bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscopic ultrasound-guided fine needle core biopsy versus aspiration for gastrointestinal mass lesions: A randomized trial.
Authors: Nguyen Nam Q.
Published: February 2017

161

Background: Endoscopic ultrasound (EUS) guided biopsy allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract (GIT). However, the amount of tissue obtained with a regular aspirating needle is not always satisfactory. A newly developed Coo Pro-Core 22G needle has been proposed to obtain core tissue and may improve diagnostic yield. This study aimed to compare the performance of two EUS guided biopsy systems, Coo 22G fine needle aspiration (FNA) versus Coo 22G Pro-Core (PC) needle, in the evaluation of mass lesions within or adjacent to the GIT.

Methods: 61 consecutive patients, who were referred for EUS guided biopsy of mass lesions within or adjacent to the upper GIT, were randomized to either the use of 22G FNA or 22G PC needle. The procedures were performed by a single experienced EUS-endoscopist. Four needle passes were taken from each lesion and all specimens were prepared as cell-block for histo-cytological analysis. Measured outcomes were diagnostic yield and complication.

Results: EUS guided biopsy was performed with 22G FNA needle in 31patients and with 22G PC needle in 30 patients. There were no differences in age, gender, site or size of biopsied lesion between the groups. Diagnostic yield from the PC group was significantly higher than that of the FNA groups (27/30 vs. 22/31, P=0.04). The ability to obtain core-like tissue and provide “histological” detail were also higher in the PC group (16/30 vs. 0/31, P<0.001). Although no patients with FNA biopsy had complications, the first 4 cases of PC needle biopsy had abdominal pain (with 1 proven pancreatitis), requiring overnight admission. No further complications occurred after the number of PC passes was reduced to 2 per lesion.

Conclusions: EUS guided biopsy with Pro-Core needles had a substantially higher diagnostic yield than that with FNA needles, with the ability to provide "histological" information in the majority of cases. Initial use of the Pro-Core needle, however, is associated with an increased risk of abdominal pain, which is reduced with fewer passes and more experience.
Use of endoscopic ultrasound to reduce the need for SpyGlass cholangioscopy and improve its diagnostic yield.
Authors: Nguyen Nam Q.
Published: February 2017

169

Background: The accuracy of SpyGlass cholangioscopy (SGC) guided biopsy is only modest (60%) due to extrinsic lesion causing ductal stricture. Endoscopic ultrasound (EUS) can visualise the biliary tree and acquire tissue via fine needle aspiration (FNA). The aim is to evaluate the utility of EUS-FNA in patients who were referred for SGC for biliary strictures.

Methods: The clinical impact of EUS-FNA was prospectively examined in 17 patients (10M; 56.2±1.9 yrs) who were referred for SGC to investigate difficult biliary strictures over 15 months. All patients had endoscopic retrograde cholangiography and biliary stenting with negative ductal brushing. Any mass lesion(s) or pathological node(s) found on EUS were biopsied. SGC and ductal biopsy were only performed if EUS-FNA could not provide a diagnosis. The results were compared to the surgical specimens or the positive histo-cytological findings from biopsies.

Results: EUS examination was able to identify all ductal or peri-ductal abnormalities responsible for the biliary strictures, with sonographic diagnoses of cholangiocarcinoma (n=10), autoimmune pancreatitis (n=2), choledochocyst related stricture (1); pancreatic cancer (n=1), gallbladder cancer (n=1), Mirrizi’s syndrome (n=1) and colorectal metastasis (n=1). EUS-FNA was possible in 13 (76%) cases and provided tissue diagnosis in 9 (59%) patients, which can potentially avoid the need for SGC and cost saving of ~$ 48,000. SGC examination was successful in 7/8 patients, with 100% correct tissue diagnosis from Spybite biopsy (4 cholangio-carcinomas, 1 autoimmune pancreatitis, 1 biliary villous adenoma, 1 hepatoma, 1 high grade dysplastic choledochocyst). SpyScope intubation was not possible in a patient with long-standing primiary sclerosing cholangitis who had tight stricturing of the entire extra-hepatic duct. Overall, tissue diagnosis was established in 94% (16/17) patients.

Conclusions: EUS able to detect 100% ductal or peri-ductal abnormalities responsible for biliary strictures referred for SGC. Together with FNA, EUS provides correct diagnosis and avoids the need for SGC in 59% of cases, resulting in significant cost saving but also improving the yield of SpyGlass guided biopsy.
Somatostatin receptor subtypes 1-5 gene expression in multiple sites in the same individual.
Authors: Hall Michael Anthony , Milosavljevic Tanja , Casey Peter , Anthony Catherine T. , Woltering Eugene
Published: February 2017

182

Background: Metastatic tumors may be fundamentally different than the primary tumor. This phenomenon may partially explain resistance of metastatic disease to therapy. We evaluated the gene expression levels of somatostatin receptor subtypes 1-5 (SSTR 1-5) in patients with disseminated neuroendocrine tumors (NETS) undergoing cytoreduction of their primary tumor and its nodal and liver metastasis.

Methods: We compared the gene expression levels for SSTR 1-5 in primary tumor and their nodal and liver metastasis. The small bowel primary (SB), a mesenteric lymph node (LN) and a liver metastasis and their normal tissue counterparts were evaluated in four patients. RNA samples from each tissue underwent gene expression analysis using a customized Real Time Quantitative PCR (RT-qPCR) gene array. Normal tissue gene expression was compared to that obtained from the tumor sample at each site.

