bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparative effectiveness and resource utilization of nab-paclitaxel plus gemcitabine (nab-P+G) versus gemcitabine monotherapy (G) in first-line treatment of advanced pancreatic adenocarcinoma (PDAC) in a U.S. community oncology setting.
Authors: Braiteh Fadi S. , Patel Manish , Parisi Monika , Ni Quanhong , Park Si yeon , Faria Claudio
Published: February 2017

429

Background: Based on a randomized clinical trial (RCT), nab-P+G had superior overall survival (OS) compared to G for the treatment of advanced PDAC, but limited data is available comparing the effectiveness of these treatment options in a real-world setting. The objective of this study is to compare treatment patterns of patients receiving nab-P+G versus G for first-line treatment of PDAC. Methods: A retrospective cohort study was performed using fully de-identified data from a nationally representative electronic medical record platform of 1,300 community oncology physicians. Patients diagnosed with advanced PDAC between September 2013 and October 2014 who received first-line therapy with either nab-P+G or Gm were included in the analysis. We calculated the median time to treatment discontinuation (TTD) and database persistence (DP), a proxy for OS, using the Kaplan Meier method, and assessed supportive care usage with Poisson regression. Results: Out of 851 patients, 168 met eligibility criteria for the analysis (nab-P+G, n=122; G, n=46). Patients in the nab-P+G arm were younger (mean age 67.0 v 72.0; p <0.01) and mostly males (60% v 44%). Other baseline characteristics were comparable. Patients treated with nab-P+G had a statistically significant longer median TTD (3.4 v 2.2 mos; p <0.01) and median DP (8.6 v 5.3 mos; p=0.03). Patients receiving nab-P+G had fewer AEs-related to discontinuation (18% v 26%); but they utilized more doses of granulocyte-colony stimulating factor (2.02 v 0.73 doses, p<0.01), erythropoietin-stimulating agents (0.90 v 0.54, p<0.01) and steroids (7.89 v 0.58 doses, p<0.01) per 100 days compared to patients receiving G. Conclusions: Similar to the RCT comparing nab-P+G with G,patients receiving nab-P+G experienced significantly longer TTD and DP in this real-world analysis compared to patients receiving G. Additionally, patients receiving nab-P+G had fewer AEs leading to discontinuation compared to patients receiving G. More supportive care may have been used in the nab-P+G group due to longer treatment duration.
Outcome analysis of primary liver carcinomas.
Authors: Doyle Maria Majella , Vachhajarani Neeta , Saad Nael , Fowler Kathryn , Tan Benjamin R. , Brunt Elizabeth , Chapman William C.
Published: February 2017

438

Background: Treatments for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHCCa) are established. Significant debate exists over optimal treatment for biphenotypic primary liver carcinomas (PLC) with combined HCC and IHCCa (B-PLC) and is considered to be a contraindication for transplantation. The purpose of this analysis is to determine single center outcomes of patients with B-PLC compared to HCC and IHCCa. Methods: A prospective database was reviewed to determine treatments and survivals of patients with HCC, IHCCa and B-PLC. Results: From 1/1/2009 to 12/31/2014, 810 patients with PLC were treated with resection (LRx) (n = 117), liver transplant (OLT) (n = 224) or liver directed therapy (LDT) (n = 469). 723 patients had HCC, 34 had IHCCa and 53 had B-PLC. Overall Survival (OS) in the LDT group, was similar comparing all tumor types at 1 yr (61.7%) and 3 yrs. (23.8%) (p =.3) Median survival (MS) was 16.2 months. OS in the LRx group was also similar between tumor types (1yr 81.1% and 5yrs. 41.1%, p =.2) and MS was 40.9 months. Comparing OLT patients with HCC (n = 212, 77% within Milan) to B-PLC (n = 10, 70% within Milan), OS (1yr 92.5% and 5 yrs. 77.0%, p =.8) was comparable and so also were disease-specific (1yr 99.0% and 5yr 97.3%, p =.6) and disease-free (1yr 88.7% and 5yrs. 73.5%, p =.4) survivals. OS for patients with B-PLC was significantly greater in patients receiving OLT vs. LRx or LDT (p =.005). Conclusions: Biphenotypic PLC has a poor prognosis and has been considered a contraindication for OLT. In this limited series, however, outcomes with transplantation appear acceptable.
A matched pair analysis of five-fraction stereotactic body radiation therapy versus protracted conventional radiation therapy in patients receiving chemotherapy for locally advanced pancreatic cancer.
Authors: Koroulakis Antony , Prins Petra , Gabrielson Andrew , Silveri Chris , Hwang Andrew , Abdulkadir Saman , McCullough Brianna , Marshall John , Pishvaian Michael J. , He Aiwu Ruth , Smaglo Brandon George , Collins Sean P. , Unger Keith Robert
Published: February 2017

