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Martos MP, Amirian H, Dickey EM, Box EW, Merchant NB, Hosein PJ, Hester CA, Datta J. Improving patient stratification and selection for curative-intent treatment in localized pancreatic cancer. Hepatobiliary Surg Nutr 2024; 13:325-328. [PMID: 38617473 PMCID: PMC11007343 DOI: 10.21037/hbsn-23-668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/01/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Mary P. Martos
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Haleh Amirian
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin M. Dickey
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Edmond W. Box
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun B. Merchant
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter J. Hosein
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Caitlin A. Hester
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jashodeep Datta
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Dickey EM, Bianchi A, Amirian H, Hosein PJ, Faustman D, Brambilla R, Datta J. Transmembrane TNF-TNFR2 signaling as a critical immunoregulatory node in pancreatic cancer. Oncoimmunology 2024; 13:2326694. [PMID: 38481728 PMCID: PMC10936673 DOI: 10.1080/2162402x.2024.2326694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 02/29/2024] [Indexed: 03/17/2024] Open
Abstract
Pancreatic cancer is characterized by extreme therapeutic resistance. In pancreatic cancers harboring high-risk genomes, we describe that cancer cell-neutrophil signaling circuitry provokes neutrophil-derived transmembrane (tm)TNF-TNFR2 interactions that dictate inflammatory polarization in cancer-associated fibroblasts and T-cell dysfunction - two hallmarks of therapeutic resistance. Targeting tmTNF-TNFR2 signaling may sensitize pancreatic cancer to chemo±immunotherapy.
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Affiliation(s)
- Erin M. Dickey
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anna Bianchi
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Haleh Amirian
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Peter J. Hosein
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Denise Faustman
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Roberta Brambilla
- The Miami Project to Cure Paralysis, Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Tan H, Hosein PJ. Detection and therapeutic implications of homologous recombination repair deficiency in pancreatic cancer: a narrative review. J Gastrointest Oncol 2023; 14:2249-2259. [PMID: 37969835 PMCID: PMC10643583 DOI: 10.21037/jgo-23-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/25/2023] [Indexed: 11/17/2023] Open
Abstract
Background and Objective Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal cancers. A major recent advance has been the identification of a subset of patients with PDAC who harbor inherited or somatic genetic alterations that result in homologous recombination deficiency (HRD) in tumor cells. These patients often respond favorably to drugs that can exploit this vulnerability. This review outlines the biomarkers that have been developed to predict HRD and their performance related specifically to PDAC, as well as novel HRD-targeted therapies for PDAC. Methods We conducted a narrative review of the HRD in PDAC based on PubMed, Google Scholar, website and citation searches. Key Content and Findings Germline mutations in BRCA1 and BRCA2 remains the only validated biomarker for the HRD state but various platforms are now available to define HRD beyond BRCA1/2 alterations. Currently, the available evidence supports the use of platinum-based chemotherapy as well as PARP inhibitors, and there is also emerging data that immune checkpoint inhibitors can produce some durable responses in these patients. Conclusions Consistently detecting clinically significant the HRD status in PDAC has remained challenging with current commercially available platforms. Multiple novel HRD-targeted therapies for PDAC are currently in development and clinical trials, offering new opportunities for these patients.
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Affiliation(s)
- Heng Tan
- Division of Internal Medicine, Department of Medicine, University of Miami, Miami, FL, USA
| | - Peter J. Hosein
- Division of Medical Oncology, Department of Medicine, University of Miami, Miami, FL, USA
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Islam MO, Thangaretnam K, Lu H, Peng D, Soutto M, El-Rifai W, Giordano S, Ban Y, Chen X, Bilbao D, Villarino AV, Schürer S, Hosein PJ, Chen Z. Smoking induces WEE1 expression to promote docetaxel resistance in esophageal adenocarcinoma. Mol Ther Oncolytics 2023; 30:286-300. [PMID: 37732296 PMCID: PMC10507159 DOI: 10.1016/j.omto.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023] Open
Abstract
Esophageal adenocarcinoma (EAC) patients have poor clinical outcomes, with an overall 5-year survival rate of 20%. Smoking is a significant risk factor for EAC. The role of WEE1, a nuclear kinase that negatively regulates the cell cycle in normal conditions, in EAC tumorigenesis and drug resistance is not fully understood. Immunohistochemistry staining shows significant WEE1 overexpression in human EAC tissues. Nicotine, nicotine-derived nitrosamine ketone, or 2% cigarette smoke extract treatment induces WEE1 protein expression in EAC, detected by western blot and immunofluorescence staining. qRT-PCR and reporter assay indicates that smoking induces WEE1 expression through miR-195-5p downregulation in EAC. ATP-Glo cell viability and clonogenic assay confirmed that WEE1 inhibition sensitizes EAC cells to docetaxel treatment in vitro. A TE-10 smoking machine with EAC patient-derived xenograft mouse model demonstrated that smoking induces WEE1 protein expression and resistance to docetaxel in vivo. MK-1775 and docetaxel combined treatment improves EAC patient-derived xenograft mouse survival in vivo. Our findings demonstrate, for the first time, that smoking-induced WEE1 overexpression through miRNA dysregulation in EAC plays an essential role in EAC drug resistance. WEE1 inhibition is a promising therapeutic method to overcome drug resistance and target treatment refractory cancer cells.
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Affiliation(s)
- Md Obaidul Islam
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Krishnapriya Thangaretnam
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Heng Lu
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Dunfa Peng
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Mohammed Soutto
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Wael El-Rifai
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
- Department of Veterans Affairs, Miami Healthcare System, Miami, FL 33136, USA
| | - Silvia Giordano
- University of Torino, Candiolo Cancer Institute - FPO, IRCCS, 10060 Candiolo, Italy
| | - Yuguang Ban
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Xi Chen
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Daniel Bilbao
- Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA
- Department of Pathology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Alejandro V. Villarino
- Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Stephan Schürer
- Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA
- Institute for Data Science and Computing, University of Miami, Coral Gables, FL 33146, USA
| | - Peter J. Hosein
- Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA
- Department of Molecular and Cellular Pharmacology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Zheng Chen
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
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Ogobuiro I, Baca Y, Ribeiro JR, Walker P, Wilson GC, Gulhati P, Marshall JL, Shroff RT, Spetzler D, Oberley MJ, Abbott DE, Kim HJ, Kooby DA, Maithel SK, Ahmad SA, Merchant NB, Xiu J, Hosein PJ, Datta J. Multiomic Characterization Reveals a Distinct Molecular Landscape in Young-Onset Pancreatic Cancer. JCO Precis Oncol 2023; 7:e2300152. [PMID: 37944072 PMCID: PMC10645414 DOI: 10.1200/po.23.00152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/28/2023] [Accepted: 08/25/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE Using a real-world database with matched genomic-transcriptomic molecular data, we sought to characterize the distinct molecular correlates underlying clinical differences between patients with young-onset pancreatic cancer (YOPC; younger than 50 years) and patients with average-onset pancreatic cancer (AOPC; 70 years and older). METHODS We analyzed matched whole-transcriptome and DNA sequencing data from 2,430 patient samples (YOPC, n = 292; AOPC, n = 2,138) from the Caris Life Sciences database (Phoenix, AZ). Immune deconvolution was performed using the quanTIseq pipeline. Overall survival (OS) data were obtained from insurance claims (n = 4,928); Kaplan-Meier estimates were calculated for age- and molecularly defined cohorts. Significance was determined as FDR-corrected P values (Q) < .05. RESULTS Patients with YOPC had higher proportions of mismatch repair-deficient/microsatellite instability-high, BRCA2-mutant, and PALB2-mutant tumors compared with patients with AOPC, but fewer SMAD4-, RNF43-, CDKN2A-, and SF3B1-mutant tumors. Notably, patients with YOPC demonstrated significantly lower incidence of KRAS mutations compared with patients with AOPC (81.3% v 90.9%; Q = .004). In the KRAS wild-type subset (n = 227), YOPC tumors demonstrated fewer TP53 mutations and were more likely driven by NRG1 and MET fusions, whereas BRAF fusions were exclusively observed in patients with AOPC. Immune deconvolution revealed significant enrichment of natural killer cells, CD8+ T cells, monocytes, and M2 macrophages in patients with YOPC relative to patients with AOPC, which corresponded with lower rates of HLA-DPA1 homozygosity. There was an association with improved OS in patients with YOPC compared with patients with AOPC with KRAS wild-type tumors (median, 16.2 [YOPC-KRASWT] v 10.6 [AOPC-KRASWT] months; P = .008) but not KRAS-mutant tumors (P = .084). CONCLUSION In this large, real-world multiomic characterization of age-stratified molecular differences in pancreatic ductal adenocarcinoma, YOPC is associated with a distinct molecular landscape that has prognostic and therapeutic implications.
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Affiliation(s)
- Ifeanyichukwu Ogobuiro
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | | | | | | | | | - Prateek Gulhati
- Robert Wood Johnson Medical School, The Cancer Institute of NJ, New Brunswick, NJ
| | | | | | | | | | | | - Hong Jin Kim
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Syed A. Ahmad
- University of Cincinnati Medical Center, Cincinnati, OH
| | - Nipun B. Merchant
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | | | - Peter J. Hosein
- Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Jashodeep Datta
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL
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Florou V, Elliott A, Bailey MH, Stone D, Affolter K, Soares HP, Nevala-Plagemann C, Scaife C, Walker P, Korn WM, Lou E, Shroff RT, Hosein PJ, Garrido-Laguna I. Comparative Genomic Analysis of Pancreatic Acinar Cell Carcinoma (PACC) and Pancreatic Ductal Adenocarcinoma (PDAC) Unveils New Actionable Genomic Aberrations in PACC. Clin Cancer Res 2023; 29:3408-3417. [PMID: 37266563 PMCID: PMC10526978 DOI: 10.1158/1078-0432.ccr-22-3724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/24/2023] [Accepted: 05/30/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE Pure pancreatic acinar cell carcinomas (PACC) are rare malignancies with no established treatment. PACC demonstrates significant genetic intertumoral heterogeneity with multiple pathways involved, suggesting using targeted cancer therapeutics to treat this disease. We aggregated one of the largest datasets of pure PACC to examine the genomic variability and explore patient-specific therapeutic targets. EXPERIMENTAL DESIGN PACC specimens (n = 51) underwent next-generation sequencing of DNA (n = 29) or whole exome (n = 22) and RNA (whole transcriptome, n = 29) at a commercial laboratory. We performed comparative analyses of a genomic cohort of pancreatic ductal adenocarcinomas (PDAC; n = 4,205). In parallel, we conducted a retrospective review of patients with PACC treated at Huntsman Cancer Institute (HCI). RESULTS The real-world dataset included samples from 51 patients with PACC. We found key molecular differences between pure PACC and PDAC, highlighting the unique characteristics of pure PACC. Major differences in PACC include lower MAPK signaling and less stromal cell abundance compared with PDAC. Pure PACC showed genomic loss-of-heterozygosity to largely coincide with mutations in BRCA1, BRCA2, and PALB2. Of the 7 patients treated at HCI, one had a tumor that harbored a BRAF-V600E mutation. Leveraging precision oncology, this patient is being treated with encorafenib plus binimetinib, achieving an exceptionally durable and ongoing complete response of more than 3 years. CONCLUSIONS There are major differences between PACC and PDAC, including downregulation of the MAPK signaling pathway, and less stromal cell abundance. In addition, genomic characterization of pure PACC revealed frequent targetable alterations, which can guide patient treatment.
