Assessment of arsenic species in human hair, toenail and urine and their association with water and staple food

Arsenic intake from household drinking/cooking water and food may represent a significant exposure pathway to induce cancer and non-cancer health effects. This study is based on the human biomonitoring of 395 volunteers from 223 households with private water sources located in rural Punjab, Pakistan. This work has shown the relative contribution of water and staple food to arsenic intake and accumulation by multiple biological matrix measurements of inorganic and organic arsenic species, while accounting for potential confounders such as age, gender, occupation, and exposure duration of the study population. Multi-variable linear regression showed a strong significant relationship between total arsenic (tAs) intake from water and concentrations of tAs, inorganic arsenic (iAs), monomethylarsonic acid (MMA), dimethylarsinic acid (DMA) in urine and toenail samples. tAs intake from staple food (rice and wheat) also showed a strong significant relationship with hair tAs and iAs. The sole impact of staple food intake on biomarkers was assessed and a significant correlation was found with all of the urinary arsenic metabolites. Toenail was found to be the most valuable biomarker of past exposure to inorganic and organic arsenic species of dietary and metabolic origin.

Arsenic species in wheat, raw and cooked rice: Exposure and associated health implications

Arsenic concentrations above 10μgL^-1 were previously found in 89% of ground water sources in six villages of Pakistan. The present study has ascertained the health risks associated with exposure to total arsenic (tAs) and its species in most frequently consumed foods. Inorganic arsenic (iAs) concentrations were found to be 92.5±41.88μgkg^-1, 79.21±76.42μgkg^-1, and 116.38±51.38μgkg^-1 for raw rice, cooked rice and wheat respectively. The mean tAs concentrations were 47.47±30.72μgkg^-1, 71.65±74.7μgkg^-1, 105±61.47μgkg^-1. Wheat is therefore demonstrated to be a significant source of arsenic exposure. Dimethylarsinic acid was the main organic species detected in rice, whilst monomethylarsonic acid was only found at trace levels. Total daily intake of iAs exceeded the provisional tolerable daily intake of 2.1μgkg^-1day^-1 body weight in 74% of study participants due to concurrent intake from water (94%), wheat (5%) and raw rice (1%). A significant association between tAs in cooked rice and cooking water resulted in tAs intake 43% higher in cooked rice compared to raw rice. The study suggests that arsenic intake from food, particularly from wheat consumption, holds particular significance where iAs is relatively low in water. Chronic health risks were found to be significantly higher from wheat intake than rice, whilst the risk in terms of acute effects was below the USEPA's limit of 1.0. Children were at significantly higher health risk than adults due to iAs exposure from rice and/or wheat. The dietary exposure of participants to tAs was attributable to staple food intake with ground water iAs <10μgL^-1, however the preliminary advisory level (200μgkg^-1) was achievable with rice consumption of ≤200gday^-1 and compliance with ≤10μgL^-1 iAs in drinking water. Although the daily iAs intake from food was lower than total water intake, the potential health risk from exposure to arsenic and its species still exists and requires exposure control measures.

Working IT Out in Medical Practice: IT Systems Design and Development as Co-Realisation

Objectives: The paper explores possibilities for situating IT design and development work within the context of use so as to support the co-realisation of technology and ‘design in use’. The aim is to build a new understanding between IT professionals and users which is grounded upon what happens as the latter grapple with the problems of applying IT, appropriating its functionalities and affordances into their work practices and relations.

Methods: Following a discussion of participatory design and ethnomethodology, a novel method called co-realisation, which aims to provide a synthesis of the preceding methods, is suggested as an alternative. Through a discussion of findings from a case study of IT systems design and development in healthcare we show how the co-realisation approach might provide work-affording systems and how user-designer relations might be reformulated. We suggest that work-affording systems can be developed through the deployment of an engaged facilitator who works with the users to unpack the work site-specific potentialities of technology.

Results: The case study shows how risk of non-adoption might be minimised through the development of partnerships, and how the presence of the facilitator in the workplace capitalises on the mundane work undertaken therein and how the facilitator might work with the users to develop artefacts that support this work as opposed to reconfiguring it.

Conclusions: The case study illustrates co-realisation in action and how it might be seen to reconfigure relations between users and designers in a way that appears productive. Co-realisation can help address the widely observed problem of IT systems failures in healthcare.

Trusting the Record

Objectives: This paper aims to contribute to a longstanding interest in documents and paperwork in healthcare work through an examination of everyday work with patient records in a clinic.

Methods: An ethnographic study of record keeping practices in a deliberate self harm clinic was conducted to consider the role that document work plays in the development of trust in the routine social interactions of a working division of labor.

Results and conclusions: Issues of trust are seen to play central roles within the complexities of organizational working and some consequent implications for the deployment and use of electronic medical record systems are considered.

Evaluating water quality and ecotoxicology assessment techniques using data from a lead and zinc effected upland limestone catchment

Point and diffuse sources associated with historical metal ore mining are major causes of metal pollution. The understanding of metal behaviour and fate has been improved by the integration of water chemistry, metal availability and toxicity. Efforts have been devoted to the development of efficient methods of assessing and managing the risk posed by metals to aquatic life and meeting national water quality standards. This study focuses on the evaluation of current water quality and ecotoxicology techniques for the metal assessment of an upland limestone catchment located within a historical metal (lead ore) mining area in northern England. Within this catchment, metal toxicity occurs at circumneutral pH (6.2-7.5). Environmental Quality Standards (EQSs) based on a simple single concentration approach like hardness based EQS (EQS-H) are more overprotective, and from sixteen sites monitored in this study more than twelve sites (>75%) failed the EQSs for Zn and Pb. By increasing the complexity of assessment tools (e.g. bioavailability-based (EQS-B) and WHAM-F_TOX), less conservative limits were provided, decreasing the number of sites with predicted ecological risk to seven (44%). Thus, this research supports the use of bioavailability-based approaches and their applicability for future metal risk assessments.

Understanding the mobilisation of metal pollution associated with historical mining in a carboniferous upland catchment

Point and diffuse pollution from metal mining has led to severe environmental damage worldwide. Mine drainage is a significant problem for riverine ecosystems, it is commonly acidic (AMD), but neutral mine drainage (NMD) can also occur. A representative environment for studying metal pollution from NMD is provided by carboniferous catchments characterised by a circumneutral pH and high concentrations of carbonates, supporting the formation of secondary metal-minerals as potential sinks of metals. The present study focuses on understanding the mobility of metal pollution associated with historical mining in a carboniferous upland catchment. In the uplands of the UK, river water, sediments and spoil wastes were collected over a period of fourteen months, samples were chemically analysed to identify the main metal sources and their relationships with geological and hydrological factors. Correlation tests and principal component analysis suggest that the underlying limestone bedrock controls pH and weathering reactions. Significant metal concentrations from mining activities were measured for zinc (4.3 mg l^-1), and lead (0.3 mg l^-1), attributed to processes such as oxidation of mined ores (e.g. sphalerite, galena) or dissolution of precipitated secondary metal-minerals (e.g. cerussite, smithsonite). Zinc and lead mobility indicated strong dependence on biogeochemistry and hydrological conditions (e.g. pH and flow) at specific locations in the catchment. Annual loads of zinc and lead (2.9 and 0.2 tonnes per year) demonstrate a significant source of both metals to downstream river reaches. Metal pollution results in a large area of catchment having a depleted chemical status with likely effects on the aquatic ecology. This study provides an improved understanding of geological and hydrological processes controlling water chemistry, which is critical to assessing metal sources and mobilization, especially in neutral mine drainage areas.

