Surgical resection criteria and neoadjuvant therapies for intrahepatic cholangiocarcinoma

The staging of intrahepatic cholangiocarcinoma (ICC) is complex, and there is no consensus among international cancer groups on how to most appropriately select candidates with nonmetastatic disease for surgical resection. Factors contributing to a higher stage of disease include larger tumor size, multiple tumors, vascular invasion (either portal venous or arterial), biliary invasion, involvement of local hepatic structures, serosal invasion, and regional lymph node metastases. For patients selected to undergo surgery, it is well-documented that R0 resection translates to a survival benefit. Estimating the risk of post-hepatectomy liver failure and post-surgical residual liver function is vital and may preclude some patients with significant tumor burden from undergoing surgery. Numerous serum and biliary biomarkers of the disease can help detect recurrence in patients undergoing surgical resection. Systemic and locoregional neoadjuvant treatments to facilitate better surgical outcomes have yielded mixed results regarding improving resectability and overall survival. Additional research is needed to identify optimal neoadjuvant treatment approaches and to evaluate which patients will benefit most from these strategies. Therapies targeting genetic mutations and protein aberrations found by tumor molecular profiling may offer additional options for future neoadjuvant treatment.

Overcoming the hurdles: surmounting acquired resistance to anti-EGFR therapy in metastatic colorectal cancer

Colorectal cancer is the third most prevalent cancer type in the United States, with an alarming incidence and mortality rate, especially among individuals younger than 50 years. The epidermal growth factor receptor (EGFR), essential for cell proliferation and survival, has surfaced as a promising therapeutic target for metastatic colorectal cancer and has demonstrated success in various clinical trials. Monoclonal antibodies such as cetuximab and panitumumab have proven to be effective against EGFR by blocking vital downstream signaling pathways and inhibiting gene transcription and cell proliferation. Despite this promise, most patients eventually develop resistance to anti-EGFR treatment, thereby limiting its long-term efficacy. Genomic alterations, such as mutations in KRAS, NRAS, and BRAF, often bypass the EGFR receptor, promoting resistance to therapy. Although our understanding of primary resistance to anti-EGFR therapy has improved, acquired resistance remains a significant hurdle. This review explores the potential mechanisms underpinning this acquired resistance and strategies to overcome it.

A randomized phase II study of SM-88 plus methoxsalen, phenytoin, and sirolimus in patients with metastatic pancreatic cancer treated in the second line and beyond

BACKGROUND

This trial explores SM-88 used with methoxsalen, phenytoin, and sirolimus (MPS) in pretreated metastatic pancreatic ductal adenocarcinoma (mPDAC) METHODS: Forty-nine patients were randomized to daily 460 or 920 mg oral SM-88 with MPS (SM-88 Regimen). The primary endpoint was objective response rate (RECIST 1.1).

RESULTS

Thirty-seven patients completed ≥ one cycle of SM-88 Regimen (response evaluable population). Disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) did not differ significantly between dose levels. Stable disease was achieved in 9/37 patients (DCR, 24.3%); there were no complete or partial responses. Quality-of-life (QOL) was maintained and trended in favor of 920 mg. SM-88 Regimen was well tolerated; a single patient (1/49) had related grade 3 and 4 adverse events, which later resolved. In the intention-to-treat population of 49 patients, the median overall survival (mOS) was 3.4 months (95% CI: 2.7-4.9 months). Those treated in the second line had an mOS of 8.1 months and a median PFS of 3.8 months. Survival was higher for patients with stable versus progressive disease (any line; mOS: 10.6 months vs. 3.9 months; p = 0.01).

CONCLUSIONS

SM-88 Regimen has a favorable safety profile with encouraging QOL effects, disease control, and survival trends. This regimen should be explored in the second-line treatment of patients with mPDAC.

CLINICALTRIALS

gov Identifier: NCT03512756.

The Role of Immunotherapy in Pancreatic Cancer

Pancreatic adenocarcinoma remains one of the most lethal cancers globally, with a significant need for improved therapeutic options. While the recent breakthroughs of immunotherapy through checkpoint inhibitors have dramatically changed treatment paradigms in other malignancies based on considerable survival benefits, this is not so for pancreatic cancer. Chemotherapies with modest benefits are still the cornerstone of advanced pancreatic cancer treatment. Pancreatic cancers are inherently immune-cold tumors and have been largely refractory to immunotherapies in clinical trials. Understanding and overcoming the current failures of immunotherapy through elucidating resistance mechanisms and developing novel therapeutic approaches are essential to harnessing the potential durable benefits of immune-modulating therapy in pancreatic cancer patients.

The current state of molecular profiling in gastrointestinal malignancies

This is a review of the current state of molecular profiling in gastrointestinal (GI) cancers and what to expect from this evolving field in the future. Individualized medicine is moving from broad panel testing of numerous genes or gene products in tumor biopsy samples, identifying biomarkers of prognosis and treatment response, to relatively noninvasive liquid biopsy assays, building on what we have learned in our tumor analysis and growing into its own evolving predictive and prognostic subspecialty. Hence, the field of GI precision oncology is exploding, and this review endeavors to summarize where we are now in preparation for the journey ahead.

Oral SM-88 plus MPS, an effective yet less toxic treatment option in second-line advanced pancreatic cancer? Final phase II/III study results

