Sara Caponi

Anti-HER agents in gastric cancer: from bench to bedside

Despite some advances in the past few years, the search for effective treatment modalities for advanced gastric and gastro-esophageal junction cancer is far from over. Available data clearly demonstrate that the development of new drugs will have little, if any, chance of success if it is not guided by in-depth knowledge of disease biology. However, using biologic agents to target key molecular pathways, such as those regulated by human epidermal growth factor receptor (HER) family members, may be effective. Indeed, the positive results achieved by the anti-HER2 agent trastuzumab in a phase III trial in HER2-positive patients support this approach. Many new anti-HER molecules are now under evaluation for the treatment of gastric and gastro-esophageal junction cancer, but so far attempts to identify reliable predictive factors from phase I and II trials have produced inconclusive results. In addition, large phase III trials are still being conducted in molecularly unselected populations. Refining patient selection is essential to maximize the benefit of targeted agents, to avoid significant toxicities and for the development of alternative therapeutic approaches in patients who have nonresponsive disease.

The good, the bad and the ugly: a tale of miR-101, miR-21 and miR-155 in pancreatic intraductal papillary mucinous neoplasms

BACKGROUND This multicenter study evaluated three candidate microRNAs (miRNAs) (miR-21, miR-155 and miR-101) as potential biomarkers in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. PATIENTS AND METHODS miRNA expression was quantified by quantitative RT-PCR in 86 laser-microdissected specimens, including 65 invasive IPMNs, 16 non-invasive IPMNs and 5 normal pancreatic ductal tissues. Univariate and multivariate analyses compared miRNAs and clinical parameters with overall (OS) and disease-free survival (DFS). RESULTS miR-21 and miR-155 were up-regulated in invasive IPMNs compared with non-invasive IPMNs, as well as in non-invasive IPMNs compared with normal tissues. Conversely, miR-101 levels were significantly higher in non-invasive IPMNs and normal tissues compared with invasive IPMNs. High levels of miR-21 were associated with worse OS [hazard ratio (HR) = 2.47, 95% confidence interval (CI) = 1.37-5.65, P = 0.0047]. Patients with high-miR-21 expression also had a shorter median DFS (10.9 versus 29.9 months, P = 0.01). Multivariate analysis confirmed miR-21 as independently prognostic for mortality and disease progression (death risk: HR = 3.3, 95% CI = 1.5-7.0, P = 0.02; progression risk: HR = 2.3, 95% CI = 1.2-4.8, P = 0.02), as well as positive lymph-node status (death risk: HR = 2.6, 95% CI = 1.1-6.3, P = 0.03; progression risk: HR = 2.2, 95% CI = 1.0-4.8, P = 0.04). CONCLUSIONS miR-21, miR-155 and miR-101 showed significant differences in invasive versus non-invasive IPMNs. miR-21 emerged as an independent prognostic biomarker in invasive IPMNs and should be validated in prospective studies.

High-Throughput MicroRNA (miRNAs) Arrays Unravel the Prognostic Role of MiR-211 in Pancreatic Cancer

Background Only a subset of radically resected pancreatic ductal adenocarcinoma (PDAC) patients benefit from chemotherapy, and identification of prognostic factors is warranted. Recently miRNAs emerged as diagnostic biomarkers and innovative therapeutic targets, while high-throughput arrays are opening new opportunities to evaluate whether they can predict clinical outcome. The present study evaluated whether comprehensive miRNA expression profiling correlated with overall survival (OS) in resected PDAC patients. Methodology/Principal Findings High-resolution miRNA profiles were obtained with the Torays 3D-Gene™-miRNA-chip, detecting more than 1200 human miRNAs. RNA was successfully isolated from paraffin-embedded primary tumors of 19 out of 26 stage-pT3N1 homogeneously treated patients (adjuvant gemcitabine 1000 mg/m2/day, days-1/8/15, every 28days), carefully selected according to their outcome (OS<12 (N = 13) vs. OS>30 months (N = 6), i.e. short/long-OS). Highly stringent statistics included t-test, distance matrix with Spearman-ranked correlation, and iterative approaches. Unsupervised hierarchical analysis revealed that PDACs clustered according to their short/long-OS classification, while the feature selection algorithm RELIEF identified the top 4 discriminating miRNAs between the two groups. These miRNAs target more than 1500 transcripts, including 169 targeted by two or more. MiR-211 emerged as the best discriminating miRNA, with significantly higher expression in long- vs. short-OS patients. The expression of this miRNA was subsequently assessed by quantitative-PCR in an independent cohort of laser-microdissected PDACs from 60 resected patients treated with the same gemcitabine regimen. Patients with low miR-211 expression according to median value had a significantly shorter median OS (14.8, 95%CI = 13.1–16.5, vs. 25.7 months, 95%CI = 16.2–35.1, log-rank-P = 0.004). Multivariate analysis demonstrated that low miR-211 expression was an independent factor of poor prognosis (hazard ratio 2.3, P = 0.03) after adjusting for all the factors influencing outcome. Conclusions/Significance Through comprehensive microarray analysis and PCR validation we identified miR-211 as a prognostic factor in resected PDAC. These results prompt further prospective studies and research on the biological role of miR-211 in PDAC.