Phase II study of alternate sunitinib schedule in patients with metastatic renal cell carinoma

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Background: Sunitinib is an antiangiogenic agent indicated for the treatment of metastatic renal cell carcinoma (mRCC). Sunitinib is given in a 4 week on, 2 week off (4/2) schedule. Significant toxicities are observed in patients in the 3rd and 4th weeks of therapy. We hypothesized that a 2 week on, 1 week off (2/1) schedule would provide improved toxicity without compromising efficacy. Methods: A multicenter, single arm study was performed, with patients initiating sunitinib 50mg on a 2/1 schedule. Schedule and dose alterations were performed if grade > 3 toxicities were observed. The primary objective was to determine the percentage of patients who experienced grade > 3 fatigue, diarrhea, or HFS. The sample size of 60 patients was selected to ensure the upper bound of a 95% confidence would fall below standard schedule rate of 25%-30% if sample rate was 10%-15%, respectively. Secondary outcomes included response rate (RR), progression free survival (PFS) and dose reductions. Results: Between August 2014 and April 2016, 60 patients were enrolled, and 59 treated. Patients had a median age of 65.5 years (ranging from 45-92). 24% of patients (14/59) had grade 3 or higher fatigue, diarrhea, or HFS (95% CI: 13.6%, 36.6%). This is similar to the average of the 4 week on, 2 week off schedule of 25%-30%, and the lower bound of the confidence interval is in the center of our target rate of 10%-15%. Among events at least possibly related to study drug, patients were most likely to experience the expected events of diarrhea (75% with 5 grade 3 events), fatigue (71% with 6 grade 3 events), and HFS (54% with 3 grade 3 events). 22 (37%) patients responded (25.0%, 50.9%). Among patients with secondary endpoint data available, median PFS was 19.3 months (95% CI: 8.2, NR) and 33/56 (59%) of patients underwent dose reduction. Conclusions: Sunitinib administered in a 2/1 schedule in this study did not result in a lower rate of grade 3 or higher fatigue, diarrhea or HFS when compared to historical data from trials employing a 4/2 schedule. However, efficacy data showed robust response rate and a prolonged PFS, suggestive of long-term tolerability in patients receiving sunitinib on a 2/1 schedule. Evaluation of toxicity kinetics and patient quality of life is ongoing. Clinical trial information: NCT02060370.

Human exposure assessment of different arsenic species in household water sources in a high risk arsenic area

Understanding arsenic speciation in water is important for managing the potential health risks associated with chronic arsenic exposure. Most arsenic monitoring studies to date have only measured total arsenic, with few looking at arsenic species. This study assessed 228 ground water sources in six unstudied villages in Pakistan for total, inorganic and organic arsenic species using ion chromatography inductively coupled plasma collision reaction cell mass spectrometry. The concentration levels approached 3090μgL^-1 (95% CI, 130.31, 253.06) for total arsenic with a median of 57.55μgL^-1, 3430μgL^-1 (median=52) for arsenate (As⁺⁵) and 100μgL^-1 (median=0.37) for arsenite (As⁺³). Exceedance of the WHO provisional guideline value for arsenic in drinking water (10μgL^-1) occurred in 89% of water sources. Arsenic was present mainly as arsenate (As⁺⁵). Average daily intake of total arsenic for 398 residents living in the sampled houses was found up to 236.51μgkg^-1day^-1. This exposure estimate has indicated that 63% of rural residents exceeded the World Health Organization's provisional tolerable daily intake (PTDI) of 2.1μgkg^-1day^-1 body weight. Average daily intake of As⁺⁵ was found to be 15.63μgkg^-1day^-1 (95% CI, 5.53, 25.73) for children ≤16 and 15.07μgkg^-1day^-1 (95% CI, 10.33, 18.02) for adults. A mean daily intake of 0.09μgkg^-1day^-1 was determined for As⁺³ for children and 0.26μgkg^-1day^-1 for adults. Organic arsenic species such as monomethylarsonic acid (MMA), dimethylarsinic acid (DMA) and Arsenobetaine (AsB) were found to be below their method detection limits (MDLs).

Ablative therapy to induce local and systemic immune changes in patients with metastatic renal cell carcinoma

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Background: Ablative therapy including cryoablation or radiofrequency ablation is a therapeutic option for small renal cell carcinomas (RCC) and provides effective palliation for symptomatic metastatic lesions, with reports of associated abscopal phenomenon in small numbers of patients. Pre-clinical animal modeling has suggested potential synergy with the use of ablative therapy and immune checkpoint blockade with ipilimumab. Methods: We performed retrospective analysis of 17 patients who underwent an ablative procedure followed later by nephrectomy. These samples were analyzed by IHC and gene expression studies. We also prospectively evaluated pre and post treatment blood samples from a different cohort of 13 patients. These samples were evaluated for immune cell subsets and cytokine profiles. Results: IHC studies revealed an increased frequency of PD-1 + immune cells in post-ablative tumor samples as compared to control samples. Gene expression studies also revealed higher expression of immune gene signatures as compared to control samples. Blood samples detected changes in regulatory T cell subsets and interleukin-6 cytokine levels in the short term, which normalized by 1 month post-ablation, suggested an active downregulation of the initial immune response. Based on these data, we initiated a clinical pilot study to treat patients with anti-CTLA-4 (tremelimumab) with or without cryoablation in patients with metastatic RCC. The primary endpoint of the trial will be safety. Secondary endpoints include objective response rate, progression free survival, and immune monitoring. A total of 30 patients, 15 in each arm, will be accrued. Initial data from the clinical trial will be presented. Conclusions: Ablative therapy causes immune changes that can be detected both at the tissue and systemic level. We hope to capitalize on these changes by combining immune checkpoint blockade and ablation in an ongoing prospective clinical trial.