Results: SSTR 2 was overexpressed (four-fold or greater, p≤ 0.01) compared to control levels in 8/12 (67%) specimens; 4/4 (100%) of the liver specimens, 3/4 (75%) of the SB specimens, and 1/4 (25%) of the LN specimens. SSTR 2 gene overexpression was not observed in all three tumor sites in any patient. No tumor had SSTR 2 downregulation. SSTR 5 was overexpressed (four-fold or greater, p≤ 0.01) compared to control levels in 6/12 (50%) specimens; 3/4 (75%) of the liver specimens, 2/4 (50%) of the SB specimens, and 1/4 (25%) of the LN specimens. SSTR 5 gene expression was up-regulated in all three tumor sites in one individual. SSTR 5 was down-regulated (7-fold, p<0.01) in one LN specimen. Changes in gene expression levels of SSTR 3 and SSTR 4 showed inconsistency between tumor sites, whereas that of SSTR1 was observed only at the metastatic sites.

Conclusions: These results explain the observed variability in somatostatin receptor expression seen in 111In pentetreotide scans in multiple tumor sites from the same individual. The observation that gene expression varies from metastasis to metastasis may also help explain the difficulty in designing therapies that cure patients rather than inducing partial remissions.
Use of the monoclonal antibody PAM4 to differentiate pancreatic ductal adenocarcinoma (PDAC) from chronic pancreatitis and benign nonmucinous cysts of the pancreas.
Authors: Shi Chanjuan , Goldenberg David M. , Gold David V.
Published: February 2017

188

Background: Previous studies have demonstrated that anti-mucin monoclonal antibody (mAb) PAM4 is highly specific for PDAC and its precursor lesions. To investigate specificity further, we examined the expression of PAM4-reactive mucin in chronic pancreatitis and benign non-mucinous cystic lesions of the pancreas.

Methods: A tissue microarray of PDAC (N=14), as well as surgical specimens from chronic pancreatitis (N=32) and benign non-mucinous cystic lesions of the pancreas (N=19), were assessed by immunohistochemistry for expression of the PAM4-reactive mucin, as well as MUC1 (mAb-MA5), MUC4 (mAb-8G7), and CEACAM6 (mAb-MN-15).

Results: PAM4-reactive mucin, MUC1, MUC4 and CEACAM6 were expressed in 79% (11/14), 100% (14/14), 86% (12/14) and 100% (14/14) of invasive pancreatic adenocarcinoma. PAM4 only weakly labeled 6% (1/19) of benign non-mucinous cystic lesions, 1 of 15 serous cystadenomas (SCAs) and 0 of 4 cysts with squamous epithelial lining (2 lymphoepithelial cysts, and 2 retention cysts with squamous metaplasia). However, the expression of MUC1, MUC4 and CEACAM6 was detected in 53% (8/15), 0% (0/15) and 13% (2/15) of SCAs, and in 4, 3 and 3 of the 4 cysts with squamous epithelial lining, respectively. PAM4 labeled 19% (6/32) of chronic pancreatitis specimens; however, this PAM4 reactivity was restricted to the PanIN precursor lesions associated with chronic pancreatitis. Inflamed tissue was negative. The expression of MUC1, MUC4 and CEACAM6 was detected in 90% (27/30), 78% (25/32), and 97% (31/32) of chronic pancreatitis. In all of the positively-labeled specimens, the reactivity was present in non-neoplastic inflamed pancreatic tissue in addition to PanIN.

Conclusions: The expression of PAM4 was detected in only 6% of benign non-mucinous cystic lesions and in the precursor lesions associated with chronic pancreatitis. These results suggest that PAM4, in contrast to MUC1, MUC4, and CEACAM6, may be useful to differentiate benign non-mucinous cystic lesions of the pancreas and chronic pancreatitis from PDAC. (Supported in part by NIH grant CA096924.)
Treating chronic hepatitis in Asian and Pacific Island populations: A comparison of program costs according to current treatment guidelines.
Authors: Robotin Monica Cristina , Patton Yumi , Kansil Melanie Q , George Jacob , Penman Andrew G
Published: February 2017

193

Background: Hepatitis B (HBV) infection is endemic in many Asian and Pacific Island countries, with 25-40% of chronic hepatitis B (CHB) patients developing cirrhosis or hepatocellular cancer (HCC). Increased migration from high HBV prevalence countries leads to Vietnamese-born Americans and Australians 11-13 times more likely to develop HCC than other groups. As antiviral therapy is more cost-effective than HCC screening, we developed a program of hepatitis B screening, monitoring and treatment targeting high–risk populations in Sydney aged >35 years (the median age for HBeAg sero-conversion in Asian populations). Here we compare estimated program costs using guidelines for HBV treatment in hepatitis B e antigen negative populations.

Methods: Using a Markov model, we modelled CHB disease progression and management costs using guidelines published by the American, European and Asian Pacific Associations for the Study of Liver Disease (AASLD, EASL and APASL) and algorithms created by US hepatology experts and our B Positive program, using different levels of alanine aminotransferase (ALT) for treatment initiation. We factored in costs for CHB screening and surveillance for liver damage provided by specialists and/or primary care providers, including CHB and HCC treatment, individualised by viral load and ALT levels. Costs were discounted by 5% and calculated in Australian dollars (AUD); incremental costs used AASLD guidelines as a baseline.

Results: Assuming a 25% enrolment in our target population of patients with CHB in South West Sydney followed up for 50 years, total program costs would amount to 9,205,680 AUD. Using AASLD guidelines, estimated cost would amount to 6,344 AUD per patient. APASL guidelines lead to a 132% cost rise, the B Positive program costs 152% more, while the US algorithm and EASL are associated with a 221% cost increment to achieve the equivalent cost/QALY.

