Bhatt
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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15
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Harshman LC, Puligandla M, Haas NB, Allaf M, Drake CG, McDermott DF, Signoretti S, Cella D, Gupta RT, Shuch BM, Choueiri TK, Lara P, Kapoor A, Heng DYC, Jewett MA, Master VA, Michaelson MD, Leibovich BC, Maskens D, Carducci MA. PROSPER: A phase III randomized study comparing perioperative nivolumab (nivo) versus observation in patients with renal cell carcinoma (RCC) undergoing nephrectomy (ECOG-ACRIN 8143). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.tps4597] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS4597 Background: The anti-PD-1 antibody nivo improves overall survival (OS) in metastatic RCC and is well tolerated. There is no standard adjuvant (adjuv) systemic therapy that increases OS over surgery alone for non-metastatic RCC. Priming the immune system prior to surgery with anti-PD-1 has shown an OS benefit compared to a pure adjuv approach in mouse solid tumor models. Multiple ph 2 studies in bladder, lung and breast cancers have shown remarkable pathologic responses with neoadjuvant (neoadj) PD-1 blockade. Two ongoing ph 2 studies of perioperative nivo in M0 RCC patients are showing preliminary feasibility and safety with no surgical delays (NCT02575222; NCT02595918). PROSPER RCC (NCT03055013) aims to improve clinical outcomes by priming the immune system prior to nephrectomy with neoadj nivo and continued engagement with adjuv blockade in patients with high risk RCC compared to surgery alone. Methods: This global, unblinded, phase 3 National Clinical Trials Network study is currently accruing patients with clinical stage ≥T2 or TanyN+ RCC of any histology planned for nephrectomy. Oligometastases are permitted if can be rendered NED. We amended the study to enhance accrual and patient quality of life by changing nivo dosing to 480mg q4 wks and requiring baseline tumor biopsy only in the nivo arm. The investigational arm receives 1 dose of nivo prior to surgery followed by 9 adjuv doses. The control arm undergoes standard nephrectomy followed by observation. Randomized patients are stratified by clinical T stage, node positivity, and M stage. Accrual of 805 patients provides 84.2% power to detect a 14.4% absolute benefit in recurrence-free survival (RFS) at 5 years assuming the ASSURE historical control of ~56% to 70% (HR = 0.70). The study is powered to evaluate a significant increase in OS (HR 0.67). Critical perioperative therapy considerations such as safety, feasibility, and quality of life endpoints have been integrated. PROSPER RCC embeds a wealth of translational work aimed at investigating the impact of the baseline immune milieu, the changes induced by neoadjuvant anti-PD-1 priming, and how both may predict clinical outcomes. Clinical trial information: NCT03055013.
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Affiliation(s)
| | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
| | - Mohamad Allaf
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - David Cella
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | | | - Toni K. Choueiri
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA
| | - Primo Lara
- University of California, Davis, Sacramento, CA
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Appleman LJ, Puligandla M, Pal SK, Harris W, Agarwal N, Costello BA, Ryan CW, Pins M, Kolesar J, Vaena DA, Parikh RA, Hashmi M, Dutcher JP, DiPaola RS, Haas NB, Carducci MA. Randomized, double-blind phase III study of pazopanib versus placebo in patients with metastatic renal cell carcinoma who have no evidence of disease following metastasectomy: A trial of the ECOG-ACRIN cancer research group (E2810). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.4502] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4502 Background: Patients with no evidence of disease (NED) after metastasectomy for metastatic renal cell carcinoma (mRCC) are at high risk of recurrence, but no systemic therapy has been shown to benefit this population. Pazopanib is an inhibitor of VEGFR and other kinases that improves progression-free survival in patients with measurable RCC metastatic disease. We performed a randomized, double-blind, placebo-controlled multicenter study to test the hypothesis that pazopanib would improve disease-free survival in patients with mRCC rendered NED after metastasectomy Methods: Patients with NED following metastasectomy were randomized 1:1 to receive pazopanib starting at 800 mg daily vs. placebo for 52 weeks. Patients were stratified by 1 vs. > 1 site of resected disease, and by disease-free interval ≤ vs. > 1 year. Clinical assessment for toxicity and patient-reported outcomes were performed every 4 weeks, and restaging scans every 12 weeks. The study was designed to observe a 42% improvement in disease-free survival (DFS) from 25% to 45% at 3 years. Results: From August 2012 to July 2017, 129 patients were enrolled. The study was unblinded after 83 DFS events had been observed (92% information). The median follow-up from randomization was 30 months (range 0.4 – 66.5 months). The study did not meet the primary endpoint: hazard ratio (95% CI) for DFS was 0.85 (0.55, 1.31) p= 0.47 in favor of pazopanib. At the time of unblinding, 22/129 (17%) of subjects had died. The HR for overall survival (OS) was 2.65 (1.02, 6.9) in favor of placebo ( p= 0.05). Patient-reported outcomes and laboratory correlates will be reported separately. Conclusions: 52 weeks of pazopanib did not improve DFS compared to blinded placebo in patients with mRCC who were NED after metastasectomy. There was a trend toward worse overall survival with pazopanib. Clinical trial information: NCT01575548.
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Affiliation(s)
| | | | | | - Wayne Harris
- Emory University School of Medicine, Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Neeraj Agarwal
- University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | | | | | - Michael Pins
- University of Illinois College of Medicine, Chicago, IL
| | - Jill Kolesar
- University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Daniel A. Vaena
- University of Iowa Hospitals and Clinics, Holden Comprehensive Cancer Center, Iowa City, IA
| | | | | | | | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
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17
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Grivas P, Puligandla M, Cole S, Courtney KD, Dreicer R, Gartrell BA, Cetnar JP, Dall'era M, Galsky MD, Jain RK, Maughan BL, Agarwal N, Koshkin VS, Hahn NM, Carducci MA. PrE0807 phase Ib feasibility trial of neoadjuvant nivolumab (N)/lirilumab (L) in cisplatin-ineligible muscle-invasive bladder cancer (BC). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.tps4594] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS4594 Background: Neoadjuvant cisplatin-based chemotherapy before radical cystectomy (RC) improves outcomes but ~50% of patients (pts) are cisplatin-unfit. Anti-PD(L)1 agents can prolong overall survival (OS) in platinum-resistant advanced BC and have shown high pathologic complete response rate (pCR) and safety as single agent in phase II trials in the neoadjuvant setting. The combination of anti-PD-1 and anti-KIR agents is feasible and very attractive based on complementary and non-overlapping roles in regulating adaptive and innate immune response as well as impacting the function CD8+ T and NK-cells. Higher CD8+ T cell density (TCD) at RC tissue correlates with longer OS. We hypothesize, that combining anti-PD1 (N) with anti-KIR (L) is safe and feasible as neoadjuvant therapy in cisplatin-unfit pts and results in high CD8+ TCD at RC. Methods: Phase Ib multi-institutional trial evaluating 2 doses (4 weeks apart) of N alone or N+L in 2 cohorts; pts will be assigned sequentially to N (Cohort 1), and if there is no negative safety signal after the first 12 pts, subsequent pts will be assigned to N+L (Cohort 2). Key eligibility: cT2-4aN0-1M0 stage, ≥20% tumor at TURBT, adequate organ function, no autoimmune disease within 2 years, no concurrent invasive upper urinary tract carcinoma or other active cancer. Primary endpoint: safety based on CTCAE v5.0 measured as the rate of ≥G3 treatment related adverse events (AE). Key secondary endpoints: CD8+ TCD absolute and % change between TURBT and RC, % of pts who do not get RC within 6 weeks after neoadjuvant treatment due to treatment-related AE, % pCR, recurrence-free survival, and evaluation of biomarkers in tumor tissue, blood, urine. Rates of ≥Grade 3 AE with neoadjuvant treatment will be reported along with 90% exact binomial CI. In Cohort 1, maximum CI width is 0.51; in Cohort 2, it is 0.36. Our hypothesis is that the change in CD8+ TCD between TURBT and RC will be about 3 CD8+ T cells / 100 tumor cells within HPF. Up to 43 pts will be enrolled for 36 eligible, treated pts (12:N, 24:N+L). Cohort 1 and 2 have 81% and 98% power, respectively, to detect the hypothesized difference with 1-sided type I error rate of 0.05. Trial is open to accrual in US. Clinical trial information: NCT03532451.