A phase II study of alternative sunitinib scheduling in patients with metastatic renal cell carcinoma

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Background: Sunitinib is an oral antiangiogenic agent indicated for the treatment of metastatic renal cell carcinoma (mRCC). Sunitinib is given in a 4 week on, 2 week off (4/2) schedule. Significant toxicities are observed in patients in the 3rd and 4thweeks of therapy. We hypothesized that a 2 week on, 1 week off (2/1) schedule would provide improved toxicity without compromising efficacy. Methods: A multicenter, single arm study was performed, with all patients initiating sunitinib 50mg on a 2/1 schedule. Schedule and dose alterations were performed if grade > 3 toxicities were observed. The primary objective was to determine the percentage of patients who experienced grade > 3 fatigue, diarrhea, or HFS. The sample size of 60 patients was selected to ensure that the upper bound of a 95% confidence would fall below the standard schedule rate of 25%-30% if the sample rate was 10%-15%, respectively. Secondary outcomes included response rate (RR), progression free survival (PFS), and dose reductions. Results: Between August 2014 and April 2016, a total of 60 patients were enrolled, and 59 were treated. Patients had a median age of 65.5 years (ranging from 45-92). 24% of patients (14/59) had grade 3 or higher fatigue, diarrhea, or HFS (95% CI: 13.6%, 36.6%). This is similar to the average of the 4 week on, 2 week off schedule of 25%-30%, and the lower bound of the confidence interval is in the center of our target rate of 10%-15%. Among events that are at least possibly related to study drug, patients were most likely to experience the expected events of diarrhea (75% with 5 grade 3 events), fatigue (71% with 6 grade 3 events), and HFS (54% with 3 grade 3 events). 22 (37%) patients responded (25.0%, 50.9%). Among patients with secondary endpoint data available, median PFS was 19.3 months (95% CI: 8.2, NR) and 33/56 (59%) of patients underwent dose reduction. Conclusions: Sunitinib administered in a 2/1 schedule in this study did not result in a lower rate of grade 3 or higher fatigue, diarrhea, or HFS when compared to historical data from trials employing a 4/2 schedule. Efficacy data were comparable to studies employing a 4/2 schedule. Clinical trial information: NCT02060370.

Refinement of arsenic attributable health risks in rural Pakistan using population specific dietary intake values

BACKGROUND

Previous risk assessment studies have often utilised generic consumption or intake values when evaluating ingestion exposure pathways. If these values do not accurately reflect the country or scenario in question, the resulting risk assessment will not provide a meaningful representation of cancer risks in that particular country/scenario.

OBJECTIVES

This study sought to determine water and food intake parameters for one region in South Asia, rural Pakistan, and assess the role population specific intake parameters play in cancer risk assessment.

METHODS

A questionnaire was developed to collect data on sociodemographic features and 24-h water and food consumption patterns from a rural community. The impact of dietary differences on cancer susceptibility linked to arsenic exposure was evaluated by calculating cancer risks using the data collected in the current study against standard water and food intake levels for the USA, Europe and Asia. A probabilistic cancer risk was performed for each set of intake values of this study.

RESULTS

Average daily total water intake based on drinking direct plain water and indirect water from food and beverages was found to be 3.5Lday^-1 (95% CI: 3.38, 3.57) exceeding the US Environmental Protection Agency's default (2.5Lday^-1) and World Health Organization's recommended intake value (2Lday^-1). Average daily rice intake (469gday^-1) was found to be lower than in India and Bangladesh whereas wheat intake (402gday^-1) was higher than intake reported for USA, Europe and Asian sub-regions. Consequently, arsenic-associated cumulative cancer risks determined for daily water intake was found to be 17 chances in children of 3-6years (95% CI: 0.0014, 0.0017), 14 in children of age 6-16years (95% CI: 0.001, 0.0011) and 6 in adults of 16-67years (95% CI: 0.0006, 0.0006) in a population size of 10,000. This is higher than the risks estimated using the US Environmental Protection Agency and World Health Organization's default recommended water intake levels. Rice intake data showed early life cumulative cancer risks of 15 chances in 10,000 for children of 3-6years (95% CI: 0.0012, 0.0015), 14 in children of 6-16years (95% CI: 0.0011, 0.0014) and later life risk of 8 adults (95% CI: 0.0008, 0.0008) in a population of 10,000. This is lower than the cancer risks in countries with higher rice intake and elevated arsenic levels (Bangladesh and India). Cumulative cancer risk from arsenic exposure showed the relative risk contribution from total water to be 51%, from rice to be 44% and 5% from wheat intake.

CONCLUSIONS

The study demonstrates the need to use population specific dietary information for risk assessment and risk management studies. Probabilistic risk assessment concluded the importance of dietary intake in estimating cancer risk, along with arsenic concentrations in water or food and age of exposed rural population.

The combination of serum insulin, osteopontin, and hepatocyte growth factor predicts time to castration-resistant progression in androgen dependent metastatic prostate cancer- an exploratory study

BACKGROUND

We hypothesized that pretreatment serum levels of insulin and other serum markers would predict Progression-free survival (PFS), defined as time to castration-resistant progression or death, in metastatic androgen-dependent prostate cancer (mADPC).

METHODS

Serum samples from treatment-naïve men participating in a randomized phase 3 trial of ADT +/- chemotherapy were retrospectively analyzed using multiplex assays for insulin and multiple other soluble factors. Cox proportional hazards regression models were used to identify associations between individual factor levels and PFS.

RESULTS

Sixty six patients were evaluable (median age = 72 years; median prostate surface antigen [PSA] = 31.5 ng/mL; Caucasian = 86 %; Gleason score ≥8 = 77 %). In the univariable analysis, higher insulin (HR = 0.81 [0.67, 0.98] p = 0.03) and C-peptide (HR = 0.62 [0.39, 1.00]; p = 0.05) levels were associated with a longer PFS, while higher Hepatocyte Growth Factor (HGF; HR = 1.63 [1.06, 2.51] p = 0.03) and Osteopontin (OPN; HR = 1.56 [1.13, 2.15]; p = 0.01) levels were associated with a shorter PFS. In multivariable analysis, insulin below 2.1 (ln scale; HR = 2.55 [1.24, 5.23]; p = 0.011) and HGF above 8.9 (ln scale; HR = 2.67 [1.08, 3.70]; p = 0.027) levels were associated with longer PFS, while adjusted by OPN, C-peptide, trial therapy and metastatic volume. Four distinct risk groups were identified by counting the number of risk factors (RF) including low insulin, high HGF, high OPN levels, and low C-peptide levels (0, 1, 2, and 3). Median PFS was 9.8, 2.0, 1.6, and 0.7 years for each, respectively (p < 0.001).

CONCLUSION

Pretreatment serum insulin, HGF, OPN, and C-peptide levels can predict PFS in men with mADPC treated with ADT. Risk groups based on these factors are superior predictors of PFS than each marker alone.

Improving ‘knife to skin time’: process modelling and new technology in medical work

As healthcare becomes information intensive technology increasingly plays an important role in managing patient care; information gathering and dissemination; and co-ordinating work. One approach to ensuring resources, staff and systems are allocated and used efficiently is process modelling. This paper presents some findings from the Dependability Interdisciplinary Research Collaboration (DIRC) project, on ‘process modelling’ as an aspect of managerial activity and the work involved in both creating and implementing process maps or models. Our ethnographic investigations document some of the problems in developing process maps of medical activity as part of a desire to ‘improve knife to skin time’. We suggest that process maps are not systematic, rational, scientific deductions of the most efficient process. Process maps are locally sensible versions of best practice, and problems may arise where such locally sensible versions are exported throughout an organization to other settings where other relevances may apply.

