bluuebunny/crossref_metadata_2025 huggingface dataset:
Streamlining universal screening for lynch syndrome (LS): Towards improved yield of genetic counseling (GC).
Authors: Sciallero Stefania , Damiani Azzurra , Zupo Simonetta , Battistuzzi Linda , Puccini Alberto , Bruzzone Carla , Gonella Edoardo , Gismondi Viviana , Dono Mariella , Mastracci Luca , Sobrero Alberto F. , Varesco Liliana , Grillo Federica
Published: January 2019

503

Background: LS is largely underdiagnosed although Universal Screening (US) in colorectal cancer (CRC) patients through MisMatch Repair deficiency (MMR-d) testing is widely endorsed. Low adherence to guidelines among oncologists may be partly due to a lack of consensus on whether all MMR-d patients should be referred to GC/Genetic Testing (GT). As BRAF mutation rules out LS, we estimated the increased yield of LS diagnosis from GC /GT which could be obtained by selecting candidates for GC through BRAF testing. Methods: From 2011 to 2016, 1447 consecutive stage I-IV CRC surgical patients at a single institution, underwent immunohistochemistry (IHC) for LS using anti MLH1, MSH2, MSH6 and PMS2 antibodies. Oncologists were invited to refer all MMR-d patients to GC/GT. BRAFV600E testing was carried out only in case of MLH1 protein loss at IHC. Results: MMR-d was found in 194 patients (13%), with 171 showing loss of MLH1 expression (88%). Oncologists referred 27 (16%) to GC. Among the 21 who underwent GC, BRAF testing and GT, 9 were BRAF wild type (wt) (43%) and none had LS. Among the 23 MMR-d patients with loss of expression of MSH2, MSH6 or PMS2 (≠MLH1), oncologists referred 9 to GC (39%): 7 underwent GC / GT and 3 carried LS (43%) at GT. Median age was 76 years (range 30-97) in the MMR-d group, 78 (range 41-97) in the MLH1 group and 63 (range 30-86) in the ≠MLH1 group. Overall, LS was diagnosed in 3 of the 28 MMR-d patients (11%) who underwent GC /GT, possibly an underestimate due to the advanced median age of our MLH1 loss patients. Had we only offered GC to the 9 BRAF wt patients among the 21 with MLH1 loss, we could have avoided 12 (57%) of the GC sessions conducted, increasing the yield of LS diagnosis from 3/28 (11%) to 3/16 (19%) (75% increase). Conclusions: When US for LS is adopted, a GC referral rate reduction of 57% among MLH1 loss patients, and an overall increase in the yield of GC of about 75% can be obtained by testing for BRAF mutation before oncologist referral to GC rather than after. As multistep selection of patients by oncologists may be unfeasible, CRC pathology reports with combined MMR-d and BRAF testing (for MLH1 loss at IHC) and an ‘LS suspicion alert’ could improve oncologists’ awareness of LS and compliance with guidelines.
Real-world fusion landscape in advanced Chinese gastric cancer using next generation sequencing: A multicenter study.
Authors: Lin Rongbo , Zhao Shen , Cai Lisheng , Chen Shaoqin , Lai Jinhuo , Fang Yong , Cai Xiuyu , Wang Liping , Fang Mei-yu , Xu Chunwei , Lin Li , Li Penquan , Xu Qi , Fang Xuefeng , Yu Genhua , Shan Jianzhen
Published: January 2019

51

Background: Gastric cancer (GC) is a highly heterogeneous disease. Cell-free DNA (cfDNA) has been a research hotspot in molecular tumor profiling. In advanced GC patients, malignant pleural effusion (MPE) and ascites provide a wealth of tumor cells that can be investigated. The aim of this study is to investigate fusion landscape in advanced GC. Methods: A multicenter study in China was initiated from Aug. 2016, and GC patients have been enrolled as of Aug. 2018. To determine the fusion frequency in GC, we analyzed data from 371clinical GC cases, each of which had results from next-generation sequencing (NGS)-based 381 genes panel assay, analogous to the index patient. Results: Of this entire cohort, 61 patients (16.44%) were identified with fusions, including TMEM45B-FGF3 (3), AXIN1-SMPD3 (3), B3GNTL1-ERBB2 (2), ERBB2-LAMA3 (2), ERBB2-ACLY (2), TRIM24-BRAF (2), ARHGEF1-CD79A (2), FGFR4-UIMC1 (2), MSH2-TTC7A (2), SMARCA4-LDLR (2), GON4L-RIT1 (2), AKT1-CPSF2 (2), GATA6-COLEC12 (2), RICTOR-EFNA5 (2), KAT6A-PLAT (2), ROCK1-CCDC178 (2), HBS1L-MYB (2), SLC30A2-ARID1A (2), MSI2-BIRC5 (2), NOTCH3-UCA1 (2), PIK3C2B-KISS1 (2), RICTOR-OSMR (2), FGFR2-MIR5694 (2), FGFR2-FGFR1 (2), MAN2A2-BLM (2), EGFR-MED15 (1), EML4-ALK(1), GOPC-ROS1 (1), FXR2-TP53 (1), NF1-PSMD11 (1), IRS2-PRKCI (1), FGFR2-KIAA1217(1), FGFR2-TACC2 (1), FGFR3-TACC3 (1). ERBB2, BRAF, EGFR, ALK and ROS1 fusionswere seen in 18.03% (11/61) of advanced Chinese gastric cancer fusion landscape patients. Conclusions: Advanced Chinese gastric cancer fusion landscape is rich, ERBB2, BRAF, EGFR, ALK and ROS1 fusions are rare but potentially druggable in TKIs. Detection of ERBB2, BRAF, EGFR, ALK and ROS1 fusions should be part of comprehensive profiling panels to determine TKIs and direct appropriate combination therapeutic strategies.
Financial distress amongst older adults with gastrointestinal (GI) malignancies.
Authors: Varnado William , Kenzik Kelly , McDonald Andrew Michael , Parman Mariel , Paluri Ravi Kumar , Navari Rudolph M. , Smith Crystal Young , Robertson Matthew , Bhatia Smita , Williams Grant Richard
Published: January 2019

