Martina Reitz

Metastatic renal carcinoma comprehensive prognostic system

The purpose of the study was to identify a comprehensive prognostic system of pretreatment clinical parameters in 425 patients (pts) with metastatic renal-cell carcinoma treated with different subcutaneous (s.c.) recombinant cytokine-based home therapies in consecutive trials. Treatment consisted of (A) s.c. interferon-α2a (INF-α), s.c. interleukin-2 (IL-2) (n=102 pts), (B) s.c. IFN-α2a, s.c. IL-2, and i.v. 5-fluorouracil (5-FU) (n=235 pts) or (C) s.c. IFN-α2a, s.c. IL-2, and i.v. 5-FU combined with p.o. 13-cis-retinoic acid (13cRA) (n=88 pts). Kaplan–Meier survival analysis, log-rank statistics, and Cox regression analysis were employed to identify risk factors and to create a multiple risk factor model. The following pretreatment risk factors were identified by univariate analysis: (1) three and more metastatic sites, (2) presence of liver, lymph node or bone metastases, (3) neutrophil count ⩾6500 cells μl−1, (4) serum lactate dehydrogenase level (LDH) ⩾220 U l−1, and (5) serum C-reactive protein level (CRP) ⩾11 mg l−1. Cox regression analysis with forward stepwise variable selection identified neutrophil count as the major prognostic factor (hazard ratio=1.9, P<0.001), while serum levels of LDH and CRP, time between diagnosis of tumour and onset of metastatic disease, number of metastatic sites, and bone metastases were significant but somewhat less important prognostic variables within the multiple risk factor model (hazard ratio ⩽1.5). Patients were assigned to one of the three risk groups according to cumulative risk defined as the sum of simplified risk s.c.ores for six pretreatment variables. Low-, intermediate-, and high-risk patients achieved a median overall survival of 32+ months (95% CI 24, 43; 5-year survival of 27%), 18+ months (95% CI 15, 20; 5-year survival of 11%), and 8+ months (95% CI 6, 10; 5-year survival of 5%), respectively. These prognostic categories are helpful both in individual patient care and in the assessment of patients entering prospective clinical trials.

Thirteen‐year, long‐term efficacy of interferon 2α and interleukin 2‐based home therapy in patients with advanced renal cell carcinoma

The goal of the current report was to demonstrate the long‐term efficacy of outpatient subcutaneous (sc) interferon α (IFN‐α) and sc interleukin 2 (IL‐2)‐based combination regimens in patients with metastatic renal cell carcinoma.

Increased Expression of the Tumor Suppressor PLZF Is a Continuous Predictor of Long-Term Survival in Malignant Melanoma Patients

Promyelocytic leukemia zinc finger (PLZF) is a transcriptional repressor and tumor suppressor inhibiting melanoma cell growth in vitro and in vivo in animal models. In this study, we analyzed the impact of in vivo primary tumor gene expression of PLZF on the long-term survival of malignant melanoma patients. PLZF expression was assessed by using DNA microarray and real-time polymerase chain reaction analysis of 41 primary malignant melanomas from patients with a defined histology and a close to 20-year clinical follow-up, of 29 melanoma metastases, and of 6 different melanoma cell lines. Kaplan-Meier survival analyses, log-rank statistics and Cox regression analysis were employed to identify the impact of PLZF expression on long-term survival. We detected PLZF expression in 92% of primary melanoma tumors in vivo but not in melanoma cell lines in vitro. By univariate analysis, we identified: (1) PLZF mRNA expression < or = 10,000 mRNA copies/mug total tumor RNA, (2) Breslow tumor thickness >4 mm, and (3) American Joint Committee on Cancer stages IIC, IIIB, IIIC, and IV as statistically significant pretreatment risk factors. We defined a continuous prognostic index (i.e., risk score) for primary melanoma patients based on the regression coefficient of PLZF mRNA expression. Applying a cutpoint to the prognostic index at - 1.65, patients were assigned to one of two risk groups: low-risk patients (n = 28) with a median overall survival of 79 months (5-year survival of 61%) and high-risk patients (n = 13) with a median overall survival of 32 months (5-year survival of 23%) (p < 0.05). This is the first time that PLZF mRNA expression has been linked to a prognostic model for primary malignant melanoma patients to derive prognostic groups for clinical purposes (e.g., improved melanoma immunotherapies).