444

Background: Stereotactic body radiation therapy (SBRT) is a novel treatment modality for unresectable, locally advanced pancreatic cancer (LAPC). SBRT delivers high doses of radiation over a shorter duration, with minimal acute toxicities, compared with conventional radiation therapy (CRT) using intensity modulated radiation therapy (IMRT) or 3D conformal techniques (3D-CRT). Few studies have compared outcomes between SBRT and CRT techniques. We conducted a retrospective matched pair analysis of LAPC patients receiving chemotherapy and either SBRT or CRT to assess local control (LC), progression-free survival (PFS), and overall survival (OS). Methods: We retrospectively analyzed 28 patients with LAPC who were treated between August 2006 and August 2014 with 5-FU- or gemcitabine-based chemotherapy combined with CRT (45–56 Gy over 25–28 fractions) or SBRT (25–30 Gy over 5 fractions). Fourteen patients treated with CRT were matched with 14 patients treated with SBRT for age (< 65 vs. ≥ 65 years); nodal staging (N0 or N1); and chemotherapy type (gemcitabine-based or 5-FU-based, administered either concurrently or as induction therapy). Tumor response was assessed using RECIST and all outcomes were calculated from the date of diagnosis. The Log Rank test of Kaplan-Meier curves was used for statistical analyses. Results: Median follow-up time was 11 months (mo). The median duration of LC, PFS, and OS for the entire cohort was 11, 8, and 14 mo, respectively. Median duration of LC was 10 mo for CRT and 11 mo for SBRT (p > 0.05). Median PFS was 8 mo for both groups (p > 0.05). The median OS times were 12 mo for SBRT and 16 mo for 3D-CRT/IMRT (p > 0.05). Conclusions: In this small matched-pair analysis, LAPC patients treated with chemotherapy had similar outcomes following 5 fractions of SBRT as compared with a protracted course of CRT. Given the shorter treatment duration with SBRT, further study is warranted with increased cohort sizes and stratification by other patient and disease characteristics.
Are practice patterns of high-volume pancreatic surgeons distinct from low-volume pancreatic surgeons? A IHPBA/AHPBA web-based survey study.
Authors: Macedo Fransisco Igor , Anantha Sandeep , Race Alice J , Singh Awinderpreet , Jacobs Michael J , Parikh Janak A
Published: February 2017

449

Background: Pancreatoduodenectomy (PD) is still one of the most complex operations with varied intraoperative techniques and postoperative management. The surgeon volume performing this complex surgery can determine patient outcomes and they might have distinct practice patterns. We aim to compare the practice patterns in perioperative management between high- (HV) and low-volume (LV) hepatobiliary surgeons. Methods: A 25-item survey questionnaire was electronically distributed using Survey Monkey to IHPBA and AHPBA members between May and August 2015 regarding their practice patterns for PD. HV surgeons were defined as those performing greater than 10 PD per year. Results: A total of 285 responses were included (HV, n=229; LV, n=57). The majority of participants were from United States (34.7%), Asia (14.3%) and Europe (28.1%). A significant higher proportion of LV surgeons were observed in Europe (p=0.04) and Asia (p=0.003). LV surgeons are more likely to continue perioperative antibiotics beyond 24 hours postoperatively (57.1% vs. 36.2%, p=0.009) and use more drains (p=0.04), however less likely to routinely measure postoperative drain amylase (73.6% vs. 85.6%, p=0.003). No significant difference was observed regarding management of infection, bile culture, or wound care. Conclusions: Practice patterns are variable between LV and HV pancreatic surgeons. LV surgeons are more likely to prolong prophylactic antibiotics, and use more suction drains, however HV surgeons have closer monitoring for signs of pancreatic leak. Further studies are warranted to elucidate the impact of these variations on surgical outcomes of patients undergoing pancreatoduodenectomy.
Carcinoid syndrome-related symptoms in pancreatic neuroendocrine tumors (pNETs) and impact on health care utilization.
Authors: Broder Michael S. , Chang Eunice , Reddy Sheila R. , Neary Maureen
Published: February 2017