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Background: Metastatic pancreatic ductal adenocarcinoma (mPDAC) has a poor prognosis in refractory patients (pts). SM-88 Regimen, which comprises oral SM-88 (racemetyrosine, TYME Inc) plus 10mg methoxsalen, 50mg phenytoin, and 0.5mg sirolimus (MPS), has previously shown clinical activity in mPDAC. Methods: We report on the final results (primary objective, ORR) of our multicenter, prospective open-label phase II/III RCT (TYME-88-Panc Part 1, NCT03512756) of SM-88 Regimen in pts with mPDAC who had received at least one prior line of therapy. Subjects received either 230 mg BID or 460 mg BID PO SM-88; oral MPS QD was given at the same dose in both arms. Results: The last subject was enrolled on Mar 12, 2019. As of Sep 1, 2021, 49 subjects were randomized to either 460 (n = 26) or 920mg (n = 23) SM-88 plus MPS daily (ITT population); 37 were deemed evaluable after completing at least one 28-day cycle of treatment (min 23 days on treatment). The study population was heterogeneous: a majority (32/37 = 86.5%) had failed at least 2 prior lines of chemotherapy. Twenty pts (54.1%) had received FOLFIRINOX in the first line and 16 pts (43.2%), a gemcitabine-based regimen. For evaluable pts, the overall disease control rate (DCR) was 27.0%: 10/37 subjects reached RECIST v1.1-verified stable disease (SD); 3 of the 10 had RECIST-confirmed SD. For the 49 ITT pts, mOS was 3.4 months (mo). For the 37 evaluable pts, mOS was 3.9 mo, and mPFS was 1.9 mo. mOS, mPFS, and DCR did not differ significantly by SM-88 dose. mOS and mPFS trended toward improvement in subjects with fewer prior lines of treatment: for pts in the second line (n = 5), mOS was 8.1 mo (95% CI: 3.0 – no UL), and mPFS was 3.8 mo (95% CI: 0.9 – no UL). Although not confirmatory, exploratory analyses showed that circulating tumor cells decreased on SM-88 Regimen. SM-88 Regimen was well tolerated: only one pt of the 48 ever dosed (2.1%) experienced related SAEs on treatment (Grade 3 abdominal pain, Grade 4 hypotension), which were eventually resolved. Enrollment criteria specified ECOG < = 2 at study entry; these scores were maintained or improved for most pts (24/37 = 64.9%) while on treatment. Overall health and quality of life (QOL) scores via EORTC QLQ-C30 were maintained, trending toward superiority for pts on 920 mg vs. 460 mg (p = ns). Conclusions: This final analysis confirmed that SM-88 Regimen was well tolerated, with pts attaining an overall DCR of 27%. Of note, for the small subset of pts treated in the second line, the mOS and mPFS were on par with results achieved in other published randomized PhIII second-line trials for mPDAC. Moreover, SM-88 Regimen exhibited far fewer Grade 3 and 4 AEs than other commonly used cytotoxic regimens in the second line. The 27% DCR, 8.1 mo mOS, and 3.8 mo mPFS in the second line, with minimal toxicity and preserved QOL, resulted in the active investigation of SM-88 Regimen in a large, ongoing second-line trial in mPDAC (NCT04229004). Clinical trial information: NCT03512756.

Impact of Sociodemographic Disparities and Insurance Status on Survival of Patients with Early-Onset Colorectal Cancer

Background

Low socioeconomic status (SES) has been linked to worse survival in patients with colorectal cancer (CRC); however, the impact of SES on early‐onset CRC remains undescribed.

Materials and Methods

Retrospective analysis of data from the National Cancer Database (NCDB) between 2004 and 2016 was conducted. We combined income and education to form a composite measure of SES. Logistic regression and χ² testing were used to examine early‐onset CRC according to SES group. Survival rates and Cox proportional hazards models compared stage‐specific overall survival (OS) between the SES groups.

Results

In total, 30,903 patients with early‐onset CRC were identified, of whom 78.7% were White; 14.5% were Black. Low SES compared with high SES patients were more likely to be Black (26.3% vs. 6.1%) or Hispanic (25.3% vs. 10.5%), have T4 tumors (21.3% vs. 17.8%) and/or N2 disease (13% vs. 11.1%), and present with stage IV disease (32.8% vs. 27.7%) at diagnosis (p < .0001, all comparisons). OS gradually improved with increasing SES at all disease stages (p < .001). In stage IV, the 5‐year survival rate was 13.9% vs. 21.7% for patients with low compared with high SES. In multivariable analysis, SES (low vs. high group; adjusted hazard ratio [HR_adj], 1.35; 95% confidence interval [CI], 1.26–1.46) was found to have a significant effect on survival (p < .0001) when all of the confounding variables were adjusted. Insurance (not private vs. private; HR_adj, 1.38; 95% CI, 1.31–1.44) mediates 31% of the SES effect on survival.

Conclusion

Patients with early‐onset CRC with low SES had the worst outcomes. Our data suggest that SES should be considered when implementing programs to improve the early detection and treatment of patients with early‐onset CRC.

Implications for Practice

Low socioeconomic status (SES) has been linked to worse survival in patients with colorectal cancer (CRC); however, the impact of SES on early‐onset CRC remains undescribed. In this retrospective study of 30,903 patients with early‐onset CRC in the National Cancer Database, a steady increase in the yearly rate of stage IV diagnosis at presentation was observed. The risk of death increased as socioeconomic status decreased. Race and insurance status were independent predictors for survival. Implementation of programs to improve access to care and early diagnostic strategies among younger adults, especially those with low SES, is warranted.

The incidence of and mortality from early‐onset colorectal cancer (CRC) is on the rise. This article details the relationship between socioeconomic status and clinical outcomes of young adults with early‐onset CRC.

Impact of socioeconomic status (SES) on colorectal cancer patient survival: An analysis of 890,867 patients in the National Cancer Database (NCDB)

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Background: SES has been associated with outcomes in cancer patients (pts). We examined associations between SES and survival of pts with colorectal cancers (CRC). Methods: The NCDB was used to examine the association of SES status with clinicopathological features and outcomes of colorectal cancer pts, categorized by the income and education level of their area of residence. Logistic regression, Cox proportional hazard model, and chi-square test were used to examine the differences between groups. Results: A retrospective analysis of 890,867 pts with CRC (right-sided 34.1%, transverse 11.9%, left-sided 46.2%, and rectal 7.8%) diagnosed between 2004 and 2016, was conducted. About half the pts were male (51.4%); 84.3% were white, 11.2% black, and 4.5% of other races. Overall, 30.8% of pts lived in the highest and 18.4% in the lowest income areas. Twenty-three percent lived in areas comprising the highest high school graduation rate areas (>93%), while 17.4% lived in the lowest (< 79%). Compared to pts living in high-income areas, pts living in the lowest income areas were more likely to be black (OR 6.2, 6.1-6.3), present at a younger age (18-30 yrs vs. >70 yrs; OR 1.28, 1.18-1.39), have T3/T4 disease at presentation (OR 1.03, 95%CI 1.02-1.04), left-sided tumors (OR 1.05, 1.04-1.06), higher Charlson-Deyo score (OR 1.34, 1.33-1.36), and have Medicaid (OR: 3.9, 3.8-4.0) or no health insurance (OR: 2.9, 2.8-3.0). Tumor location and grade, stage, age, sex, race, ethnicity, income, education, insurance status, Charlson-Deyo score, and type of treatment center were independent predictors for survival in the multivariate analysis. Pts living in the lowest income and lowest education areas had a 13% and 4% higher risk of death, respectively, compared to pts in the highest income areas and education areas. Black pts had a 7% increased risk of death. Pts with Medicaid and no insurance coverage had a 44% and 29% increased risk of death, respectively, compared to pts with private insurance. Conclusions: CRC pts living in areas of low income and low education had worse survival. Insurance status and type of treatment center also have a strong impact on survival. Sociodemographic characteristics need to be taken into account and studied further, with the aim of improving outcomes for all pts. [Table: see text]

