ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer

Background

Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes.

Methods

In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org .

Discussion

Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer.

Trial Registration

Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).

Ramucirumab combined with FOLFOX as front-line therapy for advanced esophageal, gastroesophageal junction, or gastric adenocarcinoma: a randomized, double-blind, multicenter Phase II trial

BACKGROUND

We report the first randomized, Phase II trial of ramucirumab, an anti-vascular endothelial growth factor receptor-2 monoclonal antibody, as front-line therapy in patients with advanced adenocarcinoma of the esophagus or gastric/gastroesophageal junction (GEJ).

PATIENTS AND METHODS

Patients from the USA with advanced esophageal, gastric, or GEJ adenocarcinoma randomly received (1:1) mFOLFOX6 plus ramucirumab (8 mg/kg) or mFOLFOX6 plus placebo every 2 weeks. The primary end point was progression-free survival (PFS) with 80% power to detect a hazard ratio (HR) of 0.71 (one-sided α = 0.15). Secondary end points included evaluation of response and overall survival (OS); an exploratory ramucirumab exposure-response analysis was undertaken.

RESULTS

Of 168 randomized patients, 52% of tumors were located in the stomach/GEJ and 48% in the esophagus. The trial did not meet the primary end point of PFS [6.4 versus 6.7 months, HR 0.98 (95% confidence interval 0.69-1.37)] or the secondary end point of OS (11.7 versus 11.5 months) in the intent-to-treat (ITT) population. Objective response rates (45.2% versus 46.4%) were similar between arms. Most Grade ≥3 toxicities did not differ significantly between arms, yet premature discontinuation of FOLFOX and ramucirumab (for reasons other than progressive disease) was more common among ramucirumab- versus placebo-treated patients. In an exploratory analysis that censored for premature discontinuation, the HR for PFS favored the ramucirumab arm (HR 0.76), particularly in patients with gastric/GEJ cancer. An exploratory exposure-response analysis indicated that patients with higher ramucirumab exposure had longer OS.

CONCLUSION

The addition of ramucirumab to front-line mFOLFOX6 did not improve PFS in the ITT population.

CLINICALTRIALSGOV IDENTIFIER

NCT01246960.

MicroRNA profiling of diagnostic needle aspirates from patients with pancreatic cancer

Background:

A major challenge to the development of biomarkers for pancreatic cancer (PC) is the small amount of tissue obtained at the time of diagnosis. Single-gene analyses may not reliably predict biology of PC because of its complex molecular makeup. MicroRNA (miRNA) profiling may provide a more informative molecular interrogation of tumours. The primary objective of this study was to determine the feasibility of performing miRNA arrays and quantitative real-time PCR (qRT–PCR) from archival formalin-fixed paraffin-embedded (FFPE) cell blocks obtained from fine-needle aspirates (FNAs) that is the commonest diagnostic procedure for suspected PC.

Methods:

MicroRNA expression profiling was performed on FFPE from FNA of suspicious pancreatic masses. Subjects included those who had a pathological diagnosis of pancreatic adenocarcinoma and others with a non-malignant pancreatic histology. Exiqon assay was used to quantify miRNA levels and qRT–PCR was used to validate abnormal expression of selected miRNAs.

Results:

A total of 29 and 15 subjects had pancreatic adenocarcinoma and no evidence of cancer, respectively. The RNA yields per patient varied from 25 to 100 ng. Profiling demonstrated deregulation of over 228 miRNAs in pancreatic adenocarcinoma of which the top 7 were further validated by qRT–PCR. The expression of let-7c, let-7 f, and miR-200c were significantly reduced in most patients whereas the expression of miR-486-5p and miR-451 were significantly elevated in all pancreas cancer patients. MicroRNAs let-7d and miR-423-5p was either downregulated or upregulated with a significant inter-individual variation in their expression.

Conclusion:

This study demonstrated the feasibility of using archival FFPE cell blocks from FNAs to establish RNA-based molecular signatures unique to pancreatic adenocarcinoma with potential applications in clinical trials for risk stratification, patient selection, and target validation.

Expression of microRNAs: potential molecular link between obesity, diabetes and cancer

Clinicians are routinely challenged in their management of cancer patients because of the complexities of obesity and diabetes that are often found as comorbid conditions. Although attention has been given to optimizing treatment planning for these patients, less attention has been given to manage their obesity and diabetes. This suggests that newer, comprehensive approaches must be developed for the treatment of cancer patients as a 'whole' rather than as a single disease. While the specific pathologies of each are unique, years of research have indicated intimate molecular links between these chronic diseases. The contribution of sedentary lifestyles and poor dietary habits is recognized; however, the precise molecular links are still not well-explored. In addition, emerging evidence suggests the important role of microRNAs (miRNAs) in the development and progression of several diseases, yet their roles in linking obesity, diabetes and cancer are only now beginning to be recognized. It is hoped that miRNAs will serve as novel biomarkers and molecular targets for cancer therapy in patients with comorbid conditions. In this review, we discuss the current understanding of the pathobiology of obesity, diabetes and cancer, and document molecular roles of miRNAs linking cancer with obesity and diabetes.

High linear energy transfer (LET) radiation therapy in recurrent, metastatic, or unresectable rectal adenocarcinoma

612

Background: The purpose of this study was to retrospectively analyze the outcomes of patients with recurrent, metastatic, or unresectable rectal adenocarcinoma treated with mixed beam photon and high LET radiotherapy.

Methods: Between 1995 and 2005, the high LET database was queried to identify patients with rectal adenocarcinoma. Local control and overall survival (OS) were calculated using the Kaplan-Meier method. Acute and chronic toxicities were graded using the common terminology criteria for adverse events (CTCAE) v4.0 grading system. Biological equivalent dose (BED) was calculated for tumor and normal tissue of both the photon dose and neutron dose for 10 patients.