517

Background: Many patients with cancer report financial distress (FD); however, the magnitude of FD in the growing number of older adults with cancer remains less clear, particularly in those with GI malignancies. The purpose of this study was to evaluate the proportion of older adults with GI malignancies reporting FD and to characterize geriatric assessment (GA) and cancer-related factors associated with FD. Methods: Older adults ( ≥ 60yrs) seen in the GI oncology clinic at the University of Alabama Birmingham (UAB) were asked to fill out a patient-reported GA, entitled the Cancer & Aging Resilience Evaluation (CARE), at their visit. The CARE includes questions pertaining to patient’s independence in Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), falls, physical function, polypharmacy, and comorbidity. A single item question regarding FD from the patient satisfaction questionnaire (PSQ-18) was included. FD was defined as agreement with the phrase “Do you have to pay for more medical care than you can afford.” Demographic and GA characteristics were compared between those with and without FD using Chi-square and t-tests. Results: 233 patients completed the CARE a median of 71 days after diagnosis. Median age 68y (60-96); 54.5% male and 76.0% non-Hispanic white. Most common cancer types included colorectal (39.1%) and pancreatic cancers (20.6%). A total of 62 patients (26.6%) had FD. Patients with FD were more likely to be younger (68.1 vs. 70.1y, p = 0.04), of black race (37.1% vs. 15.8%, p = 0.007), have low education ( ≤ high school: 74.2% vs. 59.6%, p = 0.02), have one or more falls (31.5% vs. 19.9%, p = 0.077), to be limited a lot in walking 1 block (54.4% vs. 27.4%, p = 0.0003), take more than 4 medications (88.3% vs. 70.8%, p = 0.007), to have more than one comorbid condition (93.1% vs. 82.6%, p = 0.052), to report impaired IADLs (61.3% vs. 43.9%, p = 0.055), and impaired ADL (27.4% vs. 14.6%, p = 0.069). No associations were found with GI cancer type or stage, marital status, time from diagnosis, or hearing/vision impairments. Conclusions: Over a quarter of the older adult population with GI malignancies report FD. Several GA and demographic factors were associated with FD that may help identify older patients at risk for FD.
Incidence of pulmonary metastasis among patients with colorectal adenocarcinoma: Correlation between sidedness and RAS mutations.
Authors: Diniz Lara Azevedo , De Brito Sales Diogo , Machado Larissa , Karani Amanda , Barros Milton Jose , Taboada Rodrigo Gomes , Pandolfi Natasha Carvalho , de Andrade Poliana , Freitas Helano C.
Published: January 2019

527

Background: Sidedness alongside with RAS status in colorectal adenocarcinoma has been proved to correlate with survival and response to systemic therapy. There are few data reporting how these clinical characteristics can predict the dissemination of metastasis. We hypothesize that lung metastasis were more common among those with RAS mutations and left colon primary cancers. Methods: In this study, 609 patients with stage I to IV colorectal adenocarcinoma were enrolled retrospectively. Patients were divided by sidedness, right and left and were also classified according to KRAS and NRAS status. The frequencies of lung metastasis were analyzed among the different groups. Results: Of the 609 patients analyzed, 129 (21.1%) had recurrent disease and 206 (33.8%) had synchronous metastasis. RAS status was available in 311 (92.8%) of the metastatic patients and 138(44.4%) were wild type. We found that 60 (34.7%) of the patients with RAS mutated tumors presented with metachronic or synchronous lung metastasis compared with 31 (22.5%) of the wild-type population (p = 0.019). Focusing only on sidedness, excluding rectal cancer since its already described increased incidence of lung metastasis, 47 (29.7%) of the patients with left sided colon cancer had lung metastasis compared with 8 (11.1%) of the right sided primary population (p = 0,002). It was observed similar frequencies of RAS mutations among patients with left (54.1%) and right (57.6%) sided tumor. Conclusions: RAS mutated colorectal adenocarcinoma is associated with an increased incidence of lung metastasis as well as left sided tumors where this finding seems to be independent of RAS status.
On the road again: Travel patterns and outcomes in rectal cancer.
Authors: Kledzik Mary , Scholer Anthony Joseph , Khader Adam , Santamaria-Barria Juan , Fischer Trevan D , Goldfarb Melanie
Published: January 2019

530

Background: Associations between high volume centers and outcomes have many advocating for centralization of cancer care, which can lead to increased travel, patient burden, and cost. There is, however, some conflicting data regarding outcomes for patients with more advanced disease. This study aims to explore factors associated with travel and the impact on survival for patients receiving surgery for rectal adenocarcinoma. Methods: All patients >18 years of age with rectal adenocarcinoma that had a surgical resection were identified using the National Cancer Database from 2004-2014. Univariate and multivariate (MV) regression analyses determined factors associated with increased travel distance (<50 miles, 50-100 miles, >100 miles) as well as the impact of travel on overall survival (OS). Results: Of 83,933 patients, those that traveled the furthest were more commonly younger, white non-Hispanic, insured, and with less comorbidities (all p<0.05 on MV analysis). Cancer stage, surgical approach, and type of surgery were not associated with travel distance (p=NS). Increased travel distance improved 5-year OS for stage IV disease (10%, p=0.002), and trended toward significance for stage II (4.0%, p=0.06) and stage 1 (4.3%, p=0.09) disease. After controlling for other factors, travel distance did not impact OS for stage II/III disease, but stage I and IV patients traveling 50-100 miles had an increased risk of death (stage I HR 1.16, CI 1.04-1.30; stage IV HR 1.19, CI 1.07-1.32). This was similar in the entire cohort where traveling 50-100 miles had an increased risk of death (HR 1.09; CI 1.03-1.14). Patients treated at non-low volume centers did have improved outcomes across all stages (p<0.01). Patients treated in academic hospitals had improved outcomes in stages I and IV (p=0.02). Conclusions: Younger, white, non-Hispanic patients are most likely to travel longer distances for rectal cancer treatment, regardless of stage. Increased hospital volume improves OS while travel and use of academic centers may impact patients with stage I/IV disease. Educating patients and providers regarding the influence of travel and hospital volume could help reallocate some resources, decrease financial toxicity, and ease the travel burden for patients.
The role of Parvimonas micra in intestinal tumorigenesis in germ-free and conventional APCmin/+ mice.
Authors: Yu Jun , Zhao Liuyang , Zhao Risheng , Long Xiaohang , Coker Olabisi Oluwabukola , Sung Joseph J.Y.
Published: January 2019