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Affiliation(s)
- Petros Grivas
- University of Washington, School of Medicine, Seattle, WA
| | | | - Suzanne Cole
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | | | | | - Marc Dall'era
- University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Matt D. Galsky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY
| | | | | | - Neeraj Agarwal
- University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | | | - Noah M. Hahn
- Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Patel HD, Puligandla M, Shuch BM, Leibovich BC, Kapoor A, Master VA, Drake CG, Heng DYC, Lara PN, Choueiri TK, Maskens D, Singer EA, Eggener SE, Svatek RS, Stadler WM, Cole S, Signoretti S, Gupta RT, Michaelson MD, McDermott DF, Cella D, Wagner LI, Haas NB, Carducci MA, Harshman LC, Allaf ME. The future of perioperative therapy in advanced renal cell carcinoma: how can we PROSPER? Future Oncol 2019; 15:1683-1695. [PMID: 30968729 PMCID: PMC6595543 DOI: 10.2217/fon-2018-0951] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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] [Received: 12/23/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022] Open
Abstract
Patients with high-risk renal cell carcinoma (RCC) experience high rates of recurrence despite definitive surgical resection. Recent trials of adjuvant tyrosine kinase inhibitor therapy have provided conflicting efficacy results at the cost of significant adverse events. PD-1 blockade via monoclonal antibodies has emerged as an effective disease-modifying treatment for metastatic RCC. There is emerging data across other solid tumors of the potential efficacy of neoadjuvant PD-1 blockade, and preclinical evidence supporting a neoadjuvant over adjuvant approach. PROSPER RCC is a Phase III, randomized trial evaluating whether perioperative nivolumab increases recurrence-free survival in patients with high-risk RCC undergoing nephrectomy. The neoadjuvant component, intended to prime the immune system for enhanced efficacy, distinguishes PROSPER from other purely adjuvant studies and permits highly clinically relevant translational studies.
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Affiliation(s)
- Hiten D Patel
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maneka Puligandla
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Brian M Shuch
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | | | - Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Viraj A Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles G Drake
- Division of Hematology/Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | | | - Primo N Lara
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Robert S Svatek
- Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Walter M Stadler
- Department of Medicine (Hematology/Oncology), University of Chicago, Chicago, IL, USA
| | - Suzanne Cole
- Department of Medicine (Hematology/Oncology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sabina Signoretti
- Department of Pathology, Brigham & Women's Hospital, Boston, MA, USA
| | - Rajan T Gupta
- Departments of Radiology & Surgery & The Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | | | - David F McDermott
- Division of Hematology-Oncology & Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lynne I Wagner
- Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Naomi B Haas
- Division of Hematology/Oncology, Abramson Cancer Center, University of Pennsylvania, PA, USA
| | - Michael A Carducci
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Lauren C Harshman
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Mohamad E Allaf
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Xu W, Puligandla M, Haas NB, Flaherty K, Uzzo R, Dutcher JP, DiPaola RS, Bhatt RS. Angiogenic factor and cytokine analysis among patients with renal cell carcinoma treated with adjuvant VEGFR TKIs. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.586] [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: 11/20/2022] Open
Abstract
586 Background: VEGFR TKIs are important therapeutic agents in RCC, but their adjuvant use remains limited. Investigating the effects of these medications on circulating angiogenic factors and cytokines in the adjuvant setting can elucidate whether changes in cytokine levels result from drug-host or drug-tumor interactions, and may reveal biomarkers to guide patient selection for adjuvant treatment. Methods: In the ECOG-ACRIN 2805 (ASSURE) trial, patients with resected RCC were randomized to sunitinib, sorafenib, or placebo. Plasma was collected at start of treatment and 4 or 6 weeks after treatment initiation. All paired samples available by July 2010 were analyzed, corresponding to 413 patients. We analyzed VEGF, PlGF, sFlt1, KDR/sVEGFR-2, Ang2, bFGF, HGF, IFNg, IL8, CXCL9, CXCL10, and CXCL11. Mixed effects models were used to test for changes from baseline. Cox models were used to assess associations between disease-free survival (DFS) and angiogenic factor and cytokine levels. Results: VEGF and PlGF increased after 4 weeks on either treatment (p < 0.0001 for both), and at 6 weeks VEGF and PIGF levels returned to baseline for patients on sunitinib (corresponding to the 2 week break in the sunitinib schedule) but not sorafenib. Levels of sFLT-1 decreased after 4 weeks on suntinib and after 6 weeks on sorafenib (p < 0.0001). sVEGFR2 decreased after both 4 and 6 weeks of treatment on both sunitinib and sorafenib (p < 0.0001). Patients on placebo had no significant changes in circulating angiogenic factor or cytokine levels. CXCL-10 levels increased after 4 weeks on both sunitinib and sorafenib but not on placebo, and remained elevated at 6 weeks on sunitinib. Higher baseline CXCL-10 was associated with worse DFS (HR 1.41 per log increase in CXCL-10, Holm adjusted p-value 0.003, 95% CI 1.18-1.70). This remained significant after adjustment for T-stage, Fuhrman grade, and ECOG PS. Conclusions: Among patients treated with VEGFR TKIs in the adjuvant setting for RCC, drug-host interactions mediate changes in cytokines and angiogenic factors. Elevated CXCL-10 prior to treatment was associated with higher recurrence risk. Studies to understand the functional consequences of these changes are underway.
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Affiliation(s)
- Wenxin Xu
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
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20
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Harshman LC, Puligandla M, Haas NB, Allaf M, Drake CG, McDermott DF, Signoretti S, Cella D, Gupta RT, Shuch BM, Choueiri TK, Lara P, Kapoor A, Heng DYC, Jewett MA, Master VA, Michaelson MD, Leibovich BC, Maskens D, Carducci MA. PROSPER: A phase III randomized study comparing perioperative nivolumab (nivo) versus observation in patients with localized renal cell carcinoma (RCC) undergoing nephrectomy (ECOG-ACRIN 8143). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.tps684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS684 Background: The anti-PD-1 antibody nivo improves overall survival in metastatic RCC and is well tolerated. There is no standard adjuvant systemic therapy that increases overall survival (OS) over surgery alone for non-metastatic RCC. Priming the immune system prior to surgery with anti-PD-1 has shown an OS benefit compared to a pure adjuvant approach in mouse solid tumor models. The PROSPER RCC trial aims to improve clinical outcomes by priming the immune system prior to nephrectomy with neoadjuvant nivo and continued engagement with adjuvant blockade in patients with high risk M0 RCC compared to surgery alone. Methods: This global, unblinded, phase 3 National Clinical Trials Network study is currently accruing patients with clinical stage ≥T2 or node positive M0 RCC of any histology. Tumor biopsy prior to randomization is mandatory to ensure RCC and permits in depth correlative science. The investigational arm will receive two doses of nivo 240mg prior to surgery followed by adjuvant nivo for 9 months (q2 wks x 3 mo followed by 480mg q4 wks x 6 mo). The control arm will undergo standard nephrectomy followed by observation. Randomized patients are stratified by clinical T stage, node positivity, and histology. To enhance accrual and patient quality of life, key upcoming amendments are being instituted. These include biopsy only in the nivo arm, allowance of oligometastatic disease and bilateral renal masses that can be fully resected/ablated, and change of nivo dosing to q4 wks (1 neoadj; 9 adj). With accrual of 766 patients, there is 84.2% power to detect a 14.4% absolute benefit in recurrence-free survival (RFS) at 5 years assuming the ASSURE historical control of ~56% to 70% (HR = 0.70). The study is also powered to evaluate a significant increase in overall survival (HR 0.67). Safety, feasibility, and quality of life endpoints critical to adjuvant therapy considerations are incorporated. PROSPER RCC embeds a wealth of translational work aimed at investigating the impact of the baseline immune milieu, the changes induced by neoadjuvant anti-PD-1 priming, and how both correlate with clinical outcomes. Clinical trial information: NCT03055013.
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Affiliation(s)
| | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
| | | | - Charles G. Drake
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | | | | | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Primo Lara
- University of California, Davis, Sacramento, CA
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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21
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Zwicker JI, Schlechter BL, Stopa JD, Liebman HA, Aggarwal A, Puligandla M, Caughey T, Bauer KA, Kuemmerle N, Wong E, Wun T, McLaughlin M, Hidalgo M, Neuberg D, Furie B, Flaumenhaft R. Targeting protein disulfide isomerase with the flavonoid isoquercetin to improve hypercoagulability in advanced cancer. JCI Insight 2019; 4:125851. [PMID: 30652973 PMCID: PMC6478409 DOI: 10.1172/jci.insight.125851] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [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] [Received: 10/26/2018] [Accepted: 01/14/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Protein disulfide isomerase (PDI) is a thiol isomerase secreted by vascular cells that is required for thrombus formation. Quercetin flavonoids inhibit PDI activity and block platelet accumulation and fibrin generation at the site of a vascular injury in mouse models, but the clinical effect of targeting extracellular PDI in humans has not been studied. METHODS We conducted a multicenter phase II trial of sequential dosing cohorts to evaluate the efficacy of targeting PDI with isoquercetin to reduce hypercoagulability in cancer patients at high risk for thrombosis. Patients received isoquercetin at 500 mg (cohort A, n = 28) or 1000 mg (cohort B, n = 29) daily for 56 days, with laboratory assays performed at baseline and the end of the study, along with bilateral lower extremity compression ultrasound. The primary efficacy endpoint was a reduction in D-dimer, and the primary clinical endpoint included pulmonary embolism or proximal deep vein thrombosis. RESULTS The administration of 1000 mg isoquercetin decreased D-dimer plasma concentrations by a median of -21.9% (P = 0.0002). There were no primary VTE events or major hemorrhages observed in either cohort. Isoquercetin increased PDI inhibitory activity in plasma (37.0% in cohort A, n = 25, P < 0.001; 73.3% in cohort B, n = 22, P < 0.001, respectively). Corroborating the antithrombotic efficacy, we also observed a significant decrease in platelet-dependent thrombin generation (cohort A median decrease -31.1%, P = 0.007; cohort B median decrease -57.2%, P = 0.004) and circulating soluble P selectin at the 1000 mg isoquercetin dose (median decrease -57.9%, P < 0.0001). CONCLUSIONS Isoquercetin targets extracellular PDI and improves markers of coagulation in advanced cancer patients. TRIAL REGISTRATION Clinicaltrials.gov NCT02195232. FUNDING Quercegen Pharmaceuticals; National Heart, Lung, and Blood Institute (NHLBI; U54HL112302, R35HL135775, and T32HL007917); and NHLBI Consortium Linking Oncology and Thrombosis (U01HL143365).