Results: 11 patients with recurrent, metastatic, or unresectable rectal adenocarcinoma were identified as being treated with mixed photon-neutron radiation. The median age of patients in the study was 58 (range: 38-79). There were 8 male patients and 3 female patients. Median follow-up was 6 months (range: 4-76 months). Patients received a median photon dose of 40Gy (range: 26-50.4Gy) and a median neutron dose of 8nGy (range: 6-10nGy). Seven patients received radiation given concurrently with 5-FU. The median OS was 16 months (range: 4-76 months), with 1 and 2-year OS of 56% and 22%, respectively. Local control was achieved in 9 of 11 (82%) patients. Local progression occurring in two patients occurred at 5 months after completion of RT. The median tumor BED in patients achieving local control was 72.5 Gy (range: 57.1-83.5 Gy). There was a nonsignificant difference in median normal tissue BED of patients with grade 3-4 late toxicity of 104.8 Gy (range: 81.1-115.1 Gy), compared with 95.3Gy (range: 89.0-104.6 Gy) for those patients with grade 1-2 late toxicity.

Conclusions: Our experience demonstrates that treatment of unresectable rectal tumors with mixed photon-neutron achieved excellent local control. With the added capabilities of intensity modulated neutron radiation therapy (IMNRT), the incidence of treatment-related morbidity may be improved while taking advantage of the superior tumor control that high-LET radiation can impart.

No significant financial relationships to disclose.

Mixed photon and neutron radiotherapy given concurrently with chemotherapy in unresectable pancreatic cancer

328

Background: Unresectable tumors of the pancreas remain difficult to treat despite the advent of targeted radiotherapy and modern chemotherapy. Randomized trials exploring the efficacy of chemotherapy and radiation have demonstrated median survival of 9 to 11 months. These survival times have not improved appreciably in the modern era. The purpose of this study was to retrospectively review our institutional experience with unresectable pancreatic cancer treated with mixed photon-neutron radiotherapy given concurrently with chemotherapy.

Methods: Thirteen patients with unresectable tumors of the pancreas were treated between 1993 and 2001. All patients were treated with mixed photon-neutron radiotherapy given concurrently with chemotherapy. Median photon dose was 39.6 Gy (30.6-45Gy) and median neutron dose was 8 nGy (7-9 nGy). 12 of 13 patients were treated with neoadjuvant chemotherapy, followed by 5-FU given concurrently with radiotherapy. Median survival, overall survival, and local control were calculated for all patients.

Results: The median age of all patients was 65 years (46-75 years). Twelve patients had histologic diagnosis of adenocarcinoma, with the other having an islet cell carcinoma. All patients are now deceased. Median survival for all patients was 11.5 months (3.0-25.6 months). The 1 and 2- year overall survival was 46.2% and 7.7%, respectively. Local control of the primary tumor was excellent at 92.3%. The rate of distant metastasis was 76.9%. One patient experienced decline without documented recurrence. No grade ≥3 acute toxicities were reported. However, there were 2 grade 5 late toxicities, both caused by gastrointestinal bleeding.

Conclusions: Our experience demonstrates that treatment of unresectable pancreatic tumors with mixed photon-neutron radiotherapy given concurrently with chemotherapy results in excellent local control, with survival time equivalent to or exceeding that demonstrated in previous series. With the added capability of intensity modulated neutron radiation therapy (IMNRT), the incidence of treatment-related morbidity may be improved while taking advantage of the superior tumor control that high-LET radiation may impart.

No significant financial relationships to disclose.

MI-219-zinc combination: a new paradigm in MDM2 inhibitor-based therapy

Zinc plays a crucial role in the biology of p53 in that p53 binds to DNA through a structurally complex domain stabilized by zinc atom. The p53 negative regulator MDM2 protein also carries a C-terminal RING domain that coordinates two zinc atoms which are responsible for p53 nuclear export and proteasomal degradation. In this clinically translatable study, we explored the critical role of zinc on p53 re-activation by MDM2-inhibitor MI-219 in colon and breast cancer cells. ZnCl₂ enhanced MI-219 activity (MTT, apoptosis and colony formation), and chelation of zinc not only blocked the activity of MI-219, it also suppressed re-activation of the p53 and its downstream effector molecules p21^WAF1 and Bax. TPEN, a specific zinc chelator but not Bapta-AM, a calcium chelator, blocked MI-219-induced apoptosis. Nuclear localization is a pre-requisite for proper functioning of p53 and our results confirm that TPEN and not Bapta-AM could abrogate p53 nuclear localization and interfered with p53 transcriptional activation. Addition of zinc suppressed the known p53 feedback MDM2 activation which could be restored by TPEN. Co-immunoprecipitation studies verified that MI-219-mediated MDM2-p53 disruption could be suppressed by TPEN and restored by zinc. As such, single agent therapies that target MDM2 inhibition, without supplemental zinc, may not be optimal in certain patients due to the less recognized mild zinc deficiency among the “at risk population” as in the elderly which are more prone to cancers. Therefore, use of supplemental zinc with MI-219 will benefit the overall efficacy of MDM2 inhibitors and this potent combination warrants further investigation.

A phase II study of bevacizumab, oxaliplatin, and docetaxel in locally advanced and metastatic gastric and gastroesophageal junction cancers

BACKGROUND

Bevacizumab has demonstrated antitumor activity in multiple diseases. This phase II study was undertaken to determine the effects of adding bevacizumab to a regimen of docetaxel and oxaliplatin in patients with advanced adenocarcinoma of the stomach or gastroesophageal junction.

PATIENTS AND METHODS

Previously untreated patients with locally advanced or metastatic disease and a performance status (PS) of 0-1 were eligible for this study. Patients received bevacizumab at 7.5 mg/kg, docetaxel at 70 mg/m(2), and oxaliplatin at 75 mg/m(2) administered on day 1 of a 21-day cycle. The primary end point of the study was progression-free survival (PFS).

RESULTS

A total of 38 eligible patients (median age 57 years, 45% gastric, 55% PS 0) were enrolled on to the study. Median PFS was 6.6 months [95% confidence interval (CI) 4.4-10.5] and median survival 11.1 months (95% CI 8.2-15.3). Complete responses were documented in 2 (5%) patients, partial responses in 14 (37%), and stable disease in 14 (37%). No treatment-related deaths were observed. The most commonly reported grade 3-4 toxicity was neutropenia (34%), and gastrointestinal perforation occurred in three patients (8%).

CONCLUSION

The combination of bevacizumab, docetaxel, and oxaliplatin has promising activity for further evaluation in randomized trials.