531

Background: Our in-house meta-analysis of fecal shotgun metagenomic sequences from colorectal cancer (CRC) and control subjects from four cohorts of various ethnicities identified a higher abundance of Parvimonas micra in CRC. We aimed to investigate the effect of P. micra in colon tumor formation and development. Methods: We collected 309 fecal samples and 259 colon biopsies from patients with CRC, advanced adenoma and healthy subjects. P. micra strain was isolated from the feces of a CRC patient. APC min/+ mice and germ-free (GF) mice were orally gavaged with P. micra, or Esherichia coli. Colon epithelial cell line NCM460 and cancer cell lines HT-29 and Caco-2 were exposed to P. micra or E. coli conditional medium. Results: P. micra was significantly enriched both in the feces (n = 207, p < 0.01) and tissue biopsies (n = 99, p < 0.01) of CRC patients compared with controls (n = 102 for fecal samples, n = 160 for tissues biopsies). APCmin/+ mice gavaged with P. micra exibited significantly higher tumor burden ( p < 0.01) and tumor load ( p < 0.01), compared to mice gavaged with either E. coli or non-bacterial control. Consistently, cell proliferation was significantly higher in the colon tissues of P. micra gavaged GF mice relative to control mice evidenced by increased Ki-67 positive cells ( p < 0.05) and PCNA protein expression ( p < 0.01) at weeks 20 and 32. In line with this, colon cell lines NCM460, HT-29 and Caco-2 exposed to P. micra conditional medium significantly increased proliferation than control group (all p < 0.05). Flow cytometry analyses showed that Th2 and Th17 cells were markedly increased, while Th1 were reduced in the lamina propria of the colon tissues of P. micra gavaged mice compared to control mice (all p < 0.01) . Consistently, P. micra colonization in GF mice was associated with increased expression of pro-inflammatory cytokines, including TNF-α, IL-6 and IL-12 (all p < 0.01). Conclusions: The abundance of P. micra was significantly increased in the feces and tissue biopsies of CRC patients. P. micra promotes intestinal carcinogenesis in APC min/+ mice and increase cell proliferation in GF mice. The tumor promoting effect of P. micra is associated with altered immune responses and enhanced inflammation in the gut.
Mismatch repair/microsatellite instability (MMR/MSI) testing practices among United States physicians treating patients (pts) with advanced/metastatic colorectal cancer (mCRC).
Authors: Eriksson Jennifer , Amonkar Mayur , Thomson Gemma , Lambert Jeremy , Malmenas Mia , Chase Monica , Sun Lucy , Kollmar Linda Grossman , Vichnin Michelle
Published: January 2019

533

Background: Approximately 12-15% of all CRCs are associated with defects in the DNA MMR pathway. NCCN 2017 guidelines endorsed universal MMR/MSI testing for all pts with a personal history of CRC. The study objective was to assess US physicians’ MMR/MSI genetic testing practices for mCRC pts. Methods: A non-interventional, cross-sectional online survey was conducted among 151 physicians (91 oncologists, 15 surgeons and 45 pathologists) treating mCRC pts in the US. A draft survey was first developed based on a targeted literature review and exploratory interviews with 15 physicians, and then pilot tested with a new series of 10 physicians. Physicians were eligible if they were US based with at least 5 years of experience treating CRC pts, had at least one mCRC pt in their routine care in the past 6 months of practice, and experienced with MMR/MSI testing including having ordered at least 1 MMR/MSI test for CRC in the past 6 months. Physicians were invited to participate through a market research panel. Descriptive and logistic regression analyses were performed. Results: Awareness of specific MMR/MSI testing guidelines was high (N = 127, 84.1%). Of those, 93.7% (119/127) physicians had awareness of specific published guidelines with majority 67.2% (80/119) being aware of NCCN guidelines. Universal testing for all CRC pts was performed by 68.9% (104/151) physicians, while 29.8% (45/151) selectively orders the test for some CRC pts. Key barriers for testing included insufficient tissue sample to enable running the test (48.3%, 73/151), patient refusal to have the test done (35.8%, 54/151) and insurance cost concerns for the pts (31.1%, 47/151), while 27.2% (41/151) reported no barriers. There were no statistically significant differences based on physician specialty, practice type and years of practice. Conclusions: The survey demonstrated high awareness and compliance with MMR/MSI testing guidelines although universal testing rates seem to be suboptimal. Addressing the key physician barriers to testing along with increased communication and education on the benefits of testing may help to enhance testing rates.
The safety assessment of robotic versus laparoscopic gastrectomy for gastric cancer using a propensity score matching method.
Authors: Makuuchi Rie , Toriumi Tetsuro , Waki Yuhei , Nakamura Kenichi , Kamiya Satoshi , Tanizawa Yutaka , Bando Etsuro , Terashima Masanori
Published: January 2019