450

Background: PNETs, rare neoplasms originating from secretory neuroendocrine cells, produce peptides and neuroamines causing hormonal syndromes, including carcinoid syndrome (CS). Somatostatin analogues (SSAs) are usual 1st-line treatment; everolimus and sunitinib are targeted therapies (TT) approved for progressive disease. Carcinoid or hormonal symptoms associated with CS may occur in pNET and are treated with SSAs. Information is limited on impact of these symptoms on health resource use in pNET. Methods: This retrospective cohort study merged 2 large HIPAA-compliant claims databases and identified pNET patients (ICD-9-CM 157.4) initiating treatment with TT or cytotoxic chemo (CC) from 2009-2012. Patients had no prior TT or CC for pNET for 1 year preindex and were continuously enrolled 1 year postindex. Descriptive statistics were reported for comorbidities and health care use, overall and by presence of symptoms defined to include: diarrhea, nausea/vomiting, flushing, cardiac palpitations, asthma, wheezing, fatigue, hypotension, or dizziness. Chi-square and t-tests were used for analyses of categorical and continuous variables, respectively. Results: This study included 338 newly treated pNET patients with 1 year followup; 237 1st-line CC and 101 TT (64 everolimus, 37 sunitinib). Mean age was 54.5; 46% female. Patients had mean of 5 (SD 2.0) chronic conditions and Charlson Index of 10.1 (SD 2.9). Utilization included 43.5% hospitalizations, 48.8% ED visits, and mean of 25.5 (SD 24.8) office visits. 212 (62.7%) patients had symptoms. Other conditions were infection (34.9%) and anemia (29.9%). PNET patients with symptoms had considerably higher rates of hospitalization, ED visits, and office visits than those without: 57.5% vs. 19.8%, 64.2% vs. 23.0%, mean 29.2 vs. 19.3, all P < 0.001. Conclusions: In this study, nearly 2/3 of treated pNET patients had carcinoid or hormonal symptoms; about 1/3 had infection and anemia. Symptoms may influence drug treatment patterns. PNET patients with symptoms were high utilizers of health resources; over half were treated as inpatients and more sought ED care. This increased use may result from a high burden of symptoms and comorbid conditions.
Comprehensive genomic profiling of advanced colorectal carcinoma in the course of clinical care to identify KRAS insertions not detected by focused molecular testing.
Authors: Rankin Andrew , Schrock Alexa Betzig , Elvin Julia Andrea , Chmielecki Juliann , Erlich Rachel , Morosini Deborah , Frampton Garrett Michael , Grothey Axel , Rosenblum Alan , Bufill Jose A. , Helton Derek A. , Sequeria Judy , George Thomas J. , Klempner Samuel Jacob , Ross Jeffrey S. , Stephens Phil , Miller Vincent A. , Ali Siraj Mahamed
Published: February 2017

497

Background: As activating RAS mutations have been shown to predict lack of benefit from anti-EGFR therapies in advanced CRC, NCCN guidelines recommend testing for KRAS exon 2 and non-exon 2 mutations; however, these alterations are thought to explain only a subset of de novo resistance to targeted therapy. In a large set of CRC assayed with comprehensive genomic profiling (CGP) in the course of clinical care, we assessed the frequency of less common KRAS short insertions that may predict failure of anti-EGFR therapy. Methods: 4,422 CRC cases were assayed with CGP performed on hybridization-captured, adaptor ligation based libraries to a mean coverage depth of > 650X for at least 236 cancer-related genes plus 47 introns from 19 genes frequently rearranged in cancer. All classes of genomic alterations (GA) were identified, including base pair substitutions, insertions/deletions, copy number alterations, and rearrangements. Pertinent available prior molecular testing results and clinical history was reviewed for selected cases. Results: Out of 4,422 CRC cases analyzed, KRAS short variants were identified in 50.9% of cases. A majority of cases contained a KRAS alteration at either codon G12 (35.5%) or G13 (9.1%), while alterations at codons Q61 or A146 were identified in 2.2% and 3.1% of cases, respectively. KRAS insertions were identified in 8 ( < 0.5%) cases. All KRAS insertions identified fell within codons 9-13, and 6/8 cases harbored V9_G10 insertions. Out of 6 patients with prior KRAS testing results available, 5 (83%) were negative by previous testing. Conclusions: CGP identifies KRAS insertions within or adjacent to hotspot regions in CRC cases which have previously tested negative for KRAS mutations. Given the importance of KRAS alterations in predicting lack of response to anti-EGFR therapies in CRC, accurate detection of these alterations in the course of clinical care is essential for effective treatment. CGP offers the possibility of identifying KRAS insertions that may impact efficacy of anti-EGFR targeted therapy and should be considered when previous focused testing for KRAS mutations is negative.
A randomized, open-label, multicenter, adaptive phase 2/3 study of trastuzumab emtansine (T-DM1) versus a taxane (TAX) in patients (pts) with previously treated HER2-positive locally advanced or metastatic gastric/gastroesophageal junction adenocarcinoma (LA/MGC/GEJC).
Authors: Kang Yoon-Koo , Shah Manish A. , Ohtsu Atsushi , Van Cutsem Eric , Ajani Jaffer A. , van der Horst Tina , Harle-Yge Marie-Laurence , Piao Yongzhe , Althaus Betsy , Thuss-Patience Peter C.
Published: February 2017