Socioeconomic status (SES) and survival outcomes in patients with gastrointestinal (GI) cancers: An analysis of 1.4 million patients in the National Cancer Database (NCDB)

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Background: SES and access to care are factors that may impact patient outcomes. We examined the impact of SES on survival in patients (pts) with GI cancers. Methods: Data obtained from the NCDB were used to examine the association between SES and outcomes of GI cancer pts. Pts were categorized by income and education levels. Logistic regression, Cox proportional hazards models, and chi-square tests were used to examine the differences between the groups. Results: A total of 1,409,177 pts diagnosed with GI cancers between 2004 and 2016 were retrospectively studied (table). The majority of pts were male (54.3%), and 83.7% were white, 11.5% black, and 4.7% of other races. Of the entire cohort, 31% of pts lived in the highest income areas, whereas 18.3% were in the lowest and 50.6% in middle-income areas; 23% lived in the highest high school graduation rate (>93%) areas, whereas 17.4% lived in the lowest graduation rate (< 79%) areas; and 82.4% resided in metropolitan areas. Pts in the lowest compared to highest income areas were more likely to be black (OR: 6.5, 6.4-6.6), uninsured (2.9, 2.8-3.0), or have Medicaid (4.13, 4.04-4.22), and have a Charlson-Deyo score ≥ 1 (1.35, 1.33-1.36). In the multivariate analysis, cancer type, stage, tumor differentiation, income, education, insurance status, gender, race, Charlson-Deyo score, and type of treatment center were independent predictors for survival. After controlling for other factors, black pts had a 3% increased risk of death (HRadj = 1.03; 1.02-1.03; p < 0.001). Pts from lowest vs highest education areas had a 2% increased risk of death (HRadj = 1.02; 1.01-1.03; p < 0.001). Pts from the lowest income vs highest income areas had a 13% increased risk of death (HRadj = 1.13; 1.12-1.14; p < 0.001). Pts with Medicaid insurance had a 33% (HRadj: 1.33, CI 1.32-1.34, p < 0.001) and uninsured pts had 22% (HRadj: 1.22 (1.20-1.23, p < 0.001) increased risk of death compared to pts with private insurance. Pts from urban or rural areas vs metropolitan areas had a 1% increased risk of death (HRadj = 1.01; 1.00-1.02; p < 0.001). Conclusions: Low SES is associated with worse survival in pts with any GI cancer. Pts with low-income status and Medicaid or no health insurance had the highest risk of mortality. These stark inequities must be addressed with renewed efforts to identify, treat, and better support pts at highest risk for poor outcomes. [Table: see text]

Phase II study of pembrolizumab plus olaparib in the treatment of patients with advanced cholangiocarcinoma

TPS4659

Background: Lack of an effective second-line treatment of patients (pts) with advanced cholangiocarcinoma (CC) necessitates the development of new therapies. Preclinical studies suggest CC susceptibility to PARP inhibition (PARPi): ERCC1 is underexpressed in 74% of CCs, and olaparib is selective for ERCC1 deficiency, profoundly inhibiting DNA repair. Additionally, PARPi exploits IDH mutation-related DNA damage repair deficiency, which is found in about 25% of CCs. Unfortunately, PARPi also upregulates PD-1-PD-L1 receptor-ligand binding, which attenuates anticancer immunity and counteracts the efficacy of PARPi. However, this can be prevented by PD-1 inhibition—blockade of PD-1-PD-L1 acts to re-sensitize cancer cells to T-cell killing. Hence, we hypothesize that the combination of olaparib and pembrolizumab will produce a durable anti-tumor response against CC by synergistically inducing DNA damage and increasing immune response. Methods: Thirty-six pts with advanced CC, who either failed to respond to or progressed on first-line therapy, will be enrolled to receive olaparib (300 mg PO bid) daily plus pembrolizumab (200 mg IV Q3 weeks) for 12 months, unless unacceptable toxicities or cancer progression occur, in which cases therapy will cease. MRI or CT tumor assessment will occur just before therapy, every 6 weeks for the first 6 months of therapy, and then every 9 weeks for the next 6 months of therapy (total, 12 months). Three tumor biopsies will be collected: at baseline; at week 4; and at time of progression. In each biopsy, ERCC1, PD-1, and PD-L1 expression, IDH1/2 mutation status, and immune cell (CD3 and CD8) response will be assessed. The total study duration will be 20-36 months. The primary endpoint will be overall response rate; the secondary endpoints will be PFS, OS, duration of response, and safety and tolerability. It is hypothesized that in pts with advanced CC, second-line therapy with olaparib plus pembrolizumab will improve the response rate from 17.5% to 35%, as well as increase PFS and OS compared to cytotoxic chemotherapy. Study enrollment began in Q1 2020. NCI number pending at time of abstract submission. Clinical trial information: pending at time of submission .

A Pilot Trial of Molecularly Tailored Therapy for Patients with Metastatic Pancreatic Ductal Adenocarcinoma

Purpose: Despite the wide adoption of tumor molecular profiling, there is a dearth of evidence linking molecular biomarkers for treatment selection to prediction of treatment outcomes in patients with metastatic pancreatic cancer. We initiated a pilot study to test the feasibility of designing a larger phase II trial of molecularly tailored treatment for metastatic pancreatic cancer.