55

Background: We have previously reported the safety of robotic gastrectomy (RG) for clinical Stage IA or IB gastric cancer in single arm phase II studies. To date, a number of retrospective case control studies comparing RG and laparoscopic gastrectomy (LG) have been performed. However, since randomized controlled trials have never been conducted, no definitive conclusion demonstrating benefits of RG over LG has been demonstrated. In this study, we aimed to evaluate the safety of RG compared to LG using propensity score matching (PSM) methods. Methods: We retrospectively reviewed 766 consecutive patients who underwent either RG (n = 231) or LG (n = 535) for gastric cancer between January 2012 and December 2017. A 1:1 PSM was performed with the matched variables of age, sex, body mass index, performance status, clinical Stage, type of gastrectomy, and extent of lymphadenectomy. We compared short-term outcomes between the patients who underwent RG (RG group) and LG (LG group). Results: After PSM analysis, 231 patients were included in the RG group and 230 in the LG group. Intraoperative blood loss was similar between the groups. Operation time was significantly longer in the RG group (326 min vs. 281 min, P < 0.001). Significantly more lymph nodes were retrieved in the RG group (42 vs. 38.5, P = 0.031). Serum CRP level were significantly lower in the RG group in postoperative day 3 (9.0 mg/dL vs. 9.8 mg/dL, P = 0.049) and 6 (3.1 mg/dL vs. 3.7 mg/dL, P = 0.034), and drain amylase level in postoperative day 3 was also significantly lower in the RG group (612 U/L vs. 856 U/L, P < 0.001). Overall postoperative complication (Clavien–Dindo classification grade IIIA or greater) was similar between the groups (RG: 3.9% vs. LG: 5.6%, P = 0.656). However, pancreatic fistula tended to be less frequent in the RG group than in the LG group (0.4% vs. 2.2%, P = 0.122), although it did not reach statistically significant difference. Conclusions: Although RG takes longer operation time, it appears to be less invasive than LG with the possibility of decreased postoperative complications. To validate the results, randomized controlled trial should be performed.
Genetic variations within the CD40L immune stimulating gene predict outcome for mCRC patients treated with first-line FOLFIRI/bevacizumab: Data from FIRE-3 and TRIBE.
Authors: Berger Martin D. , Stintzing Sebastian , Heinemann Volker , Cao Shu , Miyamoto Yuji , Suenaga Mitsukuni , Hanna Diana L. , Soni Shivani , Puccini Alberto , Tokunaga Ryuma , Naseem Madiha , Battaglin Francesca , Zhang Wu , Cremolini Chiara , Falcone Alfredo , Loupakis Fotios , Lenz Heinz-Josef
Published: January 2019

558

Background: The introduction of immunotherapy has significantly improved outcome in various tumors. Immune stimulating proteins exert an anti-tumor effect mainly through enhancing T-cell mediated immune response. Additionally, preliminary data suggest a major role of immune stimulating proteins in modulating angiogenesis. We therefore hypothesize that variations in genes involved in the immune activation pathway may predict outcome in pts with mCRC treated with first-line FOLFIRI/ bevacizumab (bev). Methods: The impact of 4 functional SNPs within the CD40L, Light, OX40L and ICOS genes on outcome was evaluated in 322 pts with mCRC treated with first-line FOLFIRI/bev in two randomized phase III trials. We used TRIBE as a discovery (n = 215) and FIRE-3 as a validation set (n = 107). One hundred twenty-nine pts treated with FOLFIRI/cetuximab (cet) served as a control cohort (FIRE-3). OncoArray, a custom array manufactured by Illumina was used for data extraction. Genomic DNA was extracted from blood. Results: Baseline characteristics: FOLFIRI/bev, discovery set (TRIBE), median PFS/OS/FU 9.7/26.2/48.9 mo; FOLFIRI/bev, validation set (FIRE-3), PFS/OS/FU 11.5/32.4/71.1 mo; FOLFIRI/cet, control set (FIRE-3) PFS/OS/FU 12.8//23.9/70.7 mo. The CD40L rs1126535 SNP showed significant association with OS. Pts in the discovery cohort harboring any T allele and treated with FOLFIRI/bev had a longer median OS compared to C/C carriers (27.9 vs. 20.0 mo) in both univariate (HR 1.83, 95% CI 1.19-2.81, p = 0.005) and multivariate analyses (HR 1.62, 95% CI 1.03-2.56, p = 0.038). Similarly, any T allele carriers in the validation cohort had a significantly longer median OS than those harboring a C/C genotype (40 vs. 19.0 mo) in the multivariate analysis (HR 2.80, 95% CI 1.05-7.50, p = 0.040). However, this association could not be shown in pts receiving FOLFIRI/cet (HR 0.60, 95% CI, 0.18-1.94, p = 0.38). Conclusions: We show for the first time that the CD40L polymorphism rs1126535 might serve as a predictive marker in pts with mCRC treated with FOLFIRI/bev. Targeting CD40L might be promising to further improve treatment against mCRC and to overcome resistance to anti-angiogenic therapy.
Genetic variants in the lipopolysaccharide (LPS) receptor complex and TLR4 expression levels to predict efficacy of cetuximab (cet) in patients (pts) with metastatic colorectal cancer (mCRC): Data from the FIRE-3 phase III trial.
Authors: Battaglin Francesca , Puccini Alberto , Cao Shu , Millstein Joshua , Tokunaga Ryuma , Naseem Madiha , Soni Shivani , Lo Jae Ho , Ning Tricia , Arai Hiroyuki , Berger Martin D. , Barzi Afsaneh , Zhang Wu , Heinemann Volker , Stintzing Sebastian , Lenz Heinz-Josef
Published: January 2019