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Affiliation(s)
- Vaia Florou
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, 2000 Circle of Hope, 84112, Salt Lake City, UT, USA
| | | | - Matthew H Bailey
- Department of Biology at Brigham Young University, Salt Lake City, UT, USA
| | - David Stone
- Department of Biology at Brigham Young University, Salt Lake City, UT, USA
| | - Kajsa Affolter
- Department of Pathology, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Heloisa P. Soares
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, 2000 Circle of Hope, 84112, Salt Lake City, UT, USA
| | - Chris Nevala-Plagemann
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, 2000 Circle of Hope, 84112, Salt Lake City, UT, USA
| | - Courtney Scaife
- Department of Surgery, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | - Emil Lou
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rachna T Shroff
- Division of Hematology and Oncology, Department of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Peter J Hosein
- Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ignacio Garrido-Laguna
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah School of Medicine, 2000 Circle of Hope, 84112, Salt Lake City, UT, USA
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Alessandrino F, Gozlan EC, Hosein PJ, Merchant NB, McKinney A, Datta J. Texture Analysis Identifies Distinct Radiomic Signals Associated with Survival in Hispanic Patients with Pancreatic Cancer. Ann Surg Oncol 2023; 30:1953-1955. [PMID: 36581727 DOI: 10.1245/s10434-022-13013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 12/12/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Francesco Alessandrino
- Division of Abdominal Imaging, Department of Radiology, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA.
| | - Etienne C Gozlan
- University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Peter J Hosein
- Division of Medical Oncology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Nipun B Merchant
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Division of Surgical Oncology, Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Alexander McKinney
- Department of Radiology, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Jashodeep Datta
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Division of Surgical Oncology, Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
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Ogobuiro I, Baca Y, Ribeiro JR, Walker P, Wilson GC, Gulhati P, Marshall JL, Shroff RT, Spetzler D, Oberley MJ, Abbott DE, Kim HJ, Kooby DA, Maithel SK, Ahmad SA, Merchant NB, Xiu J, Hosein PJ, Datta J. Multi-omic characterization reveals a distinct molecular landscape in young-onset pancreatic cancer. medRxiv 2023:2023.03.28.23287894. [PMID: 37034762 PMCID: PMC10081424 DOI: 10.1101/2023.03.28.23287894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Purpose Using a real-world database with matched genomic-transcriptomic molecular data, we sought to characterize the distinct molecular correlates underlying clinical differences between young-onset pancreatic cancer (YOPC; <50-yrs.) and average-onset pancreatic cancer (AOPC; ≥70-yrs.) patients. Methods We analyzed matched whole-transcriptome and DNA sequencing data from 2430 patient samples (YOPC, n=292; AOPC, n=2138) from the Caris Life Sciences database (Phoenix, AZ). Immune deconvolution was performed using the quanTIseq pipeline. Overall survival (OS) data was obtained from insurance claims (n=4928); Kaplan-Meier estimates were calculated for age-and molecularly-defined cohorts. Significance was determined as FDR-corrected P -values ( Q )<0.05. Results YOPC patients had higher proportions of mismatch repair-deficient (dMMR)/microsatellite instability-high (MSI-H), BRCA2 -mutant, and PALB2 -mutant tumors compared with AOPC patients, but fewer SMAD4-, RNF43-, CDKN2A- , and SF3B1- mutant tumors. Notably, YOPC patients demonstrated significantly lower incidence of KRAS mutations compared with AOPC patients (81.3% vs. 90.9%; Q =0.004). In the KRAS- wildtype subset (n=227), YOPC tumors demonstrated fewer TP53 mutations and were more likely driven by NRG1 and MET fusions, while BRAF fusions were exclusively observed in AOPC patients. Immune deconvolution revealed significant enrichment of natural killer (NK) cells, CD8 + T cells, monocytes, and M2 macrophages in YOPC patients relative to AOPC patients, which corresponded with lower rates of HLA-DPA1 homozygosity. There was an association with improved OS in YOPC patients compared with AOPC patients with KRAS -wildtype tumors (median 16.2 [YOPC- KRAS WT ] vs. 10.6 [AOPC- KRAS WT ] months; P =0.008) but not KRAS -mutant tumors ( P =0.084). Conclusion In this large, real-world multi-omic characterization of age-stratified molecular differences in PDAC, YOPC is associated with a distinct molecular landscape that has prognostic and therapeutic implications.
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Datta J, Dai X, Bianchi A, De Castro Silva I, Mehra S, Garrido VT, Lamichhane P, Singh SP, Zhou Z, Dosch AR, Messaggio F, Ban Y, Umland O, Hosein PJ, Nagathihalli NS, Merchant NB. Combined MEK and STAT3 Inhibition Uncovers Stromal Plasticity by Enriching for Cancer-Associated Fibroblasts With Mesenchymal Stem Cell-Like Features to Overcome Immunotherapy Resistance in Pancreatic Cancer. Gastroenterology 2022; 163:1593-1612. [PMID: 35948109 PMCID: PMC10257389 DOI: 10.1053/j.gastro.2022.07.076] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/09/2022] [Accepted: 07/31/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS We have shown that reciprocally activated rat sarcoma (RAS)/mitogen-activated protein kinase/extracellular signal-regulated kinase (MEK) and Janus kinase/signal transducer and activator of transcription 3 (STAT3) pathways mediate therapeutic resistance in pancreatic ductal adenocarcinoma (PDAC), while combined MEK and STAT3 inhibition (MEKi+STAT3i) overcomes such resistance and alters stromal architecture. We now determine whether MEKi+STAT3i reprograms the cancer-associated fibroblast (CAF) and immune microenvironment to overcome resistance to immune checkpoint inhibition in PDAC. METHODS CAF and immune cell transcriptomes in MEKi (trametinib)+STAT3i (ruxolitinib)-treated vs vehicle-treated Ptf1aCre/+;LSL-KrasG12D/+;Tgfbr2flox/flox (PKT) tumors were examined via single-cell RNA sequencing (scRNAseq). Clustered regularly interspaced short palindromic repeats/clustered regularly interspaced short palindromic repeats associated protein 9 silencing of CAF-restricted Map2k1/Mek1 or Stat3, or both, enabled interrogation of CAF-dependent effects on immunologic remodeling in orthotopic models. Tumor growth, survival, and immune profiling via mass cytometry by time-of-flight were examined in PKT mice treated with vehicle, anti-programmed cell death protein 1 (PD-1) monotherapy, and MEKi+STAT3i combined with anti-PD1. RESULTS MEKi+STAT3i attenuates Il6/Cxcl1-expressing proinflammatory and Lrrc15-expressing myofibroblastic CAF phenotypes while enriching for Ly6a/Cd34-expressing CAFs exhibiting mesenchymal stem cell-like features via scRNAseq in PKT mice. This CAF plasticity is associated with M2-to-M1 reprogramming of tumor-associated macrophages, and enhanced trafficking of cluster of differentiation 8+ T cells, which exhibit distinct effector transcriptional programs. These MEKi+STAT3i-induced effects appear CAF-dependent, because CAF-restricted Mek1/Stat3 silencing mitigates inflammatory-CAF polarization and myeloid infiltration in vivo. Addition of MEKi+STAT3i to PD-1 blockade not only dramatically improves antitumor responses and survival in PKT mice but also augments recruitment of activated/memory T cells while improving their degranulating and cytotoxic capacity compared with anti-PD-1 monotherapy. Importantly, treatment of a patient who has chemotherapy-refractory metastatic PDAC with MEKi (trametinib), STAT3i (ruxolitinib), and PD-1 inhibitor (nivolumab) yielded clinical benefit. CONCLUSIONS Combined MEKi+STAT3i mitigates stromal inflammation and enriches for CAF phenotypes with mesenchymal stem cell-like properties to overcome immunotherapy resistance in PDAC.
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Affiliation(s)
- Jashodeep Datta
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Xizi Dai
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Anna Bianchi
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Iago De Castro Silva
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Siddharth Mehra
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Vanessa T Garrido
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Purushottam Lamichhane
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Clovis Oncology, Boulder, Colorado
| | - Samara P Singh
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Zhiqun Zhou
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Austin R Dosch
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Fanuel Messaggio
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Yuguang Ban
- Bioinformatics and Biostatistics Shared Resource, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Oliver Umland
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Peter J Hosein
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida; Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Nagaraj S Nagathihalli
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Nipun B Merchant
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida.
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Huffman BM, Mallick AB, Horick NK, Wang-Gillam A, Hosein PJ, Morse M, Beg MS, Murphy JE, Schlechter BL, Sanoff H, Wolpin BM, Arlen P, Lacy J, Cleary JM. Abstract A019: A multicenter randomized phase II study of gemcitabine and nab-paclitaxel versus gemcitabine and nab-paclitaxel with a MUC5AC antibody (NPC-1C) in advanced pancreatic cancer previously treated with FOLFIRINOX (NCT01834235). Cancer Res 2022. [DOI: 10.1158/1538-7445.panca22-a019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract
Background: Treatment options for advanced pancreatic ductal adenocarcinoma (PDAC) beyond first-line 5-fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) are limited, and patients are commonly treated with gemcitabine and nab-paclitaxel. The aim of this study was to determine whether the addition of a MUC5AC antibody, NPC-1C, could improve the efficacy of second-line gemcitabine and nab-paclitaxel in advanced PDAC. Methods: This study was a multicenter, open label, randomized phase II clinical trial (NCT01834235) for patients with metastatic or locally advanced PDAC who had disease progression on first-line FOLFIRINOX or a FOLFIRINOX-like regimen. Eligible patients had tumors with >20% MUC5AC expression as assessed by centralized immunohistochemistry review. Patients were randomly assigned (1:1 ratio) to receive gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2 on days 1, 8, and 15 every 4-week cycle with or without IV NPC-1C 1.5 mg/kg every two weeks. The primary endpoint was overall survival (OS). Secondary endpoints were progression free survival (PFS), confirmed overall response rate (ORR) by RECIST v1.1, disease control rate (DCR) (partial response or stable disease ≥ 16 weeks), and safety. Clinical variables associated with survival were explored using Cox proportional hazards stepwise regression analysis. Results: Of the 80 randomized patients, 40 received gemcitabine/nab-paclitaxel (GA) and 38 received gemcitabine/nab-paclitaxel/NPC-1C (GA+N) between April 2014 to March 2017. The median follow-up time was 5.8 months. Enrolled patients had a median age of 62 years (range, 36-78), 32 patients (41%) were female, and 4 patients (5%) had locally advanced disease. The trial was stopped early for futility following a pre-planned interim analysis, and patients were followed. The median OS in the GA arm was 6.6 months (95% confidence interval [CI]: 4.7-8.4) and 5.0 months (95% CI: 3.3-6.5; log-rank p=0.22) in the GA+N arm. The median PFS was 2.7 months (95% CI: 1.9-4.1) for GA and 3.4 months (95% CI: 1.9-5.3; log-rank p=0.80) for GA+N. The ORR (n=66) was 3% (95% CI: 0.4%-19%) for GA and 3% (95% CI: 0.4%-20%) for GA+N. The DCR was 23.5% (95% CI: 12.1%-40.8%) for GA and 28.1% (95% CI: 15.1%-46.2%) for GA+N (Fisher exact, p=0.78). There were minimal differences in toxicity between arms, except grade ≥ 3 anemia was more common in patients treated with GA+N vs. GA (39% vs 10%, Fisher exact, p=0.003). Chemotherapy dose reductions occurred in 69% of all patients at least one time (65% GA vs. 74% GA+N, Fisher exact, p=0.47). Decreased performance status, two or more metastatic sites, lymphocyte-to-monocyte ratio < 2.8, and CA19-9 > 2000 IU/mL were independently correlated with worse outcomes in the full study population. Conclusions: NPC-1C did not enhance the efficacy of gemcitabine and nab-paclitaxel. These data provide a benchmark for survival outcomes, dose modification patterns, and prognostic factors of patients treated with second-line gemcitabine and nab-paclitaxel.
Citation Format: Brandon M. Huffman, Atrayee Basu Mallick, Nora K. Horick, Andrea Wang-Gillam, Peter J. Hosein, Michael Morse, Muhammad Shaalan Beg, Janet E. Murphy, Benjamin L. Schlechter, Hanna Sanoff, Brian M. Wolpin, Philip Arlen, Jill Lacy, James M. Cleary. A multicenter randomized phase II study of gemcitabine and nab-paclitaxel versus gemcitabine and nab-paclitaxel with a MUC5AC antibody (NPC-1C) in advanced pancreatic cancer previously treated with FOLFIRINOX (NCT01834235) [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A019.
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Affiliation(s)
| | | | - Nora K. Horick
- 3Massachusetts General Hospital/Harvard Medical School, Boston, MA,
| | | | | | | | | | - Janet E. Murphy
- 3Massachusetts General Hospital/Harvard Medical School, Boston, MA,
| | | | | | - Brian M. Wolpin
- 8Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA,
| | | | - Jill Lacy
- 11Smilow Cancer Hospital, Yale School of Medicine, New Haven, CT
| | - James M. Cleary
- 8Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA,
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11
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Datta J, Bianchi A, De Castro Silva I, Deshpande NU, Cao LL, Mehra S, Singh S, Rafie C, Sun X, Chen X, Dai X, Colaprico A, Sharma P, Dosch AR, Pillai A, Hosein PJ, Nagathihalli NS, Komanduri KV, Wilson JM, Ban Y, Merchant NB. Distinct mechanisms of innate and adaptive immune regulation underlie poor oncologic outcomes associated with KRAS-TP53 co-alteration in pancreatic cancer. Oncogene 2022; 41:3640-3654. [PMID: 35701533 DOI: 10.1038/s41388-022-02368-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 05/14/2022] [Accepted: 05/30/2022] [Indexed: 11/08/2022]
Abstract
Co-occurrent KRAS and TP53 mutations define a majority of patients with pancreatic ductal adenocarcinoma (PDAC) and define its pro-metastatic proclivity. Here, we demonstrate that KRAS-TP53 co-alteration is associated with worse survival compared with either KRAS-alone or TP53-alone altered PDAC in 245 patients with metastatic disease treated at a tertiary referral cancer center, and validate this observation in two independent molecularly annotated datasets. Compared with non-TP53 mutated KRAS-altered tumors, KRAS-TP53 co-alteration engenders disproportionately innate immune-enriched and CD8+ T-cell-excluded immune signatures. Leveraging in silico, in vitro, and in vivo models of human and murine PDAC, we discover a novel intersection between KRAS-TP53 co-altered transcriptomes, TP63-defined squamous trans-differentiation, and myeloid-cell migration into the tumor microenvironment. Comparison of single-cell transcriptomes between KRAS-TP53 co-altered and KRAS-altered/TP53WT tumors revealed cancer cell-autonomous transcriptional programs that orchestrate innate immune trafficking and function. Moreover, we uncover granulocyte-derived inflammasome activation and TNF signaling as putative paracrine mediators of innate immunoregulatory transcriptional programs in KRAS-TP53 co-altered PDAC. Immune subtyping of KRAS-TP53 co-altered PDAC reveals conflation of intratumor heterogeneity with progenitor-like stemness properties. Coalescing these distinct molecular characteristics into a KRAS-TP53 co-altered "immunoregulatory program" predicts chemoresistance in metastatic PDAC patients enrolled in the COMPASS trial, as well as worse overall survival.