Methods: Our study aimed to assess the feasibility of following a treatment algorithm based on the expression of three published predictive markers of response to chemotherapy: ribonucleotide reductase catalytic subunit M1 (for gemcitabine); excision repair cross-complementation group 1 (for platinum agents); and thymidylate synthase (for 5-fluorouracil) in patients with untreated, metastatic pancreatic cancer. Results of the tumor biopsy analysis were used to assign patients to one of seven doublet regimens. Key secondary objectives included response rate (RR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS).

Results: Between December 2012 and March 2015, 30 patients were enrolled into the study. Ten patients failed screening primarily due to inadequate tumor tissue availability. Of the remaining 20 patients, 19 were assigned into 6 different chemotherapy doublets, and achieved an RR of 28%, with a DCR rate of 78%. The median PFS and OS were 5.78 and 8.21 months, respectively.

Conclusions: The incorporation of biomarkers into a treatment algorithm is feasible and resulted in a PFS and OS similar to other doublet therapies for patients with metastatic pancreatic cancer. Based on the results from this pilot study, a larger phase II randomized trial of molecularly targeted therapy versus physicians' choice of standard of care has been initiated in the second-line setting (NCT02967770).

Precision Medicine in Metastatic Colorectal Cancer: Relevant Carcinogenic Pathways and Targets-PART 1: Biologic Therapies Targeting the Epidermal Growth Factor Receptor and Vascular Endothelial Growth Factor

The survival of patients with metastatic colorectal cancer has improved dramatically in recent years, with overall survival exceeding 3 years in large randomized clinical trials. There are now several treatment options for patients with metastatic colorectal cancer. In addition to chemotherapy backbones utilizing fluoropyrimidine, oxaliplatin, and irinotecan combinations, biologic agents that target specific oncogenic pathways have contributed to the improved survival observed in this patient population. This class of medications includes epidermal growth factor receptor (EGFR)-targeted drugs (cetuximab and panitumumab) and vascular endothelial growth factor (VEGF)-targeted therapies (bevacizumab, ramucirumab, ziv-aflibercept, and regorafenib). Bevacizumab remains the only VEGF-targeted agent approved by the US Food and Drug Administration in the first-line metastatic setting. EGFR-directed treatment should be restricted to patients with extended RAS and BRAF wild-type tumors. Tumor sidedness may be a more powerful prognostic and predictive biomarker than tumor mutational profile. Patients with left-sided primary tumors derive greater benefit from EGFR-targeted therapies whereas patients with right-sided primary tumors benefit more from bevacizumab. Herein we review drugs that target the EGFR and VEGF pathways, focusing on patient selection, drug toxicities, and how to choose agents for first-line therapy.

Precision Medicine in Metastatic Colorectal Cancer: Relevant Carcinogenic Pathways and Targets-PART 2: Approaches Beyond First-Line Therapy, and Novel Biologic Agents Under Investigation

A frequent quandary for oncologists is the selection of chemotherapy and biologic therapy for patients with metastatic colorectal cancer in second-line and higher treatment settings. While not approved by the US Food and Drug Administration (FDA) in the first-line setting, the vascular endothelial growth factor (VEGF)-targeting agents ziv-aflibercept and ramucirumab are appropriate treatment options in the second-line setting, as is continuation of first-line bevacizumab. Tumor RAS mutational status is helpful to determine which patients may benefit from epidermal growth factor receptor (EGFR)-directed therapies, and other novel biomarkers (BRAF, HER2, and mismatch repair deficiency) allow us to select patients who may benefit from biologic therapies that are FDA-approved for other malignancies. Maintenance therapy for patients with stable disease following first-line therapy is a unique clinical situation that warrants special attention. Immunotherapy has thus far been ineffective for patients with mismatch repair-proficient tumors, but novel combination strategies are being studied to break through this treatment barrier. Finally, several new biologic therapies with novel targets are under development and will likely contribute to the growing arsenal of treatment options for patients with metastatic colorectal cancer.

Pancreatic cancer, treatment options, and GI-4000

Although pancreatic cancer is but the eleventh most prevalent cancer in the US, it is predicted that of all the patients newly diagnosed with this disease in 2014, only 27% will still be alive at the end of the first year, which is reduced to 6% after 5 years. The choice of chemotherapy in the treatment of pancreatic cancer is dependent on disease stage and patient performance status but, in general, the most widely used approved regimens include 5-fluorouracil (5-FU) combinations and gemcitabine combinations. Recent therapeutic strategies have resulted in an improvement in survival of patients with pancreatic cancer but the magnitude of change is disappointing and vast improvements are still needed. The goal of immunotherapy is to enhance and guide the body's immune system to recognize tumor-specific antigens and mount an attack against the disease. Among newer immune therapies, GI-4000 consists of 4 different targeted molecular immunogens, each containing a different Ras protein (antigen) encoded by the most commonly found mutant RAS genes in solid tumors-RAS mutations exist in over 90% of pancreatic ductal adenocarcinomas. We will review pancreatic cancer epidemiology and its current treatment options, and consider the prospects of immunotherapy, focusing on GI-4000. We discuss the potential mechanism of action of GI-4000, and the performance of this vaccination series thus far in early phase clinical trials.

Regorafenib in metastatic colorectal cancer: An exploratory biomarker trial

TPS773

Background: Treatment with Regorafenib (REGO) has shown significant clinical benefits in metastatic colorectal cancer (mCRC) patients (pts) as demonstrated in the CORRECT and CONCUR trials. Results from both studies suggest that subgroups have differential responses. Further research to identify these subgroups through the identification of molecular biomarkers is needed. Methods: Forty pts with refractory mCRC are being enrolled in this study. The primary objective is to prospectively identify tissue and serum-based biomarkers that can predict response to REGO. Secondary objectives are to determine molecular mechanisms by which REGO controls refractory mCRC, as well as molecular pathways involved in the acquisition of resistance. Tumor and blood samples are obtained prior to and 2 weeks after starting REGO. Blood samples are collected on day 1 of each cycle thereafter. Pts will receive 160 mg REGO daily for 3 weeks of each 4-week cycle until disease progression or unacceptable toxicity. Multi-omic based biomarker discovery approaches will be used to uncover predictive marker candidates with special attention to the tumor microenvironment. Laser capture microdissection will be used on tumor tissue to procure highly enriched populations of pt-matched epithelial and stromal/immune cell infiltrates. Each of these entities will be analyzed for RNA expression changes and protein signaling/drug target activation mapping. Protein signaling analysis will be performed by reverse phase protein array of key REGO-related proteins and phosphoproteins (e.g. phosphoVEGFR, Tie2, phosphoRET), as well as broad-scale mapping of mitogenic, survival, autophagy, inflammatory, motility, and signaling networks. Tumor profiling will include next-generation sequencing for 592 genes with 53 selected gene fusions, and IHC and FISH/CISH for selected biomarkers, including PDL1, HER2, MSI, TS, ERCC1, and TOPO1. Blood samples will undergo protein, miRNA, and mutated DNA analysis, as well as exosomal signature study via a proprietary synthetic polyligand multiplexed aptamer-based assay. Exploratory analysis of biomarkers will be used to determine correlations between the presence of, or change in, biomarker levels and clinical response. Clinical trial information: NCT01949194.