564

Background: Large metagenomic studies associate disrupted gut microbiome signatures, comprising more prevalently gram-negative bacteria, with CRC carcinogenesis. TLR4, the LPS receptor, has been involved in microbiota-mediated tumorigenesis. High TLR4 expression is associated with poor prognosis in CRC and TLR4 can activate EGFR through ligands epiregulin and amphiregulin. Hence, we hypothesized that genetic variants in the LPS receptor complex and TLR4 expression levels may predict cetuximab efficacy in mCRC pts. Methods: Genomic DNA from blood samples of pts enrolled in the randomized FIRE-3 trial was genotyped through the OncoArray, a custom array manufactured by Illumina. The impact on outcome of 5 functional SNPs within TLR4, MD2 and CD14 was analyzed in 129 pts treated with first-line FOLFIRI/cet (discovery, mPFS/OS: 12.8/49.8 mo) and 107 pts treated with FOLFIRI/bevacizumab (bev) (mPFS/OS: 11.5/31.4 mo). Gene expression levels were measured from 102 tumor samples of pts in the cet arm by HTG EdgeSeq Oncology Biomarker Panel. Results: In the discovery cohort, pts carrying the C/T variant of TLR4 rs4986791 had significantly shorter mPFS and OS compared to the C/C genotype in both uni- and multivariable analysis (PFS: 5.4 vs 13.3 mo, adjusted P[ Padj] = .01; OS: 21.7 vs 40.7 mo, Padj= .03). Conversely, C/C carriers of rs12377632 had a longer mPFS compared to any T in uni- and multivariable analysis (15.8 vs 12.2 mo, Padj< .001). Any A allele carriers of MD2 rs12546552 and any G allele carriers of CD14 rs2569190 showed shorter mPFS in multivariable analyses. These associations were not observed in bev arm. Significant interaction was found between TLR4 rs12377632 and RAS status ( P= .015). High TLR4 expression (log2 > 10.93) was associated with worse mPFS (7.2 vs 11 mo, P= .003) and OS (19.1 vs 29.8 mo, P< .001) in FIRE-3 cet arm. Conclusions: Our results provide the first evidence that polymorphisms in the LPS receptor complex and TLR4 expression levels may have a predictive value in mCRC pts receiving first-line cetuximab-based treatment and, overall, contribute to resistance to anti-EGFRs.
Polymorphisms in the telomerase complex to predict outcome in patients (pts) with metastatic colorectal cancer (mCRC): Data from TRIBE and FIRE-3 phase III trials.
Authors: Battaglin Francesca , Loupakis Fotios , Stintzing Sebastian , Cao Shu , Puccini Alberto , Tokunaga Ryuma , Naseem Madiha , Berger Martin D. , Soni Shivani , Lo Jae Ho , Bergamo Francesca , Lonardi Sara , Millstein Joshua , Zhang Wu , Zagonel Vittorina , Cremolini Chiara , Falcone Alfredo , Heinemann Volker , Lenz Heinz-Josef
Published: January 2019

566

Background: Telomere/telomerase interplay is involved in the regulation of genomic stability and cellular replicative potential. In CRC, shortening of telomeres promotes early steps of carcinogenesis but the prognostic role of telomere length is debated. High circulating levels of telomerase reverse transcriptase (TERT) appear to be a negative prognostic biomarker and polymorphisms in the telomerase RNA component (TERC) are associated with increased cancer risk. We hypothesized that genetic variants in the telomerase/telomere capping complex may predict first-line treatment outcome in mCRC pts. Methods: The impact on outcome of 21 selected SNPs within 13 genes ( TERT, TERC, CLPTM1L, TERF1/2, POT1, ACD, NOP10, NHP2, GAR1, STN1, CTC1) was analyzed through the OncoArray, a custom array manufactured by Illumina, on genomic DNA from blood samples of 451 pts enrolled in two independent randomized trials. TRIBE FOLFIRI/bevacizumab (bev) arm (n=215, mPFS/OS: 9.7/26.2 mo) served as discovery cohort, FIRE-3 FOLFIRI/bev arm (n=107, mPFS/OS: 11.5/31.4 mo) as validation and FOLFIRI/cetuximab (cet) arm (n=129, mPFS/OS: 12.8/49.8 mo) as control. Results: In the discovery cohort, pts carrying any A allele of TERT rs2075786 showed longer mPFS (11.1 vs 9.3 mo, P= .021) and OS (33.5 vs 25 mo, P= .005) compared to the G/G genotype in multivariable analysis. Same results were observed for pts carrying any T allele of CLPTM1L rs401681 compared to the C/C genotype ( P= .022). Any C allele carriers of TERC rs2293607 also showed longer mOS in multivariable analysis ( P= .041) and the A/A genotype of ACD rs6979 was associated with longer mPFS in both uni- and multivariable analysis. Interestingly, the T/T genotype of CLPTM1L rs401681 was associated with shorter mPFS (7.8 vs 13.5 mo) in the cet cohort in uni- ( P= .003) and multivariable analysis ( P= .041). In subgroup analyses based on RAS mutational status several SNPs in additional genes were associated with PFS and/or OS in different cohorts. Conclusions: Our results suggest that SNPs in core telomerase/telomere capping complex genes may have a predictive and prognostic value in mCRC pts receiving targeted first-line treatments.
Evaluating and manipulating the immune landscape in hepatic verses peritoneal metastases arising from colorectal primary tumors.
Authors: Ramsay Robert George , Millen Rosemary , Narasimhan Vignesh , Roth Sara , Pham Toan , Kong Joseph , Guerra Glen , Phillips Wayne A , Heriot Alexander Graham
Published: January 2019

568

Background: Colorectal metastases arise predominantly in the liver, lung and peritoneum. It is becoming increasingly clear that these locations might be distinct in terms of tumor cell tropism and genetics. We explored the immunological landscape in primary colorectal tumors along with hepatic and peritoneal metastases. The ultimate intent is to identify opportunities to implore immunomodulatory strategies to improve patient outcomes. Methods: Cancer biopsies were processed to generate tumor-derived organoids and TILs from patients with primary and/or metastatic tumors. These were co-cultured with patient matched TILs to assess immune competency and opportunities to employ checkpoint blockade using an in vitro platform we recently developed to explore TIL activity in patients with rectal cancer prior to standard of care therapy. Results: We found substantively different levels of TILs, their sub-set composition and most importantly their capacity to kill tumor cells. The nature of the metastatic peritoneal and hepatic tumor TILs were distinct. Where high programmed cell death 1 (PD-1) expression was high on TILs there was an opportunity to test PD-1 receptor function with blocking antibodies whereby some TILs showed enhanced cytotoxicity while others did not. Conclusions: Using our immune function assay we have demonstrated the distinct activities of patient-matched TILs in terms of killing at different organ sites of metastases. We also found differences in response to checkpoint inhibition blockade and de novo immune resistance.
KRAS mutation is associated with upregulation of integrin beta-4 expression leading to tumor invasion in colorectal cancer.
Authors: Choi Seo-Hyun , Marco Michael , Chen Ching-Tung , Pelossof Raphael , O'Rourke Kevin Patrick , Smith Jesse Joshua , Garcia-Aguilar Julio
Published: January 2019