Conclusions: While the AASLD guidelines appear to be the least costly, uncertainties about “ideal” ALT and viral load levels for treatment initiation and the extent of the benefit conferred in terms of HCC cases averted will need to be resolved to inform large-scale prevention programs.
Use of EGF A61G polymorphism to predict overall survival in a phase III study of gemcitabine plus cetuximab versus gemcitabine in patients with locally advanced or metastatic pancreatic adenocarcinoma (SWOG 0205).
Authors: Labonte Melissa Janae , Goldman Bryan H. , Zhang Wu , Blanke C. D. , Philip Philip Agop , Wong Ralph , O'Reilly Eileen Mary , Benedetti Jacqueline K. , Lenz Heinz-Josef
Published: February 2017

203

Background: The SWOG 0205 phase III study failed to demonstrate an advantage from the addition of cetuximab to gemcitabine for overall survival (OS), progression-free survival (PFS) or objective response in advanced pancreatic cancer. Molecular markers may identify subgroups of pts who benefit from this regimen. This report summarizes the results of a pilot project aimed at screening germline single nucleotide polymorphisms (SNPs) in genes involved in gemcitabine metabolism pathway (CDA and RRM1) and EGFR signaling pathway (EGF, EGFR, IGF1, FCGR2A/3A, KRAS, IL8, COX-2, CCND1) to identify pts that may benefit from this treatment.

Methods: Genomic DNA was extracted from 88 available serum samples for this molecular correlates pilot study. Sixteen SNPs were evaluated using PCR-based protocols. There were no differences in baseline characteristics or outcome between pts included in the analysis and the entire study population. Associations between genotype and OS were assessed using stratified Cox regression, with adjustment for treatment arm. Genotypes were parameterized as the number of dominant alleles. No p value adjustments were made for multiple comparisons.

Results: Median age was 63.3 years (range: 29.6-85.0), and median OS (95% CI) was 5.7 months (mos) (range: 4.4-6.8) in this subset. There was a statistically significant association between EGF A61G SNP (rs4444903) genotype and OS (p=0.04). Among pts carrying the AA genotype, median OS was 8.4 mos (95% CI 4.9-15.0), as compared to 5.6 mos (95% CI 3.0-9.0) among those with the AG genotype and 5.3 mos. (95% CI 2.2-7.1) for the GG genotype. Evidence was weak for interaction between treatment arm and rs4444903 genotype (p=0.13). No significant associations between other SNPs and OS were observed.

Conclusions: This exploratory study suggests that the EGF A61G polymorphism may be a useful molecular marker for predicting clinical outcomes in metastatic pancreatic adenocarcinoma pts treated with gemcitabine-based chemotherapy.
Inhibition of poly (ADP-ribose) polymerase-1 (PARP-1) to increase radiosensitivity of human pancreatic cancer (PAC) cell lines proficient in homology-directed repair (HDR).
Authors: Lowery Maeve A. , Vanoli Fabio , Yu Kenneth H. , Jasin Maria , O'Reilly Eileen Mary , Moynahan Mary Ellen
Published: February 2017

204

Background: Radiation-induced single strand DNA breaks (SSBs) are primarily repaired by base excision repair, of which PARP1 is a key component. Unrepaired SSBs may cause collapse of stalled replication forks during DNA replication generating DNA double-strand breaks (DSBs). PARP inhibition has been shown to potentiate the effect of radiotherapy (RT) in a variety of human cancers in vitro and in vivo. We investigated the ability of the PARP inhibitor olaparib to radiosensitize BRCA1/2 wild-type human PAC cell lines and quantified repair capability of an induced DSB by HDR using the I-SceI-induced DSB DR-GFP assay.

Methods: MiaPaCa -2 and ASPC-1 human PAC cells lines were exposed to RT administered in a single fraction by 157-gammacell irradiator at doses of 2, 4, 6 and 8 Gy in the presence or absence of olaparib at a dose of 500nM (4 hours pre and 20 hours post RT). Plates were incubated at 37C for 10-14 days and stained with Giemsa. Clonogenic survival assays following olaparib continuous exposure at concentrations up to 10 µM for 10-14 days were also performed. HDR of an induced DNA DSB was assessed in ASPC1 and MiaPaCa cell lines by co-transfection with an I-SceI expression vector and the DR-GFP reporter plasmid(Pierce et al., 1999), and in BRCA2 deficient CAPAN-1 cells harboring a stably integrated chromosomal DR-GFP gene (Moynahan et al. 2001).

Results: Linear quadratic models were fitted to the data sets to generate survival curves. The half maximal inhibitory concentration (IC 50) of RT was 2Gy for both cell lines. The sensitivity enhancement ratio (SER) at 25% survival was 1.44 and 1.53 for MiaPaCa-2 and ASPC-1 cell lines respectively. Both cell lines were resistant to treatment with single agent olaparib to dose of 10µM and were proficient in HDR of DNA DSBs when compared to the BRCA2-deficient Capan-1 cell line.

Conclusions: Inhibition of PARP increases radiosensitivity in human PAC cell lines proficient in HDR of DNA DSBs and resistant to treatment with single agent PARP inhibitor. Therapeutic strategies incorporating PARP inhibition and RT offer potential to improve clinical outcomes for patients presenting with localized sporadic and BRCA mutated PAC.
An analysis of ERCC1, hENT1, RRM1, and RRM2 expression in resected pancreas adenocarcinoma: Implications for adjuvant treatment.
Authors: Fisher Sarah B. , Patel Sameer H. , Bagci Pelin , Kooby David A. , El-Rayes Bassel F. , Staley Charles A. , Adsay Volkan , Maithel Shishir Kumar
Published: February 2017

206

Background: Tumor overexpression of excision repair cross complementing gene 1 (ERCC1) was recently shown to be associated with decreased survival in patients with pancreas adenocarcinoma (PAC). Ribonucleotide reductase 1 and 2 (RRM) and human equilibrative nucleotide transporter 1 (hENT1) are integral to DNA synthesis and cellular transport and are implicated as poor prognostic factors in other malignancies. Their role in PAC is not well defined.

Methods: A prospective database (n=220) was used to randomly select 95 pts who underwent pancreaticoduodenectomy for PAC between 1/00-10/08. IHC analysis was performed on tumor samples for RRM1 and 2, hENT1, and ERCC1. Main outcomes were recurrence-free (RFS) and overall survival (OS).