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Affiliation(s)
- Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
- Sylvester Comprehensive Cancer Center, Miami, FL, USA.
| | - Anna Bianchi
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iago De Castro Silva
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nilesh U Deshpande
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Long Long Cao
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Siddharth Mehra
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Samara Singh
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christine Rafie
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Xiaodian Sun
- Biostatistics and Bioinformatics Shared Resource, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Xi Chen
- Biostatistics and Bioinformatics Shared Resource, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Xizi Dai
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Antonio Colaprico
- Biostatistics and Bioinformatics Shared Resource, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Prateek Sharma
- Department of Surgery, University of Nebraska, Omaha, NE, USA
| | - Austin R Dosch
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Asha Pillai
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Peter J Hosein
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nagaraj S Nagathihalli
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Krishna V Komanduri
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Julie M Wilson
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Yuguang Ban
- Biostatistics and Bioinformatics Shared Resource, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
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12
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Garrido VT, Datta J, Dai X, Bianchi A, Silva IDC, Lamichhane P, Mehra S, Singh SP, Dosch AR, Umland O, VanSaun MNN, Hosein PJ, Nagathihalli N, Merchant N. Abstract 4187: Combined MEK and STAT3 inhibition reprograms the tumor microenvironment to overcome immunotherapy resistance in pancreatic cancer. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-4187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Pancreatic ductal adenocarcinoma (PDAC) is characterized by immune exclusion, stromal desmoplasia, and resistance to immune checkpoint inhibition (ICI). We have previously demonstrated that reciprocally activated RAS/RAF/MEK/ERK and JAK/STAT3 pathways mediate therapeutic resistance, while combined MEK and STAT3 inhibition (MEKi+STAT3i) overcomes this resistance in preclinical PDAC models. Given the dramatic decrease in tumor burden observed following MEKi+STAT3i, we investigated its effect on the stromal and immune microenvironment.
Methods: Ptf1aCre/+KrasG12D/+Tgfbr2flox/flox (PKT) mice were treated with vehicle, trametinib (MEKi, 3.3 mg/Kg, oral gavage three times weekly), ruxolitinib (STAT3i, 20 mg/Kg, oral gavage three times weekly), αPD-1 antibody (200 µg/mouse, i.p. injection twice weekly), combined MEKi+STAT3i or MEKi+STAT3i with αPD-1 beginning at 4-4.5 weeks of age. Mice were sacrificed after four weeks of treatment and tumors were harvested for single cell RNA sequencing, and high-dimensional immune-profiling by mass cytometry and flow cytometry.
Results: Single-cell transcriptomic analysis revealed that combined MEKi+STAT3i not only altered stromal architecture but also reprogramed tumor-resident CAFs from Il6/Cxcl1-expressing inflammatory phenotype towards Ly6a/Cd34-expressing fibroblast phenotype with both mesenchymal and hematopoietic progenitor-like properties. This stromal plasticity was associated with a striking attenuation and reprogramming of F4/80+ macrophages, M2-like macrophages (F4/80+CD206+), and MDSCs (CD11b+F4/80-Ly6G+/Ly6C+), as well as enhanced trafficking of CD4+ and CD8+ T-cells which exhibited a distinct effector and anti-apoptotic transcriptional program. The addition of MEKi+STAT3i to PD-1 blockade overcomes immune checkpoint resistance by significantly augmenting anti-tumor responses and dramatically improving survival in PKT mice, compared with vehicle treatment (median 181 vs. 44 days, p<0.0001) or anti-PD-1 monotherapy (median 181 vs. 57 days, p=0.0005). The addition of MEKi+STAT3i to PD-1 blockade not only augmented the recruitment of activated and memory T-cell populations, but also improved their degranulating capacity and functional cytotoxicity compared to PD-1 blockade alone. Importantly, treatment of a patient with chemotherapy-refractory metastatic PDAC with MEKi (Trametinib), STAT3i (Ruxolitinib), and PD-1 inhibitor (Nivolumab) was well-tolerated and yielded significant clinical benefit.
Conclusion: These data uncover a novel paradigm in which combined MEKi+STAT3i reprograms stromal inflammation and immune tolerance to overcome immunotherapy resistance in PDAC. The clinical efficacy of combined MEKi+STAT3i and anti-PD1 treatment provides encouraging signals for its translatability and is currently being pursued in a clinical trial.
Citation Format: Vanessa Tonin Garrido, Jashodeep Datta, Xizi Dai, Anna Bianchi, Iago De Castro Silva, Purushottam Lamichhane, Siddharth Mehra, Samara P. Singh, Austin R. Dosch, Oliver Umland, Michael n N. VanSaun, Peter J. Hosein, Nagaraj Nagathihalli, Nipun Merchant. Combined MEK and STAT3 inhibition reprograms the tumor microenvironment to overcome immunotherapy resistance in pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4187.
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Terrero G, Datta J, Dennison J, Sussman DA, Lohse I, Merchant NB, Hosein PJ. Ipilimumab/Nivolumab Therapy in Patients With Metastatic Pancreatic or Biliary Cancer With Homologous Recombination Deficiency Pathogenic Germline Variants. JAMA Oncol 2022; 8:1-3. [PMID: 35446342 PMCID: PMC9026238 DOI: 10.1001/jamaoncol.2022.0611] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Gretel Terrero
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Jashodeep Datta
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Jessica Dennison
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Daniel A Sussman
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Ines Lohse
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Nipun B Merchant
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Peter J Hosein
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
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Raveh Y, Beduschi T, Hosein PJ, Vianna R, Tekin A, Selvaggi G, Nicolau-Raducu R. Intestinal Autotransplantation and In-Situ Resection of Recurrent Pancreatic Head Intraductal Tubulopapillary Neoplasm with Portal Cavernoma: A Case Report. Transplant Proc 2021; 53:2598-2601. [PMID: 34274118 DOI: 10.1016/j.transproceed.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraductal tubulopapillary neoplasm (ITPN) is a new entity of a rare premalignant pancreatic neoplasia, and a radical curative resection is indicated. As with other tumors of the root of the mesentery, the proximity of the lesion to large splanchnic vessels, abdominal aorta, and inferior vena cava poses major risks of a massive hemorrhage and visceral ischemia using conventional surgical techniques. At times, these lesions are amenable for resection using novel techniques developed from organ transplantation. Multivisceral (allo-) transplantation should be considered when radical resection of a benign tumor is likely to compromise portal flow and possibly precipitate acute liver failure, but it may be associated with a long waitlist time and tumor progression. Autotransplantation offers a safe and curative resection of otherwise inoperable tumors in a bloodless field, an excellent exposure, and prevention of warm ischemic injury to the affected viscera, which are then autotransplanted. METHODS We describe the en bloc resection of a large and recurrent ITPN of the pancreas, distal stomach, proximal duodenum, transverse colon, superior mesenteric vein, and portal cavernoma, followed by intestinal autotransplantation. RESULTS A complete tumor resection was achieved with negative margins, adequate cold preservation of the reimplanted intestine, and without significant hemorrhage. The patient was discharged from the hospital 10 days later. The histopathologic examination revealed free-margin resection of ITPN with an associated invasive carcinoma. The patient received adjuvant chemotherapy with folinic acid, fluorouracil, and oxaliplatin and remains disease-free 20 months after surgery. CONCLUSIONS Autotransplantation offers curative resection of otherwise unresectable lesions of the root of the mesentery.
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Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.
| | - Thiago Beduschi
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Peter J Hosein
- Department of Medicine, Division of Hematology/Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Gennaro Selvaggi
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
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15
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Palacio S, McMurry HS, Ali R, Donenberg T, Silva-Smith R, Wideroff G, Sussman DA, Rocha Lima CMS, Hosein PJ. DNA damage repair deficiency as a predictive biomarker for FOLFIRINOX efficacy in metastatic pancreatic cancer. J Gastrointest Oncol 2019; 10:1133-1139. [PMID: 31949930 DOI: 10.21037/jgo.2019.09.12] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Patients with pathogenic germline and somatic variants in DNA damage repair (DDR) genes may derive greater benefit with platinum-based chemotherapy in metastatic pancreatic ductal adenocarcinoma (PDAC). This study investigates the role of DDR genes as a predictive biomarker for response to first-line platinum chemotherapy with FOLFIRINOX in metastatic PDAC patients. Demographic, clinical, and pathologic variables were collected for patients with metastatic PDAC who received FOLFIRINOX as frontline treatment and who had germline and somatic genetic testing. Kaplan-Meier analysis of overall survival (OS) and progression free survival (PFS) were correlated to the presence of DDR pathogenic variants. Forty patients with metastatic PDAC met inclusion criteria. Germline genetic testing revealed germline pathogenic variants in DDR genes in 5 patients (12%), and somatic pathogenic variants in DDR genes in 4 patients (10%). Median PFS was significantly longer in patients with any (germline or somatic) pathogenic variant in DDR genes than in those without alterations 18.5 vs. 6.9 months (log-rank P=0.003). When restricted to the presence or absence of germline pathogenic variants in DDR genes, the median PFS was 18.5 vs. 7.4 months (log-rank P=0.005). The median OS for the entire cohort was 11.5 months was not statistically different between the two groups, however there were no deaths in the subgroup with germline pathogenic variants in DDR genes treated with frontline FOLFIRINOX. A subset of patients with metastatic PDAC and germline or somatic pathogenic variants in DDR genes have a statistically superior PFS when treated with the platinum containing regimen FOLFIRINOX. The role of DDR gene alterations as a predictive biomarker for FOLFIRINOX benefit should be further evaluated in prospective trials.
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Affiliation(s)
- Sofia Palacio
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Hannah S McMurry
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Robert Ali
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Talia Donenberg
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Rachel Silva-Smith
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Gina Wideroff
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Daniel A Sussman
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Peter J Hosein
- Department of Medicine, University of Miami Miller School of Medicine, and Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Janssen QP, Buettner S, Suker M, Beumer BR, Addeo P, Bachellier P, Bahary N, Bekaii-Saab T, Bali MA, Besselink MG, Boone BA, Chau I, Clarke S, Dillhoff M, El-Rayes BF, Frakes JM, Grose D, Hosein PJ, Jamieson NB, Javed AA, Khan K, Kim KP, Kim SC, Kim SS, Ko AH, Lacy J, Margonis GA, McCarter MD, McKay CJ, Mellon EA, Moorcraft SY, Okada KI, Paniccia A, Parikh PJ, Peters NA, Rabl H, Samra J, Tinchon C, van Tienhoven G, van Veldhuisen E, Wang-Gillam A, Weiss MJ, Wilmink JW, Yamaue H, Homs MYV, van Eijck CHJ, Katz MHG, Groot Koerkamp B. Neoadjuvant FOLFIRINOX in Patients With Borderline Resectable Pancreatic Cancer: A Systematic Review and Patient-Level Meta-Analysis. J Natl Cancer Inst 2019; 111:782-794. [PMID: 31086963 PMCID: PMC6695305 DOI: 10.1093/jnci/djz073] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 12/19/2018] [Accepted: 04/22/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND FOLFIRINOX is a standard treatment for metastatic pancreatic cancer patients. The effectiveness of neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer (BRPC) remains debated. METHODS We performed a systematic review and patient-level meta-analysis on neoadjuvant FOLFIRINOX in patients with BRPC. Studies with BRPC patients who received FOLFIRINOX as first-line neoadjuvant treatment were included. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival, resection rate, R0 resection rate, and grade III-IV adverse events. Patient-level survival outcomes were obtained from authors of the included studies and analyzed using the Kaplan-Meier method. RESULTS We included 24 studies (8 prospective, 16 retrospective), comprising 313 (38.1%) BRPC patients treated with FOLFIRINOX. Most studies (n = 20) presented intention-to-treat results. The median number of administered neoadjuvant FOLFIRINOX cycles ranged from 4 to 9. The resection rate was 67.8% (95% confidence interval [CI] = 60.1% to 74.6%), and the R0-resection rate was 83.9% (95% CI = 76.8% to 89.1%). The median OS varied from 11.0 to 34.2 months across studies. Patient-level survival data were obtained for 20 studies representing 283 BRPC patients. The patient-level median OS was 22.2 months (95% CI = 18.8 to 25.6 months), and patient-level median progression-free survival was 18.0 months (95% CI = 14.5 to 21.5 months). Pooled event rates for grade III-IV adverse events were highest for neutropenia (17.5 per 100 patients, 95% CI = 10.3% to 28.3%), diarrhea (11.1 per 100 patients, 95% CI = 8.6 to 14.3), and fatigue (10.8 per 100 patients, 95% CI = 8.1 to 14.2). No deaths were attributed to FOLFIRINOX. CONCLUSIONS This patient-level meta-analysis of BRPC patients treated with neoadjuvant FOLFIRINOX showed a favorable median OS, resection rate, and R0-resection rate. These results need to be assessed in a randomized trial.