A novel method for classifying cortical state to identify the accompanying changes in cerebral hemodynamics

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We classified brain state using a vector-based categorisation of neural frequencies.

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Changes in cerebral blood volume (CBV) were observed when brain state altered.

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During these state alterations, changes in blood oxygenation were also found.

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State dependent haemodynamic changes could affect blood based brain imaging.

Background

Many brain imaging techniques interpret the haemodynamic response as an indirect indicator of underlying neural activity. However, a challenge when interpreting this blood based signal is how changes in brain state may affect both baseline and stimulus evoked haemodynamics.

New method

We developed an Automatic Brain State Classifier (ABSC), validated on data from anaesthetised rodents. It uses vectorised information obtained from the windowed spectral frequency power of the Local Field Potential. Current state is then classified by comparing this vectorised information against that calculated from state specific training datasets.

Results

The ABSC identified two user defined brain states (synchronised and desynchronised), with high accuracy (∼90%). Baseline haemodynamics were found to be significantly different in the two identified states. During state defined periods of elevated baseline haemodynamics we found significant decreases in evoked haemodynamic responses to somatosensory stimuli.

Comparison to existing methods

State classification – The ABSC (∼90%) demonstrated greater accuracy than clustering (∼66%) or ‘power threshold’ (∼64%) methods of comparison.

Haemodynamic averaging – Our novel approach of selectively averaging stimulus evoked haemodynamic trials by brain state yields higher quality data than creating a single average from all trials.

Conclusions

The ABSC can account for some of the commonly observed trial-to-trial variability in haemodynamic responses which arises from changes in cortical state. This variability might otherwise be incorrectly attributed to alternative interpretations. A greater understanding of the effects of cortical state on haemodynamic changes could be used to inform techniques such as general linear modelling (GLM), commonly used in fMRI.

An international randomised trial of celecoxib versus celecoxib plus difluoromethylornithine in patients with familial adenomatous polyposis

BACKGROUND AND AIM

Although Non-steroidal anti-inflammatory drugs reduce colorectal adenoma burden in familial adenomatous polyposis (FAP), the utility of combining chemopreventive agents in FAP is not known. We conducted a randomised trial of celecoxib (CXB) versus CXB+diflouromethylornithine (DFMO) to determine the synergistic effect, if any.

METHODS

The primary endpoint was % change in adenoma count in a defined field. Secondary endpoints were adenoma burden (weighted by adenoma diameter) and video review of entire colon/rectal segments. Adverse event (AEs) were monitored by National Cancer Institution toxicity criteria.

RESULTS

112 subjects were randomised: 60 men and 52 women at a mean age of 38 years. For the 89 patients who had landmark-matched polyp counts available at baseline and 6 months, the mean % change in adenoma count over the 6 months of trial was -13.0% for CXB+DFMO and -1.0% for CXB (p=0.69). Mean % change in adenoma burden was -40% (CXB+DFMO) vs -27% (CXB) (p=0.13). Video-based global polyp change was -0.80 for CXB+DFMO vs -0.33 for CXB (p=0.03). Fatigue was the only significant AE, worse on the CXB arm (p=0.02).

CONCLUSIONS

CXB combined with DFMO yielded moderate synergy according to a video-based global assessment. No significant difference in adenoma count, the primary endpoint, was seen between the two study arms. No evidence of DFMO-related ototoxicity was seen. There were no adverse cardiovascular outcomes in either trial arm and no significant increase in AEs in the CXB+DFMO arm of the trial. Differences in outcomes between primary and secondary endpoints may relate to sensitivity of the endpoint measures themselves.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number N01-CN95040.

The role of metastasectomy in patients with renal cell carcinoma with sarcomatoid dedifferentiation: A matched controlled analysis

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Background: Renal cell carcinoma with sarcomatoid dedifferentiation (sRCC) is an aggressive tumor generally associated with a poor clinical course. Management of metastatic sRCC remains a therapeutic challenge with no standard treatment strategies. Our objective was to evaluate whether metastasectomy has any survival benefit in patients with synchronous or asynchronous metastatic sRCC treated with radical nephrectomy (RN). Methods: From an institutional database of 273 patients with sRCC treated with nephrectomy, we matched 80 patients with synchronous and asynchronous metastasis for age, ECOG performance status, histology and nodal status. Matched pairs were then retained only if patients who did not undergo metastasectomy were comparably alive at the time of metastasectomy in matched surgical patients to reduce the bias in survival outcomes. Overall survival (OS) from nephrectomy was studied using univariable and multivariable proportional hazards regression. Results: Median OS was 8.3 months (95%CI 6.5-10.5 months) and 18.5 months (95%CI 11.5-42.9 months) for patients with synchronous and asynchronous metastases, respectively. OS for patients undergoing metastasectomy for synchronous metastasis was comparable to non-surgical patients (8.4 and 8.0 months, respectively, p=0.35). Similarly, within the asynchronous cohort, median OS was 36.2 months (95%CI 7.6-Not Reached) in the metastasectomy group and 13.7 months (95%CI 8.8-41.6) in the non-metastasectomy group (p=0.29). On multivariable analysis, positive lymph node (LN) at nephrectomy was associated with increased risk of death in both synchronous and asynchronous patients groups; (HR=2.1 [95%CI 1.1-4.0] p=0.03) and (HR=3.3 [95%CI 1.2-9.2] p=0.02), respectively. Conclusions: Metastasectomy in patients with synchronous or asynchronous metastases after nephrectomy does not appear to confer significant survival benefit in patients with sRCC, particularly in patients with pathological LN positive disease at nephrectomy.

The utility of neutrophil-to-lymphocyte ratio in determining survival outcomes in patients treated with neoadjuvant chemotherapy and radical cystectomy for high-risk bladder cancer

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Background: Pre-operative neutrophil-to-lymphocyte ratio (NLR) has been found to be associated with adverse pathological results and poor long-term outcomes in patients treated with radical cystectomy (RC) for urothelial carcinoma (UC). We aimed to evaluate the predictive utility of NLR in patients treated with neoadjuvant chemotherapy (NAC) and RC for high-risk UC. Methods: We reviewed the records of 585 patients treated with NAC and RC at our institution from 2000-2013. We calculated NLR before initiation of NAC (pre-chemo NLR) and during the recovery window between NAC and RC (post-chemo NLR).. We excluded patients with concomitant infection, blood disorder, or second malignancy. We used univariate and multivariate CART models to determine the optimal NLR cut-off for survival outcomes. We estimated disease-specific (DSS) and overall survival (OS) using the Kaplan-Meier method. We used Cox proportional hazards regression to explore the association of NLR with DSS and OS. Results: 584 patients had NLR information in our cohort. The median follow-up among survivors was 4.9 years (IQR 2.4 – 8.8 years). We identified optimal NLR cut-points of 7.1 for pre-chemo, 4.9 for post-chemo, and 1.9 for change in NLR [(post-chemo) – (pre-chemo)]. Post-chemo NLR showed the strongest association with OS and DSS. Patients with a post-chemo NLR ≥ 4.9 (n = 103) had a 5-yr DSS and OS of 42% and 33% respectively, compared to 69% and 58% for patients with an NLR < 4.9 (n = 481). In the multivariable analysis, post-chemo NLR ≥ 4.9 was an independent predictor of DSS (HR = 2.5 [95% CI:1.8, 3.6] p < 0.001 ), and OS (HR = 2.1 [95% CI:1.6, 2.8] p < 0.001). Conclusions: A post-chemo NLR ≥ 4.9 is associated with poor DSS and OS in patients treated with NAC and RC. These findings may help guide treatment planning for adjuvant therapy following RC in patients with high-risk clinically localized bladder cancer.