5

Background: Trastuzumab (H) + capecitabine/fluorouracil + cisplatin is standard of care for 1st-line HER2-positive MGC/GEJC but there is no established HER2-targeted 2nd-line regimen. T-DM1 (H linked to DM1) is approved for HER2-positive metastatic breast cancer previously treated with H + TAX (separately or in combination). This and preclinical HER2-positive GC models provided the rationale for GATSBY (NCT01641939). Methods: GATSBY is a 3-arm randomized, adaptive, seamless phase 2/3 global study of T-DM1 vs TAX in pts with HER2-positive (immunohistochemistry [IHC] 3+ or IHC 2+/in situ hybridization-positive), unresectable LA/MGC/GEJC who progressed during or after 1st-line fluoropyrimidine + platinum ± HER2-targeted therapy. Pts were initially randomized 2:2:1 to T-DM1 3.6 mg/kg every 3 weeks (q3w), T-DM1 2.4 mg/kg weekly (qw), or physician’s choice of paclitaxel 80 mg/m2 qw or docetaxel 75 mg/m2q3w. An independent data monitoring committee selected T-DM1 qw for further study and subsequent patients were randomized 2:1 to this or TAX. The primary endpoint is overall survival (OS); all T-DM1 qw data are analyzed, including dose selection. Results: At clinical cutoff, 06/30/15, 415 pts had been randomized overall: 228 to T-DM1 qw, 117 to TAX (70 T-DM1 q3w pts reported separately); 77.4% had prior HER2-targeted therapy; 29.9% prior gastrectomy; 46.1% were Asian. Efficacy/safety are tabulated. Conclusions: T-DM1 2.4 mg/kg qw did not show an efficacy benefit over TAX. Grade ≥3 AE rates were numerically lower with T-DM1 vs TAX and rates of SAEs, fatal AEs, and treatment discontinuations due to AEs were comparable between arms. Clinical trial information: NCT01641939. [Table: see text]
Outcomes by hypomagnesemia (hypomag) in the randomized phase III ASPECCT trial of patients (pts) with chemofractory wild-type (WT) KRAS exon 2 metastatic colorectal cancer (mCRC).
Authors: Peeters Marc , Kim Tae Won , Li Jin , Cascinu Stefano , Ruff Paul , Suresh Attili Venkatasatya , Thomas Anne , Tjulandin Sergei , Guan Xuesong , Hoang Tien , Hei Yong Jiang , Price Timothy Jay
Published: February 2017

507

Background: ASPECCT demonstrated that panitumumab (pmab) was noninferior to cetuximab (cmab) for overall survival (OS). Ad hoc analyses from ASPECCT suggested that hypomag was associated with better outcomes for pmab and cmab (Price 2015). However, results from the phase 3 NCIC CTG/AGITG CO.17 trial indicated hypomag at day 28 was associated with worse outcomes for cmab (Vickers 2013). Methods: Patients (pts) with chemorefractory WT KRASexon 2 mCRC were randomized 1:1 to receive pmab or cmab. Ad hoc analyses by hypomag were performed from the final analysis of ASPECCT at week 5, consistent with the NCIC CTG/AGITG CO.17 trial analysis (Vickers, 2013). Results: 999 pts were treated: 496 received pmab and 503 received cmab. Any grade hypomag was 29.0% and grade ≥3 was 7.3% in the pmab arm vs 19.3% and 2.8% in the cmab arm, respectively. In the pmab arm, 1.2% of pts discontinued treatment and 5% of pts had dose modifications due to hypomag vs 0.4% and 3% in the cmab arm, respectively. Efficacy results by hypomag are shown (Table). Conclusions: In ASPECCT, rates of hypomag were higher in the pmab vs the cmab arm. Pts who developed any grade hypomag with pmab or cmab had longer median OS compared with those pts who did not. Consistent with previous analyses, development of hypomag at week 5 was associated with worse median OS for cmab. Clinical trial information: NCT01001377. [Table: see text]
To screen or not to screen: Colonoscopy, a story of successful population-based screening.
Authors: Mosquera Catalina , Lea C. Suzanne , Imai Satomi , Fitzgerald Timothy Louis
Published: February 2017

508

Background: Screening for neoplasia of the breast and prostate has come under increasing scrutiny. However, little is understood regarding the temporal impact of screening on incidence and mortality for colorectal cancer (CRC). Methods: We selected states that had both CRC screening prevalence estimates from The Behavioral Risk Factor Surveillance System (BRFSS) and cancer registry data from The Surveillance, Epidemiology, and End Results (SEER) data from 1988-2012. We used SEER*Stat to compute age-adjusted incidence and mortality rates by state.Correlation coefficients were computed for change in screening. Results: The states California, Connecticut, Georgia, Hawaii, Iowa, New Mexico, and Utah were included. Each statehad unique population and tumor characteristics for age, gender, race, socioeconomic status, stage of presentation,and location of the primary, < 0.0001. Over the study period for ages 50 +, there was an increase in screening endoscopy (41 to 64%, R2 = 0.77, p < 0.0001) and a slight decrease in fecal occult blood testing (25 to 23%, R2 = 0.28, p < 0.0001). Similar trends were noted by state. There was an inverse relationship between increased screening endoscopy and incidence of CRC (60.03 to 34.68/100.000, R2 = 0.95 and p = < 0.0001); this was pronounced for early disease (45.4 to 25.7/100,000, p = < 0.0001) and minimal for late stage disease (10.5 to 7.2/100,000, p = 0.014). There was comparable trend in mortality (23.27 to 13.47 per 100.000). When evaluating states individually, the association between increasing endoscopic screening and the trends in incidence and mortality were robust (R2 0.75 – 0.92 and R2 0.65-0.95, respectively p < 0.0001). However, when states were analyzed collectively the association of screening with decreases in incidence and mortality was weaker (R2 = 0.27, p = 0.005 and R2 = 0.65, p = 0.06, respectively). Conclusions: Increased screening for CRC coincides with a decrease in incidence and mortality, disproportionality decreasing early stage cancer. This correlation is very strong within states but diminished between states, suggesting factors in addition to creening are influencing the epidemiology of CRC.
Comparison of a large NGS panel to hot-spot testing and small panels for the ability to accurately stratify advanced colorectal cancer patients to appropriate treatment pathways.
Authors: Lyle Stephen , Powers Winslow , Xu Jia , Huettner Claudia S. , Russell Meaghan , Protopopov Alexei
Published: February 2017