576

Background: KRAS mutation ( KRASmut) is associated with aggressive biological behavior and resistance to chemoradiotherapy in colorectal cancer (CRC). The tumor microenvironment is a critical component framing the biological behavior of cancers. We have recently shown that a KRASmut modulates the tumor microenvironment by reducing the expression of extracellular matrix (ECM) genes in CRC. The effect of a KRASmut on integrins, the epithelial cell receptors for ECM proteins, remains largely unknown. Here, we investigated the impact of KRASmut on integrin expression in CRC and the effect of integrin beta 4 (ITGB4) expression on CRC phenotype. Methods: The genomic profile of 79 locally advanced rectal cancers (LARC) was characterized by the MSK-IMPACT DNA assay and RNA sequencing by Hi-Seq platform. The transcriptomic changes associated with KRAS in the LARC cohort was validated in the TCGA colon cancer dataset. Expression of ITGB4 was investigated by immunofluorescence (IF) in 39 colon cancer specimens by counting ITGB4-positive cells in an E-cadherin positive epithelial population. The relationship between KRAS and ITGB4 was also explored by manipulating KRAS expression in human cell lines and genetically engineered mouse models (GEMMs). ITGB4 knockout in HCT116 CRC cell lines and organoids from GEMMs were generated with CRISPR/Cas9. ITGB4 expression was confirmed using qRT-PCR and western blotting. Cell proliferation was assessed with the MTT assay. Cell invasion and migration were assessed in a trans-well system. Results: ITGB4 gene expression was increased in KRASmut compared to KRASwildtype in LARC and TCGA. Increased ITGB4 expression in KRASmut colon cancers was also validated by IF (p = 0.0029). Introduction of KRASmut in HCT116 CRCs and GEMMs increased ITGB4 expression by 1.5 to 2 fold. Knockout of ITGB4 reduced the migration and invasion of HCT116 CRC cells but did not alter proliferation. Conclusions: KRASmutincreases the expression of ITGB4 in CRC. Increased ITGB4 expression is associated with CRC cell invasion and migration. These results inform the biology of tumor progression in KRASmut CRC tumors.
Significance of monitoring plasma vascular endothelial growth factor signals during treatment of colorectal cancer patients.
Authors: Kakizawa Nao , Suzuki Koichi , Ishikawa Hideki , Watanabe Fumiaki , Hasegawa Fumi , Kikugawa Rina , Tsujinaka Shingo , Futsuhara Kazushige , Miyakura Yasuyuki , Rikiyama Toshiki
Published: January 2019

577

Background: Vascular endothelial growth factor (VEGF) signals may change during colorectal cancer (CRC) treatment, but monitoring real time changes has not been conducted. Methods: Blood monitoring was carried out to track changes in the status of VEGF ligands (A, C, and D) in CRC patients. Expression was determined by ELISA. Results: VEGF-A monitoring was performed in 148 CRC patients preoperatively and VEGF-C and -D monitoring was performed in 52 metastatic CRC patients. Patients with high VEGF-A had significantly shorter recurrence free survival (p = 0.00438). Univariate analysis associating with recurrence detected high VEGF-A, high pathological stage, and with lymph node metastasis were risk factors, and high VEGF-A was identified as an independent risk factor of recurrence by multivariate analysis. There was no significant difference in prognosis between metastatic CRC patients with high and low VEGF-D in early-line treatment, however, in late line patients with high VEGF-D had significantly worse prognosis than those with low VEGF-D (p = 0.0121). When they had treatment with bevacizumab, same result was seen in late line (p = 0.0416). VEGF-C showed no significant correlation with prognosis. Conclusions: Preoperative high VEGF-A is an important risk factor of recurrence and VEGF targeting drugs might be useful as an adjuvant chemotherapy for the patients with high VEGF-A. In late line chemotherapy, patients with high VEGF-D had poor prognosis in regardless of bevacizumab, therefore, they will be candidates of other anti-VEGF drugs than bevacizumab in late line chemotherapy. Measurement of plasma VEGF level can have benefit for the treatment of CRC patients to predict their recurrence and prognosis. It would be helpful for VEGF targeting drug selection and provide useful information for better treatment strategy.
Identification of site-specific genome alterations in metastatic colorectal cancer: Sub-study 003 of the SCRUM-Japan GI-SCREEN.
Authors: Mizukami Takuro , Takahashi Masaki , Sunakawa Yu , Yuki Satoshi , Kagawa Yoshinori , Takashima Atsuo , Kato Kyoko , Hara Hiroki , Denda Tadamichi , Moriwaki Toshikazu , Shiozawa Manabu , Oki Eiji , Satoh Taroh , Kawakami Hisato , Esaki Taito , Nishina Tomohiro , Okamoto Wataru , Yoshino Takayuki , Nakajima Takako Eguchi
Published: January 2019

