Tanios Bekaii-Saab

Appendiceal Mixed Adeno-Neuroendocrine Carcinoma: A Population-Based Study of the Surveillance, Epidemiology, and End Results Registry.

Introduction Mixed adeno-neuroendocrine carcinoma (MANEC) is a rare pathological diagnosis recently defined by the World Health Organization (WHO) in 2010. Prior to the definition by the WHO, tumors with both adenocarcinoma and neuroendocrine components were given multiple pathological designations making it difficult to characterize the disease. The aim of our study is to better characterize MANEC to better understand its natural history to influence patient care and positively impact outcomes. Materials and methods The surveillance, epidemiology, and end results program database was queried for all patients aged 18 years or older between 1973 and 2012 who had the diagnosis composite carcinoid (n = 249) of the appendix. Composite carcinoid tumors refer to tumors that have both adenocarcinoma and carcinoid tumor components present, consistent with that pathological diagnosis MANEC. For comparison, the database was also queried for carcinoid tumor of the appendix (n = 950), signet ring cell carcinoma of the appendix (n = 579), and goblet cell carcinoid (GCC) tumors of the appendix (n = 944). The data were retrospectively reviewed, and clinicopathological characteristics, treatment regimens, and survival data were obtained. Results The median age of diagnosis of MANEC tumors was 58 years of age. Eighty percent of patients were White, and 49% were female. Fifty-four percent of patients underwent hemicolectomy and 31% had partial/subtotal colectomy as their surgical management. Median overall survival for MANEC was 6.5 years (95% CI 4.5–9.7), which was statistically significantly shorter (p < 0.0001) in comparison to 13.8 years (95% CI 12.1–16.5) for GCC, 2.1 years (95% CI 1.8–2.3) for signet ring cell carcinoma, and 39.4 years (95% CI 37.1–NA) for carcinoid tumors. Discussion MANEC is a more aggressive clinical entity than both GCC of the appendix and carcinoid tumors of the appendix. Based on these findings, patients with MANEC tumors should undergo aggressive multidisciplinary cancer management.

Adjuvant therapy for pancreas cancer in an era of value based cancer care

In resected pancreas cancer, adjuvant therapy improves outcomes and is considered the standard of care for patients who recover sufficiently post operatively. Chemotherapy or combined chemotherapy and radiation therapy (chemoradiation; CRT) are strategies used in the adjuvant setting. However, there is a lack of evidence to suggest whether the addition of RT to chemotherapy translates to an improvement in clinical outcomes. This is true even when accounting for the subset of patients with a higher risk for recurrence, such as those with R1 and lymph node positive disease. When considering the direct and indirect costs, impact on quality of life and questionable added clinical benefit, the true “net health benefit” from added RT to chemotherapy becomes more uncertain. Future directions, including the utilization of modern RT, integration of novel therapies, and intensifying chemotherapy regimens may improve outcomes in resected pancreas cancer.

Successful Completion of Adjuvant Chemotherapy in a Patient With Colon Cancer Experiencing 5-Fluorouracil–Induced Cardiac Vasospasm

Fluoropyrimidines are the chemotherapy backbone in the treatment of adenocarcinoma of the colon. Adjuvant 5-fluorouracil (5-FU)/leucovorin (LV) has been shown to significantly increase recurrence-free survival compared to surgery alone for patients with stage III colon cancer. Furthermore, the addition of oxaliplatin to 5-FU/LV (FOLFOX) in the adjuvant setting has been shown to provide an improved disease free survival compared to adjuvant 5-FU/LV therapy alone. Cardiotoxicity associated with 5-FU or capecitabine is a rare but serious adverse effect that can present as cardiomyopathy, vasospastic angina, coronary thrombosis and dissection, ventricular arrhythmias, and sudden cardiac death. We report a case of successful completion of adjuvant FOLFOX therapy in a patient who experienced 5-FU einduced cardiotoxicity. This was completed through aggressive inpatient supportive care and cardiac monitoring. The patient showed no signs of delayed cardiotoxicity or colon cancer recurrence at 10-month follow-up.

A phase II study of modulated-capecitabine and docetaxel in chemonaive patients with advanced non-small cell lung cancer (NSCLC)