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Affiliation(s)
| | - Stefan Buettner
- See the Notes section for the full list of authors’ affiliations
| | - Mustafa Suker
- See the Notes section for the full list of authors’ affiliations
| | - Berend R Beumer
- See the Notes section for the full list of authors’ affiliations
| | - Pietro Addeo
- See the Notes section for the full list of authors’ affiliations
| | | | - Nathan Bahary
- See the Notes section for the full list of authors’ affiliations
| | | | - Maria A Bali
- See the Notes section for the full list of authors’ affiliations
| | - Marc G Besselink
- See the Notes section for the full list of authors’ affiliations
| | - Brian A Boone
- See the Notes section for the full list of authors’ affiliations
| | - Ian Chau
- See the Notes section for the full list of authors’ affiliations
| | - Stephen Clarke
- See the Notes section for the full list of authors’ affiliations
| | - Mary Dillhoff
- See the Notes section for the full list of authors’ affiliations
| | | | - Jessica M Frakes
- See the Notes section for the full list of authors’ affiliations
| | - Derek Grose
- See the Notes section for the full list of authors’ affiliations
| | - Peter J Hosein
- See the Notes section for the full list of authors’ affiliations
| | - Nigel B Jamieson
- See the Notes section for the full list of authors’ affiliations
| | - Ammar A Javed
- See the Notes section for the full list of authors’ affiliations
| | - Khurum Khan
- See the Notes section for the full list of authors’ affiliations
| | - Kyu-Pyo Kim
- See the Notes section for the full list of authors’ affiliations
| | - Song Cheol Kim
- See the Notes section for the full list of authors’ affiliations
| | - Sunhee S Kim
- See the Notes section for the full list of authors’ affiliations
| | - Andrew H Ko
- See the Notes section for the full list of authors’ affiliations
| | - Jill Lacy
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Colin J McKay
- See the Notes section for the full list of authors’ affiliations
| | - Eric A Mellon
- See the Notes section for the full list of authors’ affiliations
| | | | - Ken-Ichi Okada
- See the Notes section for the full list of authors’ affiliations
| | | | - Parag J Parikh
- See the Notes section for the full list of authors’ affiliations
| | - Niek A Peters
- See the Notes section for the full list of authors’ affiliations
| | - Hans Rabl
- See the Notes section for the full list of authors’ affiliations
| | - Jaswinder Samra
- See the Notes section for the full list of authors’ affiliations
| | | | | | | | | | - Matthew J Weiss
- See the Notes section for the full list of authors’ affiliations
| | | | - Hiroki Yamaue
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Matthew H G Katz
- See the Notes section for the full list of authors’ affiliations
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Macedo FI, Picado O, Hosein PJ, Dudeja V, Franceschi D, Mesquita-Neto JW, Yakoub D, Merchant NB. Does Neoadjuvant Chemotherapy Change the Role of Regional Lymphadenectomy in Pancreatic Cancer Survival? Pancreas 2019; 48:823-831. [PMID: 31210664 DOI: 10.1097/mpa.0000000000001339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the role of lymph node (LN) dissection and staging in outcomes of patients with pancreatic adenocarcinoma (PDAC) who underwent neoadjuvant chemotherapy (NAC). METHODS National Cancer Database was queried for patients with stages I to III PDAC diagnosed between 2004 and 2014. Overall survival (OS) was derived from Kaplan-Meier methods, and Cox-regression model was used to evaluate associations between the number of LN examined, number of positive nodes, and LN ratio with OS. RESULTS A total 35,599 patients were included, 3395 (9%) underwent NAC, 19,865 (56%) received adjuvant chemotherapy (AC), and 12,299 (35%) underwent surgery alone. Cox-regression showed superior OS in NAC compared with AC and surgery alone (26 vs 23 vs 14 months, P < 0.001). Minimum number of LN examined affecting OS was 8 LNs in NAC (23.8 vs 26.6 months, P = 0.029), and 12 LNs in AC group (22 vs 23.1 months, P = 0.028). Lymph node ratio cutoff of greater than 0.2 was associated with decreased OS (19.4 vs 24.4 months, P < 0.001). CONCLUSIONS Neoadjuvant chemotherapy is associated with improved survival in PDAC. Lymph node yield remains a significant prognostic factor after NAC, whereas the minimum number of harvested LNs associated with sufficient staging and survival is decreased.
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Affiliation(s)
| | | | | | | | | | - Jose Wilson Mesquita-Neto
- Department of Surgery, Karmanos Comprehensive Cancer Center, Wayne State University School of Medicine, Detroit, MI
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18
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Feun LG, Li YY, Wu C, Wangpaichitr M, Jones PD, Richman SP, Madrazo B, Kwon D, Garcia-Buitrago M, Martin P, Hosein PJ, Savaraj N. Phase 2 study of pembrolizumab and circulating biomarkers to predict anticancer response in advanced, unresectable hepatocellular carcinoma. Cancer 2019; 125:3603-3614. [PMID: 31251403 DOI: 10.1002/cncr.32339] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 05/09/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Checkpoint inhibitors have shown modest activity in patients with advanced hepatocellular carcinoma (HCC). Herein, the authors report a prospective single-institution clinical/translational phase 2 study of pembrolizumab in patients with advanced HCC and circulating biomarkers closely related to response. METHODS Pembrolizumab was administered at a dose of 200 mg intravenously every 3 weeks among patients who may have developed disease progression while receiving, were intolerant of, or refused sorafenib. The circulating levels of cytokines, chemokines, programmed cell death protein 1 (PD-1), programmed death-ligand 1 (PD-L1), and PD-L2 were correlated with response, tumor PD-L1 expression, and other clinicopathological features. RESULTS A total of 29 patients were treated and 28 patients were evaluable for response. The most common laboratory grade 3/4 adverse events were increases in aspartate aminotransferase and/or alanine aminotransferase and serum bilirubin, which for the most part were reversible. In terms of efficacy, one patient achieved a complete response and 8 patients achieved partial responses for an overall response rate of 32%. Four other patients had stable disease. The median progression-free survival was 4.5 months and the median overall survival was 13 months. Response did not correlate with prior sorafenib therapy, PD-L1 tumor staining, or a prior history of hepatitis. Correlative studies revealed that high baseline plasma TGF-β levels (≥200 pg/mL) significantly correlated with poor treatment outcomes after pembrolizumab. Tumor PD-L1 and plasma PD-L1/PD-1 levels were associated with plasma IFN-γ or IL-10. CONCLUSIONS Pembrolizumab was found to demonstrate activity in patients with advanced HCC. Toxicity generally was tolerable and reversible. A set of immunological markers in blood plasma as well as PD-L1 staining indicated that baseline TGF-β could be a predictive biomarker for response to pembrolizumab.
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Affiliation(s)
- Lynn G Feun
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Ying-Ying Li
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Chunjing Wu
- Division of Hematology and Oncology, Miami Veterans Affairs Healthcare System, Miami, Florida
| | - Medhi Wangpaichitr
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Patricia D Jones
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Stephen P Richman
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Beatrice Madrazo
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Paul Martin
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Peter J Hosein
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Niramol Savaraj
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Division of Hematology and Oncology, Miami Veterans Affairs Healthcare System, Miami, Florida
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Palacio S, Pollack T, Silva-Smith R, Sussman DA, Hosein PJ. Exceptional response to FOLFIRINOX in a patient with pancreatic cancer and a germline RAD51C mutation. J Gastrointest Oncol 2018; 9:E19-E22. [PMID: 30151275 PMCID: PMC6087861 DOI: 10.21037/jgo.2018.03.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 03/23/2018] [Indexed: 01/07/2023] Open
Abstract
Pancreatic cancer is projected to become the second leading cause of cancer death in the United States by 2030. Deleterious germline mutations can contribute to pancreatic cancer susceptibility. Herein we report a case of a patient with metastatic pancreatic adenocarcinoma to the lung and liver who was found to have a deleterious germline mutation in RAD51C who had a remarkable response to chemotherapy with FOLFIRINOX, a platinum-containing regimen.
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Affiliation(s)
- Sofia Palacio
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Terri Pollack
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Rachel Silva-Smith
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Daniel A Sussman
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter J Hosein
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
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20
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Husnain M, Park W, Ramos JC, Johnson TE, Chan J, Dasari A, Mudad R, Hosein PJ. Complete response to ipilimumab and nivolumab therapy in a patient with extensive extrapulmonary high-grade small cell carcinoma of the pancreas and HIV infection. J Immunother Cancer 2018; 6:66. [PMID: 29986769 PMCID: PMC6036694 DOI: 10.1186/s40425-018-0379-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) have shown promising results in many solid tumors. There are limited data on the safety and efficacy of these drugs in HIV infected patients as they have traditionally been excluded from CPIs clinical trials. CASE PRESENTATION We present a case of an HIV-positive patient with extensive extrapulmonary high-grade small cell carcinoma who was treated with dual CPIs (nivolumab and ipilimumab) with a complete response to therapy and with a manageable safety profile. We performed a comprehensive literature review identifying 62 total HIV positive cases treated with CPIs showing this to be a potentially safe option in HIV-positive patients. CONCLUSION HIV infection is not an absolute contraindication to CPI therapy. Our case and others provide justification for ongoing trials of CPI therapy in patients with HIV infection, a group that has traditionally been excluded from clinical trials.
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Affiliation(s)
- Muhammad Husnain
- Department of Medicine, Division of Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave. Suite 3400, Miami, FL, 33136, USA
| | - Wungki Park
- Department of Medicine, Division of Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave. Suite 3400, Miami, FL, 33136, USA
| | - Juan Carlos Ramos
- Department of Medicine, Division of Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave. Suite 3400, Miami, FL, 33136, USA
| | - Thomas E Johnson
- Department of Ophthalmology, University of Miami Miller School of Medicine and Bascom Palmer Eye Institute, Miami, USA
| | - Joseph Chan
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Mount Sinai Medical Center, Miami, USA
| | | | - Raja Mudad
- Department of Medicine, Division of Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave. Suite 3400, Miami, FL, 33136, USA
| | - Peter J Hosein
- Department of Medicine, Division of Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave. Suite 3400, Miami, FL, 33136, USA.
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21
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Peterson SL, Husnain M, Pollack T, Pimentel A, Loaiza-Bonilla A, Westendorf-Overley C, Ratermann K, Anthony L, Desimone P, Goel G, Kudrimoti M, Dineen S, Tzeng CWD, Hosein PJ. Neoadjuvant Nab-paclitaxel and Gemcitabine in Borderline Resectable or Locally Advanced Unresectable Pancreatic Adenocarcinoma in Patients Who Are Ineligible for FOLFIRINOX. Anticancer Res 2018; 38:4035-4039. [PMID: 29970528 DOI: 10.21873/anticanres.12692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/07/2018] [Accepted: 06/08/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Combination nab-paclitaxel/gemcitabine (AG) is superior to gemcitabine in patients with metastatic pancreatic cancer (PC). There are limited data for AG in borderline resectable (BR) or locally advanced pancreatic cancer (LAPC). Herein, we report our experience with neoadjuvant AG for BR/LAPC in patients ineligible for FOLFIRINOX. PATIENTS AND METHODS This retrospective series, included patients with BR/LAPC who received AG as neoadjuvant therapy for 3-4 months followed by radiation, then re-evaluation for surgery. RESULTS Between 10/2013-2/2018, 32 patients (22 BR, 10 LAPC) were treated with this approach. Median age was 70 years. Nine patients were converted to resectability by imaging; six had R0 resections (19%), five (16%) achieved a partial response and 24 (75%) had stable disease. CONCLUSION In this small series, the R0 resection rate and response rate were 19% and 16% respectively. These data suggest that neoadjuvant AG may be an alternate option for patients ineligible for FOLFIRINOX.
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Affiliation(s)
- Shawn L Peterson
- University of Louisville, James Graham Brown Cancer Center, Louisville, KY, U.S.A
| | - Muhammad Husnain
- University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, U.S.A
| | - Terri Pollack
- University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, U.S.A
| | - Agustin Pimentel
- University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, U.S.A
| | | | | | - Kelley Ratermann
- University of Kentucky Markey Cancer Center, Lexington, KY, U.S.A
| | - Lowell Anthony
- University of Kentucky Markey Cancer Center, Lexington, KY, U.S.A
| | - Philip Desimone
- University of Kentucky Markey Cancer Center, Lexington, KY, U.S.A
| | - Gaurav Goel
- University of Pittsburgh, Hillman Cancer Center, Pittsburgh, PA, U.S.A
| | - Mahesh Kudrimoti
- University of Kentucky Markey Cancer Center, Lexington, KY, U.S.A
| | | | - Ching-Wei D Tzeng
- The University of Texas, MD Anderson Cancer Center, Houston, TX, U.S.A
| | - Peter J Hosein
- University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, U.S.A.
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22
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Palacio S, Hosein PJ, Reis I, Akunyili II, Ernani V, Pollack T, Macintyre J, Restrepo MH, Merchan JR, Rocha Lima CM. The nab-paclitaxel/gemcitabine regimen for patients with refractory advanced pancreatic adenocarcinoma. J Gastrointest Oncol 2018; 9:135-139. [PMID: 29564179 DOI: 10.21037/jgo.2017.10.12] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The phase III MPACT trial for metastatic pancreatic cancer (PC) showed improved overall survival (OS), progression free survival (PFS) and response rates (RRs) for first-line nab-paclitaxel (Abraxane) and gemcitabine (the AG combination) compared to gemcitabine monotherapy. The safety and efficacy of the AG combination has not been systematically studied as second-line therapy or beyond for metastatic PC. We conducted an IRB-approved retrospective analysis of all patients diagnosed between September 2010 and August 2014 with advanced refractory PC that received combination treatment with AG at our institution. Demographic and survival data were extracted from the registry. Patients received nab-paclitaxel 125 mg/m2 and gemcitabine 1,000 mg/m2 and on days 1, 8 and 15 of a 28-day cycle with subsequent dose modifications based on tolerance. Data on 59 patients was available; the median age was 61; 55% were male; 56% received AG as second line therapy and 44% received it as third-line or beyond. Five (10%) patients had a confirmed partial response (PR), 23 (47%) had stable disease (SD) and 21 (43%) had disease progression as their best response. Among the 31 (52%) patients who received prior gemcitabine, 18 (58%) had clinical benefit; 3 had a PR and 15 had SD. The median OS was 3.9 months and the median progression-free survival was 3 months. Toxicity was similar to what was reported in the MPACT trial. This retrospective analysis suggests that AG is active in PC patients previously treated with either fluoropyrimidine-based therapy or gemcitabine-based therapy with manageable toxicities.