The impact of the multiple types of treatments on OS and the decline of liver function in patients with advanced stage of HCC

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Background: Hepatocellular carcinoma (HCC) is the sixth most common cancer and the second leading cause of cancer-related death worldwide. Most HCCs develop in severely damaged liver. Methods: The effect of multiple treatment options on liver function (LF) and disease outcome of patients (pts) with HCC (n = 185) were examined retrospectively. Pt tumor burden (using Barcelona clinic liver cancer [BCLC] classification) and LF (Child Pugh [CP]) were assessed at time of diagnosis and then after treatment. Using Kaplan Meier with log rank and T tests, BCLC and CP scores were correlated with overall survival (OS) following individual treatment regimens. Results: We show that better BCLC and LF scores at time of diagnosis predict a better outcome (median OS; p < 0.05). Pts received one or more of the following: no treatment, experimental treatment, TACE, Y90 radioembolization, radiofrequency ablation, resection, radiation, and sorafenib (SFB). Considering all treatment scenarios, LF improved in 9.5%, did not change in 33%, and worsened in 57% of pts. Sixty percent of untreated pts experienced LF decline, compared with 33, 54, 48 and 50% of pts receiving TACE, SFB, TACE/SFB, and Y90/SFB, respectively (no significant differences [NS]); 72% of pts receiving TACE/Y90/SFB (NS); and 85% of pts receiving other Y90/SFB combinations (p = 0.006). In general, pts who saw no change or an improvement in LF from baseline had longer median OS versus pts who had declining LF (p < 0.002). However, pts receiving TACE/Y90/SFB (n = 29) had similar OS to those receiving TACE/SFB (n = 35), despite the toxicity difference (72% [TACE/Y90/SFB] vs. 48% [TACE/SFB] of pts had declining LF). TACE/SFB or TACE/Y90/SFB led to longer median OS than any other treatment group (p = 0.017). Conclusions: The outcome of pts with HCC depends on disease stage and LF. Most pts experience LF decline during treatment. Despite LF decline in 48% of pts receiving a SFB/TACE, these pts experienced longer median OS than pts on any other treatment. Balancing survival benefit with liver toxicities is critical to the successful treatment of pts with advanced HCC. Agents with good antitumor activity and minimal liver toxicity are desperately needed for these pts.

Irreversible multitargeted ErbB family inhibitors for therapy of lung and breast cancer

Overactivation of the ErbB protein family, which is comprised of 4 receptor tyrosine kinase members (ErbB1/epidermal growth factor receptor [EGFR]/HER1, ErbB2/HER2, ErbB3/HER3, and ErbB4/HER4), can drive the development and progression of a wide variety of malignancies, including colorectal, head and neck, and certain non-small cell lung cancers (NSCLCs). As a result, agents that target a specific member of the ErbB family have been developed for the treatment of cancer. These agents include the reversible EGFR tyrosine kinase inhibitors (TKIs) erlotinib and gefitinib; the EGFR-targeting monoclonal antibodies cetuximab and panitumumab; and the HER2-targeting monoclonal antibody trastuzumab. Lapatinib is a dual TKI that targets both EGFR and HER2. In addition, TKIs that inhibit multiple members of the ErbB family and also bind their targets irreversibly are under evaluation for the treatment of cancer. Three such compounds have progressed into clinical studies: the EGFR, HER2, and HER4 inhibitors afatinib, dacomitinib, and neratinib. Phase I studies of these agents have shown clinical activity in NSCLC, breast cancer, and other malignancies. Currently, afatinib is approved for EGFR mutation-positive NSCLC and is in development for squamous NSCLC, and dacomitinib is in phase III of clinical development for NSCLC, neratinib is in phase III of clinical development for the treatment of breast cancer, and afatinib is also in phase III development in head and neck cancer. Final results from clinical trials may lead to the potential approval of these agents in a variety of solid tumor malignancies.

The Ruesch Center Symposium 2014: Fighting a Smarter War against Cancer Using Immunotherapy

The Ruesch Cancer Symposium, Washington DC, USA, 4–6 December 2014

A pilot study of molecularly tailored therapy for patients with metastatic pancreatic cancer (MPC)

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Background: We have entered an era where multiple chemotherapeutic (chemo) agents can be utilized in the treatment (Tx) of patients (pts) with MPC. However, there are no methods for selecting the optimal regimen for any individual pt, and pure empiricism has not proven to be an optimal strategy. Molecular profiling is now widely used, albeit without evidence-based studies linking molecular profiles to Tx choices. Methods: We initiated a pilot study to assess the feasibility of following a simple algorithm, basing Tx on 3 published predictive markers of response to chemo: RRM1 (for gemcitabine); ERCC1 (for platinums); and TS (for 5FU). Pts with untreated, biopsiable MPC were eligible. Tissue biopsies were analyzed by Caris, and the results used to assign pts to 1 of 7 doublet regimens. Our 1o objective was to provide preliminary data to inform a larger, randomized trial. Key 2o objectives included assessment of the response rate (RR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Results: Between 12-2012 and 08-2014, 26 pts were enrolled. Eleven failed screening primarily due to inadequate tumor tissue availability (and pts not wanting to wait for a 2ndbiopsy). Of the 15 pts profiled, 6 different doublets were assigned, reflecting the breadth of profile results. Three pts were not evaluable for response by the date of this abstract. Of the 12 pts who received Tx, the RR was 9%, but the DCR rate was 82%. The median PFS and OS were 5.9 and 10.4 months, respectively. Conclusions: The incorporation of chemo biomarkers is feasible and resulted in a promising PFS and OS for pts with MPC. Our pilot experience suggests that there may be value to assessing a pt’s tumor molecular profile to select Tx. Expansion of this experience into a randomized trial of profile-directed Tx vs. Tx based on the physician’s discretion would not only be realistic, but could be critical to realizing the full, clinically meaningful benefit of molecular profiling. We do however caution that biomarker-directed Tx can be challenging in untreated pts, where initiation of Tx is time critical, and delays due to inadequate tumor samples may be untenable. Thus, a randomized trial in the second line setting may be more appropriate. Clinical trial information: NCT01888978.