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Affiliation(s)
- Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis and
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin L. Schlechter
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Howard A. Liebman
- Jane Anne Nohl Division of Hematology, University of Southern California, Los Angeles, California, USA
| | | | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Kenneth A. Bauer
- Division of Hemostasis and Thrombosis and
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy Kuemmerle
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Ellice Wong
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ted Wun
- Division of Hematology Oncology, University of California Davis School of Medicine, VA Northern California Health Care System, Sacramento, California, USA
| | | | - Manuel Hidalgo
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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22
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Narayan V, Puligandla M, Haas NB, Subramanian P, DiPaola RS, Uzzo R. Patterns of Relapse and Implications for Post-Nephrectomy Surveillance in Patients with High Risk Nonclear Cell Renal Cell Carcinoma: Subgroup Analysis of the Phase 3 ECOG-ACRIN E2805 Trial. J Urol 2019; 201:62-68. [PMID: 30130544 DOI: 10.1016/j.juro.2018.08.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The natural history of nonclear cell renal cell carcinoma following surgery with curative intent remains poorly defined with postoperative surveillance informed by guidelines largely intended for clear cell renal cell carcinoma. We evaluated relapse patterns and potential implications for post-nephrectomy surveillance in patients with nonclear cell renal cell carcinoma enrolled in the E2805 trial, the largest randomized trial of adjuvant antiangiogenic therapy of high risk renal cell carcinoma. MATERIALS AND METHODS We retrospectively analyzed the records of patients with completely resected nonclear cell renal cell carcinoma. Participants received up to 54 weeks of postoperative therapy with sunitinib, sorafenib or placebo and underwent surveillance imaging at standardized intervals for 10 years. For recurrence rates by site the cumulative incidence was estimated, accounting for competing risks. The adequacy of strict adherence to post-nephrectomy surveillance guidelines was evaluated. RESULTS A total of 403 patients with nonclear cell renal cell carcinoma were enrolled in the study. During a median followup of 6.2 years 36% of nonclear cell renal cell carcinomas recurred. Five-year recurrence rates were comparable for nonclear and clear cell renal cell carcinoma in the 1,541 patients, including 34.6% (95% CI 29.8-39.4) and 39.5% (95% CI 36.9-42.1), respectively. However, patients with nonclear cell renal cell carcinoma were significantly more likely to have abdominal sites of relapse (5-year recurrence rate 26.4% vs 18.2%, p = 0.0008) and significantly less likely to experience relapse in the chest (5-year recurrence rate 13.7% vs 20.9%, p = 0.0005). Current surveillance guidelines would potentially capture approximately 90% of relapses at any site. CONCLUSIONS Nonclear cell renal cell carcinoma may show a distinct pattern of relapse compared to clear cell renal cell carcinoma. Our findings emphasize the importance of cross-sectional, long-term imaging in patients with high risk, resected, nonclear cell renal cell carcinoma.
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Affiliation(s)
| | | | - Naomi B Haas
- Abramson Cancer Center, Philadelphia, Pennsylvania
| | | | | | - Robert Uzzo
- Fox Chase Cancer Center, Philadelphia, Pennsylvania
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23
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Poluben L, Puligandla M, Neuberg D, Bryke CR, Hsu Y, Shumeiko O, Yuan X, Voznesensky O, Pihan G, Adam M, Fraenkel E, Rasnic R, Linial M, Klymenko S, Balk SP, Fraenkel PG. Characteristics of myeloproliferative neoplasms in patients exposed to ionizing radiation following the Chernobyl nuclear accident. Am J Hematol 2019; 94:62-73. [PMID: 30295334 DOI: 10.1002/ajh.25307] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 12/20/2022]
Abstract
Myeloproliferative neoplasms (MPNs) driver mutations are usually found in JAK2, MPL, and CALR genes; however, 10%-15% of cases are triple negative (TN). A previous study showed lower rate of JAK2 V617F in primary myelofibrosis patients exposed to low doses of ionizing radiation (IR) from Chernobyl accident. To examine distinct driver mutations, we enrolled 281 Ukrainian IR-exposed and unexposed MPN patients. Genomic DNA was obtained from peripheral blood leukocytes. JAK2 V617F, MPL W515, types 1- and 2-like CALR mutations were identified by Sanger Sequencing and real time polymerase chain reaction. Chromosomal alterations were assessed by oligo-SNP microarray platform. Additional genetic variants were identified by whole exome and targeted sequencing. Statistical significance was evaluated by Fisher's exact test and Wilcoxon's rank sum test (R, version 3.4.2). IR-exposed MPN patients exhibited a different genetic profile vs unexposed: lower rate of JAK2 V617F (58.4% vs 75.4%, P = .0077), higher rate of type 1-like CALR mutation (12.2% vs 3.1%, P = .0056), higher rate of TN cases (27.8% vs 16.2%, P = .0366), higher rate of potentially pathogenic sequence variants (mean numbers: 4.8 vs 3.1, P = .0242). Furthermore, we identified several potential drivers specific to IR-exposed TN MPN patients: ATM p.S1691R with copy-neutral loss of heterozygosity at 11q; EZH2 p.D659G at 7q and SUZ12 p.V71 M at 17q with copy number loss. Thus, IR-exposed MPN patients represent a group with distinct genomic characteristics worthy of further study.
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Affiliation(s)
- Larysa Poluben
- Division of Hematology/Oncology Cancer Research Institute, Beth Israel Deaconess Medical Center Boston Massachusetts
- National Research Center for Radiation Medicine Kyiv Ukraine
| | | | - Donna Neuberg
- Dana‐Farber/Harvard Cancer Center Boston Massachusetts
| | - Christine R. Bryke
- Division of Clinical Pathology Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Yahsuan Hsu
- Division of Clinical Pathology Beth Israel Deaconess Medical Center Boston Massachusetts
| | | | - Xin Yuan
- Division of Hematology/Oncology Cancer Research Institute, Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Olga Voznesensky
- Division of Hematology/Oncology Cancer Research Institute, Beth Israel Deaconess Medical Center Boston Massachusetts
| | - German Pihan
- Division of Clinical Pathology Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Miriam Adam
- Department of Biological Engineering Massachusetts Institute of Technology Cambridge Massachusetts
| | - Ernest Fraenkel
- Department of Biological Engineering Massachusetts Institute of Technology Cambridge Massachusetts
| | - Roni Rasnic
- School of Computer Science and Engineering & Department of Biological Chemistry Hebrew University Jerusalem Israel
| | - Michal Linial
- School of Computer Science and Engineering & Department of Biological Chemistry Hebrew University Jerusalem Israel
| | - Sergiy Klymenko
- National Research Center for Radiation Medicine Kyiv Ukraine
| | - Steven P. Balk
- Division of Hematology/Oncology Cancer Research Institute, Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Paula G. Fraenkel
- Division of Hematology/Oncology Cancer Research Institute, Beth Israel Deaconess Medical Center Boston Massachusetts
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Carney BJ, Uhlmann EJ, Puligandla M, Mantia C, Weber GM, Neuberg DS, Zwicker JI. Intracranial hemorrhage with direct oral anticoagulants in patients with brain tumors. J Thromb Haemost 2019; 17:72-76. [PMID: 30450803 DOI: 10.1111/jth.14336] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [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] [Received: 08/28/2018] [Indexed: 11/29/2022]
Abstract
Essentials Intracranial hemorrhage (ICH) is common in patients with brain tumors. We compared rates of ICH with DOACs and low molecular weight heparin. DOACs were associated with a lower incidence of ICH in primary brain tumors. DOACs appear safe to administer to patients with brain tumors. SUMMARY: Background Direct oral anticoagulants (DOACs) are efficacious in the treatment of cancer-associated thrombosis but are associated with an increased risk of hemorrhage compared with low-molecular-weight heparin in certain malignancies. Whether the DOACs increase the incidence of intracranial hemorrhage (ICH) in patients with brain tumors is not established. Objectives To determine the cumulative incidence of ICH in DOACs compared with Low-molecular-weight heparin (LMWH) in patients with brain tumors and venous thromboembolism. Patients and methods A retrospective comparative cohort study was performed. Radiographic images for all ICH events were reviewed and the primary endpoint was cumulative incidence of ICH at 12 months following initiation of anticoagulation. Results and conclusions A total of 172 patients with brain tumors were evaluated (42 DOAC and 131 LMWH). In the primary brain tumor cohort (n = 67), the cumulative incidence of any ICH was 0% in patients receiving DOACs vs. 36.8% (95% confidence interval [CI], 22.3-51.3%) in those treated with LMWH, with a major ICH incidence of 18.2% (95% CI, 8.4-31.0). In the brain metastases cohort (n = 105), DOACs did not increase the risk of any ICH relative to enoxaparin, with an incidence of 27.8% (95% CI, 5.5-56.7%) compared with 52.9% (95% CI, 37.4-66.2%). Similarly, DOAC did not increase the incidence of major ICH in brain metastases, with a cumulative incidence 11.1% (95% CI, 0.5-40.6%) vs. 17.8% (95% CI, 10.2-27.2%). We conclude that DOACs are not associated with an increased incidence of ICH relative to LMWH in patients with brain metastases or primary brain tumors.