510

Background: It is well established that KRAS mutations confer resistance to anti-EGFR therapy for colorectal cancer patients. More recently, other RAS mutations (NRAS and BRAF) have been determined to cause similar resistance and treatment guidelines are changing to incorporate testing of these genes as well. In addition, evidence suggests that mutations outside of hot-spot regions (Codons 12 & 13 of KRAS and NRAS; BRAF V600E) can also mediate therapeutic response. Recent data also suggest that other genes are relevant for treatment planning. We evaluated the ability of a 415 gene panel, CancerPlex, to accurately stratify colorectal cancer patients to appropriate treatment pathways compared to single gene “hot-spot” testing and small gene panels ( ≤ 50 genes). Methods: 70 colorectal cancer samples were analyzed by a large NGS panel of 415 genes that includes full-gene sequencing for SNPs, short insertions and deletions, and CNVs. All actionable mutations for each patient were recorded. We calculated relative frequencies of variants present in key oncogenic drivers to compare the effectiveness of current single gene testing with data obtained using a large panel. Testing was performed in a CLIA-certified laboratory (KEW Group Inc, Cambridge, MA). Results: 40% of samples contained a KRAS hot-spot mutation. When expanded to NRAS and BRAF hot-spots, an additional 8% of patients were identified as resistant to anti-EGFR therapy. An additional 15% of clinically significant variants were captured by full-gene sequencing of these 3 genes. Thus, > 25% of mutations lie outside traditional hot-spot regions. The majority of BRAF mutations were not V600E. The 415 gene panel identified clinically significant driver mutations in 99% of patients, while in smaller panels missed a significant number of actionable changes. In very few patients were actionable changes limited to KRAS, NRAS and BRAF hot-spots. Conclusions: Hot-spot testing and small gene panels can miss clinically significant genomic alterations. The detection of mutations outside of small panels and hot-spots may lead to more appropriate and successful treatment of colorectal cancers.
The quality of CT surveillance in resected colorectal cancer survivors at Veterans Health Administration facilities.
Authors: Sehdev Amikar , Sherer Eric A , Hui Sui , Wu Jingwei , Haggstrom David Andrew
Published: February 2017

525

Background: Annual CT scan for three years is the current standard for post-treatment surveillance of colorectal cancer (CRC) survivors following curative treatment. We conducted a retrospective study with the primary aim to assess the patient, physician & organizational characteristics associated with quality of CT surveillance at Veterans Administration (VA) facilities. Methods: The Department of Veterans Affairs Central Cancer Registry was used to identify patients with stage I-III CRC between 2001 & 2009. Patient (age, race, marital status, income, priority status, year of diagnosis, stage, comorbidity), provider (primary care, specialist, other) & facility (region & organizational survey) characteristics were measured. In the primary analysis, we analyzed the impact of the 2005 ASCO update in CRC surveillance guidelines. In the secondary analysis, we included only patients diagnosed after 2005 to avoid any bias due to change in guidelines. Overuse (OU) was defined as > 1 CT/12 months, whereas underuse (UU) was defined as < 1 CT/12 months. The Wald test was used for univariate analysis & logistic regression models, for multivariate analysis. Results: The primary analysis demonstrated no change in the receipt of CT scans before & after the 2005 guideline update, as there was an increasing trend favoring more CT scans in general.In the secondary analysis, there were a total of 2,263 patients. Overall, UU (19.44% patients) occurred more often than OU (15% patients). In univariate analyses, age, stage, insurance status, provider type & facility region were significant in both OU & UU analyses (p <.001). Comorbidity was associated with OU only (p =.02). Different organizational characteristics were significant for OU & UU cohorts. Multivariate analyses showed younger age [AOR = 2.17 (1.65 - 2.86)] & higher stage [AOR =.71 (.59 -.85)] were associated with OU at p <.001. Older age [AOR = 1.89 (1.54 - 3.10)], lower stage [AOR =.63 (.49 -.81)] at p <.001 & facility region [AOR = 1.84 (1.01 - 3.35)] at p =.04 were associated with UU. Conclusions: While present, there did not appear to be substantial rates of UU or OU among CRC survivors in the VA. Age & cancer stage were associated with the quality of CT surveillance.
Sensitive, specific, and modular KRAS, NRAS, and BRAF assays for simultaneous detection of 30 important point mutations in colorectal cancer specimens.
Authors: Madanahally Divakar Kiran , Concepcion Alvin , Shea Jessica , Gupta Smriti , Kong Lilly
Published: February 2017