18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) as a prognostic and predictive biomarker in metastatic colorectal cancer (mCRC)

e15037

Background: Information on the prognostic and predictive role of FDG-PET in the management of patients (pts) with mCRC is limited. The growing complexity of current therapies and the increasing number of agents to be tested in this disease warrants better understanding of the role of FDG-PET in earlier treatment decisions. Methods: Consecutive pts with 2 or more serial FDG-PET scans at baseline and during the treatment course were studied. Tumor standardized uptake value (SUV) and its percentage change (%ΔSUV) were each studied for their potential association with time to progression (TTP) via univariate Cox models to estimate the hazard ratio (HR) for progression. Results: 27 pts (median age 58.2 yrs) with mCRC were studied. 85% of pts were treated in the first line setting. 44% had received prior adjuvant therapy. 63%, 26% and 11% received oxaliplatin based, irinotecan based and fluropyrimidine only regimens, respectively. 85% received concurrent bevacizumab. Median pretreatment SUV was 9.0 (range 1.7 - 46.0); Median post treatment SUV was 3.4 (0–13.5); median %ΔSUV was -77.2 (range -10% to -100%). Mean interval between scans was 4.1 months. Ten (37%) patients had no tumor uptake on post treatment scans. 56% and 37% of pts had partial response and stable disease (RECIST criteria), respectively. Median TTP was 13.0 months (90% CI: 10.9 - 16.3 mos), with a median follow-up time for progression of 7.8 months. The HRs for baseline SUV and %ΔSUV were 0.972 (90% CI: 0.901 - 1.048, p=0.534) and 1.018 (90% CI: 1.003 - 1.033, p=0.049), respectively. The median TTP of patients whose post-treatment SUV reached zero was 13.8 months vs. 10.9 months (p=0.17) for pts whose post-treatment SUV did not reach zero. Conclusions: Systemic therapy significantly decreased the SUV on follow up PET scans in pts treated for mCRC. However, no significant association was seen between either baseline SUV or %ΔSUV and TTP. There may be a very weak statistical association of decreasing SUV with decreasing risk of progression. Further work is needed to optimize and standardize evaluation of tumor response in mCRC patients with FDG-PET.

No significant financial relationships to disclose.

A retrospective review of squamous cell carcinoma of the anal canal in HIV-positive and HIV-negative patients

e15586

Background: Human immunodeficiency virus (HIV) infected patients (pts) are at increased risk for squamous cell carcinoma of the anal canal (SCCAC) and the incidence of SCCAC has increased in the era of HAART (highly active antiretroviral therapy). The outcome of SCCAC in HIV (+) pts has not been evaluated in prospective trials and the published literature is limited to small retrospective case series. The aim of this study is to describe the outcome, tolerability, and overall survival (OS) in pts with and without HIV infection treated at Karmanos Cancer Institute, at Wayne State University from 1991 to 2007. Methods: We performed a retrospective chart review. We collected data regarding HIV status, demographics (age, gender, race), stage at diagnosis, treatment, response to treatment, toxicity, and survival. Results: Fifty pts with SCCAC were identified, of whom 18 were HIV (+) and 32 were HIV (−), 26% Caucasians, 68% African American, 56% males and 44% females. HIV (+) pts had significantly better stage (p = 0.011) and less frequent reduced chemotherapy dose (p = 0.001). There were no significant differences by HIV status in type of chemotherapy received, frequency of reduced radiotherapy dosage, use of diverting colostomy, or frequency of relapse. Diverting colostomy was required in 29% of HIV (+) pts and 18% of HIV (−) pts. The major toxicities observed in HIV (+) and (−) pts were diarrhea (36% vs. 64%), neutropenia (27% vs. 21%), and skin toxicity secondary to radiotherapy (XRT: 82% vs. 100%; p = 0.034). Median (OS) was 62.6 months for HIV (+) pts and 71.8 months for HIV (−) pts (p = 0.787). Conclusions: HIV (+) pts had better stage, received standard chemotherapy dose more often, and had more frequent XRT dermatitis than HIV (−) pts. Otherwise, there was no major difference in treatment toxicities. A higher proportion of HIV (+) pts required diverting colostomy. Survival is somewhat shorter among HIV (+) patients.

No significant financial relationships to disclose.

Stereoselectivity in metabolism of ifosfamide by CYP3A4 and CYP2B6

The aim was to identify the hepatic cytochromes P450 (CYPs) responsible for the enantioselective metabolism of ifosfamide (IFA). The 4-hydroxylation, N2- and N3-dechloroethylation of IFA enantiomers were monitored simultaneously in the same metabolic systems using GC/MS and pseudoracemate techniques. In human and rat liver microsomes, (R)-IFA was preferentially metabolized via 4-hydroxylation, whereas its antipode was biotransformed in favour of N-dechloroethylation. CYP3A4 was the major enzyme responsible for metabolism of IFA enantiomers in human liver. The study also revealed that CYP3A (human CYP3A4/5 and rat CYP3A1/2) and CYP2B (human CYP2B6 and rat CYP2B1/2) enantioselectively mediated the 4-hydroxylation, N2- and N3-dechloroethylation of IFA. CYP3A preferentially supported the formation of (R)-4-hydroxyIFA (HOIF), (R)-N2-dechloroethylIFA (N2D) and (R)-N3-dechloroethylIFA (N3D), whereas CYP2B preferentially mediated the generation of (S)-HOIF, (S)-N2D and (S)-N3D. The enantioselective metabolism of IFA by CYP3A4 and CYP2B1 was confirmed in cDNA transfected V79 cells.