Pancreatic cancer, treatment options, and GI-4000

Although pancreatic cancer is but the eleventh most prevalent cancer in the US, it is predicted that of all the patients newly diagnosed with this disease in 2014, only 27% will still be alive at the end of the first year and only 6% will make it past 5 years. The choice of chemotherapy in the treatment of pancreatic cancer is dependent on disease stage and patient performance status but, in general, the most widely used approved regimens include 5-fluorouracil (5-FU) combinations and gemcitabine combinations. Recent therapeutic strategies have resulted in an improvement in survival of patients with pancreatic cancer but the magnitude of change is disappointing and vast improvements are still needed. The goal of immunotherapy is to enhance and guide the body's immune system to recognize tumor-specific antigens and mount an attack against the disease. Among newer immune therapies, GI-4000 consists of 4 different targeted molecular immunogens, each containing a different Ras protein (antigen) encoded by the most commonly found mutant RAS genes in solid tumors--RAS mutations exist in over 90% of pancreatic ductal adenocarcinomas. We will review pancreatic cancer epidemiology and its current treatment options, and consider the prospects of immunotherapy, focusing on GI-4000. We discuss the potential mechanism of action of GI-4000, and the performance of this vaccination series thus far in early phase clinical trials.

Future of targeted agents in metastatic colorectal cancer

Great strides have been made in improving the outcome of patients with metastatic colorectal cancer and targeted agents are an important part of the treatment arsenal. The approved monoclonal antibodies, bevacizumab, cetuximab and panitumumab, are part of the standard of care, yet only recently have we begun to define which patients benefit from these therapies using predictive tumor biomarkers. More recently, novel agents including aflibercept and regorafenib have had promising results and may become approved therapies. In addition, agents targeting the mTOR pathway and the TNF pathway have demonstrated early evidence of benefit. In the coming years, we may experience an influx of new therapies, possibly leading to further prolongation of patient survival or even, for some, a cure.

Actions of some autacoids and peptides, including relaxin, on costo-uterine muscle from rats

1. The actions of angiotensin II, bradykinin, oxytocin, arginine vasopressin, relaxin, serotonin and the prostaglandins E2 and F2 alpha were examined on preparations of costo-uterine muscle from stilboestrol-treated rats. 2. All the agonists, except relaxin, when used in concentrations which contract the rat uterus, also produced contractions of costo-uterine muscles. Concentration-response curves were steep and maximal responses to the agonists were comparable. The negative log molar EC50 values were: serotonin, 6.5; angiotensin II, 8.8; bradykinin, 8.4; PGE2, 8.3; PGF2 alpha, 7.1. The EC50 values (units/L) for oxytocin and vasopressin were 4.4 and 2.7 respectively. 3. Indomethacin (2.8 or 5 mumol/L) did not decrease the contractile effects of the peptides or serotonin. The effects of serotonin were reduced, but not reversed, by methysergide (0.94 mumol/L). 4. Porcine relaxin inhibited field stimulation-induced contractions of costo-uterine muscle and uterine horns from immature rats pretreated with oestradiol cypionate and from stilboestrol-treated mature rats. It was much less potent, and its effects were less clearly concentration-related, on costo-uterine muscle. 5. The inhibitory effects of relaxin on the uterus were unaffected by propranolol (1 mumol/L), confirming that on this tissue relaxin acts independently of the release of catecholamines. Progesterone (30 mumol/L) was also without effect on the action of relaxin on the uterus. 6. These results taken together indicate that the costo-uterine muscle of the rat: (i) contracts in response to serotonin and the peptides angiotensin II, arginine vasopressin, bradykinin and oxytocin independently of the release of the contractile prostaglandins F2 alpha and E2; and (ii) in contrast to the uterus, may lack a significant population of receptors for relaxin.(ABSTRACT TRUNCATED AT 250 WORDS)

(+/-)-Pindolol has beta 2-adrenoceptor antagonist but not agonist action on the costo-uterine muscle of the rat

1. The effects of isoprenaline and (+/-)-pindolol on rat isolated costo-uterine muscle have been compared. 2. Isoprenaline produced reproducible concentration-dependent inhibition of contractions, and maximal doses (less than 0.1 mumol/l) produced mean inhibition of 87, 94 and 97% of field, carbachol and potassium-stimulated preparations, respectively. 3. (+/-)-Pindolol, when effective, produced inhibition only in concentrations greater than its pA2 value (9.87) as an antagonist of isoprenaline; mean maximal effects were less than 60% of those produced by isoprenaline. 4. It is concluded that (+/-)-pindolol is a potent antagonist, but has only variable agonist action, at the beta 2-adrenoceptors of the rat costo-uterine muscle.