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Affiliation(s)
- B J Carney
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - E J Uhlmann
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - M Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - C Mantia
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - G M Weber
- Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center and Center for Biomedical Informatics, Boston, MA, USA
| | - D S Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - J I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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25
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Athale UH, Puligandla M, Stevenson KE, Asselin B, Clavell LA, Cole PD, Kelly KM, Laverdiere C, Leclerc JM, Michon B, Schorin MA, Sulis ML, Welch JJG, Harris MH, Neuberg DS, Sallan SE, Silverman LB. Outcome of children and adolescents with Down syndrome treated on Dana-Farber Cancer Institute Acute Lymphoblastic Leukemia Consortium protocols 00-001 and 05-001. Pediatr Blood Cancer 2018; 65:e27256. [PMID: 29878490 DOI: 10.1002/pbc.27256] [Citation(s) in RCA: 21] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/10/2018] [Accepted: 04/20/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children and adolescents with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) are reported to have increased relapse rates and therapy-related mortality (TRM). Treatment regimens for DS-ALL patients often include therapy modifications. Dana-Farber Cancer Institute (DFCI) ALL Consortium protocols have used same risk-stratified treatment for patients with and without DS. PROCEDURES We compared clinical and outcome data of DS (n = 38) and non-DS (n = 1,248) patients enrolled on two consecutive DFCI ALL trials 00-001 (2000-2004) and 05-001 (2005-2011) with similar risk adapted therapy regardless of DS status. RESULTS There was no difference in demographic or presenting clinical features between two groups except absence of T-cell phenotype and lower frequency of hyperdiploidy in DS-ALL group. All DS-ALL patients achieved complete remission; four relapsed and one subsequently died. There was no TRM in DS-ALL patients. DS-ALL patients had significantly higher rates of mucositis (52% vs. 12%, p < 0.001), non-CNS thrombosis (18% vs. 8%; p = 0.036), and seizure (16% vs. 5%, p = 0.010). Compared to non-DS-ALL patients, DS-ALL patients had a higher incidence of infections during all therapy phases. The 5-year event-free and overall survival rates of DS-ALL patients were similar to non-DS-ALL patients (91% [95% confidence interval (CI), 81-100] vs. 84% [95% CI, 82-86]; 97% [95% CI, 92-100] vs. 91% [95% CI, 90-93]). CONCLUSION The low rates of relapse and TRM indicate that uniform risk-stratified therapy for DS-ALL and non-DS-ALL patients on DFCI ALL Consortium protocols was safe and effective, although the increased rate of toxicity in the DS-ALL patients highlights the importance of supportive care during therapy.
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Affiliation(s)
- Uma H Athale
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kristen E Stevenson
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Barbara Asselin
- Department of Pediatrics, University of Rochester Medical Center and School of Medicine, Rochester, NY, USA
| | - Luis A Clavell
- Department of Pediatrics, San Jorge Children's Hospital, San Juan, Puerto Rico
| | - Peter D Cole
- Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Division of Pediatric Hematology/Oncology, Jacob's School of Medicine and Biomedical Sciences, University of Buffalo, NY, USA
| | - Caroline Laverdiere
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Jean-Marie Leclerc
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Bruno Michon
- Pediatrics, Centre Hospitalier Universitaire de Quebec, Sainte-Foy, QC, Canada
| | | | - Maria Luisa Sulis
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, USA
| | - Jennifer J G Welch
- Pediatric Hematology Oncology, Hasbro Children's Hospital/Brown University, Providence, RI, USA
| | - Marian H Harris
- Department of Pathology, Boston Children's Hospital, Boston, MA, USA
| | - Donna S Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stephen E Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA, USA
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Buti S, Puligandla M, Bersanelli M, DiPaola RS, Manola J, Taguchi S, Haas NB. Validation of a new prognostic model to easily predict outcome in renal cell carcinoma: the GRANT score applied to the ASSURE trial population. Ann Oncol 2018; 29:1604. [PMID: 29608641 DOI: 10.1093/annonc/mdx799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Poluben L, Puligandla M, Neuberg D, Bryke CR, Hsu N, Klymenko S, Mishcheniuk O, Shumeiko O, Balk S, Yuan X, Voznesensky O, Pihan G, Adam M, Fraenkel E, Fraenkel PG. Abstract 3093: Genomic characteristics of myeloproliferative neoplasms in patients exposed to ionizing radiation following the Chernobyl nuclear accident. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-3093] [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: 11/16/2022]
Abstract
Abstract
Philadelphia-chromosome negative chronic myeloproliferative neoplasms (MPNs) are a unique group of hematological malignancies including Polycytemia Vera (PV), Essential Thrombocythemia (ET) and Primary Myelofibrosis (PMF) characterized by impaired function and structure of bone marrow. MPN driver mutations are usually found in Janus Kinase 2 (JAK2), Thrombopoietin Receptor (MPL) and Calreticulin (CALR) genes, however, 10-15% of MPN cases are triple negative (TN) for these mutations. A previous study showed a lower rate of JAK2 V617F mutations in PMF patients exposed to sublethal doses of ionizing radiation (IR) from the Chernobyl accident in Ukraine. We hypothesized a lower rate of the usual driver mutations in IR-exposed MPN patients. To examine whether there are distinct driver mutations, 281 Ukrainian IR-exposed and unexposed MPN patients, were enrolled in the study. Their records were reviewed for classification by the WHO 2016 MPN criteria. Genomic DNA was obtained from the peripheral blood leukocytes of 281 MPN patients to identify JAK2 V617F, MPL W515, and type 1- and 2-like CALR mutations by allele-specific PCR, Sanger Sequencing and RT-PCR, respectively. Copy number alterations and copy-neutral loss of heterozygosity (cnLOH) were assessed in 30 PMF patients by high-density Affymetrix CytoScan HD oligo-SNP microarray platform. Whole exome sequencing was used to identify additional genetic variants in these 30 PMF patients. Statistical significance for categorical variables and continuous variables were evaluated by Fisher's exact test and Wilcoxon's rank sum test using Statistical Analysis R, version 3.4.2. Clinical features of exposed and unexposed MPN patients were similar. More PMF IR-exposed patients were transfusion dependent (32.4%) than PMF unexposed patients (14.1%) (p = 0.04). JAK2 V617F was detected in 58% of IR-exposed and in 74% of unexposed MPN patients (p = 0.007). JAK2 V617F was also less frequent in IR-exposed PV patients, but not statistically significant. Type 1-like CALR mutation was detected in 12% of exposed and 3% of unexposed patients (p = 0.033). Overall, exposed patients were TN in 28% of IR-patients versus 16% of unexposed patients (p = 0.027). Among other genetic variants, ATM S1691R mutation with cnLOH at 11q22.3 was identified in one TN IR-exposed PMF patient. Previously the mutation was reported, but not in MPN patients. Missense mutations in EZH2 at 7q36.1 and SUZ12 at 17q11.2 with copy number loss were also identified in TN IR-exposed PMF patients. Our results confirm a lower rate of JAK2 V617F and higher rate of TN cases among IR-exposed MPN patients versus unexposed. We also demonstrated a higher frequency of type 1-like CALR mutation in IR-exposed MPN patients and new potential MPN driver mutations. Thus, IR-exposed MPN patients represent a disease group with distinct genomic characteristics worthy of further study.