CA 19–9 as a predictor of response and survival in patients with pancreatic cancer treated with gemcitabine and cisplatin based chemotherapy

15094

Background: Radiologic evaluation of the efficacy of chemotherapy (CT) regimens in pancreatic cancer is complicated by the retroperitoneal location and the desmoplastic nature of the tumor. The aim of this study was to evaluate the role of baseline CA 19–9 and the decrease in CA 19–9 after one cycle of CT as predictors of response, time to progression (TTP) , and overall survival (OS). Methods: We conducted 3 consecutive phase II trials evaluating gemcitabine and cisplatin based CT between 1997 and 2004. A retrospective chart review of the 111 patients yielded demographic data, best response status, TTP, OS, and CA19–9 levels. Response by CA 19–9 (R-CA19–9) was defined as a decrease of = 50% in CA 19–9 after the completion of the first cycle of chemotherapy. Results: The median age was 59 years with 60% males. Median performance status (PS) was 1. No significant difference was observed across the three trials with respect to age, sex, or PS. Baseline CA19–9 was known for 102 patients, and was dichotomized near the median as: < 1,000; and = 1,000 ng/mL. Lower baseline CA19–9 levels were not associated with higher radiologic response (RR) rate (p = 0.82): 22%, and 19%, respectively. Lower baseline CA19–9 was associated with longer OS, (p = 0.0057), as shown in a recent UK study. Median OS was 9.2, and 6.1 months, respectively. Similar results were observed for TTP, with p = 0.0146, and median TTP of 6.4 and 4.2 months, respectively. The change in CA19–9 from baseline to the end of treatment cycle 1 was available for 68 patients. The patients with R-CA19- 9 had a higher RR rate (29%) than did the other patients (24%), but not significantly so (p = 0.7495). The patients with R-CA19–9 had longer OS (median 8.7 vs 7.1 months) and longer TTP (median 7.1 vs 5.4 months), but not significantly so (p > 0.73 for each endpoint). Conclusions: Lower baseline CA19–9 (but not R-CA19–9 after treatment cycle 1) was positively associated with OS and TTP prognosis in our patient population. A 50% decrease in CA19–9 after the first cycle of chemotherapy was not a useful predictor of response, TTP, or OS.

No significant financial relationships to disclose.

Phase III study of gemcitabine [G] plus cetuximab [C] versus gemcitabine in patients [pts] with locally advanced or metastatic pancreatic adenocarcinoma [PC]: SWOG S0205 study

LBA4509

Background: Epidermal growth factor receptor [EGFR] pathway is a rational target for therapeutic intervention. This study tested the efficacy of an anti-EGFR monoclonal antibody and gemcitabine [G] combination in the Phase III setting in patients with advanced PC. Methods: Eligibility included locally advanced unresectable or metastatic PC; adequacy of organ function; performance status (PS) 0- 2; no prior EGFR therapy; no prior systemic chemotherapy except for adjuvant chemotherapy; and submission of tumor for EGFR immunostaining. The primary endpoint was overall survival. Secondary endpoints included objective response, time to progression, pain control, and quality of life. Assuming 6 months median survival, the study was designed to detect a median improvement to 8 months (1.33 hazard ratio) with 90% power, based on a one-sided 0.0125 test, and 704 eligible patients. Primary analyses used a Cox regression model, stratified for factors used in the randomization. Patients were stratified by PS, stageand prior pancreatectomy, and randomized to either G alone or G plus C. G was given at a dose of 1,000 mg/m2/wk for seven weeks out of 8, then 3 weeks on and one week off. C was given as a loading dose of 400 mg/m2 on week 1 and then 250 mg/m2 weekly. Results: 766 pts (735 eligible) with a median age of 64 (30–91) were enrolled by SWOG and CTSU between January 2004 and April 2006. Of those, 51% were males, 21.5% had locally advanced disease, and 13% had PS of 2. The study closed with full accrual. The median survival was 6 months in the G arm and 6.5 months in the G plus C arm for an overall HR of 1.09 (95% CI 0.93–1.27, p= 0.14) . The corresponding PFS was 3 months and 3.5 months, for G and G+C arms, respectively (HR =1.13, 95%CI .97–1.3, p=.058). The confirmed response probabilities were 7 % in each arm, and inclusion of unconfirmed responses yielded 14% in the G arm and 12% in the G + C arm.702 pts were evaluable for toxicity. 90 pts experienced at least one grade 4 toxicity; 14% on the G plus C, 11% on G alone. Conclusions: This study failed to demonstrate a clinically significant advantage of the addition of cetuximab to gemcitabine for overall survival, PFS and response in advanced PC.

No significant financial relationships to disclose.

Activity and safety of carboplatin and paclitaxel followed by capecitabine and radiation as adjuvant therapy for gastric cancer (GC)

15162

Background: Adjuvant 5FU based chemo-radiotherapy is considered the standard of care for the treatment of GC. However, the reduction in distant metastases has not been significant indicating the poor systemic effect of this regimen. A regimen of carboplatin and paclitaxel followed by capecitabine and radiation was adopted at the Karmanos Cancer Institute to improve the systemic effects of adjuvant therapy and to utilize the significant antitumor effects of taxanes demonstrated in advanced GC. Methods: We reviewed the outcomes of 21 consecutive patients with GC who were treated with carboplatin (AUC 5 mg/ml x min) and paclitaxel (175–200 mg/m2), followed by concurrent capecitabine (1600–2000 mg/ m2) and radiation (45–50.4 Gy) since January, 1999 for curatively resected GC. Patients received a total of 4–6 cycles of carboplatin and paclitaxel. Results: The median age at diagnosis was 60 years old. Sixteen patients had stage 3 disease and 7 of them had positive margins (R1/R2 resection), 3 patients were stage 2 and 2 patients were stage 1 and both groups had negative margins; all patients had D1/D2 lymph node dissection. Thirteen patients had recurrent disease, 10 of whom had distant metastases. The median recurrence free survival was 12.3 months (90% CI; 9.7–27.7 months). Seven patients are still alive. The median OS was 16.0 months (90% CI; 13.3- 28.8 months). The median follow up for OS was 30.4 months. Grade 3–4 hematologic toxicities were found in 7 patients (33.3 %). Non-hematologic toxicities included grade 3 diarrhea in 3 patients (14%), severe fatigue in 2 patients (10%). No treatment related deaths were observed. Conclusions: Carboplatin and paclitaxel alongside radiation plus capecitabine is a well tolerated regimen in the adjuvant setting. The activity of this regimen in this relatively high risk group of GC patients is of interest for future development.

No significant financial relationships to disclose.