547

Background: Point mutations in KRAS, NRAS, and BRAF are implicated in the oncogenic RAS/RAF/MEK/ERK pathway and are prognostic and predictive markers in treating metastatic colorectal cancer patients. Here, we report the performance of three single tube highly multiplex and modular KRAS/NRAS/BRAF Assays capable of detecting 30 point mutations from FFPE-extracted DNA on the fully automated Modaplex System. Methods: Primers for multiplex KRAS/NRAS/BRAF Assays to detect 13, 13, and 4 point mutations for KRAS, NRAS, and BRAF genes, respectively, were designed using proprietary technology. Analytical sensitivity of each mutation was assessed using mutation specific ultramer oligos or Horizon Dx Mockblock specimens. Analytical specificity was determined on known wild-type FFPE DNAs. The assays were tested on DNA extracted from clinical FFPE specimens that were characterized by pyrosequencing. Modaplex data on these specimens were compared to pyrosequencing for concordance. Results: The modular Modaplex KRAS/NRAS/BRAF point mutation panels detect and differentiate 30 mutations in the KRAS, NRAS, and BRAF genes in three wells. Each assay requires just 5 µL of clinical sample extract (10-50ng DNA per assay) with a setup time of 15-30 minutes. The total run time including data analysis and setup is 4 hours. The kit includes an internal control to determine mutation status; and calibration controls to determine amplicon size. Analytical studies demonstrate the assays are sensitive (number of copies detected in one reaction), selective (mutant to wild-type ratio), and specific (relative to wild-type genomic DNA background). Nearly 110 clinical FFPE samples were tested, and the assays showed more than 95% concordance with pyrosequencing method (98% for BRAF, 97% for KRAS, and 100% for NRAS). Conclusions: Modaplex KRAS/NRAS/BRAF assays provide an accurate and sensitive method of mutation detection. These automated multiplexed assays to detect key mutations in three genes can be performed on a single platform facilitating clinical or translational research. *Modaplex KRAS/NRAS/BRAF Assays are for Research Use Only. Not for clinical diagnostic use.
Demographic, tumor characteristics, and outcomes associated with SMAD4 mutation in colorectal cancer.
Authors: Mehrvarz Sarshekeh Amir , Overman Michael J. , Kee Bryan K. , Fogelman David R. , Dasari Arvind , Raghav Kanwal Pratap Singh , Vilar Sanchez Eduardo , Manuel Shanequa , Shureiqui Imad , Wolff Robert A. , Patel Keyur , Luthra Rajyalakshmi , Shaw Kenna Rael , Eng Cathy , Maru Dipen M. , Routbort Mark , Meric-Bernstam Funda , Kopetz Scott
Published: February 2017

565

Background: SMAD4 regulates signaling in TGF-β pathway as inactivation of SMAD4 renders resistance of cells to TGF-β1-induced growth inhibition. Sporadic mutation of SMAD4 has been reported to be present in 8.6-25% of colorectal cancers (CRC), but the clinicopathologic features and outcomes associated with this mutation have not been described. Methods: Data for patients (pts) with metastatic or locally advanced unresectable CRC who received treatment at MD Anderson Cancer Center whose tumors underwent genotyping for SMAD4 mutation were reviewed and clinicopathologic characteristics, and survival outcomes were evaluated. Tumors were sequenced using a hotspot panel (Ion Torrent, Life Technology) predicted to cover 80% of the reported mutations in SMAD4, and further targeted resequencing that included full-length SMAD4 was performed on mutated ones by HiSeq (Illumina) with full exome coverage to an average depth of 800. Results: Among 616 pts (47.4% females) with CRC, 11.2% of pts (n = 69) had SMAD4 mutation by hotspot testing. SMAD4 mutation was associated with colon cancer versus rectal cancer (OR = 2.1, p = 0.01) and female gender (15% vs 8%, OR = 2.12, p = 0.004). There was no association between the presence of SMAD4 mutation and age, stage at the presentation, tobacco history, colonic location, presence of distant metastasis, histology, nor tumor grade. When compared to pts with wild-type SMAD4, those with SMAD4 mutation had shorter survival from date of testing (median survival of 20.2 months versus 14 months, respectively; log-rank, HR = 1.4, p = 0.014). Full-length sequencing was performed on mutated tumors and it confirmed that missense mutations in R361 and P356 in the MH2 domain were the most common, which are predictive of disruption of both homo- and hetero-oligomerization required for activation. Conclusions: This study is the largest retrospective study to date characterizing SMAD4 mutation in metastatic CRC, and demonstrates a prognostic role for this subgroup of CRC. The prevalence and spectrum of SMAD4 mutations is consistent with previous studies and data from TCGA. Further studies are required to evaluate the implication of the dysregulated TGF- β pathway on response to therapy.
Micro-RNAs in stage II colorectal cancer: Is there any role?
Authors: Mohamed Salem Eid , Allahloubi Nasr Mohamed Ali , Bahnassy Abeer Ahmed , Khorshid Ola , Gadelmola Mohamed Elsayed
Published: February 2017