Citation Format: Larysa Poluben, Maneka Puligandla, Donna Neuberg, Christine R. Bryke, Nancy Hsu, Sergiy Klymenko, Olga Mishcheniuk, Oleksandr Shumeiko, Steven Balk, Xin Yuan, Olga Voznesensky, German Pihan, Miriam Adam, Ernest Fraenkel, Paula G. Fraenkel. Genomic characteristics of myeloproliferative neoplasms in patients exposed to ionizing radiation following the Chernobyl nuclear accident [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3093.
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Affiliation(s)
| | | | | | | | - Nancy Hsu
- 1Beth Israel Deaconess Medical Center, Boston, MA
| | - Sergiy Klymenko
- 3National Research Center for Radiation Medicine, Kyiv, Ukraine
| | | | | | - Steven Balk
- 1Beth Israel Deaconess Medical Center, Boston, MA
| | - Xin Yuan
- 1Beth Israel Deaconess Medical Center, Boston, MA
| | | | - German Pihan
- 1Beth Israel Deaconess Medical Center, Boston, MA
| | - Miriam Adam
- 4Massachusetts Institute of Technology, Cambridge, MA
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Narayan V, Puligandla M, Subramanian P, Uzzo R, DiPaola RS, Haas NB. Patterns of relapse and implications for post-nephrectomy surveillance for patients with high-risk non-clear cell renal cell carcinoma: Subgroup analysis of the phase 3 ECOG-ACRIN E2805 trial. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.4564] [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: 11/20/2022] Open
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Harshman LC, Puligandla M, Haas NB, Drake CG, McDermott DF, Signoretti S, Cella D, Gupta RT, Wagner LI, Shuch BM, Lara P, Choueiri TK, Kapoor A, Heng DYC, Michaelson MD, Jewett MA, Van Allen EM, George DJ, Carducci MA, Allaf M. PROSPER: A phase III randomized study comparing perioperative nivolumab (nivo) vs. observation in patients with localized renal cell carcinoma (RCC) undergoing nephrectomy (ECOG-ACRIN 8143). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.tps4597] [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: 11/20/2022] Open
Affiliation(s)
| | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
| | - Charles G. Drake
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | | | | | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Lynne I. Wagner
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Primo Lara
- University of California, Davis, Sacramento, CA
| | | | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Hoffman-Censits J, Puligandla M, Trabulsi E, Plimack E, Kessler E, Matin SF, Godoy G, Alva A, Hahn NM, Carducci M, Margulis V. LBA26 PHASE II TRIAL OF NEOADJUVANT CHEMOTHERAPY FOLLOWED BY EXTIRPATIVE SURGERY FOR PATIENTS WITH HIGH GRADE UPPER TRACT UROTHELIAL CARCINOMA (HG UTUC): RESULTS FROM ECOG-ACRIN 8141. J Urol 2018. [DOI: 10.1016/j.juro.2018.03.098] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McQuade JL, Daniel CR, Hess KR, Mak C, Wang DY, Rai RR, Park JJ, Haydu LE, Spencer C, Wongchenko M, Lane S, Lee DY, Kaper M, McKean M, Beckermann KE, Rubinstein SM, Rooney I, Musib L, Budha N, Hsu J, Nowicki TS, Avila A, Haas T, Puligandla M, Lee S, Fang S, Wargo JA, Gershenwald JE, Lee JE, Hwu P, Chapman PB, Sosman JA, Schadendorf D, Grob JJ, Flaherty KT, Walker D, Yan Y, McKenna E, Legos JJ, Carlino MS, Ribas A, Kirkwood JM, Long GV, Johnson DB, Menzies AM, Davies MA. Association of body-mass index and outcomes in patients with metastatic melanoma treated with targeted therapy, immunotherapy, or chemotherapy: a retrospective, multicohort analysis. Lancet Oncol 2018; 19:310-322. [PMID: 29449192 PMCID: PMC5840029 DOI: 10.1016/s1470-2045(18)30078-0] [Citation(s) in RCA: 440] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Obesity has been linked to increased mortality in several cancer types; however, the relation between obesity and survival outcomes in metastatic melanoma is unknown. The aim of this study was to examine the association between body-mass index (BMI) and progression-free survival or overall survival in patients with metastatic melanoma who received targeted therapy, immunotherapy, or chemotherapy. METHODS This retrospective study analysed independent cohorts of patients with metastatic melanoma assigned to treatment with targeted therapy, immunotherapy, or chemotherapy in randomised clinical trials and one retrospective study of patients treated with immunotherapy. Patients were classified according to BMI, following the WHO definitions, as underweight, normal, overweight, or obese. Patients without BMI and underweight patients were excluded. The primary outcomes were the associations between BMI and progression-free survival or overall survival, stratified by treatment type and sex. We did multivariable analyses in the independent cohorts, and combined adjusted hazard ratios in a mixed-effects meta-analysis to provide a precise estimate of the association between BMI and survival outcomes; heterogeneity was assessed with meta-regression analyses. Analyses were done on the predefined intention-to-treat population in the randomised controlled trials and on all patients included in the retrospective study. FINDINGS The six cohorts consisted of a total of 2046 patients with metastatic melanoma treated with targeted therapy, immunotherapy, or chemotherapy between Aug 8, 2006, and Jan 15, 2016. 1918 patients were included in the analysis. Two cohorts containing patients from randomised controlled trials treated with targeted therapy (dabrafenib plus trametinib [n=599] and vemurafenib plus cobimetinib [n=240]), two cohorts containing patients treated with immunotherapy (one randomised controlled trial of ipilimumab plus dacarbazine [n=207] and a retrospective cohort treated with pembrolizumab, nivolumab, or atezolizumab [n=331]), and two cohorts containing patients treated with chemotherapy (two randomised controlled trials of dacarbazine [n=320 and n=221]) were classified according to BMI as normal (694 [36%] patients), overweight (711 [37%]), or obese (513 [27%]). In the pooled analysis, obesity, compared with normal BMI, was associated with improved survival in patients with metastatic melanoma (average adjusted hazard ratio [HR] 0·77 [95% CI 0·66-0·90] for progression-free survival and 0·74 [0·58-0·95] for overall survival). The survival benefit associated with obesity was restricted to patients treated with targeted therapy (HR 0·72 [0·57-0·91] for progression-free survival and 0·60 [0·45-0·79] for overall survival) and immunotherapy (HR 0·75 [0·56-1·00] and 0·64 [0·47-0·86]). No associations were observed with chemotherapy (HR 0·87 [0·65-1·17, pinteraction=0·61] for progression-free survival and 1·03 [0·80-1·34, pinteraction=0·01] for overall survival). The association of BMI with overall survival for patients treated with targeted and immune therapies differed by sex, with inverse associations in men (HR 0·53 [0·40-0·70]), but no associations observed in women (HR 0·85 [0·61-1·18, pinteraction=0·03]). INTERPRETATION Our results suggest that in patients with metastatic melanoma, obesity is associated with improved progression-free survival and overall survival compared with those outcomes in patients with normal BMI, and that this association is mainly seen in male patients treated with targeted or immune therapy. These results have implications for the design of future clinical trials for patients with metastatic melanoma and the magnitude of the benefit found supports further investigation of the underlying mechanism of these associations. FUNDING ASCO/CCF Young Investigator Award, ASCO/CCF Career Development Award, MD Anderson Cancer Center (MDACC) Melanoma Moonshot Program, MDACC Melanoma SPORE, and the Dr Miriam and Sheldon G Adelson Medical Research Foundation.