A randomised phase II study of OSI-7904L versus 5-fluorouracil (FU)/leucovorin (LV) as first-line treatment in patients with advanced biliary cancers

The prognosis of advanced biliary tract carcinoma is poor with chemotherapy limited to a palliative role. This randomised study was designed to evaluate the effectiveness of a new liposomal thymidylate synthase inhibitor (TSI), OSI-7904L, in parallel with a modified de Gramont regimen of 5-FU/LV in patients with advanced biliary cancer. Patients with previously untreated advanced or metastatic carcinoma of the biliary tract were randomised to receive either OSI-7904L 12 mg/m2 intravenously every 21 days or a modified de Gramont schedule of 5-FU/LV (intravenous l-LV 200 mg/m2, bolus 5-FU 400 mg/m2 and a 46-h infusion of 5-FU 2,400 mg/m2) every 14 days. Twenty-two patients were randomised, 11 to each group. No patients responded in the OSI-7904L arm, while one patient achieved a partial response in the 5-FU/LV arm. The rates of disease stabilisation were 4/11 (OSI-7904L) and 10/11 (5-FU/LV). Both treatment arms were generally well tolerated. These results show that the activity of OSI-7904L is below a level of clinical relevance in advanced biliary tract cancer, providing only a small degree of disease stabilisation. A simplified de Gramont schedule appears to have marginally more activity. Both treatments were well tolerated.

A retrospective review of anal squamous cell carcinoma in HIV positive and HIV negative patients

4153

Background: The incidence of invasive anal cancer is 120 times higher in the HIV infected patients than in the general population. The outcome of anal cancer in HIV infected patients has not been evaluated in prospective trials and the published literature is limited to small retrospective case series. The aim of this study is to describe the outcome, tolerability, event free survival, and overall survival in patients with squamous cell carcinoma of anal canal (SCCAC) with and without HIV infection treated at Karmanos Cancer Institute/Wayne State University from 1991 to 2005. Methods: We performed a retrospective chart review. Patients were identified using the SEER database. We collected data regarding HIV status, demographics (age, gender, race), stage at diagnosis, treatment, response to treatment, toxicity and survival. Results: Forty patients with SCCAC were identified, of which 13 were HIV positive and 27 were HIV negative. The HIV-positive and HIV-negative groups differed by mean age (44 vs. 55 years), male gender (100 vs. 37 percent), and African American race (92 vs. 59 percent). There were no differences in stage at diagnosis, type of chemotherapy received. HIV positive population received reduced chemotherapy (67 vs. 8 percent), and RT (22 vs. 7 percent) dosage. The major toxicities observed in HIV positive and negative patients were mucositis (23% vs. 29%), neutropenia (8% vs. 33%) and skin toxicity (46% vs. 55%) secondary to radiotherapy. Only 61 percent of HIV-positive patients were disease free vs. 60 percent of HIV-negative patients. Conclusions: We found that HIV positive patients received lower doses of chemo-radiotherapy. Patients with HIV tolerated the lower dose chemoradiotherapy and had a similar toxicity profile to the HIV negative patients. No major difference in the risk of recurrence between HIV positive and negative patients was observed.

No significant financial relationships to disclose.

A dose attenuated schedule of irinotecan and capecitabine in combination with celecoxib in advanced colorectal cancer

3584

Background: The cyclooxygenase-2 (COX-2) enzyme is overexpressed in the majority of colorectal cancers. Inhibition of the COX-2 enzyme can sensitize colorectal cancer cells to the apoptotic effects of chemotherapeutic agents and block angiogenesis. This phase II study was undertaken to determine the effects of adding celecoxib to a dose attenuated irinotecan and capecitabine regimen. Methods: The primary objective was to estimate the objective response rate of patients with metastatic colorectal cancer treated with irinotecan, capecitabine, and celecoxib. Previously untreated patients, except for adjuvant therapy, with metastatic colorectal adenocarcinoma were eligible for this study. Patients received irinotecan 70 mg/m2 (over 30 minutes) on days 1 and 8, and capecitabine 2,000 mg/m2/day from day 1 to 14 of a 21-day cycle. Celecoxib was administered at a dose of 400 mg twice-daily starting on day -7 until termination from study. Results: A total of 51 patients (median age 58 years) have been enrolled on the study. The results presented are for the first 48 patients registered to the study. Median performance status was 1. A median number of 5.5 cycles (range 0- 18) were administered. In an intention to treat analysis, objective response rate was 50%. The median progression free survival was 6.9 months (90%CI; 4.7–8.2). Median survival is ≥19.4 months. No treatment related deaths were observed. The only grade 4 toxicity was diarrhea in 2 (4%) patients. Grade 3 toxicities were diarrhea (33%), hand-foot syndrome (8%), nausea (13%), vomiting (8%) and neutropenia (12%). Conclusion: Lowering the dose intensity of irinotecan in this study did not appear to compromise the treatment outcome and markedly improved the therapeutic index of this combination. Celecoxib can be safely administered in combination with irinotecan and capecitabine. Based on the observed progression free survival and response rate, the regimen has promising activity.

No significant financial relationships to disclose.

Feasibility of a multi-institutional liver cancer registry

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Background: Hepatocellular carcinoma (HCC) is one of major causes of cancer-related death globally, with increasing incidence in the United States. There is still a lack of effective therapy for the disease. Many small phase II studies of systemic therapies for advanced HCC have been performed in the US. Most studies are too small to make definitive conclusions. This registry was developed to pool phase II studies from member institutions of the Liver Cancer Research Group (LCRG) to evaluate the characteristics and outcomes of patients receiving systemic treatments in an attempt to validate known and to identify potentially new prognostic factors in HCC. Methods: An Internet based registry was initiated on the OncoLink website ( https://www.oncolink.org ) and directed by the LCRG. This registry has undergone IRB approval. All data is password protected and maintained on physical and electronically secure servers. The registry contains 37 fields for each patient, which details demographics, tumor parameters, underlying liver disease, and detailed treatment information of chemotherapy and/or biological therapies. Results: As of 1/10/2006, 101 patients have been entered in the database from 5 institutions. The median age of patients in these studies is 59 years old (range 26–82) with 22 female (22%) patients. The racial distribution was: 67% of Caucasian, 15% African American, 11% Asian, and 6% Hispanic. The median performance status of patients included in these phase II studies was ECOG 1 (PS 0/1/2: 41/56/4). A variety of cytotoxic and biological agents (either as a single agent or as combination) were included in the analysis including doxorubicin, epirubicin, gemcitabine, oxaliplatin, capecitabine, thalidomide, erlotinib, and bevacizumab. All patients had extensive disease, most of them with multiple lesions (51% ≥ 5 lesions) and bilobar involvement (69%). The mean size of lesions was 8.3 cm (range 1–20 cm). Within the population, 25% patents have hepatitis B and 44% have hepatitis C as their background diseases. Conclusions: This multi-institutional database for HCC treated on phase II clinical trials in the US is feasible. This database continues to expand through the support of the LCRG. As the data matures, future studies on outcomes related to biological and chemotherapeutic regimens will be presented.