Results: Median age was 63 yrs; median FU, RFS, and OS was 49, 10.6 and 15.5 mo. Median tumor size was 3cm, 26% had a positive margin, 34% were poorly differentiated, 61% had positive lymph nodes (LN), 88% had perineural invasion (PNI), and 45% had lymphovascular invasion (LVI). High expression of RRM1, RRM2, hENT1, and ERCC1 was present in 40%, 17%, 85%, and 16% of patients, respectively. High RRM2 was associated with reduced RFS (6.9 vs 16.0 mo; p<0.0001) and decreased OS (9.1 vs 18.4 mo; p<0.0001). High ERCC1 was associated with reduced RFS (6.1 vs 15 mo; p=0.04) and decreased OS (8.9 vs 18.1 mo; p=0.03). RRM1 and hENT1 were not associated with survival. After accounting for known adverse factors, high RRM2 and ERCC1 persisted as negative prognostic factors for RFS and OS (Table). A subset analysis of those who received adjuvant therapy (n=74) revealed the same negative effect of high RRM2 and ERCC1 on RFS and OS.

Conclusions: High RRM2 and ERCC1 tumor expression are associated with reduced RFS and OS after resection of pancreas cancer. These biomarkers may help personalize adjuvant therapy.

[Table: see text]
Significance of CEACAM6 expression in biliary tract carcinoma.
Authors: Rocha Flavio G. , Torres Javierra , Chou Joanne F. , Katabi Nora , Gönen Mithat , DeMatteo Ronald P. , Fong Yuman , Allen Peter J , D'Angelica Michael Ian , Klimstra David S. , Jarnagin William R.
Published: February 2017

207

Background: The entire biliary tree is at risk for malignant change, but little is known about differences in molecular pathogenesis with respect to anatomic site. CEACAM6 is a membrane protein involved in cell adhesion and signaling that is overexpressed in pancreatic adenocarcinoma and associated with poor prognosis. This study examines CEACAM6 expression in the entire spectrum of biliary carcinomas and its relationship to outcome.

Methods: Tissue microarrays containing triplicate cores of paraffin-embedded surgical specimens from patients with bile duct carcinoma (hilar, intrahepatic, distal) and control tissue were stained for CEACAM6 by immunohistochemistry. Clinical, pathologic and survival data were analyzed and correlated with CEACAM6 expression. Survival was estimated using the Kaplan-Meier method and compared with log rank test.

Results: One hundred twenty cases of bile duct carcinomas from 1992-2007 were assembled in the tissue microarrays. Strong CEACAM6 signal was present in 30/60 (50%) of hilar tumors, 7/45 (16%) of intrahepatic tumors, 7/15 (47%) of distal tumors, and none of the control tissues. Overall median survival and follow-up were 36.4 months and 98.3 months, respectively. CEACAM6 staining did not correlate with sex, grade, positive lymph nodes, vascular invasion or metastases but was associated with age > 65 (p<0.05) and higher T stage (p<0.05). After R0 resection, CEACAM6 expression was associated with disease-specific survival (DSS) only in the subset of patients with intrahepatic cholangiocarcinoma (median DSS 78 months for negative and 16 months for positive, p<0.002). Vascular invasion was the sole independent predictor of survival on multivariate proportional hazards regression (HR=1.742 [1.048-2.895 95%CI], p<0.03) in the entire cohort.

Conclusions: CEACAM6 may serve as a marker of poor outcome in patients with intrahepatic cholangiocarcinoma and should be further evaluated as a means of selecting patients for adjuvant therapy after resection.
Is the number of TACE treatments in HCC patients associated with improved survival? A SEER-Medicare population analysis.
Authors: Shaya Fadia T. , Breunig Ian Michael , Hanna Nader , Pandya Naimish B. , Chirikov Viktor , Seal Brian S. , Mullins C. Daniel
Published: February 2017

210

Background: We examine treatment patterns and associated survival outcomes of TACE at all stages of Hepatocellular Carcinoma in SEER Medicare.

Methods: Medicare enrollees, 65 and older, with a diagnosis of a primary HCC between 2000-07 who received treatment were followed through end of 2009 using the Surveillance, Epidemiology and End-Results Program (SEER) and linked Medicare databases, with claims from Medicare parts A and B. Using Cox proportional hazards models, we assessed the impact on mortality, of each additional TACE, systemic chemotherapy, SIRT, external beam radiation therapy, ablation and surgical resection, controlling for cancer stage, general health status, underlying liver disease (alcohol related, Hepatitis B and C, moderate/severe liver dysfunction), and demographics. We assessed overall and HCC-related mortality for all, then for TACE-only treated patients, and stratified outcomes by stage.

Results: Out of 3322 treated non-transplant HCC patients, 1094 got TACE, 74% were Caucasian, 6% African American, 66% male, and 45% were at stage 1/2, 17% at stage 3 and 14% at stage 4. Most (56%) received 1, 23% 2, 11% 3 and 10% 4 or more TACEs. In the adjusted models, both overall and HCC mortality reduction were associated with treatment with up to 2 TACEs (HR=0.68, P=<0.001 and HR=0.73, P=<0.001, respectively). A third TACE, but not a fourth, provided a further decrease in overall mortality (0.46, <0.001) and HCC mortality (.45, <0.001). When stratified by stage, the second TACE had a significant marginal effect within Stage 3, and only the first TACE had benefit within Stage 4. No effects were found for TACE in early HCC. In the adjusted models, liver conditions were not associated with HCC mortality among TACE treated patients only.