566

Background: Patients with stage II CRC have a varying survival outcome. Therefore, it is critical to identify new prognostic biomarkers that can help to identify more aggressive forms of the disease. The aim of this study was to identify the potential prognostic value of miRNAs in patients with stage II CRC. Methods: The study included 124 patients with stage II CRC who attended the NCI - Medical Oncology clinics, received treatment and followed-up during the period from January 2004 to December 2014. The expression levels of the five studied miRNAs were examined by qRT-PCR analysis. Additionally, blood samples were drawn from 41 patients recruited in the study in the last 3 years of recruitment to assess the level of miRNAs in blood. Results: In tumor tissues of 124 patients, miR-137, miR-145 and miR-320 were significantly under-expressed in 39.5%, 38.4% and 52.4% of cases, respectively while miR-21 and miR-498 were significantly over-expressed in 48.4% and 40.3%, respectively. On the other hand, assessment of these miRNAs in the blood of 41 cases revealed that miR-137, miR-145 and miR-320 were significantly under-expressed in 46.3%, 46.3% and 51.2% of cases, respectively while miR-21 and miR-498 were significantly over-expressed in 46.3% and 43.9%, respectively. The concordance between tissue and blood was weak with miR-320 and miR-145 (kappa 40-65%), intermediate with miR-498 and miR-137 (kappa 65-75%) while strong concordance has been achieved with miR-21 (kappa 75-85%). Performance status, over-expression of miR-21 and miR-498 and under-expression of miR-137, miR-145, and miR-320 were associated with significantly inferior DFS and OS in univariate analysis. In a multivariate analysis, deregulated miR-498 and miR-320 were independent prognostic factors for worse DFS, while over-expressed miR-498 and miR-21 were found to be independent prognostic factors for inferior OS. Conclusions: MiRNAs play an important role as prognostic markers in stage II CRC patients. Large-scale collaborative efforts are still absolutely essential to aid in determining the clinical potential of miRNAs as diagnostic, prognostic, and predictive biomarkers in CRC in order to achieve better survival outcomes.
Clinical and molecular assessment of response to regorafenib.
Authors: Kakizawa Nao , Suzuki Koichi , Takayama Yuji , Ichida Kosuke , Fukui Taro , Watanabe Fumiaki
Published: February 2017

568

Background: Regorafenib provides anti-tumor effects in 3rd or 4th line for metastatic colorectal cancer patients (pts), but some of pts show severe adverse effects (AE). It is, therefore, crucial to select patients more likely benefit from regorafenib. Methods: Twenty pts were treated with regorafenib for metastatic colorectal cancer and 91 plasma samples from 16 pts were available for monitoring of circulating tumor DNA (ctDNA) in blood. The treatment response, adverse effects, progression-free survival (PFS), overall survival (OS) and morphologic response in CT image were evaluated. KRAS mutant ctDNA (MctDNA) was determined by digital PCR. Results: According to Response Evaluation Criteria in the Solid tumors (RECIST), 6 patients (30%) showed SD, and 8 pts (40%) exhibited PD. Median PFS was 1.2 months (range; 0.2-14.2 months), and median OS was10.6 months (range; 0.7-15.6 months). Treatments are continued for 4 pts but discontinued for others. The reasons of discontinuation were PD for 8 pts and AE for 7 pts. Seven pts showing AE include 3 pts with liver function disorder, 3 pts with severe fatigue and one pt with Grade 3 skin toxicity. Three pts with liver function disorder showed extensive multiple liver tumors. PS 2 was seen in 2 pts with severe fatigue. PFS in pts showing treatment discontinuation due to AE was 0.6 month but PFS in pts with other reasons rather than AE was 3.3 months. According to morphologic response criteria, 3 among 6 pts harboring SD in RECIST, showed optimal response in early period of the treatment. These 3 pts with morphological response showed better PFS such as 3.5, 5.3, and 14.2 months, respectively. Six pts displayed KRAS mutant ctDNA (MctDNA) in blood. Among them, 2 pts showed MctDNA during treatment and then exhibited tumor progression. Emergence of MctDNA was observed in one pt without KRAS mutation in tumor tissues. MctDNA was detectable in the blood of these 2 pts prior to radiographic detection of disease progression. Conclusions: Pts with extensive multiple liver tumor or poor PS unlikely benefit from Regorafenib. Pts with optimal morphologic response likely benefit from Regorafenib by adequate management of other AEs. In addition, monitoring of KRAS mutation in ctDNA could be predictive biomarker for treatment response.
Interaction of KRAS somatic mutation and colorectal carcinoma and its association with differential DNA methylation.
Authors: Jasmine Farzana , Kamal Mohammed , Roy Shantanu , Rahman Mustafizur , Raza Maruf , Paul Rupash , Hasan Kamrul , Haq Zahidul , Ahsan Habibul , Kibriya Muhammad Ghulam
Published: February 2017