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Affiliation(s)
- Jennifer L. McQuade
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Carrie R. Daniel
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Kenneth R. Hess
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Carmen Mak
- Independent Statistical Consultant, Westfield, NJ, USA 07091
| | - Daniel Y. Wang
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Rajat R. Rai
- Melanoma Institute Australia and The University of Sydney; 40 Rocklands Rd, North Sydney 2060, NSW, Australia
| | - John J. Park
- Crown Princess Mary Cancer Centre, Westmead Hospital, 166-174 Hawkesbury Rd, Westmead NSW 2145, Sydney, Australia
| | - Lauren E. Haydu
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Christine Spencer
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | | | - Stephen Lane
- Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ, USA 07936
| | - Dung-Yang Lee
- Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ, USA 07936
| | - Mathilde Kaper
- Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ, USA 07936
| | - Meredith McKean
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Kathryn E Beckermann
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Samuel M. Rubinstein
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Isabelle Rooney
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Luna Musib
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Nageshwar Budha
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Jessie Hsu
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Theodore S. Nowicki
- University of California Los Angeles Medical Center, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | | | - Tomas Haas
- Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ, USA 07936
| | - Maneka Puligandla
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 USA
| | - Sandra Lee
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 USA
| | - Shenying Fang
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Jennifer A. Wargo
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Jeffrey E Gershenwald
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Jeffrey E. Lee
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Patrick Hwu
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
| | - Paul B. Chapman
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jeffrey A. Sosman
- Northwestern University, 675 N. Saint Clair St., Galter Pavilion, Chicago, IL 60611, USA
| | - Dirk Schadendorf
- University Hospital Essen & German Cancer Consortium, Hufelandstraße 55, 45147, Essen, Germany
| | - Jean-Jacques Grob
- Centre Hospitalo-Universitaire Timone, Aix Marseille University, 264 Rue St Pierre, 13885 Marseille CEDEX 05, France
| | - Keith T. Flaherty
- Massachusetts General Hospital Cancer Center, 55 Fruit Street, Boston, MA, USA 02114
| | - Dana Walker
- Bristol-Myers Squibb, 345 Park Ave, New York, NY 10154, USA
| | - Yibing Yan
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Edward McKenna
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Jeffrey J. Legos
- Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ, USA 07936
| | - Matteo S. Carlino
- Melanoma Institute Australia and The University of Sydney; 40 Rocklands Rd, North Sydney 2060, NSW, Australia,Crown Princess Mary Cancer Centre, Westmead Hospital, 166-174 Hawkesbury Rd, Westmead NSW 2145, Sydney, Australia
| | - Antoni Ribas
- University of California Los Angeles Medical Center, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - John M. Kirkwood
- Hillman University of Pittsburgh Medical Center Cancer Center, 5117 Centre Avenue, Pittsburgh, PA 15232, USA
| | - Georgina V. Long
- Melanoma Institute Australia and The University of Sydney; 40 Rocklands Rd, North Sydney 2060, NSW, Australia,Royal North Shore and Mater Hospitals Reserve Rd, St Leonards NSW 2065, Australia
| | - Douglas B. Johnson
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Alexander M Menzies
- Melanoma Institute Australia and The University of Sydney; 40 Rocklands Rd, North Sydney 2060, NSW, Australia,Royal North Shore and Mater Hospitals Reserve Rd, St Leonards NSW 2065, Australia
| | - Michael A. Davies
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA 77030
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Harshman LC, Puligandla M, Haas NB, Allaf M, Drake CG, McDermott DF, Signoretti S, Cella D, Gupta RT, Bhatt RS, Van Allen EM, Choueiri TK, Lara P, Kapoor A, Heng DYC, Shuch BM, Jewett MA, George DJ, Michaelson MD, Carducci MA. A phase III randomized study comparing perioperative nivolumab vs. observation in patients with localized renal cell carcinoma undergoing nephrectomy (PROSPER RCC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.tps710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS710 Background: The anti-PD-1 antibody nivolumab (nivo) improves overall survival (OS) in metastatic treatment refractory RCC and is generally tolerable. In 2017, there is no standard adjuvant therapy proven to increase OS over surgery alone in non-metastatic (M0) disease. Mouse solid tumor models have revealed an OS benefit with a short course of neoadjuvant PD-1 blockade compared to adjuvant therapy. Two ongoing phase 2 studies of perioperative nivo in RCC patients (pts) are showing preliminary feasibility and safety with no surgical delays/complications. PROSPER RCC will examine if the addition of perioperative nivo to radical or partial nephrectomy can improve clinical outcomes in pts with locally advanced RCC. We are implementing a three-pronged, multidisciplinary approach of presurgical priming with nivo followed by resection and adjuvant PD-1 blockade with the goal of increasing cure and recurrence-free survival (RFS) rates in M0 RCC. Methods: Tumor biopsy prior to randomization is mandatory to ensure RCC diagnosis but will also permit unparalleled correlative science in this global, unblinded, phase 3 National Clinical Trials Network randomized study. 766 pts with clinical stage ≥T2 or any node positive M0 RCC of any histology will be enrolled. The study arm will receive nivo 240mg IV for 2 doses prior to surgery followed by adjuvant dosing for 9 mo (q2 wks x 3 mo followed by q4 wks x 6 mo). The control arm will undergo the current standard of care: surgical resection followed by observation. Pts are stratified by clinical T stage, node positivity, and histology. There is 84.2% power to detect a 14.4% absolute increase in the primary endpoint of RFS from the ASSURE historical control of 55.8% to 70.2% at 5 yrs (HR 0.70). The study is also powered to detect a significant OS benefit (HR 0.67). Safety, feasibility, and quality of life are key secondary endpoints. PROSPER RCC exemplifies team science and incorporates a host of correlative work to examine the significance of the baseline immune milieu and changes induced by neoadjuvant priming and to identify predictive gene expression patterns. New collaborations welcomed. Clinical trial information: NCT03055013.
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Affiliation(s)
| | | | - Naomi B. Haas
- Penn Medicine Abramson Cancer Center, Philadelphia, PA
| | | | - Charles G. Drake
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | | | | | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Toni K. Choueiri
- Dana-Farber Cancer Institute/ Brigham and Women’s Hospital/ Harvard Medical School, Boston, MA
| | - Primo Lara
- University of California Davis, Sacramento, CA
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Gupta N, Goumnerova L, Ayyanar K, Gump W, Bendel A, Nagib M, Bowers D, Weprin B, Bredlau AL, Gururangan S, Fuchs H, Cohen K, Jallo G, Dorris K, Handler M, Comito M, Dias M, Fangusaro JR, Goldman S, Tomita T, Alden T, DiPatri A, Gardner S, Karajannis M, Harter D, Gauvain K, Limbrick D, Leonard J, Geyer JR, Leary S, Browd S, Khatib Z, Ragheb J, Bhatia S, MacDonald T, Aguilera D, Brahma B, Manley P, Chi S, Mueller S, Banerjee A, Murray J, Nazemi K, Baird L, Robison N, Kiehna E, Krieger M, Sandler E, Aldana P, Wang J, Sood S, Neuberg D, Puligandla M, Greenspan L, Wright K, Prados M, Bandopadhayay P, Ligon K, Kieran M. PDCT-20. FEASIBILITY AND SAFETY OF SURGICAL BIOPSY FOR PATIENTS WITH DIPG: PRELIMINARY RESULTS FROM DIPG-BATS. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Buti S, Puligandla M, Bersanelli M, DiPaola RS, Manola J, Taguchi S, Haas NB. Validation of a new prognostic model to easily predict outcome in renal cell carcinoma: the GRANT score applied to the ASSURE trial population. Ann Oncol 2017; 28:2747-2753. [PMID: 28945839 PMCID: PMC5815563 DOI: 10.1093/annonc/mdx492] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [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: 02/03/2023] Open
Abstract
Background Prognostic scores have been developed to estimate the risk of recurrence and the probability of survival after nephrectomy for renal cell carcinoma (RCC). The use of these tools, despite being helpful to plan a customized schedule of follow-up, to the patient's tailored counselling and to select individuals who could potentially benefit from adjuvant treatment, currently is not routine, due to their relative complexity and to the lack of histological data (i.e. necrosis). Patients and methods We developed a simple score called GRade, Age, Nodes and Tumor (GRANT) based on four easily obtained parameters: Fuhrman grade, age, pathological nodal status and pathological tumor size. Patients with 0 or 1 factor are classified as favorable risk, whereas patients with two or more risk factors as unfavorable risk. The large population of RCC patients from the ASSURE adjuvant trial was used as independent dataset for this external validation, to investigate the prognostic value of the new score in terms of disease-free survival and overall survival and to evaluate its possible application as predictive tool. Statistical analyses were carried out by the Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute (Boston, USA) for the ASSURE trial patients' population. Results The performance of the new model is similar to that of the already validated score systems, but its strength, compared with the others already available, is the ease and clarity of its calculation, with great speed of use during the clinical practice. Limitations are the use of the Fuhrman nuclear grade, not valid for rare histologies, and the TNM classification modifications over time. Conclusion The GRANT score demonstrated its potential usefulness for clinical practice. ClinicalTrials.gov Identifier for the ASSURE trial NCT00326898.
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Affiliation(s)
- S Buti
- Medical Oncology Unit, University Hospital of Parma, Parma, Italy
| | - M Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston
| | - M Bersanelli
- Medical Oncology Unit, University Hospital of Parma, Parma, Italy.