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Affiliation(s)
- Sofia Palacio
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter J Hosein
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Isildinha Reis
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Ikechukwu I Akunyili
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Vinicius Ernani
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Terri Pollack
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jessica Macintyre
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maria H Restrepo
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jaime R Merchan
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Caio M Rocha Lima
- Division of Oncology, Gibbs Comprehensive Cancer Center and Research Institute, Spartanburg, SC, USA
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23
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Feun LG, Wangpaichitr M, Li YY, Kwon D, Richman SP, Hosein PJ, Savaraj N. Phase II trial of SOM230 (pasireotide LAR) in patients with unresectable hepatocellular carcinoma. J Hepatocell Carcinoma 2018; 5:9-15. [PMID: 29392123 PMCID: PMC5769585 DOI: 10.2147/jhc.s153672] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background A phase II trial of pasireotide was performed to assess its efficacy and safety in advanced or metastatic hepatocellular carcinoma (HCC). Patients and methods Patients with advanced HCC and Child-Pugh score ≤7 received pasireotide LAR 60 mg intramuscularly every 28 days. Primary endpoint was disease control rate. Secondary endpoints were time to tumor progression, response rate, treatment-related adverse events, and overall survival. Serum insulin growth factor-1 was measured before and after pasireotide. Results Twenty patients were treated and evaluable. Eighteen patients (90%) had prior therapy; 16 patients (80%) had multiple therapies. Median age was 65, 75% had Barcelona Clinic Liver Cancer stage C, and 55% had metastatic disease. The main toxicity was hyperglycemia. Rare adverse effects included reversible grade 4 elevation in alanina transaminase/aspartate transaminase in one patient. The best response was stable disease in 9 patients (45%). Median time to tumor progression for the 20 patients was 3 months, and median survival was 9 months. Conclusion Pasireotide had limited clinical benefit as second-line or third-line treatment in patients with advanced or metastatic HCC. Low baseline insulin growth factor-1 level may be indicative when SOM230 treatment may be ineffective, and decreasing levels after treatment may be indicative of disease control.
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Affiliation(s)
- Lynn G Feun
- Department of Medicine, Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami
| | | | - Ying-Ying Li
- Department of Medicine, Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Core, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Stephen P Richman
- Department of Medicine, Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami
| | - Peter J Hosein
- Department of Medicine, Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami
| | - Niramol Savaraj
- Department of Medicine, Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami.,Department of Surgery, Miami VA Healthcare System, Research Service
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24
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Hilal T, Nakazawa M, Hodskins J, Villano JL, Mathew A, Goel G, Wagner L, Arnold SM, DeSimone P, Anthony LB, Hosein PJ. Comprehensive genomic profiling in routine clinical practice leads to a low rate of benefit from genotype-directed therapy. BMC Cancer 2017; 17:602. [PMID: 28854908 PMCID: PMC5577820 DOI: 10.1186/s12885-017-3587-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 08/22/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Describe a single-center real-world experience with comprehensive genomic profiling (CGP) to identify genotype directed therapy (GDT) options for patients with malignancies refractory to standard treatment options. METHODS Patients who had CGP by a CLIA-certified laboratory between November 2012 and December 2015 were included. The medical records were analyzed retrospectively after Institutional Review Board (IRB) approval. The treating oncologist made the decision to obtain the assay to provide potential therapeutic options. The objectives of this study were to determine the proportion of patients who benefited from GDT, and to identify barriers to receiving GDT. RESULTS A total of 125 pediatric and adult patients with a histologically confirmed diagnosis of malignancy were included. Among these, 106 samples were from adult patients, and 19 samples were from pediatric patients. The median age was 54 years for adults. The majority had stage IV malignancy (53%) and were pretreated with 2-3 lines of therapy (45%). The median age was 8 years for pediatric patients. The majority had brain tumors (47%) and had received none or 1 line of therapy (58%) when the profiling was requested. A total of 111 (92%) patients had genomic alterations and were candidates for GDT either via on/off-label use or a clinical trial (phase 1 through 3). Fifteen patients (12%) received GDT based on these results including two patients who were referred for genomically matched phase 1 clinical trials. Three patients (2%) derived benefit from their GDT that ranged from 2 to 6 months of stable disease. CONCLUSIONS CGP revealed potential treatment options in the majority of patients profiled. However, multiple barriers to therapy were identified, and only a small minority of the patients derived benefit from GDT.
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Affiliation(s)
- Talal Hilal
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Mary Nakazawa
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jacob Hodskins
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - John L Villano
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Aju Mathew
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Guarav Goel
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Lars Wagner
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Susanne M Arnold
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Philip DeSimone
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Lowell B Anthony
- Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Peter J Hosein
- Hematology/Oncology, University of Miami School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA.
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25
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Narayanan G, Hosein PJ, Beulaygue IC, Froud T, Scheffer HJ, Venkat SR, Echenique AM, Hevert EC, Livingstone AS, Rocha-Lima CM, Merchan JR, Levi JU, Yrizarry JM, Lencioni R. Percutaneous Image-Guided Irreversible Electroporation for the Treatment of Unresectable, Locally Advanced Pancreatic Adenocarcinoma. J Vasc Interv Radiol 2016; 28:342-348. [PMID: 27993507 DOI: 10.1016/j.jvir.2016.10.023] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/18/2016] [Accepted: 10/25/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To describe safety and effectiveness of percutaneous irreversible electroporation (IRE) for treatment of unresectable, locally advanced pancreatic adenocarcinoma (LAPC). MATERIALS AND METHODS This retrospective study included 50 patients (23 women, 27 men; age range, 46-91 y; median age, 62.5 y) with biopsy-proven, unresectable LAPC who received percutaneous computed tomography (CT)-guided IRE. The primary objective was to assess the safety profile of the procedure; the secondary objective was to determine overall survival (OS). All patients had prior chemotherapy (1-5 lines, median 2), and 30 (60%) of 50 patients had prior radiation therapy. Follow-up included CT at 1 month and at 3-month intervals thereafter. RESULTS There were no treatment-related deaths and no 30-day mortality. Serious adverse events occurred in 10 (20%) of 50 patients (abdominal pain [n = 7], pancreatitis [n = 1], sepsis [n = 1], gastric leak [n = 1]). Median OS was 27.0 months (95% confidence interval [CI], 22.7-32.5 months) from time of diagnosis and 14.2 months (95% CI, 9.7-16.2 months) from time of IRE. Patients with tumors ≤ 3 cm (n = 24) had significantly longer median OS than patients with tumors > 3 cm (n = 26): 33.8 vs 22.7 months from time of diagnosis (P = .002) and 16.2 vs 9.9 months from time of IRE (P = .031). Tumor size was confirmed as the only independent predictor of OS at multivariate analysis. CONCLUSIONS Percutaneous image-guided IRE of unresectable LAPC is associated with an acceptable safety profile.
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Affiliation(s)
- Govindarajan Narayanan
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136.
| | - Peter J Hosein
- Division of Medical Oncology, Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Isabelle C Beulaygue
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Tatiana Froud
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Hester J Scheffer
- Department of Radiology and Nuclear Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Shree R Venkat
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Ana M Echenique
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | | | - Alan S Livingstone
- Department of Medicine, Sylvester Comprehensive Cancer Center, and Department of Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Caio M Rocha-Lima
- Division of Oncology, Gibbs Cancer Center & Research Institute, Spartanburg, South Carolina
| | - Jaime R Merchan
- Division of Medical Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Joseph U Levi
- Department of Medicine, Sylvester Comprehensive Cancer Center, and Department of Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Jose M Yrizarry
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
| | - Riccardo Lencioni
- Department of Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Avenue, C-080, Miami, FL 33136
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26
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Berera S, Koru-Sengul T, Miao F, Carrasquillo O, Nadji M, Zhang Y, Hosein PJ, McCauley JL, Abreu MT, Sussman DA. Colorectal Tumors From Different Racial and Ethnic Minorities Have Similar Rates of Mismatch Repair Deficiency. Clin Gastroenterol Hepatol 2016; 14:1163-71. [PMID: 27046481 DOI: 10.1016/j.cgh.2016.03.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/18/2016] [Accepted: 03/13/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Microsatellite instability (MSI) in colorectal cancer cells results from deficient mismatch repair (MMR) protein function, either acquired or from germline alterations such as in patients with Lynch syndrome. Universal screening initiatives for Lynch syndrome have been encouraged. However, little is known about the true prevalence of MMR deficiency and MSI in colorectal tumors among individuals from different racial and ethnic subgroups or their clinical effects in these populations. METHODS We performed a retrospective analysis of 253 surgically resected, primary colorectal adenocarcinoma specimens identified from the University of Miami tumor registry from 2005 through 2010. We collected clinical data, including overall survival (OS), the proportion of patients alive at specific intervals, from non-Hispanic white, Hispanic, and black patients matched by stage. We performed immunohistochemical staining to detect MMR proteins in all specimens and polymerase chain reaction analysis of 51 tumors to detect MSI. RESULTS We detected MMR deficiency in 28 of 253 cases (11.1%), evenly distributed among blacks (9.6%), non-Hispanic whites (10.4%), and Hispanics (12.6%) (P = .79). Combined deficiencies in MLH1 and PMS2 were found in 23 of 28 MMR-deficient samples (82.1%); MSH2 and MSH6 were most frequently absent in tumor samples from Hispanics (P = .03). Eleven of 51 tumor samples (21.6%) had high levels of MSI, and we observed a high level of concordance between MMR and MSI (κ = .81). OS was significantly better in patients whose tumors had deficient MMR (hazard ratio for patients with MMR-deficient tumors vs MMR proteins intact = 0.37; 95% confidence interval, 0.15-0.91; P = .03). Race and ethnicity were not significant predictors of OS. CONCLUSIONS MMR deficiency in colorectal tumors occurs with similar rates among patients of different racial and ethnic groups, which is based on immunohistochemical analysis of 253 primary tumor specimens. This finding indicates the potential value of universal testing of colorectal cancer by immunohistochemistry in minority populations and confirms the benefit of MMR deficiency to OS.
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Affiliation(s)
- Shivali Berera
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Tulay Koru-Sengul
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Leonard Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Feng Miao
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Leonard Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Olveen Carrasquillo
- Division of General Internal Medicine, Department of Internal Medicine, University of Miami Leonard Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Mehrdad Nadji
- Department of Pathology, University of Miami Leonard Miller School of Medicine, Miami, Florida
| | - Yaxia Zhang
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Peter J Hosein
- Division of Hematology and Oncology, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky/Sylvester Comprehensive Cancer Center, Lexington, Kentucky
| | - Jacob L McCauley
- Center for Genome Technology, John P. Hussman Institute for Human Genomics, University of Miami Leonard Miller School of Medicine, Miami, Florida
| | - Maria T Abreu
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Daniel A Sussman
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, Florida.