No significant financial relationships to disclose.

Secondary cancers after a lung carcinoid primary: A population-based analysis

Carcinoid tumors of the lung were first described in 1937, yet little is known about their etiology. The aim of the present investigation was to determine if there was excess risk of secondary cancers in a population-based sample after a lung carcinoid tumor diagnosis which may provide insight to the etiology. Subjects were 1882 cases diagnosed with carcinoid tumors of the lung between 1988 and 2000 whose information was obtained from the Surveillance, Epidemiology and End Results (SEER) Program database. Standardized incidence ratios were calculated by dividing the observed number of second primary cancers by the expected number of cancers. Excess risk of breast cancer was seen following diagnosis of a carcinoid tumor (SIR=1.80 95% CI 1.22-2.55). When stratified by time after diagnosis, excess risk of breast cancers in women was seen in the first 5 years after carcinoid diagnosis (SIR=1.68 95% CI 1.08-2.50) but fewer than expected breast cancers were diagnosed greater than 5 years after carcinoid diagnosis (SIR=0.29 95% CI 0.09-0.68). Prostate cancers also occurred 2.8 times more often than expected (95% CI 1.66-4.43), with risk being elevated only in the first 5 years post-carcinoid diagnosis. Development of lung carcinoids may be the result of genetic predisposition or environmental exposures, particularly those that are hormonally related. The role of genetics and sex hormones in lung carcinoid development, as well as the identification of other risk factors, should be explored.

Interleukin-2 in the treatment of malignant melanoma

Interleukin-2 (IL-2) is a lymphokine produced by T-cells that has a number of immunomodulatory effects. Treatment of metastatic melanoma with recombinant interleukin-2 (rIL-2)-based therapies represents one of the earliest attempts at systemic immunomodulation as a therapy for cancer. Initial studies showed objective response rates with rIL-2 therapy alone in the range of 15 - 20% with some durable responses. A multitude of studies have been undertaken with various rIL-2 regimens, with and without co-administration of lymphokine-activated cells or tumour-infiltrating lymphocytes. However, the optimum dose and treatment schedule for rIL-2-based therapy in metastatic melanoma, remains controversial. There are also no clear immunological parameters that can reliably predict antitumour response to rIL-2-based therapy. Ongoing research remains active in exploring the role of rIL-2 in the therapy of malignant melanoma (MM), particularly in conjunction with cytotoxic therapy.

A phase II study of carboplatin and paclitaxel in esophageal cancer

BACKGROUND

This study was conducted to evaluate the efficacy and toxicity of combination carboplatin and paclitaxel in patients with esophageal cancer.

MATERIALS AND METHODS

Thirty-five patients were enrolled. Patients were treated with paclitaxel 200 mg/m(2) intravenously (i.v.) over 3 h and carboplatin i.v. at an AUC of 5 mg/h/ml. Thirty-three patients were assessable for toxicity and objective response.

RESULTS

A total of 166 treatment courses were administered with a median of five courses per patient. The objective response rate was 43% [90% confidence interval (CI) 0.3-0.58] by the intention-to-treat analysis. The median response duration was 2.8 months (90% CI 2.1-5.4). The median survival time was 9 months (90% CI 7-13.8) and the 1-year survival rate was 43% (90% CI 0.29-0.57). The major grade 3-4 toxicity observed was neutropenia, occurring in 17 patients (52%). There were no treatment-related deaths.

CONCLUSIONS

The combination of carboplatin and paclitaxel is an moderately active and tolerable regimen in advanced esophageal cancer.

Phase II study of gemcitabine, cisplatin, and infusional fluorouracil in advanced pancreatic cancer

PURPOSE

This phase II study was undertaken to determine the efficacy of adding infusional fluorouracil (FU) to the chemotherapy doublet of gemcitabine and cisplatin in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

The eligibility criteria included histologically or cytologically confirmed adenocarcinoma of the pancreas that was either unresectable or metastatic. No prior gemcitabine therapy was allowed. Patients received a combination of gemcitabine 1000 mg/m2 intravenously (IV) on days 1, 8, and 15; cisplatin 50 mg/m2 IV on days 1 and 15; and FU 175 mg/m2/d from days 1 to 15 by continuous IV infusion. Cycles were repeated every 28 days. Objective tumor response and toxicity were evaluated according to the World Health Organization criteria.

RESULTS

A total of 47 patients (median age, 57 years; males, 59%) were enrolled. Sixteen patients had locally advanced (LA) disease, and 31 patients had metastatic disease. A total of 183 cycles of chemotherapy were administered. In patients with metastatic disease (n = 31), the probability of survival at 6 and 12 months was 66% and 34%, respectively. Objective partial response or stable disease was observed in 26% (90% confidence interval [CI], 0.14 to 0.41) and 61% (90% CI, 0.45 to 0.74) of patients, respectively. In patients with LA disease (n = 16), there were three partial responses (19%; 90 CI, 0.07 to 0.39). One patient in this group was successfully resected after FU-based radiotherapy. The most common grade 3 to 4 toxicities were neutropenia (60%), thrombocytopenia (42%), and anemia (26%). Thirteen patients were hospitalized for treatment-related complications.

CONCLUSION

The combination of gemcitabine, cisplatin, and infusional FU has significant activity in patients with advanced pancreatic cancer.

Developments in the systemic therapy of pancreatic cancer

Pancreatic adenocarcinoma is the fourth leading cause of cancer mortality in the United States of America. Progress in the treatment of this disease in the past several decades has been very modest. Several new agents with activity against pancreatic cancer have been identified. Of these, gemcitabine is the most promising agent when used in combination with other drugs. Pilot phase II studies combining gemcitabine with 5-flourouracil, irinotecan, docetaxel, or cisplatin show improved outcomes in objective response rates and survival that need to be confirmed in larger randomized studies. Advancement in the understanding of the molecular biology of neoplasia in recent years has helped identify several molecular targets for future new drug development in pancreatic cancer. Assessment of response to therapy of pancreatic cancer has been a difficult challenge. Functional imaging with techniques such as positron emission tomography (PET) may yield a more precise and timely objective evaluation of response to treatment.