| | - R S DiPaola
- Medical Oncology Unit, Medical Center, University of Kentucky, Lexington, USA
| | - J Manola
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston
| | - S Taguchi
- Department of Urology, The University of Tokyo, Tokyo, Japan
| | - N B Haas
- Abramson Cancer Center, Philadelphia, USA
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Jilaveanu LB, Puligandla M, Weiss SA, Wang XV, Zito C, Flaherty KT, Boeke M, Neumeister V, Camp RL, Adeniran A, Pins M, Manola J, DiPaola RS, Haas NB, Kluger HM. Tumor Microvessel Density as a Prognostic Marker in High-Risk Renal Cell Carcinoma Patients Treated on ECOG-ACRIN E2805. Clin Cancer Res 2017; 24:217-223. [PMID: 29066509 DOI: 10.1158/1078-0432.ccr-17-1555] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/29/2017] [Accepted: 10/20/2017] [Indexed: 01/10/2023]
Abstract
Purpose: Increased vascularity is a hallmark of renal cell carcinoma (RCC). Microvessel density (MVD) is one measurement of tumor angiogenesis; however, its utility as a biomarker of outcome is unknown. ECOG-ACRIN 2805 (E2805) enrolled 1,943 resected high-risk RCC patients randomized to adjuvant sunitinib, sorafenib, or placebo. We aimed to determine the prognostic and predictive role of MVD in RCC.Experimental Design: We obtained pretreatment primary RCC nephrectomy tissues from 822 patients on E2805 and constructed tissue microarrays. Using quantitative immunofluorescence, we measured tumor MVD as the area of CD34-expressing cells. We determined the association with disease-free survival (DFS), overall survival (OS), treatment arm, and clinicopathologic variables.Results: High MVD (above the median) was associated with prolonged OS for the entire cohort (P = 0.021) and for patients treated with placebo (P = 0.028). The association between high MVD and OS was weaker in patients treated with sunitinib or sorafenib (P = 0.060). MVD was not associated with DFS (P = 1.00). On multivariable analysis, MVD remained independently associated with improved OS (P = 0.013). High MVD correlated with Fuhrman grade 1-2 (P < 0.001), clear cell histology (P < 0.001), and absence of necrosis (P < 0.001) but not with gender, age, sarcomatoid features, lymphovascular invasion, or tumor size.Conclusions: High MVD in resected high-risk RCC patients is an independent prognostic, rather than predictive, biomarker of improved OS. Further studies should assess whether incorporating MVD into clinical models will enhance our ability to predict outcome and if low MVD can be used for selection of high-risk patients for adjuvant therapy trials. Clin Cancer Res; 24(1); 217-23. ©2017 AACR.
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Affiliation(s)
- Lucia B Jilaveanu
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah A Weiss
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Xin Victoria Wang
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher Zito
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Biology, University of Saint Joseph, School of Health and Natural Sciences, West Hartford, Connecticut
| | - Keith T Flaherty
- Division of Hematology/Oncology, Department of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Marta Boeke
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Veronique Neumeister
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Robert L Camp
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Adebowale Adeniran
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Pins
- Department of Pathology, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | - Judith Manola
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Naomi B Haas
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Harriet M Kluger
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.
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Harshman L, Drake C, Haas N, Manola J, Puligandla M, Signoretti S, Cella D, Gupta R, Bhatt R, Van Allen E, Lara P, Choueiri T, Kapoor A, Heng D, Shuch B, Jewett M, George D, Michaelson D, Carducci M, McDermott D, Allaf M. Transforming the Perioperative Treatment Paradigm in Non-Metastatic RCC-A Possible Path Forward. Kidney Cancer 2017; 1:31-40. [PMID: 30334002 PMCID: PMC6179104 DOI: 10.3233/kca-170010] [Citation(s) in RCA: 7] [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] [Indexed: 12/14/2022]
Abstract
In 2017, there is no adjuvant systemic therapy proven to increase overall survival in non-metastatic renal cell carcinoma (RCC). The anti-PD-1 antibody nivolumab improves overall survival in metastatic treatment refractory RCC and is generally tolerable. Mouse solid tumor models have revealed a benefit with a short course of neoadjuvant PD-1 blockade compared to adjuvant therapy. Two ongoing phase 2 studies of perioperative nivolumab in RCC patients have shown preliminary feasibility and safety with no surgical delays or complications. The recently opened PROSPER RCC trial (A Phase 3 RandOmized Study Comparing PERioperative Nivolumab vs. Observation in Patients with Localized Renal Cell Carcinoma Undergoing Nephrectomy; EA8143) will examine if the addition of perioperative nivolumab to radical or partial nephrectomy can improve clinical outcomes in patients with high risk localized and locally advanced RCC. With the goal of increasing cure and recurrence-free survival (RFS) rates in non-metastatic RCC, we are executing a three-pronged, multidisciplinary approach of presurgical priming with nivolumab followed by resection and adjuvant PD-1 blockade. We plan to enroll 766 patients with clinical stage ≥T2 or node positive M0 RCC of any histology in this global, randomized, unblinded, phase 3 National Clinical Trials Network study. The investigational arm will receive two doses of nivolumab 240 mg IV prior to surgery followed by adjuvant nivolumab for 9 months. The control arm will undergo the current standard of care: surgical resection followed by observation. Patients are stratified by clinical T stage, node positivity, and histology. The trial is powered to detect a 14.4% absolute benefit in the primary endpoint of RFS from the ASSURE historical control of 55.8% to 70.2% at 5 years (HR = 0.70). The study is also powered to detect a significant overall survival benefit (HR 0.67). Key safety, feasibility, and quality of life endpoints are incorporated. PROSPER RCC exemplifies team science with a host of planned correlative work to investigate the impact of the baseline immune milieu and changes after neoadjuvant priming on clinical outcomes.
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Affiliation(s)
- L.C. Harshman
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - C.G. Drake
- Division of Hematology/Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - N.B. Haas
- Division of Hematology/Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - J. Manola
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - M. Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S. Signoretti
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
| | - D. Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - R.T. Gupta
- Departments of Radiology and Surgery and The Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - R. Bhatt
- Division of Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - E. Van Allen
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - P. Lara
- University of California Davis School of Medicine, Sacramento, CA, USA
| | - T.K. Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - A. Kapoor
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - D.Y.C. Heng
- Tom Baker Cancer Center, Calgary, AB, Canada
| | - B. Shuch
- Division of Urology, Yale Cancer Institute, New Haven, CT, USA
| | - M. Jewett
- Departments of Surgery(Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - D. George
- Duke University Departments of Medicine, Surgery, and Pharmacology and Cancer Biology, Division of Medical Oncology, The Duke Cancer Institute, Durham, NC, USA
| | - D. Michaelson
- Genitourinary Cancer Center, Massachusetts General Hospital, Boston, MA, USA
| | - M.A. Carducci
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - D. McDermott
- Division of Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M. Allaf
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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Gupta N, Goumnerova L, Ayyanar K, Gump W, Bendel A, Nagib M, Bowers D, Weprin B, Bredlau AL, Gururangan S, Fuchs H, Cohen K, Jallo G, Dorris K, Handler M, Comito M, Dias M, Fangusaro J, Goldman S, Tomita T, Alden T, DiPatri A, Gardner S, Karajannis M, Harter D, Gauvain K, Limbrick D, Leonard J, Geyer R, Leary S, Browd S, Khatib Z, Ragheb J, Bhatia S, MacDonald T, Aguilera D, Brahma B, Manley P, Chi S, Mueller S, Banerjee A, Murray J, Nazemi K, Baird L, Robison N, Kiehna E, Krieger M, Sandler E, Aldana P, Wang J, Sood S, Neuberg D, Puligandla M, Greenspan L, Wright K, Prados M, Bandopadhayay P, Ligon K, Kieran M. TRTH-23. FEASIBILITY AND SAFETY OF SURGICAL BIOPSY FOR PATIENTS WITH DIPG: PRELIMINARY RESULTS FROM DIPG-BATS. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox083.234] [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: 11/14/2022] Open
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Khan SA, Puligandla M, Dahlberg SE, Masters GA, Langer CJ, Brahmer JR, Hanna NH, Bonomi P, Gerber DE, Johnson DH, Schiller JH, Ramalingam SS. Impact of prior radiation on survival in metastatic lung cancer ECOG-ACRIN trials. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.9051] [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: 11/20/2022] Open
Abstract
9051 Background: Up to 50% of advanced NSCLC patients receive radiation therapy at some point in their course. We sought to determine whether patients with prior radiation demonstrate altered outcomes on subsequent metastatic clinical trials. Methods: We reviewed 8 ECOG-ACRIN advanced non-small cell lung cancer studies conducted between 1993 and 2011 in which information was collected about receipt of prior radiation. Whether radiotherapy was given with curative or palliative intent, or to specific sites was not recorded. Median follow-up among all trials was 66 months. We used the log-rank, Wilcoxon and Fisher’s exact tests to compare patients, and Cox Model and Kaplan-Meier method to calculate survival. Results: 574/3041 (18.9%) patients had received prior radiation. These patients were more likely to be male (64% vs 58%), have squamous histology (20% vs 14%) and have had prior surgery (48% vs 33%) compared to those with no prior radiation. At registration, prior radiation patients were more likely to have an ECOG PS of 1 (66% vs 58%), while they were less likely to have a PS of 0 (24% vs 36%) or have a pleural effusion (23% vs 37%). Patients who received radiation were more likely to have been registered on to studies between 1993-1999 than 2000-2011 (69% vs 31%) (all p < 0.001). Median Overall Survival (OS) for patients with prior radiation was 7.6 months (range 7-8.3) vs 9.5 (9.1-9.8) for those without (p < 0.001). Median Progression Free Survival (PFS) for those with prior radiation was 3.5 months (3-3.9) vs 4.2 (4.1-4.4) for those without (p < 0.001). In multivariable analysis controlling for stage IIIB/IV, sex, PS, histology, and prior surgery, the impact of prior radiation on overall survival remained significant (p = 0.042, HR (95% CI) = 1.11 (1.00, 1.22)). Conclusions: Almost one-fifth of lung cancer patients on systemic therapy trials for advanced disease previously received radiation. They are more likely to be male, have squamous histology, have an ECOG PS of 1 and have had prior surgery. Prior radiation is significantly associated with inferior OS and PFS. For advanced NSCLC clinical trials, documentation of whether curative intent/palliative intent radiation was given and stratification by prior radiation exposure should be considered.