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Suker M, Beumer BR, Sadot E, Marthey L, Faris JE, Mellon EA, El-Rayes BF, Wang-Gillam A, Lacy J, Hosein PJ, Moorcraft SY, Conroy T, Hohla F, Allen P, Taieb J, Hong TS, Shridhar R, Chau I, van Eijck CH, Koerkamp BG. FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis. Lancet Oncol 2016; 17:801-810. [PMID: 27160474 PMCID: PMC5527756 DOI: 10.1016/s1470-2045(16)00172-8] [Citation(s) in RCA: 613] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/27/2016] [Accepted: 03/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND 35% of patients with pancreatic cancer have unresectable locally advanced disease at diagnosis. Several studies have examined systemic chemotherapy with FOLFIRINOX (leucovorin and fluorouracil plus irinotecan and oxaliplatin) in patients with locally advanced pancreatic cancer. We aimed to assess the effectiveness of FOLFIRINOX as first-line treatment in this patient population. METHODS We systematically searched Embase, MEDLINE (OvidSP), Web of Science, Scopus, PubMed Publisher, Cochrane, and Google Scholar from July 1, 1994, to July 2, 2015, for studies of treatment-naive patients of any age who received FOLFIRINOX as first-line treatment of locally advanced pancreatic cancer. Our primary outcome was overall survival. Secondary outcomes were progression-free survival; rates of grade 3 or 4 adverse events; and the proportion of patients who underwent radiotherapy or chemoradiotherapy, surgical resection after FOLFIRINOX, and R0 resection. We evaluated survival outcomes with the Kaplan-Meier method with patient-level data. Grade 3 or 4 adverse events, and the proportion of patients who underwent subsequent radiotherapy or chemoradiotherapy or resection, were pooled in a random-effects model. FINDINGS We included 13 studies comprising 689 patients, of whom 355 (52%) patients had locally advanced pancreatic cancer. 11 studies, comprising 315 patients with locally advanced disease, reported survival outcomes and were eligible for patient-level meta-analysis. Median overall survival from the start of FOLFIRINOX ranged from 10·0 months (95% CI 4·0-16·0) to 32·7 months (23·1-42·3) across studies with a pooled patient-level median overall survival of 24·2 months (95% CI 21·7-26·8). Median progression-free survival ranged from 3·0 months (95% CI not calculable) to 20·4 months (6·5-34·3) across studies with a patient-level median progression-free survival of 15·0 months (95% 13·8-16·2). In ten studies comprising 490 patients, 296 grade 3 or 4 adverse events were reported (60·4 events per 100 patients). No deaths were attributed to FOLFIRINOX toxicity. The proportion of patients who underwent radiotherapy or chemoradiotherapy ranged from 31% to 100% across studies. In eight studies, 154 (57%) of 271 patients received radiotherapy or chemoradiotherapy after FOLFIRINOX. The pooled proportion of patients who received any radiotherapy treatment was 63·5% (95% CI 43·3-81·6, I(2) 90%). The proportion of patients who underwent surgical resection for locally advanced pancreatic cancer ranged from 0% to 43%. The proportion of patients who had R0 resection of those who underwent resection ranged from 50% to 100% across studies. In 12 studies, 91 (28%) of 325 patients underwent resection after FOLFIRINOX. The pooled proportion of patients who had resection was 25·9% (95% CI 20·2-31·9, I(2) 24%). R0 resection was reported in 60 (74%) of 81 patients. The pooled proportion of patients who had R0 resection was 78·4% (95% CI 60·2-92·2, I(2) 64%). INTERPRETATION Patients with locally advanced pancreatic cancer treated with FOLFIRINOX had a median overall survival of 24·2 months-longer than that reported with gemcitabine (6-13 months). Future research should assess these promising results in a randomised controlled trial, and should establish which patients might benefit from radiotherapy or chemoradiotherapy or resection after FOLFIRINOX. FUNDING None.
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Affiliation(s)
- Mustafa Suker
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Berend R Beumer
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Eran Sadot
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lysiane Marthey
- Department of Hepatogastroenterology, Antoine Beclère Hospital, Assistance publique-Hôpitaux de Paris, Paris Sud University, Clamart, France
| | - Jason E Faris
- Department of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Eric A Mellon
- Department of Radiation Oncology, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Bassel F El-Rayes
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Andrea Wang-Gillam
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jill Lacy
- Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Peter J Hosein
- Department of Medicine, Division of Medical Oncology, University of Kentucky-Markey Cancer Center, Lexington, KY, USA
| | - Sing Yu Moorcraft
- Department of Medicine, The Royal Marsden National Health Service Foundation Trust, London and Surrey, UK
| | - Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Florian Hohla
- Department of Hematology, Medical Oncology, Hemostasis, Rheumatology and Infectious Diseases, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Peter Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julien Taieb
- Department of Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, Assistance publique-Hôpitaux de Paris, Sorbonne Paris Cité, Paris Descartes University, Cancer Research Personalized Medicine (CARPEM), Paris, France
| | - Theodore S Hong
- Department of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Cancer Institute, Orlando, FL, USA
| | - Ian Chau
- Department of Medicine, The Royal Marsden National Health Service Foundation Trust, London and Surrey, UK
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands.
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Saeed H, Hnoosh D, Huang B, Durbin EB, McGrath PC, Desimone P, Maynard E, Anthony LB, Dineen SP, Hosein PJ, Tzeng CWD. Defining the optimal timing of adjuvant therapy for resected pancreatic adenocarcinoma: A statewide cancer registry analysis. J Surg Oncol 2016; 114:451-5. [PMID: 27238300 DOI: 10.1002/jso.24314] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/16/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Long-term results of the ESPAC-3 trial suggest that while completing adjuvant therapy (AT) is necessary after resection of pancreatic ductal adenocarcinoma (PDAC), early initiation (within 8 weeks) may not be associated with improved overall survival (OS). The primary aim of this study was to evaluate the OS impact of early versus late AT in a statewide analysis. METHODS Patients with stages I-III PDAC in the Kentucky Cancer Registry (KCR) from 2004 to 2013, were evaluated. Those undergoing pancreatectomy were stratified into two groups ("early," <8 weeks, vs. "late," 8-16 weeks). RESULTS Of 2,221 diagnosed patients with stages I-III, 831 (37.4%) underwent pancreatectomy upfront. Of these, only 420 (50.5%) received AT. Initiation date of AT was not associated with OS (median OS: early, 20.2 vs. late, 19.0 months, P = 0.97). On multivariate analysis, factors that affected OS included stage (II, HR-1.82, P = 0.017; III, HR-3.77, P < 0.001), node positivity (HR-1.51, P = 0.004), poorly/undifferentiated grade (HR-1.34; P = 0.011), but not AT initiation date. CONCLUSIONS In this statewide analysis, there was no difference in OS between early and late AT initiation for resected PDAC. The ideal window for AT initiation remains unknown as tumor biology continues to trump regimens from the past decade. J. Surg. Oncol. 2016;114:451-455. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Hayder Saeed
- Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Dima Hnoosh
- Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky
| | - Bin Huang
- Department of Biostatistics, College of Public Health, Lexington, Kentucky.,Kentucky Cancer Registry, Markey Cancer Center, Lexington, Kentucky
| | - Eric B Durbin
- Department of Biostatistics, College of Public Health, Lexington, Kentucky.,Kentucky Cancer Registry, Markey Cancer Center, Lexington, Kentucky
| | - Patrick C McGrath
- Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky
| | - Philip Desimone
- Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Erin Maynard
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Lowell B Anthony
- Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Sean P Dineen
- Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky
| | - Peter J Hosein
- Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Ching-Wei D Tzeng
- Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky
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Vilchez V, Turcios L, Zaytseva Y, Stewart R, Lee EY, Maynard E, Shah MB, Daily MF, Tzeng CWD, Davenport D, Castellanos AL, Krohmer S, Hosein PJ, Evers BM, Gedaly R. Cancer stem cell marker expression alone and in combination with microvascular invasion predicts poor prognosis in patients undergoing transplantation for hepatocellular carcinoma. Am J Surg 2016; 212:238-45. [PMID: 27033253 DOI: 10.1016/j.amjsurg.2015.12.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/27/2015] [Accepted: 12/12/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND The cancer stem cell hypothesis provides an explanation for hepatocellular carcinoma (HCC) heterogeneity. We investigated the expression of CD44 and CD133 alone and in combination with microvascular invasion (MVI) as predictors of prognosis in patients undergoing liver transplantation for HCC. METHODS Explanted livers from 95 patients transplanted for HCC were analyzed. Marker expression was evaluated by immunofluorescence. RESULTS Seventy-seven patients were male with a mean age of 56 years. The most common etiologies of cirrhosis were hepatitis C (50%) and alcoholic liver disease (41%). Forty-one patients had laboratory model for end-stage liver disease score greater than 15. Overall survival (OS) at 1-, 3-, and 5-years was 86%, 75%, and 64%, respectively. Recurrence rate was 13% with a median follow-up of 64 months. The 5-year OS was significantly lower in those patients with MVI and CD44 (36.9%) or CD133 (40%). CD44(+) and CD133(+) correlated with increased risk of poorly differentiated HCC, and elevated alpha-fetoprotein levels. In combination with MVI, both markers were independently associated with increased recurrence and worse OS (recurrence P < .003, odds ratio = 8.05; P = .001, odds ratio = 9.5, survival P = .001, HR = 3.7; P = .004, HR = 3.2 respectively). CONCLUSIONS CD44 or CD133 alone and in combination with MVI are independent predictors of poor prognosis in patients undergoing transplantation for HCC.
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Affiliation(s)
- Valery Vilchez
- Department of Surgery, University of Kentucky, Lexington, KY, USA; Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lilia Turcios
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Rachel Stewart
- Markey Cancer Center - University of Kentucky, Lexington, KY, USA
| | - Eun Y Lee
- Department of Pathology, University of Kentucky, Lexington, KY, USA
| | - Erin Maynard
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Malay B Shah
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Michael F Daily
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Daniel Davenport
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Steven Krohmer
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Peter J Hosein
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Bernard Mark Evers
- Department of Surgery, University of Kentucky, Lexington, KY, USA; Markey Cancer Center - University of Kentucky, Lexington, KY, USA
| | - Roberto Gedaly
- Department of Surgery, University of Kentucky, Lexington, KY, USA.
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30
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Peterson S, Loaiza-Bonilla A, Ben-Josef E, Drebin JA, Westendorf-Overley C, Anthony LB, DeSimone PA, Goel G, Kudrimoti MR, Dineen SP, Tzeng CWD, Hosein PJ. Neoadjuvant nab-paclitaxel and gemcitabine (AG) in borderline resectable (BR) or unresectable (UR) locally advanced pancreatic adenocarcinoma (LAPC) in patients ineligible for FOLFIRINOX. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
328 Background: AG is superior to gemcitabine in patients with advanced pancreas cancer. There are limited data on the use of AG in BR or UR LAPC. Although FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan and oxaliplatin) is an option for such patients, many are not eligible due to age, poor performance status (PS) or comorbidities. Herein, we report our experience with neoadjuvant AG for BR/UR LAPC in patients ineligible for FOLFIRINOX. Methods: In this retrospective series, we included patients with BR/UR LAPC who received neoadjuvant AG. The treatment algorithm included AG for 3-4 months followed by radiation, then re-evaluation for surgery. The published AG regimen doses were modified based on patient tolerance. The primary outcome measure was R0 resection rate. Secondary outcomes were response rate, tolerability, and overall survival (OS). Results: Between 10/2013-9/2015, 20 patients (14 BR, 6 UR) at two institutions were treated with this approach. Median age was 69 years (range 44-90); 11/20 were female; PS ranged from 0-3; 14 patients have completed therapy and 6 remain on treatment. Five were converted to resectability by imaging and subsequently underwent operation; 4 had R0 resections (29% of patients who have finished therapy). To date, 6 patients died from progressive disease (PD), 2 are alive with PD and 12 remain alive on therapy or surveillance. All patients who achieved R0 resections are alive and disease free. The best response to AG was a partial response in 4 patients (20%), stable disease in 11, and progression in 2 with 3 patients still pending re-evaluation. Mean dose intensity was 77% for AG. Toxicities were similar to the published AG regimen. Conclusions: In this small series, both the R0 resection rate and the response rate were at least 20%, despite frequent dose reductions and relatively low dose intensity. Elderly and/or poor PS patients with LAPC have been historically excluded from curative-intent strategies. Our data suggest that these patients may now have a possibility for cure with the use of neoadjuvant AG.
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31
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Vilchez V, Shah MB, Daily MF, Pena L, Tzeng CWD, Davenport D, Hosein PJ, Gedaly R, Maynard E. Long-term outcome of patients undergoing liver transplantation for mixed hepatocellular carcinoma and cholangiocarcinoma: an analysis of the UNOS database. HPB (Oxford) 2016; 18:29-34. [PMID: 26776848 PMCID: PMC4750226 DOI: 10.1016/j.hpb.2015.10.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/18/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mixed hepatocellular and cholangiocarcinoma (HCC-CC) have been associated with a poor prognosis after liver transplantation (LT). We aimed to evaluate long-term outcomes in patients undergoing LT for HCC-CC versus patients with hepatocellular carcinoma (HCC) or cholangiocarcinoma (CC). METHODS Retrospective analysis of the United Network for Organ Sharing (UNOS) database from 1994-2013. Overall survival (OS) in patients with HCC-CC, HCC, and CC, were compared. RESULTS We identified 4049 patients transplanted for primary malignancy (94 HCC-CC; 3515 HCC; 440 CC). Mean age of patients with HCC-CC was 57 ± 10 years, and 77% were male. MELD score did not differ among the groups (p = 0.637). Hepatitis C virus was the most common secondary diagnosis within the HCC-CC (44%) and HCC (36%) cohorts, with primary sclerosing cholangitis in the CC (16%) cohort. OS rates at 1, 3 and 5 years for HCC-CC (82%, 47%, 40%) were similar to CC (79%, 58%, 47%), but significantly worse than HCC (86%, 72%, and 62% p = 0.002). DISCUSSION Patients undergoing LT for HCC had significantly better survival compared to those transplanted for HCC-CC and CC. LT for mixed HCC-CC confers a survival rate similar to selected patients with CC. Efforts should be made to identify HCC-CC patients preoperatively.
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Affiliation(s)
- Valery Vilchez
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Malay B Shah
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Michael F Daily
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Luis Pena
- Department of Gastroenterology, University of Kentucky, Lexington, KY, 40536, USA
| | - Ching-Wei D Tzeng
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Daniel Davenport
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Peter J Hosein
- Department of Internal Medicine, University of Kentucky, Lexington, KY, 40536, USA
| | - Roberto Gedaly
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Erin Maynard
- Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA.