Peripheral Blood Neutrophils as Independent Immunologic Predictor of Response and Long-Term Survival upon Immunotherapy in Metastatic Renal-Cell Carcinoma

The aim of this study was to evaluate the prognostic impact of pretreatment neutrophils, previously rendered statistically independent, on the response and on long-term survival of metastatic renal carcinoma patients treated with outpatient subcutaneous (s.c.) interleukin-2 (IL-2) and s.c. interferon (IFN)-alpha. We assessed a total of 495 patients receiving s.c. IL-2/s.c. IFN-alpha-based therapy. While 417 patients with neutrophil counts <6500 cells/microL at baseline achieved 30% objective responses and a median survival of 22 months, 78 patients with pretreatment neutrophil counts >or= 6500 cells/microL had 18% objective responses and a median survival of 9 months (p=0.0000). In conclusion, pretreatment peripheral blood neutrophils <6500/microL constitute an immunologic predictor of tumor response and long-term survival in metastatic renal-cell carcinoma patients treated with s.c. IL-2 and s.c. IFN-alpha-based regimens.

An approach to estimating prognosis using fractional polynomials in metastatic renal carcinoma

We present a prognostic model for metastatic renal cell carcinoma based on fractional polynomials. We retrospectively analysed 425 metastatic renal cell carcinoma patients treated with subcutaneous recombinant cytokine-based home therapies in consecutive trials. In our approach, we categorised a continuous prognostic index produced by the multivariable fractional polynomial (MFP) algorithm, using a strategy in which continuous predictors are kept continuous. The MFP algorithm selected five prognostic factors as significant at the 5% level in a multivariable model: lymph node metastases, liver metastases, bone metastases, age, C-reactive protein and neutrophils. The MFP model allowed us to divide patients into four risk groups achieving median overall survivals of 38 months (low risk), 23 months (low intermediate risk), 15 months (high intermediate risk) and 5.6 months (high risk). Our approach, based on categorising a continuous prognostic index produced by the MFP algorithm, allowed more flexibility in the determination of risk groups than traditional approaches.

Predictive Impact of Retinoid X Receptor-Alpha-Expression in Renal-Cell Carcinoma

PURPOSE Retinoid receptors are nuclear transcription factors that mediate the effects of retinoids on gene expression. In our study, we analyzed the expression of retinoid X receptor-alpha (RXR-alpha) and its prognostic value in renal-cell carcinoma (RCC) patients exhibiting stage IV disease upon first diagnosis or thereafter. MATERIALS AND METHODS Detection of RXR-alpha was performed on tumor specimens from 63 patients with primary RCC, using immunohistochemical techniques. For our evaluation of the immunostaining results, we developed a new cell-counting system based on the subcellular distribution of immunoreactivity. The impact of the subcellular distribution of RXR-alpha on the prognosis of patients with RCC was analyzed statistically among other clinicopathologic factors. The primary end point was survival. RESULTS In 34 RCC samples (54.0%), RXR-alpha was detected predominantly in the nucleus, while 25 RCC specimens (39.7%) displayed an aberrant subcellular distribution pattern, with a predominantly cytoplasmic staining with nuclear sparing in 15 specimens (23.8%), and a combined nuclear and cytoplasmic staining in 10 specimens (15.9%). Very faint to undetectable immunoreactivity was noted in 4 cases (6.3%) of RCC. Univariate Kaplan-Meier analysis showed that patients with a predominantly nuclear localization of RXR-alpha had a significantly prolonged survival after primary tumor diagnosis, when compared to patients with a predominantly aberrant subcellular distribution profile (p < 0.01). Furthermore, multivariate analysis revealed that an aberrant subcellular distribution of RXR-alpha in RCC was an independent predictor of poor survival (p < 0.01). CONCLUSIONS Our study indicated that the subcellular intratumoral distribution pattern of RXR-alpha could independently predict the survival of RCC patients. However, the exact mechanisms underlying the aberrant compartmentalization and the functions of RXR-alpha in RCC remain to be determined.