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Affiliation(s)
- Saad A. Khan
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | | | - Corey J. Langer
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA
| | - Julie R. Brahmer
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
| | - Nasser H. Hanna
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
| | | | - David E. Gerber
- The University of Texas Southwestern Medical Center, Dallas, TX
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Weiss SA, Puligandla M, Jilaveanu L, Haas NB, Wang XV, Zito C, Boeke M, Neumeister V, Manola J, DiPaola RS, Kluger HM. Microvessel density as a prognostic marker in high-risk renal cell carcinoma. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.4565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4565 Background: Increased vascularity is a hallmark of renal cell carcinomas (RCC), particularly clear cell RCC. The vascular endothelial growth factor (VEGF) pathway, implicated in tumor angiogenesis, is dysregulated in RCC. The phase 3 trial ECOG-ACRIN E2805 enrolled 1,943 patients (pts) with resected high-risk RCC (pT1b high grade to pT4 any grade or N any). Pts were randomized to adjuvant sunitinib, sorafenib, or placebo. Our aim was to determine the prognostic and predictive role of microvessel density (MVD), VEGF receptors, and ligands in nephrectomy specimens. Methods: We obtainedpre-treatment primary RCC tissue from 822 pts and built tissue microarrays using 3 cores from each sample. Using quantitative immunofluorescence we measured tumor MVD (area of CD34-expressing cells) and intensity of the VEGF/VEGF-R family (VEGF-R1, R2, R3 and VEGF-A, B, C, D) in tumor cells. We tested for association with disease-free survival (DFS) and overall survival (OS) by the stratified log-rank test. Associations with treatment arm and clinicopathologic variables were determined. Results: High MVD (above the median) was associated with prolonged OS for the entire cohort (p = 0.021, HR 0.63) and for pts treated in the placebo group (p = 0.014). The association between high MVD and OS was weaker in patients treated with sunitinib or sorafenib (p = 0.060). High VEGFD expression overall was associated with shorter OS (p = 0.027) but not for placebo (p = 0.16). Yet high MVD was not associated with improved DFS (p = 1.00). High MVD correlated with above-median age ( > 56) (p = 0.032), Fuhrman grade I/II (p < 0.001), clear cell histology (p < 0.001), and absence of necrosis (p < 0.001) but not with gender, sarcomatoid features, lymphovascular invasion, or tumor size. In multivariable analysis, MVD remained independently associated with improved OS for the entire cohort (p = 0.013). Conclusions: High MVD in nephrectomy specimens of high-risk RCC pts is associated with improved OS, regardless of treatment arm. MVD is thus an independent prognostic, rather than predictive, biomarker. Further studies should assess whether incorporating MVD into clinical models will predict outcome in resected high-risk RCC pts and if MVD can be used for pt selection for adjuvant therapy.
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Harshman LC, Puligandla M, Haas NB, Allaf M, Drake CG, McDermott DF, Signoretti S, Cella D, Gupta RT, Bhatt RS, Van Allen EM, Choueiri TK, Lara P, Kapoor A, Heng DYC, Shuch BM, Jewett MA, George DJ, Michaelson MD, Carducci MA. A phase III randomized study comparing perioperative nivolumab vs. observation in patients with localized renal cell carcinoma undergoing nephrectomy (PROSPER RCC). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.tps4596] [Citation(s) in RCA: 7] [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] [Indexed: 11/20/2022] Open
Abstract
TPS4596 Background: The anti-PD-1 antibody nivolumab (nivo) improves overall survival (OS) in metastatic treatment refractory RCC and is generally tolerable. In 2017, there is no standard adjuvant therapy proven to increase OS over surgery alone in non-metastatic (M0) disease. Mouse solid tumor models have revealed an OS benefit with a short course of neoadjuvant PD-1 blockade compared to adjuvant therapy. Two ongoing phase 2 studies of perioperative nivo in RCC patients (pts) have shown preliminary feasibility and safety with no surgical delays or complications. The PROSPER RCC trial will examine if the addition of perioperative nivo to radical or partial nephrectomy can improve clinical outcomes in pts with locally advanced RCC. With the goal of increasing cure and recurrence-free survival (RFS) rates in M0 RCC, we propose a three-pronged, multidisciplinary approach of presurgical priming with nivo followed by resection and adjuvant PD-1 blockade. Methods: Tumorbiopsy prior to randomization is mandatory to ensure the correct diagnosis and will permit unparalleled correlative science in this global, randomized, unblinded, phase 3 National Clinical Trials Network study. 766 pts with clinical stage ≥T2 or any node positive M0 RCC of any histology will be enrolled. The study arm will receive nivo 240mg IV for 2 doses prior to surgery followed by nivo adjuvantly for 9 months (q2 wks x 3 mo followed by q4 wks x 6 mo). The control arm will undergo the current standard of care: surgical resection followed by observation. Pts are stratified by clinical T stage, node positivity, and histology. There is 84.2% power to detect a 14.4% absolute increase in the primary endpoint of RFS from the ASSURE historical control of 55.8% to 70.2% at 5 yrs (HR 0.70). The study is also powered to detect a significant OS benefit (HR 0.67). Key safety, feasibility, and quality of life endpoints are incorporated. PROSPER RCC exemplifies team science with a host of planned correlative work to investigate the significance of the baseline immune milieu and changes after neoadjuvant priming and to identify predictive gene expression patterns. Additional collaborations are welcomed.
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Affiliation(s)
| | | | | | - Mohamad Allaf
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charles G. Drake
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | | | | | - David Cella
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rajan T Gupta
- Duke University Medical Center, Department of Radiology, Durham, NC
| | | | | | - Toni K. Choueiri
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | - Primo Lara
- University of California, Davis, Sacramento, CA
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael A.S. Jewett
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Daniel J. George
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
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Stopa JD, Neuberg D, Puligandla M, Furie B, Flaumenhaft R, Zwicker JI. Protein disulfide isomerase inhibition blocks thrombin generation in humans by interfering with platelet factor V activation. JCI Insight 2017; 2:e89373. [PMID: 28097231 DOI: 10.1172/jci.insight.89373] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND: Protein disulfide isomerase (PDI) is required for thrombus formation. We previously demonstrated that glycosylated quercetin flavonoids such as isoquercetin inhibit PDI activity and thrombus formation in animal models, but whether extracellular PDI represents a viable anticoagulant target in humans and how its inhibition affects blood coagulation remain unknown. METHODS: We evaluated effects of oral administration of isoquercetin on platelet-dependent thrombin generation in healthy subjects and patients with persistently elevated anti-phospholipid antibodies. RESULTS: Following oral administration of 1,000 mg isoquercetin to healthy adults, the measured peak plasma quercetin concentration (9.2 μM) exceeded its IC50 for inhibition of PDI by isoquercetin in vitro (2.5 ± 0.4 μM). Platelet-dependent thrombin generation decreased by 51% in the healthy volunteers compared with baseline (P = 0.0004) and by 64% in the anti-phospholipid antibody cohort (P = 0.015) following isoquercetin ingestion. To understand how PDI affects thrombin generation, we evaluated substrates of PDI identified using an unbiased mechanistic-based substrate trapping approach. These studies identified platelet factor V as a PDI substrate. Isoquercetin blocked both platelet factor Va and thrombin generation with an IC50 of ~5 μM. Inhibition of PDI by isoquercetin ingestion resulted in a 53% decrease in the generation of platelet factor Va (P = 0.001). Isoquercetin-mediated inhibition was reversed with addition of exogenous factor Va. CONCLUSION: These studies show that oral administration of isoquercetin inhibits PDI activity in plasma and diminishes platelet-dependent thrombin generation predominantly by blocking the generation of platelet factor Va. These pharmacodynamic and mechanistic observations represent an important step in the development of a novel class of antithrombotic agents targeting PDI. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01722669) FUNDING: National Heart, Lung, and Blood Institute (U54 HL112302) and Quercegen Pharma.
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Affiliation(s)
- Jack D Stopa
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Donna Neuberg
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Bruce Furie
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Robert Flaumenhaft
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Jeffrey I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School
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Haas NB, Puligandla M, McDermott DF, Dutcher JP, Manola J, Pins M, Carducci MA, Vuky J, Carthon BC, Plimack ER, Appleman LJ, Pitot HC, Kuzel T, DiPaola RS. ECOG 1808: Randomized phase II trial of sunitinib with or without gemcitabine in advanced kidney cancer with sarcomatoid features. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.4511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Naomi B. Haas
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Michael Pins
- University of Illinois College of Medicine, Chicago, IL
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