Conclusions: TACE provides a survival benefit for elderly HCC patients in clinical practice. However, the survival benefit may decrease beyond 3 TACE treatments and varies by stage. Additional TACE treatments may be confounded if 4+ TACE treatments are utilized mainly to treat biologically aggressive disease related to extensive tumor burden, advanced disease or recurrences. Treatment selection bias cannot be excluded and should be further explored.
Phase Ib study of ipilimumab alone or in combination with allogeneic pancreatic tumor cells transfected with a GM-CSF gene (vaccine) in pancreatic cancer.
Authors: Le Dung Thi , Lutz Eric , Huang Lanqing , Onners Beth , Uram Jennifer , Solt Sara , Sugar Elizabeth , Zheng Lei , Jaffee Elizabeth M. , Laheru Dan
Published: February 2017

211

Background: Ipilimumab (IPI) at 3mg/kg has been tested in pancreatic ductal adenocarcinoma (PDA) with a low but detectable response rate. This supports a role for immunotherapy in PDA. Melanoma (MEL) studies demonstrate a dose-response relationship with IPI. Preclinical studies show synergy between anti-CTLA-4 antibodies and GM-CSF cell-based vaccines. This study evaluated IPI 10mg/kg alone (Arm 1) versus IPI 10mg/kg + vaccine (Arm 2) in PDA.

Methods: 30 subjects with previously treated, locally advanced or metastatic PDA were randomized (1:1) to Arm 1 or 2. Induction treatments were administered every 3 weeks (wk) X 4 doses. Subjects with stable disease (SD) or better between wk 14 and 22 were eligible for maintenance doses every 12 wks. Activity was assessed by response and overall survival (OS). IFN-g Elispots and ELISAs were used to detect induction of mesothelin-specific T cells and galectin-3 antibodies (Abs), respectively.

Results: Baseline characteristics were similar (87% metastatic, 100% gemcitabine-treated) with the exception that Arm 1 had a lower % of subjects with > 1 prior therapies (60 vs 100%). Arm 1 had 2 SD (7 and 22 wks). Arm 2 had 3 SD (1 delayed regression starting at wk 14 and maintained until wk 31, 1 delayed stabilization starting at wk 22 and ongoing at wk 57, 1 SD ongoing at wk 64). Transient CA19-9 declines were seen only in Arm 2 (7/15). Median OS was 3.3 vs 5.5 months in Arm 1 vs Arm 2 (p=0.12) with a 12 month OS of 7 vs 27%. 73% (Arm 1) and 80% (Arm 2) of subjects experienced immune related adverse events (IRAE). 20% of subjects on both arms had Grade 3-4 IRAEs including rash (1), colitis (2), Guillain-Barre (1), nephritis (1), and pneumonitis (1). Rash was less frequent in Arm 1 (53 vs 73%). IRAEs (p=0.037), mesothelin T cell responses (p=0.012), and enhancement of the T cell repertoire (p=0.026) were associated with OS in both arms. Galectin-3 Ab responses were associated with OS in Arm 2 (p=0.002).

Conclusions: Immunotherapy has potential even in advanced PDA. IRAEs in PDA are similar to IRAEs in MEL. Delayed responses suggest that standard RECIST criteria will underestimate activity and targeting a population with a longer life expectancy may improve efficacy.
Use of high-resolution fluorescence laparoscopy with fluorophore-conjugated tumor-specific antibodies for the detection of pancreatic cancer metastasis invisible with standard laparoscopy.
Authors: Metildi Cristiina A. , Kaushal Sharmeela , Tran Cao Hop S. , Snyder Cynthia S. , Talamini Mark A. , Luiken George A. , Hoffman Robert M. , Bouvet Michael
Published: February 2017

212

Background: Standard laparoscopy for pancreatic cancer often leads to false negative results, causing understaging of the disease. Improved sensitivity and resolution are necessary.

Methods: Orthotopic and carcinomatosis mouse models of human pancreatic cancer were established with red fluorescent protein (RFP)-expressing or non-fluorescent BxPC-3 human pancreatic cancer cells. The mice with orthotopic unlabeled pancreatic cancer were administered Alexa 488- or 555-conjugated anti-CEA by tail-vein injection 2-4 weeks after tumor implantation. Diagnostic laparoscopy was performed with a Stryker L9000 LED light source or X8000 xenon light source 24 hours later. Pancreatic tumors were detected and localized under each light mode. After laparoscopy, intravital images were obtained with the OV-100 and Maestro CRI Small Animal Imaging Systems as positive controls. Tumors were collected for histologic analysis.

Results: Fluorescence laparoscopy (FL) with the use of 495-nm excitation filter and an LED light source enabled more rapid and accurate identification and localization of primary tumors and metastases than bright light laparoscopy (BL). The use of fluorescent conjugates antibody-labeled tumors improved the accuracy of staging laparoscopy, increasing the sensitivity from 40% in BL to 96% in FL (p<0.001). FL was sufficiently sensitive to detect sub-millimeter tumor deposits that went undetected under BL. With adjustments to the LED light source, we could simultaneously detect tumor lesions of different fluorescent colors and surrounding structures with minimal autofluorescence.

Conclusions: The use of FL and fluorophore-labeled anti-CEA antibodies permits rapid detection and accurate localization of primary and metastatic CEA-expressing human pancreatic cancer, including tumors that were undetectable with BL. The introduction of an LED light source allows simultaneous identification of fluorescent tumor of different wavelengths without compromising background illumination. Further development of this technology for clinical use can improve the staging and treatment of pancreatic cancer.
Systemic inflammatory response to predict clinical outcome in patients with resected pancreatic cancer treated with adjuvant gemcitabine monotherapy.
Authors: Morinaga Soichiro , Watanabe Takuo , Numata Masakatsu , Mikayama Yo , Tamagawa Hiroshi , Yamamoto Naoto , Shiozawa Manabu , Akaike Makoto
Published: February 2017

223

Background: Systemic inflammatory response (SIR) has been shown to associate with poor outcome in either inoperable or operable pancreatic cancer. However, whether the presence of a SIR predicts poor clinical outcome of pancreatic cancer patients in adjuvant setting is unclear. The aim of present study was to determine the relationship between SIR, as evaluated by Modified Glasgow prognostic score (mGPS), and outcome of pancreatic cancer patients treated with adjuvant chemotherapy.