Prognostic factors in gemcitabine–cisplatin polychemotherapy regimens in pancreatic cancer: XPD‐Lys751Gln polymorphism strikes back

The use of platinated agents in combination chemotherapy regimens for advanced pancreatic cancer is controversial owing to the lack of an outstanding impact on the outcome and a substantial increase in hematologic and extra‐hematologic toxicities. Pharmacogenetic studies to identify patients who could benefit most from such therapies are urgently needed. The Xeroderma‐Pigmentosum group‐D polymorphism at codon‐751 (XPD‐Lys751Gln) emerged as the most significant independent predictor for death‐ and progression‐risk in our previous study on functional polymorphisms in 122 advanced pancreatic cancer patients treated with cisplatin–docetaxel–capecitabine–gemcitabine and cisplatin–epirubicin–capecitabine–gemcitabine (or EC‐GemCap). To confirm the prognostic role of this variable, we further evaluated the correlation of XPD‐Lys751Gln with outcome in another 125 patients treated with the same regimens, and 90 treated with gemcitabine monotherapy. Genotyping was successfully carried out in the vast majority of DNA samples. Genotype frequencies followed Hardy–Weinberg equilibrium, and XPD‐Lys751Gln was associated with differential progression‐free and overall‐survival. Multivariate analysis confirmed its prognostic significance in platinum‐based regimens. In particular, XPD‐Gln751Gln was significantly associated with risk of death (hazard ratio, HR = 1.7, 95% confidence interval [CI], 1.1–2.6, p = 0.011) and risk of progression (HR = 1.7, 95% CI, 1.1–2.5, p = 0.013). No correlation was observed in gemcitabine monotherapy‐treated patients. The analysis of DNA damage using extra‐long‐PCR in lymphocytes supported the association of XPD‐Gln751Gln with greater resistance to cisplatin‐induced damage. The increasing evidence of XPD‐Lys751Gln impact on the outcome of gemcitabine–cisplatin‐based polychemotherapy leads to plan prospective studies to validate the role of this polymorphism as a new tool for optimization of the currently available treatments in pancreatic cancer.

Second-line Treatment for Non–Small-Cell Lung Cancer: One Size Does Not Fit All

After progression following first-line treatment, many patients with advanced non-small-cell lung cancer (NSCLC) still have a good performance status and can be considered for further treatments. Based on 2 randomized phase III trials, docetaxel was the first approved second-line therapy associated with longer survival and better quality of life compared with best supportive care alone and vinorelbine or ifosfamide. Since then, other agents have been approved for the second-line treatment of NSCLC (ie, pemetrexed, erlotinib, and gefitinib). Recently, new molecular-targeted agents are being increasingly considered in this setting, above all, bevacizumab and vandetanib. The discovery and validation of predictive markers of efficacy for both chemotherapy drugs and the new targeted therapies is of primary importance for the selection of second-line treatment for all patients with advanced NSCLC.

Adjuvant chemotherapy seems beneficial for invasive intraductal papillary mucinous neoplasms

AIMS The incidence of intraductal papillary mucinous neoplasm (IPMN) is rising and these neoplasms now represent up to 25% of resected pancreatic neoplasms. The optimal postoperative management of resected invasive IPMN is still debated in the absence of large prospective clinical trials and of validated prognostic factors in this setting. The objective of our study was to identify potential prognostic factors and to investigate the role of adjuvant therapies for patients radically resected for invasive IPMN. METHODS We retrospectively reviewed clinical and pathological data regarding a large series of patients with invasive IPMN who underwent surgical resection in the last six years at University Hospital of Pisa. RESULTS Sixty-four patients were considered for the analysis, thirty-three of whom received adjuvant chemotherapy with gemcitabine. In our series node involvement and high tumoral grade emerged as the major pathologic prognostic factors. Patients treated with adjuvant chemotherapy with gemcitabine experienced a longer disease-free survival than those who received surgery alone. CONCLUSIONS Gemcitabine-based chemotherapy seems beneficial as adjuvant treatment for patients with resected invasive IPMN.

A polymorphism in the promoter is associated with EZH2 expression but not with outcome in advanced pancreatic cancer patients

AIM EZH2 expression is a prognostic marker in radically resected pancreatic ductal adenocarcinoma (PDAC) patients. Here we investigated its role in locally advanced/metastatic patients, as well as candidate polymorphisms. MATERIALS & METHODS EZH2 expression and polymorphisms were evaluated by quantitative reverse transcription PCR in 32 laser microdissected tumors, while polymorphisms were also studied in blood samples from two additional cohorts treated with gemcitabine monotherapy (n = 93) or polychemotherapeutic regimens (n = 247). RESULTS EZH2 expression correlated with survival and with the rs6958683 polymorphism in the first cohort of patients, but this polymorphism was not associated with survival in our larger cohorts. CONCLUSION EZH2 is a prognostic factor for locally advanced/metastatic PDACs, while candidate polymorphisms cannot predict clinical outcome. Other factors involved in EZH2 regulation, such as miR-101, should be investigated in accessible samples in order to improve the clinical management of advanced PDAC.