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Venkat S, Hosein PJ, Narayanan G. Percutaneous Approach to Irreversible Electroporation of the Pancreas: Miami Protocol. Tech Vasc Interv Radiol 2015; 18:153-8. [DOI: 10.1053/j.tvir.2015.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Hosein PJ, Sandoval-Sus JD, Goodman D, Arteaga AG, Reis I, Hoffman J, Stefanovic A, Rosenblatt JD, Lossos IS. Updated survival analysis of two sequential prospective trials of R-MACLO-IVAM followed by maintenance for newly diagnosed mantle cell lymphoma. Am J Hematol 2015; 90:E111-6. [PMID: 25737247 DOI: 10.1002/ajh.23996] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/06/2015] [Accepted: 02/27/2015] [Indexed: 11/11/2022]
Abstract
A phase II trial of R-MACLO-IVAM followed by thalidomide maintenance for mantle cell lymphoma (MCL) demonstrated promising progression-free survival (PFS) and overall survival (OS) rates. Thalidomide maintenance was associated with significant toxicity and was subsequently modified to rituximab maintenance. Herein, we present updated results and follow-up. Two sequential phase II trials included chemotherapy-naïve patients with MCL up to 75 years old. Four cycles of R-MACLO-IVAM chemotherapy were delivered as previously described. Patients who achieved complete responses (CR) were eligible for thalidomide or rituximab maintenance therapy. Among 36 patients enrolled, the MCL International Prognostic Index (MIPI) was low in 53%, intermediate in 36% and high in 11%. Thirty-five patients completed at least 2 cycles of chemotherapy; 34 (94%) achieved a CR. After a median follow-up of 74.4 months, the 5-year PFS was 51% (95% CI 33-68%) and the 5-year OS was 85% (95% CI 73-97%). Two deaths occurred during the chemotherapy phase due to disease progression and neutropenic sepsis, respectively. One patient developed secondary acute myeloid leukemia after 7 years. R-MACLO-IVAM chemotherapy is effective for patients with newly diagnosed MCL.
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Affiliation(s)
- Peter J. Hosein
- Department of Medicine; Markey Cancer Center; University of Kentucky; Lexington Kentucky
- Division of Medical Oncology, Markey Cancer Center; University of Kentucky; Lexington Kentucky
| | - Jose D. Sandoval-Sus
- Division of Hematological Malignancies; H. Lee Moffitt Cancer Center; Tampa Florida
| | - Deborah Goodman
- Department of Medicine; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Hematology-Oncology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
| | - Alexandra Gomez Arteaga
- Department of Medicine; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Hematology-Oncology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
| | - Isildinha Reis
- Department of Public Health Sciences; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Biostatistics, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
| | - James Hoffman
- Department of Medicine; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Hematology-Oncology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
| | - Alexandra Stefanovic
- Department of Medicine; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Hematology-Oncology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
| | - Joseph D. Rosenblatt
- Department of Medicine; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Hematology-Oncology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
| | - Izidore S. Lossos
- Department of Medicine; Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Division of Hematology-Oncology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
- Department of Molecular and Cellular Pharmacology, Sylvester Comprehensive Cancer Center; University of Miami Miller School of Medicine; Miami Florida
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Socola F, Nguyen DM, Ochoa RE, Rocha Lima CM, Hosein PJ. A cohort study evaluating the role of surgery for lung metastases from colorectal cancer. Anticancer Res 2015; 35:3431-3435. [PMID: 26026106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIM Surgery may be curative in some patients with metastatic colorectal cancer (mCRC). We analyzed the role of lung metastatectomy in this population. PATIENTS AND METHODS In this retrospective cohort study, cases were defined as mCRC patients with lung metastases (LM's) who underwent metastatectomy. Controls had LM's but did not undergo resection. RESULTS There were 28 cases and 46 controls. The median overall survival (OS) was 53 months among the cases and 26.3 months for the controls. The cases were more likely to have 1 or 2 lung metastases, unilateral versus bilateral LM's, metachronous versus synchronous presentation of LM's and more likely to have a carcinoembryonic antigen (CEA) level less than 10 ng/ml at diagnosis. The interval from diagnosis to the development of lung metastases was significantly longer in cases versus controls (22.9 versus 8.5 months). CONCLUSION Patients selected using these criteria may have prolonged survival with therapy that includes lung metastatectomy.
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Affiliation(s)
- Francisco Socola
- Department of Internal Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, U.S.A
| | - Dao M Nguyen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, U.S.A
| | | | - Caio M Rocha Lima
- Department of Medicine, Division of Hematology/Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, U.S.A
| | - Peter J Hosein
- Department of Medicine, Division of Medical Oncology, University of Kentucky Markey Cancer Center, Lexington, KY, U.S.A.
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Lossos IS, Fabregas JC, Koru-Sengul T, Miao F, Goodman D, Serafini AN, Hosein PJ, Stefanovic A, Rosenblatt JD, Hoffman JE. Phase II study of90Y Ibritumomab tiuxetan (Zevalin) in patients with previously untreated marginal zone lymphoma. Leuk Lymphoma 2014; 56:1750-5. [DOI: 10.3109/10428194.2014.975801] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hosein PJ, Echenique A, Loaiza-Bonilla A, Froud T, Barbery K, Rocha Lima CM, Yrizarry JM, Narayanan G. Percutaneous irreversible electroporation for the treatment of colorectal cancer liver metastases with a proposal for a new response evaluation system. J Vasc Interv Radiol 2014; 25:1233-1239.e2. [PMID: 24861662 DOI: 10.1016/j.jvir.2014.04.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 04/11/2014] [Accepted: 04/11/2014] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To describe an initial experience with irreversible electroporation (IRE) in patients with colorectal liver metastasis (CLM). MATERIALS AND METHODS A retrospective analysis of patients undergoing IRE for the management of CLM was performed. Procedures were done percutaneously under general anesthesia. Patients were then followed for adverse events, tumor response, and survival. RESULTS Between March 2010 and February 2013, 29 patients underwent percutaneous ablation of 58 tumors in 36 IRE sessions. Most patients (89%) had an absolute or relative contraindication to thermal ablation. The median age was 62 years, and the median time from diagnosis to IRE was 28 months. The median number of lesions treated per patient was two, and the median tumor size was 2.7 cm. Patients had received previous chemotherapy regimens (range, 1-5 per patient). A new Metabolic Imaging And Marker Integration response evaluation criteria was used for response assessment, and was a predictor of progression-free and overall survival. The 2-year progression-free survival rate was 18% (95% confidence interval, 0%-35%), and the 2-year overall survival rate was 62% (95% confidence interval, 37%-87%). Complications included arrhythmias (n = 1) and postprocedure pain (n = 1). Both patients recovered without sequelae. CONCLUSIONS Percutaneous IRE of CLM is feasible and safe. A new response evaluation system for colorectal cancer appears to be prognostic.
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Affiliation(s)
- Peter J Hosein
- Department of Medicine and Division of Hematology/Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136.
| | - Ana Echenique
- Department of Radiology and Division of Vascular/Interventional Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
| | - Arturo Loaiza-Bonilla
- Department of Medicine and Division of Hematology/Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
| | - Tatiana Froud
- Department of Radiology and Division of Vascular/Interventional Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
| | - Katuzka Barbery
- Department of Radiology and Division of Vascular/Interventional Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
| | - Caio M Rocha Lima
- Department of Radiology and Division of Vascular/Interventional Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
| | - Jose M Yrizarry
- Department of Radiology and Division of Vascular/Interventional Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
| | - Govindarajan Narayanan
- Department of Radiology and Division of Vascular/Interventional Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Suite 3400, Miami, FL 33136
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Lossos C, Bayraktar S, Weinzierl E, Younes SF, Hosein PJ, Tibshirani RJ, Sutton Posthumus J, DeAngelis LM, Raizer J, Schiff D, Abrey L, Natkunam Y, Lossos IS. LMO2 and BCL6 are associated with improved survival in primary central nervous system lymphoma. Br J Haematol 2014; 165:640-8. [PMID: 24571259 DOI: 10.1111/bjh.12801] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/10/2014] [Indexed: 11/30/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an aggressive sub-variant of non-Hodgkin lymphoma (NHL) with morphological similarities to diffuse large B-cell lymphoma (DLBCL). While methotrexate (MTX)-based therapies have improved patient survival, the disease remains incurable in most cases and its pathogenesis is poorly understood. We evaluated 69 cases of PCNSL for the expression of HGAL (also known as GCSAM), LMO2 and BCL6 - genes associated with DLBCL prognosis and pathobiology, and analysed their correlation to survival in 49 PCNSL patients receiving MTX-based therapy. We demonstrate that PCNSL expresses LMO2, HGAL(also known as GCSAM) and BCL6 proteins in 52%, 65% and 56% of tumours, respectively. BCL6 protein expression was associated with longer progression-free survival (P = 0·006) and overall survival (OS, P = 0·05), while expression of LMO2 protein was associated with longer OS (P = 0·027). Further research is needed to elucidate the function of BCL6 and LMO2 in PCNSL.
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Affiliation(s)
- Chen Lossos
- Division of Hematology-Oncology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
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Hosein PJ, Maragulia JC, Salzberg MP, Press OW, Habermann TM, Vose JM, Bast M, Advani RH, Tibshirani R, Evens AM, Islam N, Leonard JP, Martin P, Zelenetz AD, Lossos IS. A multicentre study of primary breast diffuse large B-cell lymphoma in the rituximab era. Br J Haematol 2014; 165:358-63. [PMID: 24467658 DOI: 10.1111/bjh.12753] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/15/2013] [Indexed: 11/26/2022]
Abstract
Primary breast diffuse large B-cell lymphoma (DLBCL) is a rare subtype of non-Hodgkin lymphoma (NHL) with limited data on pathology and outcome. A multicentre retrospective study was undertaken to determine prognostic factors and the incidence of central nervous system (CNS) relapses. Data was retrospectively collected on patients from 8 US academic centres. Only patients with stage I/II disease (involvement of breast and localized lymph nodes) were included. Histologies apart from primary DLBCL were excluded. Between 1992 and 2012, 76 patients met the eligibility criteria. Most patients (86%) received chemotherapy, and 69% received immunochemotherapy with rituximab; 65% received radiation therapy and 9% received prophylactic CNS chemotherapy. After a median follow-up of 4·5 years (range 0·6-20·6 years), the Kaplan-Meier estimated median progression-free survival was 10·4 years (95% confidence interval [CI] 5·8-14·9 years), and the median overall survival was 14·6 years (95% CI 10·2-19 years). Twelve patients (16%) had CNS relapse. A low stage-modified International Prognostic Index (IPI) was associated with longer overall survival. Rituximab use was not associated with a survival advantage. Primary breast DLBCL has a high rate of CNS relapse. The stage-modified IPI score is associated with survival.
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Affiliation(s)
- Peter J Hosein
- Hematology/Oncology, University of Miami School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Palacio S, Loaiza-Bonilla A, Kittaneh M, Kyriakopoulos C, Ochoa RE, Escobar M, Arango B, Restrepo MH, Merchan JR, Rocha Lima CMSR, Hosein PJ. Successful use of Trastuzumab with anthracycline-based chemotherapy followed by trastuzumab maintenance in patients with advanced HER2-positive gastric cancer. Anticancer Res 2014; 34:301-306. [PMID: 24403478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND There is no standard chemotherapy regimen that is universally accepted for the treatment of advanced gastric cancer. Trastuzumab added to chemotherapy improves survival in patients with metastatic human epidermal growth factor receptor-2 (Her2/neu)-overexpressing gastric cancer. Data are lacking for the combination of trastuzumab with other chemotherapy regimens, apart from the cisplatin/fluorouracil backbone used in the pivotal TOGA trial. PATIENTS AND METHODS In this retrospective analysis, we included patients with gastric cancer with HER2 overexpression who received trastuzumab in addition to their first-line chemotherapy, with or without trastuzumab maintenance therapy. The end-points were response and tolerance to treatment. RESULTS We identified seven patients who met the search criteria; six had metastatic disease and one had locally advanced unresectable disease. Four patients received epirubicin/oxaliplatin/capecitabine/trastuzumab, and the others had non-anthracycline-based chemotherapy with trastuzumab. All patients had radiological responses to treatment - one had a complete response and six had partial responses. Among the four patients who received anthracycline-based chemotherapy with trastuzumab, there was a transient decline in cardiac ejection fraction in three, but all resolved without sequelae. All patients received a period of chemotherapy induction followed by trastuzumab monotherapy for maintenance. The median progression-free survival was 14.6 months and median overall survival was 16.4 months. CONCLUSION Trastuzumab is an important agent for the treatment of HER2-overexpressing gastric cancer. We recorded an acceptable safety and efficacy profile in this small cohort treated with anthracycline-based chemotherapy with trastuzumab followed by trastuzumab maintenance.
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Affiliation(s)
- Sofia Palacio
- 1475 NW 12th Avenue. Suite 3400, Miami, 33136, FL, U.S.A.