A single-institution experience with concurrent capecitabine and radiation therapy in gastrointestinal malignancies

PURPOSE

We report our clinical experience with 32 patients receiving concurrent irradiation and capecitabine.

METHODS AND MATERIALS

Medical records of patients with gastrointestinal malignancies treated with radiation and capecitabine therapy were reviewed.

RESULTS

The population consisted of 20 males and 12 females, with a median age of 67.5 years (45-84 years) and adequate hepatic and bone marrow function. Histology was adenocarcinoma in all patients, except two with esophageal squamous carcinoma. Twenty-one patients received the regimen as adjuvant therapy, three received preoperative therapy, and 8 patients received therapy for palliation. The median dose of capecitabine was 1600 mg/m(2)/day (1200-2500 mg/m(2)/day) orally for 5 days per week for the duration of radiation therapy. Thirty patients received a total dose ranging from 45 Gy to 64 Gy over 4-6 weeks. Two previously radiated patients received total doses of 29.9 Gy and 46 Gy. Grade 3/4 toxicities observed were neutropenia in 3 patients and diarrhea, thrombocytopenia, fatigue, and myocardial infarction in 1 patient each. No treatment-related mortality was observed. Twenty of 21 patients (95.2%) who received adjuvant therapy continue to be in complete remission. Four of 11 (36%) evaluable patients demonstrated a response.

CONCLUSION

Concurrent capecitabine and radiation were very well tolerated and warrant further investigation in prospective trials.

Pancreatic cancer: the evolving role of systemic therapy

Pancreatic adenocarcinoma is the fourth leading cause of cancer mortality in the US. The outcome for patients with pancreatic cancer has not essentially altered over the past few decades. Several new drugs with activity against pancreatic cancer have recently been identified for use in palliative settings. Of these, gemcitabine is the most widely used agent against the disease, but its benefit is very modest. Pilot Phase II studies combining gemcitabine with 5-fluorouracil (5-FU), irinotecan, docetaxel or cisplatin show improved outcomes that need to be confirmed in randomised studies. Concurrent administration of gemcitabine and external beam radiation therapy (EBRT) for locally advanced pancreatic cancer is feasible and is currently undergoing efficacy evaluations. Current research in pancreatic cancer involves newer dosing schedules of gemcitabine, and combinations of gemcitabine with novel agents. Ultimately, better understanding of the molecular biology of pancreatic neoplasia will identify potential cellular targets for future development of new agents for pancreatic cancer.

Bryostatin 1 induces differentiation and potentiates the antitumor effect of Auristatin PE in a human pancreatic tumor (PANC-1) xenograft model

Pancreatic cancer has the worst prognosis of all cancers with a dismal 5-year survival rate. Hence, there is a tremendous need for development of new and effective therapy for this tumor. In an earlier study we reported a potent antitumor activity of Auristatin PE (AuriPE) against pancreatic tumor. In addition, we have also reported that bryostatin 1 (bryo1) induces differentiation of leukemia cells, but the effect of bryo1 has not been investigated in pancreatic tumors. This is the first report where we demonstrate that bryo1 induces differentiation and potentiates the antitumor effect of AuriPE in a human pancreatic tumor (PANC-1) xenograft model. A xenograft model was established by injecting the PANC-1 cells s.c. in severe combined immune deficient (SCID) mice. After development of the s.c. tumors, tumors were dissected and small fragments were transplanted in vivo to new SCID mice, with a success rate of 100% and a doubling time of 4.8 days. The SCID mouse xenograft model was used to test the in vivo differentiation effect of bryo1 and its efficacy when given alone or in combination with AuriPE. Sections from paraffin-embedded tumors excised from untreated (control) SCID mice revealed typical poorly differentiated adenocarcinoma of the pancreas. Interestingly, sections of s.c. tumors taken from bryo1-treated mice revealed carcinomas that were much lower grade and less aggressive, and displayed prominent squamous and glandular differentiation. In this study, the tumor growth inhibition (T/C), activity score and cure rate for bryo1, AuriPE and bryo1+AuriPE were 80%, (+) and 0/4; 0.0%, (++++) and 3/5; and 0.0%, (++++) and 3/4, respectively. Mice treated with either AuriPE or bryo1+AuriPE were free of tumors for more than 150 days and were considered cured. The use of bryo1 as a novel differentiating agent and its combination with AuriPE should be further explored for the treatment of adenocarcinoma of the pancreas.

Phase II study of gemcitabine and cisplatin in the treatment of patients with advanced pancreatic carcinoma

BACKGROUND

Pancreatic carcinoma is considered among the most chemoresistant of human malignancies. The most commonly used cytotoxic single agents, 5-fluorouracil and 2'-deoxy-2',2'-difluorocytidine (gemcitabine), have objective response rates of less than 10% in large studies. Hypothesizing noncross resistance and a synergistic interaction between gemcitabine and cisplatin, early clinical studies have demonstrated significant activity with this combination in patients with several types of malignant disease. A Phase II study was undertaken to determine the efficacy of gemcitabine in combination with cisplatin in patients with locally advanced and metastatic pancreatic carcinoma based on these considerations.

METHODS

The eligibility criteria included histologically confirmed, locally advanced, unresectable or metastatic exocrine carcinoma of the pancreas with no prior gemcitabine therapy; prior adjuvant therapy was allowed provided the last day of therapy was at least 6 months prior to starting treatment; clinically measurable or evaluable disease; a Southwest Oncology Group scale performance status of 0-2; a life expectancy of > 12 weeks; and adequate bone marrow, hepatic, and renal function. A total of 42 patients, 4 patients with locally advanced, unresectable disease and 38 patients with metastatic disease, were treated and received a total of 211 cycles of therapy between May 1997 to March 1999. The median age of patients was 61.5 years. The patients were treated in the outpatient setting with a combination of gemcitabine 1,000 mg/M(2) intravenously over 30 minutes administered on Days 1, 8, and 15 of each cycle and cisplatin 50 mg/M(2) intravenously administered after gemcitabine infusion on Days 1 and 15 with adequate prehydration accompanied by adequate urinary output. Cycles were repeated every 28 days. Response and toxicity were assessed according to World Health Organization and standard criteria.