Pilot study of dovitinib in patients with VHL disease

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Background: Von Hippel-Lindau (VHL) is an autosomal dominant inherited disease occurring in 1 in 35,000 births. Individuals with germline mutations in the VHL gene may phenotypically express a variety of lesions including hemangioblastomas (HBs), pancreatic cysts, renal cysts, and renal cell carcinomas (RCC). Previous studies have shown differentially increased FGFR3 levels in HBs compared to RCC. In this pilot trial, we investigated the safety and efficacy profile of TKI 258 (dovitinib), a tyrosine kinase inhibitor of VEGF and FGF receptors, in VHL related lesions, focusing on HBs. Methods: A MDACC IRB-approved protocol planned to enroll 25 subjects who had genetically confirmed VHL disease or clinical diagnosis of VHL, and measurable HBs with no immediate risk of needing intervention. Dovitinib 500mg/day was given in a 4 week cycle on 5 day on/2 day off schedule. In the absence of adverse events (AE), treatment lasted 6 cycles or until disease progression. Evaluation of response to treatment was done every 8 weeks including imaging, laboratory, and clinical evaluation. The trial design used a continuous Bayesian stopping rule based on toxicities that resulted in discontinuation of dovitinib and another for lack of efficacy. Signed informed consent completed on all patients enrolled. Results: Trial stopped after six patients enrolled due to toxicity stopping rule. Patients’ ages ranged 18-61 with 5/6 being male. With regards to safety, 6/6 subjects had at least one AE with the most common AEs being rash, diarrhea, and fatigue including a grade 3 AE (severe rash) in one patient. 1/6 was stopped due to noncompliance, 1/6 stopped due to progression, 3/6 stopped due to side effects despite dose reduction, and 1/6 completed full six cycles at full dose. Best response in 6/6 subjects was stable disease (SD) in HBs. Conclusions: This pilot study of dovitinib in patients with VHL disease with measureable HBs did not show a favorable safety or efficacy profile for this dose and schedule. Half of the patients discontinued the drug due to AEs before study completion, and the best achieved response was SD. Further investigation into alternative scheduling and other FGFR inhibitors in the treatment of HBs is warranted given the strong pre-clinical data. Clinical trial information: NCT01266070.

Risk group stratification in patients with micropapillary bladder cancer treated with radical cystectomy and/or neoadjuvant chemotherapy

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Background: Micropapillary bladder cancer (MPBC) is an aggressive variant of urothelial carcinoma. We have previously published clinical risk stratification groups for patients with conventional urothelial carcinoma and sought to identify if these were valid in patients with this variant histology. Methods: An IRB approved review of 1910 patients in our radical cystectomy database revealed 106 patients with preoperative diagnosis of ≤cT4aN0M0 MPBC between December 1992 and January 2012 who underwent upfront radical cystectomy (RC, n = 74) or neoadjuvant chemotherapy (NAC) followed by RC (n = 32). To determine whether patients with MPBC can be risk stratified using traditional risk factors, a recursive partitioning analysis (RPA) was performed. Results: In multivariate analyses, hydronephrosis (HR=3.1; p=0.01), and extent of MPBC at transurethral resection (TUR) (HR=1.9; p=0.04) were associated with shortened OS. In the reduced model, clinical stage also achieved significance (HR=2.8; p=0.03). Results were similar for DSS: hydronephrosis (HR=2.4, p=0.03), extent of MPBC (HR=2.1, p=0.03) and clinical stage (HR=4.7, p=0.02). Using the RPA analysis, following risk groups were identified according to OS or DSS: 1) cT1 disease with no hydronephrosis; 2) cT2 or higher with no hydronephrosis; or 3) hydronephrosis (with any cT stage). These groups corresponded to a low, intermediate and high-risk groups with 5-year OS and DSS rates of 85% and 91%, 50% and 57% and 16% and 17%, (p<0.001), respectively. We found these risk groups to hold true in those treated with NAC or upfront RC; those who received NAC trended towards better outcomes. Conclusions: In patients with MPBC, preoperative risk factors can help stratify patients into different risk groups similar to what is seen in patients with conventional UC. Presence of hydronephrosis is an especially ominous sign.

Percentage of sarcomatoid component as a prognostic indicator for survival in sarcomatoid renal cell carcinoma

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Background: Renal cell carcinoma with sarcomatoid component (sRCC) is characterized by the microscopic spectrum of spindle cells within a background of RCC. The presence of sarcomatoid elements is associated with higher stage of presentation and decreased patient survival. The objective of this study is to examine the clinicopathological characteristics associated with overall survival (OS), specifically examining the percentage of sarcomatoid component (PSC) to stratify risk. Methods: We retrospectively reviewed data for all radical nephrectomy patients with pathologically confirmed sarcomatoid component from 1987−2011. All slides were re−reviewed by a GU pathologist to ascertain PSC. Patient characteristics were tabulated overall and by disease status (metastatic vs. localized). Cutpoints in the percent sarcomatoid providing a meaningful difference in OS were identified by recursive partitioning analysis (RPA) as univariate and combined with patient characteristics. Factors selected included age, gender, race, clinical stage, tumor histology, and treatment. The Kaplan−Meier method and two−sided log−rank test was used to assess differences in OS. Results: Among 186 patients with sRCC, 64 (34%) had localized and 122 (66%) metastatic disease. Patients were primarily white (76%) males (63%) with clear cell histology (73%), and did not receive neoadjuvant or adjuvant therapy (87%). The median follow−up time was 12.1 months (range, 0.1 to 242.2 months). The median OS was 12.6 months (95% confidence interval (CI) 10.7−14.9 months). Two subgroups were identified with a cut−point of 12.5% for PSC after univariate RPA. Patients with PSC ≥ %12.5 were at higher risk of death compared to patients with <%12.5 (45% vs. 61% 1 year OS; p value=0.04). Mutlivariate RPA revealed clinical stage and percent sarcomatoid were significantly associated with OS. Patients with localized disease were most likely to be alive at 1 year (74%). Among patients with metastatic disease with PSC<%42.5 had 1−year OS of 44% vs. 27% for patients with ≥%42.5 cutoff (p<0.001). Conclusions: The PSC appears to be a prognostic factor in the OS of patients with RCC, with larger percentage of involvement portending a worse survival.