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Narayanan G, Hosein PJ, Arora G, Barbery KJ, Froud T, Livingstone AS, Franceschi D, Rocha Lima CM, Yrizarry J. Percutaneous irreversible electroporation for downstaging and control of unresectable pancreatic adenocarcinoma. J Vasc Interv Radiol 2013. [PMID: 23177107 DOI: 10.1016/j.jvir.2012.09.012] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Treatment of unresectable locally advanced pancreatic cancer (LAPC) usually includes chemotherapy and/or radiation therapy in an attempt to downstage these tumors to the extent of resectability, but outcomes remain poor. Irreversible electroporation (IRE) is an ablative modality that may be useful in this population. The aim of this study was to evaluate the safety of percutaneous IRE in patients with pancreatic adenocarcinoma. MATERIALS AND METHODS IRE was performed in patients with pancreatic cancer whose tumors remained unresectable after, or who were intolerant of, standard therapy. The procedures were all done percutaneously under general anesthesia. Patients were then followed for adverse events, tumor response, and survival. RESULTS Fifteen IRE procedures were performed in 14 patients (one was treated twice). Three patients had metastatic disease and 11 had LAPC. All patients had received chemotherapy previously, and 11 had received radiation. The median tumor size was 3.3 cm (range, 2.5-7 cm). Immediate and 24-hour postprocedural scans demonstrated patent vasculature in the treatment zone in all patients. Two patients underwent surgery 4 and 5 months after IRE, respectively. Both had margin-negative resections, and one had a pathologic complete response; both remain disease-free after 11 and 14 months, respectively. Complications included spontaneous pneumothorax during anesthesia (n = 1) and pancreatitis (n = 1), and both patients recovered completely. There were no deaths directly related to the procedure. All three patients with metastatic disease at IRE died from progression of their disease. CONCLUSIONS Percutaneous IRE for pancreatic adenocarcinoma is feasible and safe. A prospective trial is being planned.
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Affiliation(s)
- Govindarajan Narayanan
- Department of Radiology, Division of Vascular/Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Ave., Miami, FL 33136, USA.
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Hosein PJ, Macintyre J, Kawamura C, Maldonado JC, Ernani V, Loaiza-Bonilla A, Narayanan G, Ribeiro A, Portelance L, Merchan JR, Levi JU, Rocha-Lima CM. A retrospective study of neoadjuvant FOLFIRINOX in unresectable or borderline-resectable locally advanced pancreatic adenocarcinoma. BMC Cancer 2012; 12:199. [PMID: 22642850 PMCID: PMC3404979 DOI: 10.1186/1471-2407-12-199] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 05/29/2012] [Indexed: 12/22/2022] Open
Abstract
Background 5-fluorouracil, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) is superior to gemcitabine in patients with metastatic pancreatic cancer who have a good performance status. We investigated this combination as neoadjuvant therapy for locally advanced pancreatic cancer (LAPC). Methods In this retrospective series, we included patients with unresectable LAPC who received neoadjuvant FOLFIRINOX with growth factor support. The primary analysis endpoint was R0 resection rate. Results Eighteen treatment-naïve patients with unresectable or borderline resectable LAPC were treated with neoadjuvant FOLFIRINOX. The median age was 57.5 years and all had ECOG PS of 0 or 1. Eleven (61 %) had tumors in the head of the pancreas and 9 (50 %) had biliary stents placed prior to chemotherapy. A total of 146 cycles were administered with a median of 8 cycles (range 3-17) per patient. At maximum response or tolerability, 7 (39 %) were converted to resectability by radiological criteria; 5 had R0 resections, 1 had an R1 resection, and 1 had unresectable disease. Among the 11 patients who remained unresectable after FOLFIRINOX, 3 went on to have R0 resections after combined chemoradiotherapy, giving an overall R0 resection rate of 44 % (95 % CI 22–69 %). After a median follow-up of 13.4 months, the 1-year progression-free survival was 83 % (95 % CI 59-96 %) and the 1-year overall survival was 100 % (95 % CI 85-100 %). Grade 3/4 chemotherapy-related toxicities were neutropenia (22 %), neutropenic fever (17 %), thrombocytopenia (11 %), fatigue (11 %), and diarrhea (11 %). Common grade 1/2 toxicities were neutropenia (33 %), anemia (72 %), thrombocytopenia (44 %), fatigue (78 %), nausea (50 %), diarrhea (33 %) and neuropathy (33 %). Conclusions FOLFIRINOX followed by chemoradiotherapy is feasible as neoadjuvant therapy in patients with unresectable LAPC. The R0 resection rate of 44 % in this population is promising. Further studies are warranted.
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Affiliation(s)
- Peter J Hosein
- Department of Medicine, Division of Hematology/Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA.
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Warsch S, Hosein PJ, Maeda LS, Alizadeh AA, Lossos IS. A retrospective study evaluating the efficacy and safety of bendamustine in the treatment of mantle cell lymphoma. Leuk Lymphoma 2012; 53:1299-1305. [PMID: 22185662 DOI: 10.3109/10428194.2011.649476] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Bendamustine is approved in the United States for relapsed indolent lymphoma. However, it has not been widely studied in mantle cell lymphoma (MCL). We retrospectively reviewed the records of all patients with MCL who were treated with bendamustine at three centers. The primary endpoint was overall response rate (ORR). Thirty patients with MCL received bendamustine, 25 for relapsed disease. After a median follow-up of 12 months, there were 15 complete responses (CRs) with an ORR of 83% (95% confidence interval [CI] 70-97%). Factors significantly associated with longer survival were achieving a CR and classical (versus blastic) variant of MCL. Grade 3 or 4 neutropenia, anemia and thrombocytopenia occurred in 23%, 3% and 20%, respectively. There was one case of progressive multifocal leukoencephalopathy 10 months after therapy completion. Bendamustine in combination with rituximab demonstrated a high response rate in this study of patients with predominantly relapsed MCL.
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Affiliation(s)
- Sean Warsch
- Department of Medicine, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter J Hosein
- Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Lauren S Maeda
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ash A Alizadeh
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Izidore S Lossos
- Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA.,Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Hosein PJ, Craig MD, Tallman MS, Boccia RV, Hamilton BL, Lewis JJ, Lossos IS. A multicenter phase II study of darinaparsin in relapsed or refractory Hodgkin's and non-Hodgkin's lymphoma. Am J Hematol 2012; 87:111-4. [PMID: 22081459 DOI: 10.1002/ajh.22232] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 10/16/2011] [Accepted: 10/18/2011] [Indexed: 11/09/2022]
Affiliation(s)
- Peter J Hosein
- Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine, Florida, USA
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Hosein PJ, Pastorini VH, Paes FM, Eber D, Chapman JR, Serafini AN, Alizadeh AA, Lossos IS. Utility of positron emission tomography scans in mantle cell lymphoma. Am J Hematol 2011; 86:841-5. [PMID: 21922524 DOI: 10.1002/ajh.22126] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 06/22/2011] [Accepted: 06/24/2011] [Indexed: 02/06/2023]
Abstract
Positron emission tomography (PET) scans are widely used in patients with lymphoma but little is known about their utility in mantle cell lymphoma (MCL). MCL patients were included from two prospective trials and one observational study at our institution. A total of 276 PET scans were performed among 52 patients. After a median follow-up of 37.5 months, the 3-year event-free survival (EFS) and overall survival (OS) were 73% (95% confidence interval [CI]: 61-85%) and 92% (95% CI 85-100%), respectively. There were 34 pretreatment PET scans, 26 interim, 28 end-of-treatment, 162 surveillance, and 26 scans at relapse or beyond. Pretreatment PETs were positive in 94%. A negative interim or end-of-therapy PET scan was not significantly associated with better EFS or OS, but no deaths were observed in patients who had a negative interim or end-of-therapy PET. Surveillance PET scans had a high false positive rate (35%) and low positive predictive value (8%). PET scans contributed to an earlier diagnosis of relapse in only two out of the 18 patients (11%) who relapsed. PET scans did not meaningfully contribute to staging or surveillance of MCL patients in this study. There was a trend toward improved survival in patients who had a negative end-of-therapy PET scan.
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Affiliation(s)
- Peter J Hosein
- Department of Medicine, Division of Hematology/Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida 33136, USA
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Carrion AF, Hosein PJ, Cooper EM, Lopes G, Pelaez L, Rocha-Lima CM. Severe colitis associated with docetaxel use: A report of four cases. World J Gastrointest Oncol 2010; 2:390-4. [PMID: 21160890 PMCID: PMC2999675 DOI: 10.4251/wjgo.v2.i10.390] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 07/28/2010] [Accepted: 08/04/2010] [Indexed: 02/05/2023] Open
Abstract
Diarrhea is a common side effect of chemotherapy. Pseudomembranous colitis is a well known complication of antibiotic treatment that can also be observed, albeit rarely, with certain chemotherapeutic agents. We present four cases of severe colitis in patients undergoing treatment with taxane-based chemotherapy for pancreatic, lung and breast cancer. None of them had recently received antibiotics. One patient presented with a bowel perforation and three had endoscopic findings of pseudomembranous colitis. Two of these three patients had negative stool toxin assays for Clostridium difficile. In the patient presenting with perforation, an emergency left hemicolectomy was performed and the pathological findings in the colon were acute inflammation and ischemic necrosis; the other three patients were treated with oral vancomycin and/or oral or intravenous metronidazole leading to complete resolution of the symptoms. Apart from pseudomembranous colitis, we describe patients presenting with neutropenic enterocolitis as well as ischemic colitis after docetaxel use. These cases provide some insight into the spectrum and varied clinical presentations of severe colitis associated with taxane-based chemotherapy.
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Affiliation(s)
- Andres F Carrion
- Andres F Carrion, Peter J Hosein, Eugene M Cooper, Liset Pelaez, Caio M Rocha-Lima, Department of Medicine, Division of Gastroenterology, Hematology/Oncology, Pathology, University of Miami Miller School of Medicine, Miami, FL 33136, United States
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Tupayachi MG, Hosein PJ, Nguyen DM, Thurer RT, Garcia MT, Raez LE, Donna E. Accuracy of Endobronchial Ultrasound-Directed Transbronchial Needle Aspiration (EBUS-TBNA) for Diagnosis of Mediastinal Lymphadenopathy in Patients With Suspected Malignancy. Chest 2010. [DOI: 10.1378/chest.10801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hosein PJ, Lossos IS. The evolving role of F-FDG PET scans in patients with aggressive non-Hodgkin's lymphoma. European J Clin Med Oncol 2010; 2:131-138. [PMID: 22140415 PMCID: PMC3227521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Functional imaging by (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) is being increasingly incorporated into the evaluation of patients with aggressive non-Hodgkin lymphoma (NHL). Its use for the initial staging in combination with computed tomography has now become standard. PET has recently been included in consensus criteria for response after therapy for Hodgkin lymphoma and aggressive NHL. At the end of therapy, PET has a high positive and negative predictive value (PPV, NPV) for relapse in the pre-rituximab era. However, in the rituximab era, there appears to be a higher rate of false-positive PET scans, making the PPV lower, while the NPV remains high. Interim PET scans are an attractive concept for early evaluation of response, and possibly to guide intensification or de-escalation of therapy. Similar to the end-of-therapy scans, the PPV for mid-therapy scans appears to be low in the rituximab era. Trials testing the modification of therapy based on an interim PET scan are ongoing. For surveillance of patients in remission from aggressive NHL, there is as yet no convincing data that monitoring with PET is superior to traditional surveillance. The evidence to date suggests that a positive PET scan during or after rituximab-based therapy for aggressive NHL should be confirmed by a biopsy if major treatment decisions will be made using the results.
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Affiliation(s)
- Peter J. Hosein
- Department of Medicine, Division of Hematology-Oncology, University of Miami, Miami, FL
| | - Izidore S. Lossos
- Department of Medicine, Division of Hematology-Oncology, University of Miami, Miami, FL
- Department of Molecular and Cellular Pharmacology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
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Lossos IS, Hosein PJ, Morgensztern D, Coleman F, Escalón MP, Byrne GE, Rosenblatt JD, Walker GR. High rate and prolonged duration of complete remissions induced by rituximab, methotrexate, doxorubicin, cyclophosphamide, vincristine, ifosfamide, etoposide, cytarabine, and thalidomide (R-MACLO-IVAM-T), a modification of the National Cancer Institute 89-C-41 regimen, in patients with newly diagnosed mantle cell lymphoma. Leuk Lymphoma 2009; 51:406-14. [DOI: 10.3109/10428190903518345] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The majority of patients with nonmetastatic rectal cancer are candidates for an aggressive multimodality approach with curative intent. Preoperative staging is critical in determining which patients should be offered neoadjuvant therapy. Available staging tools include digital rectal examination, transrectal ultrasound, computed tomography, positron-emission tomography, and magnetic resonance imaging scans. Magnetic resonance imaging has emerged as the most accurate staging modality in experienced centers. Multidisciplinary preoperative patient evaluation, better staging techniques, neoadjuvant chemoradiation, acceptance of shorter distal rectal margins, and transanal excision of T1 N0 rectal tumors in close proximity to the anal sphincter have resulted in decreased rates of abdominoperineal resections. Total mesorectal excision has been adopted as the standard surgical approach because of a reduction in rates of pelvic relapse. Preoperative and postoperative radiation therapy was shown to decrease the local recurrence rate, but not overall survival, in patients with resectable rectal cancer. The addition of chemotherapy to radiation was consistently shown to improve local control, and in some trials, improved overall survival. Neoadjuvant combined chemotherapy and radiation therapy are superior to adjuvant combined-modality therapy because of higher rates of sphincter preservation, less toxicity, and lower local recurrence rates. For patients with stage II or III disease, neoadjuvant continuous-infusion 5-fluorouracil (5-FU), concurrently with pelvic radiation, followed by postoperative 5-FU-based chemotherapy, remains the standard multimodality approach. Ongoing trials are testing the integration of newer cytotoxic agents such as capecitabine, oxaliplatin, irinotecan, and biologic agents such as cetuximab and bevacizumab to chemoradiation.
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Affiliation(s)
- Peter J Hosein
- Division of Hematology/Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, Florida 33136, USA.
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