Cholinoreceptors in the isolated costo-uterine muscle of the rat

1 The aim of this study was to examine the cholinoreceptor population in the rat costo-uterine muscle. 2 The nicotinic cholinoreceptor agonists nicotine and DMPP, and the ganglionic muscarinic cholinoreceptor stimulant McNeil A-343, had no effects upon isolated preparations of this tissue. 3 Acetylcholine was more potent than carbachol and approximately equipotent with methacholine (the mean EC50 values were 7.0, 6.3 and 6.7 respectively) in producing contractions of the preparation; each was a full agonist. The potencies of carbachol and methacholine were similar in preparations taken from animals in oestrus and in dioestrus. 4 Atropine competitively antagonised the effects of carbachol and methacholine, the pA2 values were 9.37 and 9.41 respectively. The pA2 value for pirenzepine with carbachol as the agonist was 6.69. 5 Pilocarpine produced phasic contractions of the tissue (EC50 value = 4.17), and competitively antagonised the effects of carbachol with a pA2 value of 5.26. The anticholinesterase, physostigmine, produced only a small potentiation of the effects of acetylcholine. 6 It is concluded that the cholinoreceptors which mediate contraction of the rat costo-uterine muscle are muscarinic, homogeneous in nature and unaffected by fluctuating levels of ovarian hormones occurring during the oestrous cycle. The consequences of inhibition of cholinesterase activity in isolated preparations of the tissue are minimal.

Uterine contractility and actions of catecholamines in longitudinal and circular uterine layers from ovariectomised guinea-pigs: the effects of ovarian steroids

The influence of ovarian steroids upon responses to electrical stimulation and to activation of adrenoreceptors in field-stimulated preparations of longitudinal and circular myometrium from ovariectomised guinea-pigs has been investigated. Adult virgin guinea-pigs were bilaterally ovariectomised and were treated two weeks later with thrice-weekly injections of oestradiol cypionate for two weeks, or treated as in then given oestradiol cypionate and progesterone for a further four days. Control groups of bilaterally ovariectomised and sham ovariectomised animals remained untreated. Both myometrial layers from untreated ovariectomised guinea-pigs were atrophied. Responses to field stimulation in the circular myometrium were much smaller than those in the longitudinal layer. Steroid pretreatment, most notably treatment with oestradiol and progesterone, were associated with decreased and increased responsiveness to electrical stimulation in the circular and longitudinal myometrial layers respectively. Adrenaline and noradrenaline were consistently excitatory on preparations of circular myometrium from ovariectomised animals. Responses comprised either enhancement of electrically-evoked contractions, or, with the higher concentrations, the appearance of rapid contractions superimposed upon an increase in basal tone. The latter effects were also evident in preparations of circular myometrium from sham operated animals. In preparations of longitudinal myometrium from untreated ovariectomised animals noradrenaline consistently and adrenaline usually caused a simple enhancement of the magnitude of the evoked contractions. Phentolamine reduced the excitatory effects of both amines in both layers. In circular myometrium from the oestrogen-treated group both catecholamines produced phentolamine-sensitive enhancement of electrically-evoked contractions, but did not cause high frequency contractions or increased tonus. Noradrenaline and adrenaline produced qualitatively similar phentolamine-sensitive effects in preparations of longitudinal myometrium from this group.(ABSTRACT TRUNCATED AT 250 WORDS)

The costo-uterine muscle of the rat contains a homogeneous population of beta-adrenoceptors

The effects of two selective beta-adrenoceptor antagonists on the inhibitory responses to some sympathomimetic amines of electrically-stimulated preparations of costo-uterine muscle, taken from virgin rats, have been examined quantitatively. pA2 values for the antagonist, atenolol (beta 1-selective) and ICI 118,551 (beta 2-selective) were obtained using as agonists, fenoterol (beta 2-selective agonist) and noradrenaline (alpha- and beta-adrenoceptor agonist, beta 1-selective); and in addition, with ICI 118,551 only, isoprenaline (beta-agonist, non-selective) and adrenaline (alpha- and beta-adrenoceptor agonist, beta 2-selective). Catecholamine uptake mechanisms and alpha-adrenoceptors were not blocked in any of these experiments. Atenolol competitively antagonized the effects of fenoterol and noradrenaline to a similar extent, the pA2 values being 5.4 and 5.7, respectively. ICI 118,551 competitively antagonized the effects of fenoterol, isoprenaline, adrenaline and noradrenaline to a similar extent; pA2 values ranged from 8.7 with noradrenaline to 9.1 with isoprenaline. These results extend our previous observations which indicated that the adrenoceptors mediating inhibition of electrically-evoked contractions of costo-uterine muscle of the virgin rat are homogeneous and of the beta 2-subtype. The potency of the beta 1-selective agonist RO 363 in producing inhibition of electrically-evoked contractions of this tissue was also examined. RO 363 was 200 times less potent than isoprenaline but was a full agonist. This indicates that there is efficient coupling between beta 2-adrenoceptor activation and tissue response in this non-innervated preparation.

The rat costo-uterine muscle: a preparation of smooth muscle containing a homogeneous population of beta-adrenoreceptors

This paper describes some histological features of the costo-uterine muscle of the rat together with the effects of some sympathomimetic amines upon contractions evoked by field electrical stimulation of isolated preparations. Light and electron microscopy confirmed that the costo-uterine muscle of the rat consists of smooth muscle bundles, arranged longitudinally and interspersed with collagen. There were close contacts between individual cells within bundles. No axon profiles were observed. Histochemical techniques revealed only sparse catecholamine fluorescence at the border of the tissue in association with blood vessels. Isoprenaline, fenoterol, adrenaline, noradrenaline, salbutamol and phenylephrine consistently inhibited contractions evoked by field stimulation (40V, 30Hz, 2 ms for 5 sec every 200 sec). In contrast, tyramine was without effect upon electrically evoked contractions in concentrations of up to 200 mumol/l. The slopes of the log concentration-response curves of effective amines were similar, and all of these were capable of producing 100% inhibition of contraction. The potencies of the amines relative to isoprenaline = 100 were: fenoterol 135; salbutamol 16; adrenaline 16; noradrenaline 0.7; phenylephrine 0.1; tyramine less than 0.001. Propranolol, added to preparations in the absence of inhibitors of amine uptake and alpha-adrenoreceptors, competitively antagonised the effects of the amines. Schild plots had slopes which did not differ significantly from minus one, and the mean pA2 values fell within a narrow range, e.g. 8.65 with salbutamol; 9.20 with fenoterol. Mean pA2 values for propranolol with noradrenaline and isoprenaline were unaffected by the combined presence of phentolamine (10 mumol/l), cocaine (10 mumol/l), and corticosterone (10 mumol/l). The potencies of the agonists were also unaffected by the presence of these drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of adrenaline and noradrenaline in separated longitudinal and circular myometrial preparations from the guinea-pig: selective modulation by ovarian steroids