Geographic distribution of regional metastatic nodes affects the outcome of trimodality-eligible patients with esophageal adenocarcinoma

BACKGROUND/AIM

Malignant nodes in patients with localized esophageal adenocarcinoma (L-EAC) portend a poor prognosis. We assessed the correlation of the distribution of nodes with the outcome of patients undergoing chemoradiation/surgery (trimodality therapy).

METHODS

We studied 209 L-EAC patients who had confirmed or suspicious nodes at baseline staging. All patients received trimodality therapy and were grouped according to the nodal geography: above the diaphragm (AD), below the diaphragm (BD), or above and below the diaphragm (ABD). Survival estimates were calculated using the Kaplan-Meier method, and the outcomes of the groups were assessed by the log-rank test.

RESULTS

Patients were primarily Caucasian (91%) and male (93%), with a baseline stage III L-EAC (89%). The median follow-up was 2.8 years (range, 0.4-11.7). Of the 209 patients, 35% (n = 73) had AD nodes, 20% (n = 41) had BD nodes, and 45% (n = 95) had ABD nodes. ABD patients had a 5-year overall survival rate of 33%, whereas this rate was 55% in AD patients and 60% in BD patients (p = 0.02). Patients with a higher histology grade were also at a higher risk of relapse and had a poor survival (p < 0.01 for both).

CONCLUSIONS

L-EAC patients in the ABD group had the worst outcome after trimodality treatment compared to those in the AD or BD group. Novel strategies are needed for ABD patients.

Prognosis of gastric cancer (GC) patients with positive peritoneal cytology

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Background: Laparoscopic staging of patients with GC can disclose peritoneal metastases. Although this finding is associated with a poor prognosis, some patients achieve a long-term survival. In an attempt to provide explanation we compared the overall survival (OS) of patients with GC peritoneal metastases from two settings: cytology positive only (Cy+) and grossly positive (Gross+). Methods: 146 GC patients with peritoneal metastases were identified between 2000 and 2014. Cox-model regression was used for overall survival (OS) analyses. Results: Patient/treatment characteristics were as follows: males (66%), good ECOG scores (0-1; 89%), metastases confirmed by a diagnostic laparoscopy (84%), poorly differentiated histology(92%), received chemotherapy (89%), received chemoradiation (22%), and received surgery (10%). The median follow-up time for all patients was 12.9 months and median OS was 15 months. Patients with Gross+ were at higher risk of death compared to Cy+ patients (50% vs. 83%1-year OS, respectively). Only diagnostic laparoscopy and metastasis type (Gross+ vs. Cy+) were significant in both univariate and multivariate OS models. With both factors in the same model, patients with Gross+ were more than twice as likely to die when compared to those with Cy+ (HR=2.23; p=0.001) while patients having a diagnostic laparoscopy were half as likely to die (HR=0.52; p=0.01). Conclusions: The one-year OS of patients with Cy+ peritoneal metastases is significantly longer than those with Gross+ findings. As such, novel strategies for Cy+ patients may further prolong their survival. From U. T. M. D. Anderson Cancer Center (UTMDACC), Houston, Texas, USA. (Supported in part by UTMDACC, and CA 138671 and CA172741 from the NCI).

Characterization of Anthropometric Changes that Occur During Neoadjuvant Therapy for Potentially Resectable Pancreatic Cancer

BACKGROUND

Little is known about changes in body composition that may occur during neoadjuvant therapy for pancreatic cancer. This study was designed to characterize these changes and their potential relationships with therapeutic outcomes.

METHODS

The study population consisted of patients with potentially resectable pancreatic cancer treated on a phase II trial of neoadjuvant chemotherapy and chemoradiation. Skeletal muscle and adipose tissue compartments were measured before and after administration of neoadjuvant therapy using SliceOMatic software (TomoVision, 2012) and protocol-mandated CT scans. Sarcopenia was defined using gender-adjusted norms.

RESULTS

Among 89 eligible patients, 46 (52 %) patients met anthropometric criteria for sarcopenia prior to the initiation of neoadjuvant therapy. Further depletion of skeletal muscle, visceral adipose tissue, and subcutaneous adipose tissue occurred during neoadjuvant therapy, but these losses did not preclude the performance of potentially curative surgery. Degree of skeletal muscle loss correlated with disease-free survival while visceral adipose loss was associated with overall and progression-free survival. However, completion of all therapy, including pancreatectomy, was the only independently significant predictor of outcome in a multivariate analysis of overall survival.

DISCUSSION

These data suggest that body composition analysis of standard CT images may provide clinically relevant information for patients with potentially resectable pancreatic cancer who receive neoadjuvant therapy. Anthropometric changes must be considered in the design of preoperative therapy regimens, and further efforts should focus on maintenance of muscle and visceral adipose tissue in the preoperative setting.

Human Pancreatic Cancer-Associated Stellate Cells Remain Activated after in vivo Chemoradiation

Pancreatic ductal adenocarcinoma (PDAC) is characterized by an extensive fibrotic reaction or desmoplasia and complex involvement of the surrounding tumor microenvironment. Pancreatic stellate cells are a key mediator of the pancreatic matrix and they promote progression and invasion of pancreatic cancer by increasing cell proliferation and offering protection against therapeutic interventions. Our study utilizes human tumor-derived pancreatic stellate cells (HTPSCs) isolated from fine needle aspirates of pancreatic cancer tissue from patients with locally advanced, unresectable pancreatic adenocarcinoma before and after treatment with full-dose gemcitabine plus concurrent hypo-fractionated stereotactic radiosurgery. We show that HTPSCs survive in vivo chemotherapy and radiotherapy treatment and display a more activated phenotype post-therapy. These data support the idea that stellate cells play an essential role in supporting and promoting pancreatic cancer and further research is needed to develop novel treatments targeting the pancreatic tumor microenvironment.

The effect of peritransplant minimal residual disease in adults with acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation

BACKGROUND

Allogeneic HSCT is highly effective for treating ALL. However, many ALL patients relapse after HSCT. There has been a continuing effort to improve identification of patients at high risk of relapse, with the goal of early intervention to improve outcome.

PATIENTS AND METHODS

In this retrospective analysis, we examined the effect of MRD on the risk of hematologic relapse in 149 adult patients with ALL in morphologic remission undergoing allogeneic HSCT. MRD was assessed at the time of HSCT and after HSCT.