INTRODUCTION This phase II single-arm trial of docetaxel and capecitabine in previously untreated non-small cell lung cancer (NSCLC) patients was designed to evaluate response rate of this regimen based on promising efficacy data from phase II testing in pre-treated NSCLC patients. The trial also evaluated the correlation between peripheral blood dihydropyrimidine dehydrogenase (DPD) expression and efficacy/toxicity. METHODS Patients with advanced NSCLC (metastatic, including malignant pleural effusion) without prior chemotherapy were enrolled. Baseline DPD screening was performed; patients with baseline DPD level < 0.07 nmol/min/mg protein were considered ineligible for the study. Treatment included a 28-day cycle of docetaxel 36 mg/m(2) on days 1, 8, 15 and capecitabine 1250 mg/m(2)/day in divided doses on days 5-18. Overall response rate (RR) was the primary endpoint with a target RR of 50%. Correlative studies included evaluation of DPD activity levels in peripheral blood and correlation with clinical responses. RESULTS Twenty-eight patients received 86 cycles of treatment (median 3 cycles) and were evaluable for response. The RR was 18% (5 patients); RR did not meet the pre-specified efficacy endpoint and the trial was stopped. 14 patients had stable disease (SD - 50%) and 4 patients had SD >12 weeks. Median time to progression was 3.3 months (95% CI 1.5-4.6 months). Median overall survival was 10.5 months (95% CI: 3.2-15 months). Main toxicities included fatigue, stomatitis and leukopenia. DPD levels ranged from 0.06 to 0.26 nmol/min/mg. The majority of responders (4/5) had DPD levels ≤0.1 nmol/min/mg. Most of the responders (4/5) experienced grade 3 toxicities including leukopenia, dehydration, fatigue, and diarrhea. None of the patients (0/4) with higher DPD levels (> 0.2 nmol/min/mg) had a response. CONCLUSION The response rate for the regimen did not demonstrate sufficient activity and further study of this regimen in this setting is not indicated. Interestingly, the results suggest that low DPD expression may be associated with response to capecitabine but also with increased toxicity.

A mechanistic radiographic and biologic phase 2 study of sunitinib in relapsed/refractory esophageal (E) and gastroesophageal (GE) cancers.

149 Background: Patients (pts) with relapsed or treatment-refractory E and GE cancers carry a poor prognosis. Inhibition of the vascular endothelial growth factor (VEGF) pathway may be a potential treatment approach. We conducted a phase II trial to assess the efficacy of sunitinib, a tyrosine kinase inhibitor that inhibits VEGFR 1 and 2. Methods: Pts received sunitinib 37.5 mg orally, daily. Primary endpoint was progression free survival (PFS) at 24 weeks. Secondary endpoints included overall response rate (ORR), overall survival (OS), PFS, and toxicity. Pts underwent serial functional imaging with DCE-MRI and measurements of serum VEGF, PIGF, VEGFR 2 and 3. Gene expression profiling and somatic mutational analysis using next-generation sequencing were also performed on tumor specimens (results to be presented at the symposium). Results: Clinical results are in the table. The PFS in the group that had clinical benefit [partial response (PR) + stable disease (SD)] with sunitinib was 99 days (95% CI: 74-16...

Abstract A76: Enhancement of cetuximab-induced antibody-dependent cellular cytotoxicity with lenalidomide in advanced solid tumors: A Phase I trial.

Introduction: Antibody-dependent cellular cytotoxicity (ADCC) is one mechanism of action of monoclonal antibody (mAb) therapy. ADCC occurs via the innate immune system9s ability to recognize mAb coated cancer cells and activate effector cells. Lenalidomide is an immunomodulatory agent with capacity to stimulate T cell proliferation, activate natural killer cells, and effect immune cytokines including IL-2, IL-12, and interferon gamma. Both preclinical and clinical data demonstrate the ability of lenalidomide to increase ADCC activity of mAb therapy. This Phase I CTEP sponsored trial aims to evaluate the combination of cetuximab with lenalidomide to enhance ADCC activity in advanced colorectal (CRC) and head and neck squamous cell cancers (HNSCC). Patients/Methods: This Phase I dose escalation trial included patients with locally advanced or metastatic CRC (KRAS wild type) or HNSCC. Treatment consisted of cetuximab 500 mg/m2 IV every 2 weeks with lenalidomide orally days 1-21 every 28 days. Cetuximab dose was the same in all cohorts although dose reductions were permitted for toxicity. Three dose levels of lenalidomide were evaluated (15 mg, 20 mg, and 25 mg). Prior treatment with cetuximab, panitumumab, or other EGFR directed therapy was allowed. Planned correlative studies include measurement of ADCC using an in vitro chromium release assay, serum interferon gamma and NK cytokine profiles, and Fc gamma receptor polymorphisms. Results: A total of 22 patients have been treated (19 CRC, 3 HNSCC). Grade 3 fatigue has been the only observed dose-limiting toxicity. One partial response was observed and 7 patients had stable disease as best response. Two patients remain on treatment. The recommended Phase II dose is cetuximab 500 mg/m2 with lenalidomide 25 mg daily days 1-21. Conclusions: Cetuximab and lenalidomide was well-tolerated with minimal activity. Although response was not a primary endpoint, there is evidence of anti-tumor activity and clinical efficacy. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):A76. Citation Format: Erin M. Bertino, Jeffrey S. Rose, Christina Wu, Tanios Bekaii-Saab, Panayiotis S. Savvides, Richard M. Goldberg, Miguel Villalona, Gerard Lozanski, William Carson, Michael Grever, Gregory Otterson. Enhancement of cetuximab-induced antibody-dependent cellular cytotoxicity with lenalidomide in advanced solid tumors: A Phase I trial. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr A76.