Not only chemotherapy in the second-line treatment of metastatic gastric cancer

ABSTRACT The role of second-line treatments after first-line chemotherapy in metastatic gastric cancer is reinforcing. Two different options, chemotherapy and anti-VEGFR therapy, are available and confirmed efficacy in this setting. The combination of the two strategies as used in other cancers is promising and could become a new standard for second-line treatment of metastatic gastric cancer. The results of the RAINBOW trial, a phase III study evaluating ramucirumab in combination with paclitaxel versus paclitaxel alone, will add new information on this topic considering that the study met its primary end point of improved overall survival.

Modified FOLFOXIRI in Advanced Pancreatic Cancer

Context The combination regimen of 5-fluorouracil, folinic acid, oxaliplatin and irinotecan named FOLFIRINOX has been proposed as a new standard of care for metastatic pancreatic cancer patients. However, FOLFIRINOX was associated with high incidence of grade 3 and 4 toxicities (neutropenia in 45.7% of patients with G-CSF use in 42.5% of patients; febrile neutropenia in 5.4%; diarrhea in 12.7%). Our group had developed a very similar schedule in colorectal cancer named FOLFOXIRI which contains no bolus 5-fluorouracil and a slight lower dose of irinotecan. Objective The objective of this study was to prospectively evaluate the tolerability and activity of a modified (m)FOLFOXIRI regimen in metastatic or locally advanced pancreatic cancer patients. Methods The regimen included a lower dose of irinotecan (administered at 150 mg/m 2 on day 1 every 14 days) and of infusional 5-fluorouracil (2,800 mg/m 2 administered as a 48-hour continuous infusion on days 1 to 3 every 14 days). Folinic acid and oxaliplatin remained unchanged. Results Thirty-nine patients with cytological or histological diagnosis of pancreatic adenocarcinoma have been treated with (m)FOLFOXIRI from August 2010 onwards; 17 had metastatic disease while 22 had locally advanced disease. A total of 260 cycles have been administered so far. The grade 3-4 toxicities reported are: neutropenia in 35.9% of patients, thrombocytopenia 2.6%, diarrhea 5.1%, stomatitis 7.7%, nausea/vomiting 5.1%, fatigue 2.6%, liver toxicity 5.1%, sensory neuropathy 5.1%. No toxic deaths and no febrile neutropenia have been occurred. G-CSF has been used in seven patients (18%). A delay in the administration of chemotherapy was required in 12 patients (31%) and a reduction of doses in 7 cases (18%). Among 30 evaluable patients 11 partial responses (36.7%) and 14 stable disease (46.7%) have been observed. Median progression-free survival (PFS) was 11.5 months and median overall survival (OS) 25.5 months. For metastatic patients only, response rate resulted 33% with a PFS and OS of 8.4 and 14.8 months, respectively. Conclusion The (m)FOLFOXIRI regimen as we used resulted feasible and quite well tolerated and it maintained its good activity in metastatic pancreatic cancer.

EGFR and AKT1 overexpression are mutually exclusive and associated with a poor survival in resected gastric adenocarcinomas

PURPOSE The evaluation of molecular targets in gastric cancer has demonstrated the predictive role of HER2 amplification for trastuzumab treatment in metastatic gastric cancer. Besides HER2, other molecular targets are under evaluation in metastatic gastric tumors. However, very little is known about their role in resected tumors. We evaluated the expression of HER2, EGFR, MET, AKT1 and phospho-mTOR in resected stage II-III adenocarcinomas. METHODS Ninety-two patients with resected stomach (63%) or gastro-esophageal adenocarcinomas (27%) were evaluated. Antibodies anti-HER2, EGFR, MET, AKT1 and phospho-mTOR were used for immunostaining of formalin-fixed paraffin-embedded slides. Using FISH, HER2 amplification was evaluated in cases with an intermediate (+2) staining. RESULTS EGFR overexpression (11%) was a poor prognostic factor for overall survival (3-year OS: 47% vs 77%; Log-Rank p= 0.033). MET overexpression (36%) was associated with a trend for a worse survival (3-year OS: 65% vs 77%; Log-Rank p= 0.084). HER2 amplification/overexpression and mTOR hyper-phosphorylation were observed in 13% and 48% of tumors, respectively. AKT1 overexpression (8%) was not a prognostic factor by itself (p= 0.234). AKT1 and EGFR overexpression was mutually exclusive and patients with EGFR or AKT1 overexpression experienced a poor prognosis (3-year OS: 52% vs. 79%, Log-Rank p= 0.005). CONCLUSIONS EGFR is confirmed a poor prognostic factor in resected gastric cancers. We firstly describe a mutually exclusive overexpression of EGFR and AKT1 with potential prognostic implications, suggesting the relevance of this pathway for the growth of gastric cancers.