RESULTS

The complete and partial response rate among all 42 registered patients was 11 of 42 patients (26%; 95% confidence interval, 0.14-0.42). Stabilization of disease was seen in 15 patients (38%). Two additional patients with metastatic disease who achieved major responses to chemotherapy were rendered free of disease surgically, achieving a complete response status. The median overall survival was 7.1 months (95% confidence interval [CI], 6.3-9.1 months), with 64% of patients alive at 6 months and 19% of patients alive at 12 months. The median time to disease progression was 5.4 months (range, 0.9-20.8 months). Major toxicities were neutropenia and thrombocytopenia, with one episode of neutropenic fever.

CONCLUSIONS

The combination of gemcitabine and cisplatin appeared to have significantly greater activity than single-agent gemcitabine in this Phase II study, with tolerable toxicity. The antitumor activity of this combination needs to be confirmed in multi-institutional or comparative trials.

Phase II study of gemcitabine and cisplatin in the treatment of patients with advanced pancreatic carcinoma

BACKGROUND

Pancreatic carcinoma is considered among the most chemoresistant of human malignancies. The most commonly used cytotoxic single agents, 5-fluorouracil and 2'-deoxy-2',2'-difluorocytidine (gemcitabine), have objective response rates of less than 10% in large studies. Hypothesizing noncross resistance and a synergistic interaction between gemcitabine and cisplatin, early clinical studies have demonstrated significant activity with this combination in patients with several types of malignant disease. A Phase II study was undertaken to determine the efficacy of gemcitabine in combination with cisplatin in patients with locally advanced and metastatic pancreatic carcinoma based on these considerations.

METHODS

The eligibility criteria included histologically confirmed, locally advanced, unresectable or metastatic exocrine carcinoma of the pancreas with no prior gemcitabine therapy; prior adjuvant therapy was allowed provided the last day of therapy was at least 6 months prior to starting treatment; clinically measurable or evaluable disease; a Southwest Oncology Group scale performance status of 0-2; a life expectancy of > 12 weeks; and adequate bone marrow, hepatic, and renal function. A total of 42 patients, 4 patients with locally advanced, unresectable disease and 38 patients with metastatic disease, were treated and received a total of 211 cycles of therapy between May 1997 to March 1999. The median age of patients was 61.5 years. The patients were treated in the outpatient setting with a combination of gemcitabine 1,000 mg/M(2) intravenously over 30 minutes administered on Days 1, 8, and 15 of each cycle and cisplatin 50 mg/M(2) intravenously administered after gemcitabine infusion on Days 1 and 15 with adequate prehydration accompanied by adequate urinary output. Cycles were repeated every 28 days. Response and toxicity were assessed according to World Health Organization and standard criteria.

RESULTS

The complete and partial response rate among all 42 registered patients was 11 of 42 patients (26%; 95% confidence interval, 0.14-0.42). Stabilization of disease was seen in 15 patients (38%). Two additional patients with metastatic disease who achieved major responses to chemotherapy were rendered free of disease surgically, achieving a complete response status. The median overall survival was 7.1 months (95% confidence interval [CI], 6.3-9.1 months), with 64% of patients alive at 6 months and 19% of patients alive at 12 months. The median time to disease progression was 5.4 months (range, 0.9-20.8 months). Major toxicities were neutropenia and thrombocytopenia, with one episode of neutropenic fever.

CONCLUSIONS

The combination of gemcitabine and cisplatin appeared to have significantly greater activity than single-agent gemcitabine in this Phase II study, with tolerable toxicity. The antitumor activity of this combination needs to be confirmed in multi-institutional or comparative trials.

A phase II trial of bryostatin 1 in the treatment of metastatic colorectal cancer

Current chemotherapy for patients with advanced colorectal cancer is relatively ineffective and may be associated with significant toxicity. Bryostatin 1 (bryo 1) influences cell proliferation, intracellular metabolism and signaling, differentiation, and apoptosis in human cancer cell lines via modulation of protein kinase C (PKC) activity. This trial investigates the efficacy and toxicity of bryo 1 as a novel therapeutic agent for patients with advanced colorectal cancer who have had previous 5-fluorouracil therapy. The primary end point was tumor response to bryo 1. Toxicity was also assessed. Twenty-eight patients with advanced colorectal cancer were enrolled. The mean age was 59 years (range, 38-76), with 16 men and 12 women, and good minority representation (11 African-Americans). The first 10 patients initially received 25 microg/m2 of bryo 1 weekly as a 24-h infusion for 3 weeks of every 4-week cycle, with dose escalation to 35 microg/m2 starting with the second cycle. The remaining patients were started at 35 microg/m2 and escalated to 40 microg/m2, if toxicity was minimal. Twenty-five patients were evaluable for objective tumor response, and complete data on toxicity were collected on 26 patients. No partial or complete tumor responses were observed. All 25 patients had disease progression within four cycles. Myalgia was the most common toxicity. Myelosuppression was not seen. bryo 1 as a weekly 24-h continuous infusion lacks single-agent antitumor activity in advanced colorectal cancer. Toxicity differs from that of traditional chemotherapeutic drugs.

Biochemotherapy for melanoma

Systemic therapy for advanced melanoma includes chemotherapy, either with dacarbazine (DTIC) alone or a multiagent combination chemotherapy, and biologic therapy with recombinant interferon-alpha and/or interleukin-2. However, none of these treatment options has produced long-term control of the disease except on rare occasions. Combined chemo-immunotherapy (biochemotherapy) has shown high objective response rates (approximately 50%) and a significant though small proportion of long-term complete responders in metastatic melanoma. It has, however, been associated with greater toxicity. Overall results of sequential versus concurrent biochemotherapy are similar, but the toxicity appears to be less severe in patients treated with the concurrent regimen. At this time, biochemotherapy is under evaluation in a well-designed prospective, randomized trial to identify whether there is benefit to this strategy, compared with chemotherapy alone.