Methods: A total of 42 resected pancreatic cancer patients were analyzed for mGPS before adjuvant gemcitabine chemotherapy. The mGPS was constructed as follows: patients with both an elevated C-reactive protein (> 0.3mg/dl) and hypoalbuminaemia (< 3.5mg/dl) were allocated a score of 2. Patients with one or none of these abnormalities were allocated a score of 1or 0, respectively.

Results: There were 25 patients assigned to score 0, 12 patients to score 1, and 5 patients to score 2. The median OS in patients with score 0, score 1, and score 2 were 23.9 months, 10.3 months, and 9.9 months, respectively. The DFS in patients with score 0, score 1, and score 2 were 11.0 months, 5.9 months, and 3.6 months, respectively. The OS and DFS after surgery of the patients with SIR (score 1 and 2) were significantly poorer than that of the patients with score 0 (P=0.0278 for OS, P=0.0011 for DFS by log-rank test).

Conclusions: The presence of SIR, as evaluated by Modified Glasgow prognostic score (mGPS), predicts poor clinical outcome in resected pancreatic cancer patients treated with adjuvant gemcitabine monotherapy.
Possible role of autophagy inhibition in hypoxia-induced chemoresistance of pancreatic cancer cells.
Authors: Ko Yoon Ho , Cho Young-Seok , Won Hye Sung , Jeon Eun Kyoung , Hong Young Seon
Published: February 2017

224

Background: Autophagy is a catabolic process and provides metabolic support for the cell by degradation of intracellular macromolecules. Various types of stress, including hypoxia, activate autophagy. Recent studies have suggested that hypoxia has been shown to associate with resistance to chemotherapy and radiation therapy and hence poor prognosis in pancreatic cancer. This study investigated the role of autophagy in the treatment of pancreatic cancer with gemcitabine under hypoxic condition.

Methods: To evaluate the role of autophagy inhibition in hypoxia-induced chemoresistance, BxPC-3 human pancreatic cancer cell line was used under normoxic and hypoxic conditions.We evaluated the extent of LC3-II, as an autophagosome marker, induced by gemcitabine, by western blotting to measure the hypoxia- or chemotherapy- induced autophagy. We then examined the effects of gemcitabine on induction of apoptosis under normoxic and hypoxic conditions. Next, to determine the effect of 3-MA, a known inhibitor of autophagy, on overcoming hypoxia-induced chemoresistance, the MTS assay and flow cytometry were performed.

Results: Compared with normoxia, gemcitabine-induced cell death under hypoxia was significantly decreased, as a result of the reduced apoptosis. Western blotting analysis demonstrated that LC3-II was increased under hypoxia, compared with normoxia.However, we found that 3-MA can enhance the growth inhibition and apoptotic effect of gemcitabine, even under hypoxia. These findings mean that autophagy mediates the chemoresistance under hypoxia.

Conclusions: Activated autophagy plays a role in hypoxia-induced chemoresistance of pancreatic cancer cells. These findings may have important implications for future therapeutic strategies using gemcitabine against pancreatic cancer.
A GEP-NEN analysis of incidence, ethic variation, and mortality using the SEER database.
Authors: Lawrence Ben , Kidd Mark , Gustafsson Bjorn , Chan Anthony , Schimmack Simon , Modlin Irvin M
Published: February 2017

225

Background: A decade of epidemiological analysis of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) has defined this malignancy as more common than previously recognized, but the cause of an apparent increase in incidence is controversial. The maturity of the contemporary SEER17 database allows this issue to be addressed.

Methods: We analyzed the most recent SEER17 database (including 32,862 cases of GEP-NEN) to calculate incidence, primary site distribution and survival (cause-specific and all-cause) by age and ethnicity in 2000 to 2008, then examined 20-year limited-duration prevalence and the pattern of second cancer risk.

Results: The incidence of GEP-NENs continues to rise (APC; 4.2% per year) and is now 3.6/100,000 but this reflects an improved diagnostic acuity rather than a true increase in disease occurrence. Of paramount import, the prevalence of GEP-NENs (23/100,000) accounts for only approximately 2% of the prevalence observed in autopsy studies (1,110/100,000), providing the necessary perspective to recognize the change in incidence as “trivial” relative to the undiagnosed disease burden. The current analysis also reminds us that GEP-NENs are not uniformly fatal. Cause-specific GEP-NEN survival is considerably more favorable than the commonly described ‘all-cause’ survival, so that many patients with rectal (62%), gastric (49%), small intestinal (44%), appendiceal (24%), and colonic (19%) NENs died from other causes. The high proportion of rectal primaries in Japan (56%) persists after population migration to the US (65%), suggesting a “relatively” stable inherited predisposition. The risk of second cancers after GEP-NENs is increased by 55% and occurs in organs with epithelium that contain neuroendocrine cells (both GI and distant), not limited to the luminal sites potentially exposed to a dietary carcinogen.

Conclusions: The increase in GEP-NEN incidence is illusory, disease specific survival is higher than previously recognized while the stable ethnic differences and systemic second cancer risk support a non-environmental genetic etiology for tumorigenesis.
Activity of fractionated radioimmunotherapy (RAIT) with 90Y clivatuzumab tetraxetan (90Y-hPAM4) plus gemcitabine (Gem) in advanced pancreatic cancer (APC): Final results from a two-part study.
Authors: Ocean Allyson J. , Guarino Michael J. , Pennington Kenneth Lee , Springett Gregory M. , Gulec Seza A , Bekaii-Saab Tanios S. , Montero Alberto J. , Mitchell Edith P. , Kauh John S , Sung Max W. , Gold David V. , Horne Heather , Wegener William A. , Goldenberg David M.
Published: February 2017

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Background: A Phase I/II trial was undertaken to evaluate repeated cycles of 90Y-labeled anti-mucin humanized mAb (90Y-hPAM4) plus Gem as first-line therapy in Stage 3-4 APC.