RESULTS

Patients with pretransplant MRD had a trend for shorter progression-free survival (PFS) at 2 years compared with patients without MRD, nearing statistical significance; 28% versus 47%, P = .08, on univariate analysis. This trend remained on multivariate analysis with better PFS in patients without MRD at the time of HSCT, hazard ratio (HR), 0.62 (95% confidence interval, 0.37-1.04); P = .07. Additionally, emergence of MRD after HSCT was a strong predictor for overt hematologic relapse (HR, 4; P < .001) with a median latency interval of 3.8 months.

CONCLUSION

These findings demonstrate the predictive value of monitoring for MRD around the time of transplant in adult patients with ALL.

Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis

OBJECTIVE

To compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis.

DESIGN

Systematic review with network meta-analysis, to allow comparison of treatments within a coherent framework. Comprehensive searches were undertaken up to January 2013 to identify randomised controlled trials in patients with osteoarthritis of the knee, which reported pain.

RESULTS

Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. Most trials studied short-term effects and many were classed as being of poor quality with high risk of bias, commonly associated with lack of blinding (which was sometimes impossible to achieve). End of treatment results showed that eight interventions: interferential therapy, acupuncture, TENS, pulsed electrical stimulation, balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise produced a statistically significant reduction in pain when compared with standard care. In a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or muscle-strengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardised mean difference: 0.49, 95% credible interval 0.00-0.98).

CONCLUSIONS

As a summary of the current available research, the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. However, much of the evidence in this area of research is of poor quality, meaning there is uncertainty about the efficacy of many physical treatments.

Adenoma detection in patients undergoing a comprehensive colonoscopy screening

Measures shown to improve the adenoma detection during colonoscopy (excellent bowel preparation, cecal intubation, cap fitted colonoscope to examine behind folds, patient position change to optimize colon distention, trained endoscopy team focusing on detection of subtle flat lesions, and incorporation of optimum endoscopic examination with adequate withdrawal time) are applicable to clinical practice and, if incorporated are projected to facilitate comprehensive colonoscopy screening program for colon cancer prevention. To determine adenoma and serrated polyp detection rate under conditions designed to optimize quality parameters for comprehensive screening colonoscopy. Retrospective analysis of data obtained from a comprehensive colon cancer screening program designed to optimize quality parameters. Academic medical center. Three hundred and forty-three patients between the ages of 50 years and 75 years who underwent first screening colonoscopy between 2009 and 2011 among 535 consecutive patients undergoing colonoscopy. Comprehensive colonoscopy screening program was utilized to screen all patients. Cecal intubation was successful in 98.8% of patients. The Boston Bowel Preparation Scale for quality of colonoscopy was 8.97 (95% confidence interval [CI]; 8.94, 9.00). The rate of adenoma detection was 60% and serrated lesion (defined as serrated adenomas or hyperplastic polyps proximal to the splenic flexure) detection was 23%. The rate of precancerous lesion detection (adenomas and serrated lesions) was 66%. The mean number of adenomas per screening procedure was 1.4 (1.2, 1.6) and the mean number of precancerous lesions (adenomas or serrated lesions) per screening procedure was 1.6 (1.4, 1.8). Retrospective study and single endoscopist experience. A comprehensive colonoscopy screening program results in high-quality screening with high detection of adenomas, advanced adenomas, serrated adenomas, and multiple adenomas.

A phase II, randomized, double blind comparison of calcium aluminosilicate clay (CASAD) versus placebo (dibasic calcium carbonate) for the prevention of diarrhea in patients (pts) with metastatic colorectal cancer (mCRC) treated with irinotecan (I)

3600

Background: CASAD is a naturally occurring calcium montmorrilonite clay that serves as a cation exchange absorbent. One of the active metabolites of Irinotecan is SN-38, which is adsorbed by CASAD in vitro. The study hypothesis was that oral CASAD would reduce the rate of grade 3/4 diarrhea in mCRC patients treated with irinotecan. Methods: The study is a multicenter, prospective, randomized, double blinded placebo-controlled phase II trial. One hundred patients receiving I-based chemotherapy were randomized equally between CASAD (1000 mg po 4x daily) and placebo in order to have 75% power to detect a difference in the proportions of patients with grade 3/4 diarrhea within 6 weeks at a 1-sided 5% significance level. We also compared symptom burden using the MDASI questionnaire summed over the 13 symptom items for weeks 0, 3, 5, and 6. Results: Between 5/2009 and 5/2012, 100 patients were randomized in a 1:1 ratio between study arms. Median age 57 yrs, 54% male, 74% Non-Hispanic White, 93% performance status 0 or 1. Serious diarrhea was less frequent than expected based upon prior studies with Irinotecan. In evaluable patients, no significant difference in the rate of G3/4 diarrhea was seen (the primary endpoint): CASAD arm: 7/43 pts (16%), Placebo arm: 3/32 pts (9%), p=0.70. The rate of any diarrhea among all pts was also similar: CASAD arm 64% vs. Placebo arm 70%. The rate of study dropout was 14% in CASAD and 38% for placebo (p=0.01; 2-sided). No differences were found in symptom burden or individual symptom items or serious adverse events. Conclusions: Compared with placebo, CASAD use was safe but ineffective in preventing diarrhea in mCRC patients treated with irinotecan-containing chemotherapy regimens. There were no favorable or unfavorable signals in terms of the patient experience related to symptoms, but there were significantly more dropouts in the placebo arm. Future CASAD trials are focused on active treatment of diarrhea. Clinical trial information: NCT00748215.

Lynch syndrome testing in ethnically diverse patients: Mutation spectrum and performance of prediction models

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Background: Lynch syndrome (LS) is characterized by deficiency in DNA mismatch repair (MMR). Several models can predict the probability of MMR gene mutations, but all were derived from populations in Northern Europe and America. We aimed to characterize MMR mutations and to evaluate the performance of 4 models (Leiden, MMRpredict, MMRpro, and PREMM1,2,6) in an ethnically diverse high-risk population. Methods: Mutation and pedigree data from 387 distinct probands tested for germline MMR mutations at a single center between 2003-2012 were analyzed. Mutation testing was triggered by suggestive tumor microsatellite results and/or clinical/family history. Race/ethnicity was self-reported: 84 (22%) were ethnically-diverse (African American, 19; Hispanic, 29; Asian/Arabic, 34; and other, 2) and 303 (78%) were white. Area under the receiver operating curve (AUC) for all 4 models was analyzed by logistic regression. Results: Pathogenic mutations were detected in 152 patients (39%; MLH1 in 37, MSH2/EPCAM in 84, MSH6 in 21, and PMS2 in 10). The detection rate was significantly lower in ethnically-diverse patients when compared to white patients (30 vs. 42%; p=0.04). The mutation frequency of the major MMR genes MLH1 and MSH2 differed, although the overall mutation distribution did not reach statistical significance (MLH1, 40 vs. 22%; MSH2: 36 vs. 59%; MSH6: 20 vs. 13%; and PMS2: 4 vs. 7%; p=0.10 vs. white). The Leiden, MMRpredict, MMRpro, and PREMM1,2,6 models trended toward inferior discrimination for the ethnically diverse patients, with AUCs of 0.63, 0.64, 0.63, and 0.66 respectively (vs. AUCs of 0.71, 0.69, 0.72, and 0.76 for white patients), but the difference was not statistically significant(p=0.11, 0.17, 0.09, and 0.08, respectively). Adjusting for family size did not significantly alter results. Conclusions: In ethnically-diverse patients, the overall detection rate for pathogenic MMR mutations is significantly lower, with associated differences in mutation frequencies and in predictive model performance. We caution against relying solely on predictive scores, as high-risk ethnically-diverse patients without an identified mutation may deserve to be followed as clinical LS patients.