Cisplatin, gemcitabine, and treosulfan in relapsed stage IV cutaneous malignant melanoma patients

To evaluate the efficacy of cisplatin, gemcitabine, and treosulfan (CGT) in 91 patients with pretreated relapsed AJCC stage IV cutaneous malignant melanoma. Patients in relapse after first-, second-, or third-line therapy received 40 mg m−2 intravenous (i.v.) cisplatin, 1000 mg m−2 i.v. gemcitabine, and 2500 mg m−2 i.v. treosulfan on days 1 and 8. Cisplatin, gemcitabine, and treosulfan therapy was repeated every 5 weeks until progression of disease occurred. A maximum of 11 CGT cycles (mean, two cycles) was administered per patient. Four patients (4%) showed a partial response; 15 (17%) patients had stable disease; and 72 (79%) patients progressed upon first re-evaluation. Overall survival of all 91 patients was 6 months (2-year survival rate, 7%). Patients with partial remission or stable disease exhibited a median overall survival of 11 months (2-year survival rate, 36%), while patients with disease progression upon first re-evaluation had a median overall survival of 5 months (2-year survival rate, 0%). Treatment with CGT was efficient in one-fifth of the pretreated relapsed stage IV melanoma patients achieving disease stabilisation or partial remission with prolonged but limited survival.

Age has no significant impact on overall survival and on treatment tolerability in relapsed stage IV cutaneous malignant melanoma patients receiving Cisplatin, Gemcitabine, and Treosulfan.

Objectives: We compared the efficacy and tolerability of cisplatin, gemcitabine, and treosulfan (CGT) therapy in younger patients (age, <60 years) and in elderly patients (age, ≥60 years) with pretreated relapsed American Joint Committee on Cancer stage IV cutaneous malignant melanoma. Patients and Methods: A total of 91 patients at the age of 18 to 80 years, in relapse after first-, second-, or third-line therapy received 40 mg/m2 intravenous (i.v.) cisplatin, 1000 mg/m2 i.v. gemcitabine, and 2500 mg/m2 i.v. treosulfan on days 1 and 8. CGT-therapy was repeated every 5 weeks until progression of disease occurred. Results: Younger (n = 49) and elderly (n = 42) patients showed a significant difference in disease stabilization in 25% versus 7% (P ≤ 0.05), as opposed to 69% versus 91% patients exhibiting disease progression. In contrast, the overall median survival probability was not significantly different (P = 0.8153). Neither treatment-related toxicity nor toxicity-associated dose reduction showed substantial differences. Conclusions: Our results demonstrated that CGT therapy could be safely administered to a patient up to age 80 years.

Abstract 4652: Identification and validation of a novel nine-gene signature predicting clinical outcome in malignant melanoma

Incidence of malignant melanoma is rapidly increasing - with a doubling rate of 10-20 years. Conventional histopathological and clinical staging (based on Breslow tumor thickness, lymph node status, and ulceration) is largely inadequate for predicting clinical outcome of malignant melanoma. On the other hand, molecular prognostic markers are not yet available. Here, we identified a nine-gene signature which is closely associated with overall survival of melanoma patients. To identify prognostic genes we correlated gene expression profiles of 136 primary melanomas with patient overall survival using Cox regression analysis: Initially, a comparative analysis of 20 high-risk vs. 20 low-risk primary melanomas with a clinical follow-up of more than 20 years (training cohort) was performed using whole-genome DNA microarray analysis and yielded 92 prognostically relevant candidate genes. Technical and statistical validation using TaqMan Array real-time RT-PCR and correlation of gene expression with patient overall survival reduced candidate gene number to 11. Expression of these 11 genes was further analyzed in an extended group of 91 primary melanomas (study cohort), yielding a nine-gene signature with prognostic significance. This novel prognostic melanoma gene signature was successfully validated using an independent set of 45 primary melanomas (validation cohort). A risk score, based on the expression of the nine genes of the signature (KRT9, SPINK7/ECG2, KBTBD10, DCD, HES6, COL6A6, PIP, SCGB1D2, SCGB2A2), or any subgroup thereof, predicted patient overall survival in the study cohort (p = 0.0004, hazard ratio 3.83), independently of conventional AJCC 2002 staging. When combining gene expression score and AJCC staging, approximately two thirds (29/45, 64%) of patients with AJCC intermediate prognosis (i.e. stages IIA, IIB, and IIIA) were reclassified into good prognosis, exhibiting a long-term overall survival probability of 95%. Misclassification rate of all patients classified into good prognosis (low-risk gene score combined with AJCC stages I IIA/B, or IIIA) was very low at 4.6% and 6.25% in the training and validation cohorts, respectively. The prognostic value of this novel signature-based risk score is its ability to identify patients at low risk, not identified by AJCC staging. This re-classification may allow these patients to stay treatment-free while experiencing excellent long-term survival. The remaining patients are risk patients and are in need of adjuvant therapies. Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4652.