Methods: Pts received Gem once-weekly x 4 with 90Y-hPAM4 on wks 2, 3 and 4, with cycles repeated until progression or unacceptable toxicity. In Part I, pts were treated in cohorts with escalating 90Y doses and Gem fixed at a low 200 mg/m2 dose for radiosensitization. In Part II, the Gem doses were increased up to standard levels, with 90Y doses fixed for first cycle, but decreased for subsequent cycles. Tumor responses were assessed by CT, FDG/PET and serum CA19-9; safety by NCI-CTCv3.

Results: Of 100 untreated pts enrolled, 10 withdrew early, while 90 (73 stage IV) received 1-4 cycles. In Part I, 38 pts received 90Y-hPAM4 weekly x 3 at 90Y doses of 6.5 (N=4), 9 (N=12), 12 (N=17) or 15 (N=5) mCi/m2, with the same cycle repeated 1-3 times in 13 pts. Grade 3-4 platelets or ANC developed in 20/38 (53%) after cycle 1 (all reversible to Grade 1) and in all retreated pts (irreversible in 4/9 pts at 12 or 15 mCi/m2). There were 3 febrile neutropenias, 4 other infections treated with IV antibiotics, but no major bleeding or other AEs. By CT-RECIST criteria, 6 pts (16%) had PRs and 16 (42%) had stabilization as best response (58% disease control). After cycle 1, 52% (13/25) with PET-avid images became negative or had >25% SUV reduction, and 33% (9/27) with elevated CA19-9 levels decreased by >50%. The median overall survival was 7.7 mo., but 11.8 mo. for retreated pts [46% (6/13) survived ≥1 yr.], with improved efficacy at higher 90Y doses. In Part II, 52 pts received 12 mCi/m2 90Y-hPAM4 x 3 with Gem doses of 200 (N=17), 600 (N=8) or 1000 mg/m2 (N=27), with 13 pts now retreated at 90Y doses of 6.5 or 9 mCi/m2. Results so far indicate no advantage to giving higher doses of Gem with RAIT. Toxicity, response and survival data for this group will be presented at the conference.

Conclusions: Fractionated RAIT with 90Y-hPAM4 combined with low-dose gemcitabine appears to be a manageable and active first-line therapy for APC. It may provide comparable efficacy yet less toxicity compared to other regimens.
Relationship between serum HER2 level and histologic HER2 status in patients with advanced/recurrent gastric cancer.
Authors: Sasaki Takahide , Fuse Nozomu , Kuwata Takeshi , Takahashi Mari , Asano Hiromichi , Kaneko Kazuhiro , Doi Toshihiko , Yoshino Takayuki , Kojima Takashi , Ochiai Atsushi , Ohtsu Atsushi
Published: February 2017

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Background: The HER2 extracellular domain can be quantitatively measured in terms of the serum HER2 level by using a CLIA. Increased serum HER2 levels have been reported to be found in 20-25% of metastatic breast cancer patients and correlated with HER2 protein overexpression, increased tumor volume, and worse prognosis. However, the prevalence of HER2 expression in the serum of gastric cancer (GC) patients is not known.

Methods: This study retrospectively analyzed the tumor tissue and serum samples of 100 patients who had histologically confirmed advanced/recurrent stomach adenocarcinoma, had started chemotherapy at National Cancer Center Hospital East during 2007–2011, did not have any other active malignancies, and whose serum and tumor tissue samples had been collected and stored at the baseline. HER2 protein expression was determined by immunohistochemistry (IHC; I-VIEW Pathway 4B5 kit) with the GC scoring system (Hofmann, 2008), and gene amplification was determined by fluorescence in situ hybridization (FISH; PathVysion HER2 DNA probe kit), with HER2:CEP17 ≥ 2.0 seen in tumor tissue. Serum HER2 levels were measured using a CLIA (ADIVA Centaur XP). HER2 positivity was defined as IHC 2+ with FISH positive or IHC 3+.

Results: The baseline characteristics were as follows: men, 66; median age, 66 years (range, 29–85); advanced/recurrent, 96/4; and intestinal/diffuse/mixed, 38/41/21. An IHC score of 0/1+/2+/3+ was noted in 41/32/6/21 patients, respectively. Gene amplification in FISH was noted in 28 cases. The number of HER2 positive patients was 21. The median serum HER2 level was 9.3 ng/mL (range, 5.0–332.4). With a cutoff level of 15 ng/mL (mean + 2SD of 241 healthy control women), the sensitivity of serum HER2 levels with respect to HER2 positivity was 52.4%; specificity, 93.7%; positive predictive value, 68.8%; negative predictive value, 84.1%; and accuracy, 85.0%. The area under the receiver operating characteristic curve was 0.894.

Conclusions: Increased serum HER2 levels were noted in GC patients and were associated with HER2 overexpression in tumor tissue. Further investigations of serum HER2 in terms of the clinical significance are warranted.
HER2 expression in patients with advanced pancreatic cancer: Preliminary results from a multifactorial biologic analysis.
Authors: Faloppi Luca , Mandolesi Alessandra , Maccaroni Elena , Giampieri Riccardo , Bianconi Maristella , Bittoni Alessandro , Del Prete Michela , Antognoli Stefania , Scartozzi Mario , Bearzi Italo , Cascinu Stefano
Published: February 2017

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Background: Pancreatic cancer is the deadliest solid cancer and currently the fourth most frequent cause of cancer-related deaths. Many studies have demonstrated that pancreatic cancer is a group of heterougeneous disease with different therapeutical implications and prognosis. Aim of our analysis was to analyze the HER-family status in pancreatic cancer.

Methods: We immunohistochemically assessed surgical specimens and macrobiopses for several biological targets. K-ras, HER-1, HER-2 and HER-3 were analyzed.

Results: 62 specimens were analyzed in our centre. 30 samples were K-ras wild-type, 70% of these were EGFR positive. While 32 samples have a mutant form of K-ras, 87.5% were EGFR positive. HER-2 resulted negative in all specimens. In the K-ras wild-type group, 17% have high expression of HER-3, 20% a low one; in mutant K-ras group 16% are high expressing while 34% have a low HER-3.