578

Background: Primary tumor sidedness is known to be an independent prognostic factor and a predictor for the efficacy of anti-EGFR antibody. However, limited information is available regarding the role of primary tumor site for the treatment of metastatic colorectal cancer (mCRC) patients (pts), including gene mutation profiles, prognosis, and prediction for treatment. This study was conducted as a sub-study of the SCRUM-Japan GI-SCREEN, the Nationwide Cancer Genome Screening Project in Japan. Methods: Among participants of the GI-Screen 2013-01-CRC, untreated pts with mCRC which samples were collected from primary site were eligible. DNA and RNA were extracted from FFPE tumor samples and then were analyzed by the Oncomine Cancer Research Panel detecting gene mutations, copy number variants (CNV), and fusions across 143 genes in a CLIA certified CAP accredited laboratory. The detected genomic variant data were classified according to genetic drivers of cancer including gain- and loss-of-function or single nucleotide variant based on the Oncomine Knowledgebase. Results: Among 1011 enrolled pts from Feb. 2015 to Mar 2017, a total of 561 samples were analyzed (median age, 66.0 years; 232 [41.4 %] female). Frequency of female, undifferentiated, mucinous or signet ring cell subtype were gradually increased as the primary site became the right side. Median site-specific survival was 22.4 months (m) in the cecum, 25.3 m in the ascending colon, 21.2 m in the transverse colon, 72.5 m in the descending colon, 36.5 m in the sigmoid colon, and 39.6 m in the rectum. Gene alterations differed in each primary site. Among frequently observed gene alterations, FBXW7 mutation in rectum, ATM mutation in transverse colon, BRAF and SMAD4 mutations in ascending colon significantly contributed to poor prognosis. Conclusions: This study revealed the site-specific survival and gene alterations in Japanese mCRC pts. These novel knowledges provide an intriguing background to investigate new targeted approaches in these pts and represent the progress toward precision medicine. We will analyze the site-specific therapeutic effect of molecular targeting agents, including anti-EGFR antibody. Clinical trial information: UMIN000031242.
Epigenetic priming prior to pembrolizumab in mismatch repair-proficient advanced colorectal cancer.
Authors: Murphy Adrian Gerard , Walker Rosalind , Lutz Eric R. , Parkinson Rose , Ahuja Nita , Zheng Lei , Jaffee Elizabeth M. , Azad Nilofer Saba
Published: January 2019

591

Background: Pembrolizumab results in compelling responses in MMR-deficient CRC. However, most advanced CRC patients have MMR proficient (MMR-p) tumors resistant to PD1 blockade. DNA methyltransferases (DNMT) and histone deacetylases (HDAC) result in silencing of tumor suppressor genes. Preclinical combined HDAC/DNMT inhibition induces susceptibility to immune checkpoints and inhibit tumor growth by re-expressing silenced tumor suppressors. Methods: Single institution, open-label, randomized pilot study (NCT02512172) enrolling patients with advanced MMR-p CRC who progressed on ≥ 1 line of chemotherapy. Patients were randomized to A: oral 5-azacitidine (5AZA, CC486), B: romidepsin or C: combined 5AZA and romidepsin. Patients had pre-treatment biopsy, 14 days of epigenetic therapy with repeat biopsy. All groups began pembrolizumab 200 mg combined with epigenetic therapy until disease progression. Toxicity was assessed using CTCAE v4.0. Results: From 2016 to 2018, 24 patients enrolled with median age of 60 (range 40-69) and median treatment cycles was 3 (range 1-16). There were 2 deaths on study (1 acute kidney injury/ sepsis, 1 cardiac arrest, both unrelated to study drugs). The most common treatment-related hematological AEs in all arms were anemia (63%), lymphopenia (50%) and thrombocytopenia (29%). Most common treatment-related non-hematological AEs in arm A (n = 7) were diarrhea (86%), nausea (86%), fatigue (71%) and anorexia (71%); Arm B (n = 8) were fatigue (63%), dysgeusia (63%), anorexia (63%) and vomiting (63%); and Arm C (n = 9) were nausea (100%), vomiting (100%), fatigue (78%) and anorexia (67%). Treatment-related non-laboratory AEs ≥ grade 3 occurred in 0 patients in Arm A, 3 patients (38%) in Arm B and 3 patients (33%) in Arm C. The most common laboratory AEs in all arms were raised alkaline phosphatase (38%), increased ALT (33%), hyperglycemia (29%), and hypophosphatemia (29%). Conclusions: In this study, the combination of epigenetic agents 5-azacitidine and romidepsin with pembrolizumab is considered safe and generally tolerable in patients with advanced p-MMR colorectal cancer. Further comparison of pre- and post-treatment biopsies is required to determine predictors of response. Clinical trial information: NCT02512172.
Th17 cell pathway-related genetic variants in metastatic colorectal cancer: A meta-analysis using TRIBE, MAVERICC, and FIRE-3.
Authors: Tokunaga Ryuma , Cao Shu , Battaglin Francesca , Lo Jae Ho , Loupakis Fotios , Stintzing Sebastian , Naseem Madiha , Puccini Alberto , Berger Martin D. , Zhang Wu , Mancao Christoph , Salhia Bodour , Mumenthaler Shannon M , Weisenberger Daniel J , Liang Gangning , Cremolini Chiara , Heinemann Volker , Falcone Alfredo , Millstein Joshua , Lenz Heinz-Josef
Published: January 2019