Field-stimulated strips of circular and longitudinal myometrium from virgin adult guinea-pigs were used to study the influence of ovarian steroids upon uterine responses to adrenaline and noradrenaline. Preparations were taken from animals (i) untreated, on day 9 or 10 of the oestrous cycle; (ii) treated for 14 days with oestradiol cypionate, beginning on day 9 or 10; and (iii) treated as in (ii) then given both oestradiol cypionate and progesterone for a further four days. Oestradiol treatment led to a 2-fold increase in the circulating level of progesterone; subsequent treatment of oestradiol-primed animals with progesterone resulted in even higher circulating progesterone levels, comparable with those occurring during mid-pregnancy in this species. Both adrenaline and noradrenaline produced phentolamine-sensitive motor responses of circular myometrial preparations from each treatment group. Steroid treatment was without significant effect on the potencies or maximal effects of the two amines on the circular muscle layer. Both catecholamines effected phentolamine-sensitive excitatory responses of longitudinal myometrial preparations from untreated guinea-pigs. Adrenaline usually produced propranolol-sensitive inhibitory responses of longitudinal preparations from oestradiol-treated animals, while noradrenaline did so only in a minority of cases. The potencies of adrenaline as an inhibitory agonist and noradrenaline as an excitatory agonist were markedly increased in preparations from oestradiol-primed animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of ovarian steroids upon responses mediated by adrenoceptors in separated layers of the myometrium and in the costo-uterine muscle of the guinea-pig

1 This study describes the effects of ovarian steroid hormones upon the responses to adrenoceptor agonists of isolated myometrium, separated into its longitudinal and circular layers, and of costo-uterine muscle from guinea-pigs. The preparations were field-stimulated at 100 s intervals, and the adrenoceptor agonists phenylephrine and isoprenaline produced enhancement or inhibition of the evoked contractions.2 Isoprenaline produced propranolol-sensitive inhibitory effects in longitudinal and circular myometrium and costo-uterine muscle preparations from animals from all experimental groups: i.e. from nonsteroid-treated animals (ovariectomized and intact); intact animals treated with either oestrogen or progesterone alone; ovariectomized animals treated with oestrogen; ovariectomized and intact animals treated with progesterone following oestrogen priming; and from animals 1-4 days post-partum. Longitudinal myometrial preparations from progesterone-treated oestrogen-primed and from post-partum animals were most sensitive to this agonist.3 Phenylephrine produced phentolamine-sensitive excitatory effects in circular myometrial and costo-uterine muscle preparations from animals from all the experimental groups. In contrast, propranolol-sensitive inhibitory responses to phenylephrine occurred in longitudinal myometrial preparations taken from animals treated with progesterone following oestrogen priming, and from post-partum animals. Longitudinal myometrium from animals from the remaining experimental groups exhibited phentolamine-sensitive excitatory responses to phenylephrine.4 The basis for the selective effect upon the longitudinal myometrium of exposure to progesterone following a period of oestrogen priming, is discussed. The results described are consistent with the possibility that in the longitudinal layer of guinea-pig uterus exposed to progesterone following oestrogen priming there is an increase in the proportion of beta-adrenoceptors in this layer. This increase may reduce the likelihood of contractions arising via direct stimulation of alpha-adrenoceptors in this layer in response to sympathetic activation during pregnancy.

Responses mediated by adrenoceptors in the separated layers of the myometrium and in the costo-uterine muscle of the guinea pig during the estrous cycle

The mechanical responses of field-stimulated preparations of the longitudinal and circular myometrium, and of the costo-uterine muscle of the guinea pig to adrenoceptor agonists have been examined on Days 1, 4, 10 and 15-16 of the estrous cycle. The alpha-adrenoceptor agonist, phenylephrine, was exclusively excitatory in all three preparations taken from animals at each of the cycle days studied. Concentration-response curves for phenylephrine in all three tissues were unaffected by the fluctuations in ovarian hormones occurring during the estrous cycle. Isoproterenol (1 nmol/1-5 mumol/1) usually inhibited field-stimulation-induced contractions of the longitudinal uterine layer and the costo-uterine muscle; higher doses usually caused enhancement of contractions. In neither tissue did the potency or maximum effect of this inhibitory agonist differ at differing cycle stages. In the circular myometrium, the inhibitory effects of isoproterenol were less consistently observed, particularly in preparations taken at proestrus (Days 15-16). It is concluded that, except perhaps in the circular myometrium at proestrus, the fluctuations in ovarian hormones occurring during the estrous cycle in this species are insufficient to modify uterine responses mediated via alpha- and beta-adrenoceptors. It remains to be established whether the steroid hormones are capable of modulating responses mediated by adrenoceptors in the costo-uterine muscle.

The influence of neuronal uptake upon the relative potencies of agonists acting at prejunctional alpha 2-adrenoceptors in the rat isolated vas deferens

The effects of inhibition of neuronal uptake upon the potency of the alpha-adrenoceptor antagonist phentolamine and upon the potencies of several agonists which produce inhibition of twitches evoked by field stimulation of the prostatic third of the rat vas deferens are described. In doses producing similar inhibition of the uptake of 3H-noradrenaline, cocaine produced a greater inhibition of the effects of (-)-noradrenaline than did desipramine or diphenhydramine. Cocaine differentially potentiated the effects of the sympathomimetic amines used such that the relative order of agonist potency was changed from xylazine greater than (-)-adrenaline greater than (+)-noradrenaline greater than (-)-metaraminol greater than or equal to (-)-noradrenaline greater than or equal to dopamine, to xylazine greater than (-)-adrenaline greater than (-)-noradrenaline greater than (-)-metaraminol greater than dopamine greater than or equal to (+)-noradrenaline. Prazosin enhanced and yohimbine reduced the twitch inhibition produced by (-)-noradrenaline in the absence of uptake blockers. In contrast, phentolamine had little effect upon the position of the log concentration curve for (-)-noradrenaline except when uptake was inhibited. These experiments demonstrate the marked influence of neuronal uptake upon estimates of the relative potencies of agonists activating alpha 2-adrenoceptors, and upon the estimate of the potency of phentolamine as an antagonist of noradrenaline at these receptors in this densely innervated tissue.