Conclusions: Over the past decades, there has hardly been any substantial therapeutic progress regarding clinical endpoints in pancreatic cancer, thus in the era of target therapies the molecular biological classification of these neoplasms have an ever more important role for developing tailored therapies. Our analysis show a low rate of k-ras mutations (52%) and seems to suggest that anti-EGFR strategies may represent an interesting treatment option in pancreatic cancer as long as a preliminary molecular selection is applied. Numerous international trials are evaluating the role of new drugs targeting HER-2 in association with chemotherapy in metastatic pancreatic cancer. On the contrary, our data suggest that HER-2 directed therapies are not likely to represent a relevant choice in this setting.
RTOG 0438: A phase I trial of highly conformal radiation therapy for patients with liver metastases.
Authors: Katz Alan W. , Winter Kathryn A. , Dawson Laura A. , Schell Michael C , Kim Joon-Hyung J. , Chen Yuhchyau , Roberge David , Crane Christopher H. , Willett Christopher
Published: February 2017

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Background: This multi-institutional phase I trial was conducted to determine the maximally tolerated dose (MTD) of hypofractionated, highly conformal radiation therapy (RT) in patients (pts) with liver metastases.

Methods: Eligibility criteria included non-surgical pts with ≤ 5 liver metastases; total measurement for all lesions ≤ 8 cm. There were four dose levels (DLs) escalating from 35 Gy to 50 Gy in 5 Gy increments given in 10 fractions with defined normal tissue dose limits. Accrual began at 40 Gy. The clinical target volume (CTV) included all metastases identified on contrast CT/MRI with a 5 mm margin. The planning target margin ranged from 4 to 30 mm around the CTV. For quality assurance the Image-Guided Therapy Center (ITC) remote review tool was used to evaluate treatment planning images and dosimetry information. Dose limiting toxicities (DLTs) were defined as treatment-related grade (Gr) ≥ 4 hepatic, gastrointestinal (GI), thrombocytopenia, or radiation induced liver disease (RILD) within 90 days (dys) of the start of RT.

Results: 26 pts were enrolled between 11/05 and 12/10, and 23 were evaluable; 8, 7, and 8 on the 40, 45, and 50 Gy DLs respectively. Two pts assigned to the 50 Gy DL received 35 Gy because of normal tissue constraints, therefore an additional 2 pts were accrued and treated at the 50 Gy DL. The study was temporarily closed for toxicity evaluation after 6 pts on each DL were followed for a minimum of 90 dys from start of treatment. There were no DLTs observed on any of the DLs. Four pts developed treatment-related Gr 3 toxicities; 2 each on the 45 and 50 Gy DLs. On the 45 Gy DL, 1 pt had two Gr 3 GI toxicities: enteritis (37 dys from RT start) and diarrhea (22 dys) while another pt had Gr 3 lymphopenia (23 dys). On the 50 Gy DL, 1 pt had Gr 3 hyperglycemia (74 dys) and another pt had three Gr 3 toxicities: lymphopenia (13 dys), colonic hemorrhage (325 dys), and GI obstruction (325 dys).

Conclusions: When normal tissue constraints could be met, treatment of liver metastases with 50 Gy in 5 Gy/fx is feasible and safe in a multi-institutional setting. Further studies looking at higher doses and alternate fractionation regimens are warranted. Supported by RTOG U10 CA21661, CCOP U10 CA37422 and ATC U24 CA 81647 NCI grants.
Prognostic significance of LINE-1 methylation level in esophageal squamous cell carcinoma.
Authors: Baba Yoshifumi , Iwagami Shiro , Watanabe Masayuki , Shigaki Hironobu , Ida Satoshi , Nagai Yohei , Ishimoto Takatsugu , Iwatsuki Masaaki , Sakamoto Yasuo , Miyamoto Yuji , Baba Hideo
Published: February 2017

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Background: Genome-wide DNA hypomethylation plays a role in genomic instability and carcinogenesis. DNA methylation in the long interspersed nucleotide element-1, L1 (LINE-1) repetitive element is a good indicator of global DNA methylation level. LINE-1 methylation is a useful marker for predicting cancer prognosis and monitoring efficacy of adjuvant therapy. Esophageal squamous cell carcinoma, the major histological type of esophageal cancer in East Asian countries, is one of the most aggressive malignant tumors. Nonetheless, prognostic significance of LINE-1 hypomethylaiton in esophageal cancer remains uncertain.

Methods: Using 217 curatively resected esophageal squamous cell carcinomas, we quantified LINE-1 methylation using bisulfite-PCR-pyrosequencing assay. Cox proportional hazards model was used to calculate mortality hazard ratio (HR), adjusted for clinical, epidemiologic, and pathological variables.

Results: Esophageal cancers showed significantly lower LINE-1 methylation level compared to matched normal esophageal mucosa (p<0.0001; N=50). Tumoral LINE-1 methylation ranged from 24.8 to 91.8 of 0-100 scale (N=217; mean 64.5; median 65.0; standard deviation 12.8). LINE-1 hypomethylation was significantly associated with disease-free survival [log-rank p=0.0008; univariate HR= 2.31, 95% confidence interval (CI) 1.38-3.84, p=0.0017; multivariate HR=1.81, 95% CI 1.06-3.05, p=0.031] and overall survival (log-rank p=0.0013; univariate HR=2.21, 95% CI 1.33-3.60, p=0.0026; multivariate HR=1.87, 95% CI 1.12-3.08, p=0.018].

Conclusions: LINE-1 hypomethylation in esophageal cancer is associated with shorter survival, suggesting its role as a prognostic biomarker. Given that epigenetic changes, including DNA methylation alterations, are reversible and can thus be targets for therapy or chemoprevention, our findings may have considerable clinical implications.