594

Background: Th17 cells constitute a subset of T-helper cells, and play a role in immune response to extracellular pathogens in the human intestinal tract. Further, Th17 cells are associated with tumor angiogenesis and enhanced efficacy of 5-FU treatment. We thus investigated associations between the Th17 cell pathway-related SNPs and clinical outcomes in patients with metastatic colorectal cancer (mCRC) treated with conventional chemotherapy. Methods: We analyzed a total of 884 patients with mCRC enrolled in three randomized clinical trials (TRIBE, MAVERICC, and FIRE-3: where patients were treated with FOLFIRI, mFOLFOX6, or FOLFOXIRI combined with bevacizumab or cetuximab as the first-line chemotherapy). Multivariable logistic regression and Cox regression were performed to evaluate the association between candidate SNPs in the Th17 cell pathway and clinical outcomes [tumor response (TR), progression-free survival (PFS), and overall survival (OS)] in each treatment cohort. The meta-analysis approach using the METASOFT software were implemented to quantify the prognostic effect of each SNP using the inverse-variance-weighted effect size, and also to evaluate the heterogeneity across cohorts using the Q statistic. SNPs were coded as additive, dominant, or recessive in the analysis. The Pegasus analysis was also used to identify effects across multiple SNPs and treatment arms. Results: Pathway analysis showed that the Th17 cell pathway was significantly associated with TR ( P = 0.011). There were suggestive associations of IL17F rs763780 with TR (log OR = 0.64, SE = 0.31; P = 0.038), of IL23R rs10889677 with TR (log OR = 0.37, SE = 0.18; P = 0.039), of IRF4 rs872071 with TR (log OR = -0.26, SE = 0.13; P = 0.037), and of IL21 rs2221903 with PFS (log HR = 0.33, SE = 0.15; P = 0.026), although these results were not significant after FDR adjustment. In addition, IL23R rs10889677 had suggestive heterogeneity of effects for PFS across the six cohorts after Cochran’s Q statistic ( P = 0.013). Conclusions: Th17 cell pathway-related SNPs may be predictors for the first-line chemotherapy in mCRC. Upon validation, our findings would provide novel insight for selecting treatment strategies for mCRC.
Association of consensus molecular subtypes (CMS) with time to progression (TTP), progression free survival (PFS), and overall survival (OS) with second-line FOLFIRI ± regorafenib in metastatic colorectal cancer (mCRC).
Authors: Lee Michael Sangmin , Selitsky Sara R. , Parker Joel S. , Auman James Todd , Wu Yunhan , Hammond Kelli , O'Neil Bert , Sanoff Hanna Kelly , Innocenti Federico
Published: January 2019

597

Background: LCCC1029 was a 2:1 randomized phase II trial of second-line FOLFIRI plus either regorafenib or placebo in mCRC that showed no statistically significant difference in PFS or OS. CMS, defined using gene expression, is prognostic for PFS and OS in previously untreated mCRC, but the impact of CMS in second-line treatment is unclear, as well as its impact on regorafenib efficacy. Methods: RNAseq on archival tumor tissue was successfully performed in 68 LCCC1029 patients (49 on regorafenib, 19 on placebo). A multinomial elastic net CMS classifier was trained using 6 CRC gene expression data sets with known CMS classification. We built our model with only CMS1-4 classified samples and then applied it to normalized and median adjusted RNASeq from LCCC1029 to classify all samples into CMS1-4. TTP, PFS, and OS were compared using Kaplan-Meier method and log-rank tests, and hazard ratios were estimated using Cox proportional hazards method. Results: Our model had > 93% sensitivity and specificity for CMS1-4 in the training data set; the 17% of non-consensus samples in the training data were predominantly labeled CMS2. We classified the LCCC1029 samples as CMS1 (12%), CMS2 (63%), CMS3 (4%), and CMS4 (21%). CMS was prognostic for TTP (log-rank p=0.03), with median for CMS1 of 2.0 months (95% CI 0.0-4.8) versus 5.6 months (5.3-5.9) for CMS2 and 7.8 months (5.5-10.1) for CMS4. There was a trend toward association between CMS and either PFS (log-rank p = 0.11) or OS (log-rank p = 0.085). CMS2 had superior OS compared to CMS1 (HR 0.39, 95% CI 0.17-0.87, p = 0.02). With our limited sample size, we found no significant interaction between CMS and treatment arm for TTP, PFS, or OS. Conclusions: CMS is associated with significant differences in TTP in second-line treatment of mCRC in LCCC1029, and specific CMS types also have differences in OS. Thus, the prognostic impact of CMS extends to second-line treatment in mCRC, meriting further study of CMS classification in additional non-first-line studies.
Detection of methylated BCAT1 and IKZF1 in stage II/III rectal cancer receiving chemoradiation.
Authors: Chen Chin-Tung , Tufts Lauren , Aggarwal Piyush , Heller Frederick , Weiser Martin R.
Published: January 2019

602

Background: In liquid biopsy, analyses of circulating tumor DNA (ctDNA) in blood have been used as a tool in cancer screening, identifying tumor mutations and monitoring treatment responses/recurrences. Aberrant methylation of some genes have been associated with cancer. Two genes, BCAT1 and IKZF1, are highly methylated and specific to colorectal cancer (CRC) in blood. Detection of these two methylated genes in post-surgery samples also correlates with higher chance of recurrence. Here we investigated the presence of methylated BCAT1 and IKZF1 at multiple time-points for each patient. Methods: Plasma was extracted from blood within 4 hours of the blood collection. ctDNA were extracted from plasma and bisulphite converted using commercially available kits. Real-time qPCR was used to analyze the converted DNA in three replicates and deemed positive if at least one replicate detected either methylated BCAT1 or IKZF1. Quantification of both genes were determined using separate gene-specific standard curves. Results: Nine Stage II/III rectal cancer (RC) patients was enrolled into the study, with one pre-treatment blood draw and several subsequent draws collected throughout the treatment cycles. five patients tested positive for at least one of the methylated genes prior to treatment. Four of these five patients showed an immediate drop in detection for the assayed genes after one cycle of chemotherapy and either remains at low concentration or is undetectable through the rest of the treatment cycles. These patients either have partial or complete response to the treatment regimen. One patient with continuous high levels of methylated BCAT1 and IKZF1 post-treatment have recurred two months after surgery. Conclusions: Methylated BCAT1 and/or IKZF1 were detected in over 50% of the Stage II/III RC patients pre-treatment. This assay is sensitive to the effect of chemotherapy regimen. A significant number of these patients showed a partial/complete response to their treatment regimen and/or reduction in tumor burden, which is reflected in the loss of detection of these two genes. This study shows that this assay may be a viable tool to pair with Imaging for assessment of patient response to treatment regimen.