Serum insulin to predict time to castration-resistant progression and overall survival in metastatic androgen-dependent prostate cancer (mADPCa)

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Background: Duration of response to androgen-deprivation therapy (ADT) is highly variable in patients with mADPC and prognostic markers are needed. Insulin resistance and hyperinsulinemia may contribute to prostate cancer progression. We hypothesized that pretreatment serum insulin levels would predict time to castration-resistant progression (PFS) and overall survival (OS). Methods: Sera from men treated on a randomized phase 3 trial of first line ADT vs. ADT plus chemotherapy were retrospectively analyzed using a multiplex ELISA for cytokines and angiogenic factors (CAFs). Univariate and multivariate Cox proportional hazards regression models were used to identify associations between CAFs and PFS/OS. Results: 66 pts were evaluable, 86% Caucasian, median age 72 yrs, median PSA 31.5ng/mL, 77% Gleason score of ≥8, and 53% high volume metastatic disease (HVM). Thirty-five pts received ADT; 31 pts received ADT+chemo. In univariate analysis, higher pretreatment insulin and C-peptide were positively correlated with PFS, whereas higher hepatocyte-growth factor (HGF), osteopontin (OPN) and HVM were negatively correlated with PFS. In multivariate analysis, only higher insulin was associated with longer PFS (HR=0.72, 95%CI 1.32 -0.87; p<0.001), whereas higher HGF and OPN were associated with reduced PFS (HR=1.82, 95%CI 0.59-2.83, p<0.01 and HR=1.81, 95%CI 1.18-2.47, p<0.001, respectively). Higher Insulin and Program Death 1 (PD1) were associated with longer OS on multivariate analysis (HR=0.78 p<0.02 and HR=0.55 p<0.02, respectively), whereas HVM and higher OPN were associated with reduced OS (HR=2.28 p<0.01 and HR=1.60 p<0.02). Using low insulin, high HGF and high OPN as 3 independent risk factors (RF), 3 distinct risk groups could predict PFS: good (zero RF), intermediate (1 or 2 RF) and poor risk (3 RF), with median PFS of 6.90, 1.97, and 0.86 years, respectively (p<0.001). Conclusions: Higher pretreatment insulin was associated with prolonged PFS and OS in men with mADPC treated with ADT. Our data suggest that insulin levels are a biomarker for sensitivity to ADT and highlight the complex interactions between metabolism and PCa progression.

Stereotactic body radiation therapy with concurrent full-dose gemcitabine for locally advanced pancreatic cancer: a pilot trial demonstrating safety

Background

Concurrent chemoradiation is a standard option for locally advanced pancreatic cancer (LAPC). Concurrent conventional radiation with full-dose gemcitabine has significant toxicity. Stereotactic body radiation therapy (SBRT) may provide the opportunity to administer radiation in a shorter time frame with similar efficacy and reduced toxicity. This Pilot study assessed the safety of concurrent full-dose gemcitabine with SBRT for LAPC.

Methods

Patients received gemcitabine, 1000 mg/m² for 6 cycles. During week 4 of cycle 1, patients received SBRT (25 Gy delivered in five consecutive daily fractions of 5 Gy prescribed to the 75-83% isodose line). Acute and late toxicities were assessed using NIH CTCAE v3. Tumor response was assessed by RECIST. Patients underwent an esophagogastroduodenoscopy at baseline, 2, and 6 months to assess the duodenal mucosa. Quality of life (QoL) data was collected before and after treatment using the QLQ-C30 and QLQ-PAN26 questionnaires.

Results

Between September 2009 and February 2011, 11 patients enrolled with one withdrawal during radiation therapy. Patients had grade 1 to 2 gastrointestinal toxicity from the start of SBRT to 2 weeks after treatment. There were no grade 3 or greater radiation-related toxicities or delays for cycle 2 of gemcitabine. On endoscopy, there were no grade 2 or higher mucosal toxicities. Two patients had a partial response. The median progression free and overall survival were 6.8 and 12.2 months, respectively. Global QoL did not change between baseline and immediately after radiation treatment.

Conclusions

SBRT with concurrent full dose gemcitabine is safe when administered to patients with LAPC. There is no delay in administration of radiation or chemotherapy, and radiation is completed with minimal toxicity.

Characteristics and clinical outcomes of patients with renal cell carcinoma with sarcomatoid dedifferentiation (sRCC)

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Background: sRCC is an aggressive subset of renal cell carcinomas that is associated with poor prognosis. We describe clinical and pathological characteristics and outcomes of the largest single-institutional cohort of patients with sRCC who underwent nephrectomy. Methods: Data were collected from 1986 to 2011 for patients identified as having sRCC. 221 patients with complete data who underwent a radical or partial nephrectomy and had a sarcomatoid component in the primary kidney tumor were included in the analysis. Clinical and pathologic variables were reviewed and Kaplan-Meier curves were used to compare differences in overall survival. Results: Mean age at diagnosis was 57 years and median tumor size was 11 cm (range 1.5-27.0 cm). 93% of patients were symptomatic at presentation and 96% had an ECOG performance status of 0 or 1. 12 patients had a preoperative biopsy that showed sRCC. 75% of patients were pT3 or higher at time of nephrectomy and 69% presented with metastatic disease. Of these, 11.8% had radiographic evidence of regional nodal involvement alone and 88.2% had distant metastatic disease. The associated epithelial component was clear cell in 72% of the patients, papillary in 12.7% and chromophobe in 3.1%. 29 patients received presurgical systemic therapy, while 161 patients received postoperative systemic therapy. During a median follow-up of 20.5 months, 187 patients (84%) died. Overall survival for the entire cohort at 1 year was 48%. Overall 1-, 2-, and 3-year survival rates for patients with metastatic disease at presentation versus no metastatic disease were 36, 20, and 16% versus 74, 51, and 44% respectively (p < 0.001). Patients with clear cell RCC epithelial component had a survival advantage over those with non-clear cell components with 1-, 2-, and 3-year survival rates of 52, 34, and 31% versus 38, 19, and 12% (p = 0.0057). Conclusions: The majority of patients with sRCC who underwent nephrectomy present with metastatic disease and outcomes are dismal despite surgical intervention and multimodal therapy. Overall survival is better for patients who present without metastatic disease and have clear cell histology at time of nephrectomy.