577

Background: We examined if KRAS somatic mutation in colorectal carcinoma (CRC) is associated with differential tumor DNA methylation. Methods: We did a genome-wide methylation assay (450K) for a total of 250 paired samples from 125 CRC patients (m = 72, f = 53) at different stages (stage 1: 25, stage II: 33 and stage III: 67). Of them 101 had left-sided CRC (descending colon to rectum); 30 had MSI, and 34 had somatic mutation in KRAS (rs112445441). Results: Frequency of KRAS mutation was not different between right and left-sided CRC (29% vs. 27%). But, like other series, MSI was more frequent in the right-sided tumor (54% vs. 17%, p = 0.003). In patients with wild type KRAS tumor (n = 91), paired comparison between tumor and corresponding normal tissue identified a total of 1244 tumor-specific differential methylation loci (DML) covering 532 genes that were significant at FDR 0.001 and magnitude of difference ≥ 20%; But similar analysis in patients with KRAS mutation (n = 34) revealed 7612 tumor-specific DML covering 2357 genes - suggesting an association of KRAS mutation and DNA methylation. We also found that MSI in tumor tissue was associated with DNA methylation change too. Next, we identified 726 genes that are markedly differentially methylated in tumor compared to corresponding normal tissue only in presence of KRAS mutation, irrespective of MSI status, staging, and location of tumor (KRAS mutation associated tumor-specific genes – list enriched in GO ontology “developmental process”, “biological regulation”). We also identified 241 genes that are differentially methylated in tumor compared to normal tissue irrespective of KRAS mutation, MSI status, staging, and location of tumor. (common tumor-specific genes) Conclusions: KRAS somatic mutation is independently associated with methylation changes in a number of genes related to carcinogenesis in CRC.
Alteration of ADCC-related genes as a novel predictor of efficacy of cetuximab (cet)-based chemotherapy in patients (pts) with metastatic colorectal cancer (mCRC) (JACCRO CC-05/06 AR).
Authors: Sunakawa Yu , Yang Dongyun , Cao Shu , Roberts Chris , Wang Eva , Moran Miriana , Astrow Stephanie H. , Thompson Debrah , Hsiang Jack , Zhang Wu , Tsuji Akihito , Takahashi Takehiro , Denda Tadamichi , Kochi Mitsugu , Shimada Ken , Takeuchi Masahiro , Fujii Masashi , Nakajima Toshifusa , Ichikawa Wataru , Lenz Heinz-Josef
Published: February 2017

589

Background: Cet exerts its therapeutic effects not only through EGFR-signal blockade but also through antibody-dependent cell-mediated cytotoxicity (ADCC), mainly driven by natural killer (NK) cells. NK cells play a key role by releasing granzyme B (GZMB) via perforin (PRF1)-formed pores, leading to tumor cell apoptosis. CD137 (TNFRSF9) is expressed on NK cells, which regulates activation and proliferation of T cells. We hypothesized that genetic alteration in NK cell-mediated ADCC may serve as a predictor of cet in mCRC pts. Methods: Genomic DNA and RNA were isolated from tumor tissues of 77 KRAS exon2 wild-type (wt) pts enrolled in 2 Japanese phase II trials of cet plus oxaliplatin-based chemotherapy as 1st-line therapy, FOLFOX (n= 28/57, UMIN000004197) and SOX (n= 49/67, UMIN000007022). We evaluated associations between functional polymorphisms and gene expression of TNFRSF9, GZMB, and PRF1, and clinical outcome using PCR-based direct sequencing and molecular profiling panel (HTG EdgeSeq Oncology Biomarker Panel) based on next generation sequencing. Recursive partitioning (RP) method was also used to explore the associations. Results: In the population with median age of 63 years and follow-up time of 31.4 months (m), response rate (RR), median progression-free survival (PFS), and overall survival (OS) were 73 %, 10.0 m, and 33.9 m, respectively. TNFRSF9 rs161826 (A > G) was associated with PFS but not RR or OS in both univariate (any G vs A/A: 9.2 m vs 13.8 m, HR 1.75, P= 0.030) and multivariate analyses (P= 0.050). No association of rs161826 with gene expression was observed. PRF1 polymorphisms were not associated with outcome, while high PRF1 mRNA expression had association with shorter PFS (9.7 m vs 18.0 m, HR 2.60, P= 0.028), and it remained significant in multivariate analysis (P= 0.002). In RP analysis, PRF1 mRNA expression also showed significant association with PFS. Conclusions: TNFRSF9 rs161826 and PRF1 gene expression are significantly associated with PFS in pts with KRAS wt mCRC treated with cet-based chemotherapy. Gene expression and variation in NK cell-mediated ADCC may predict efficacy of cet (UMIN000010635). Clinical trial information: UMIN000010635.
The lymphocyte-to-monocyte ratio as a predictor of overall survival in comparison to established systemic markers of inflammation in resectable colorectal cancer.
Authors: Chan Joseph , Diakos Connie Irene , Chan David , Gill Anthony J , Engel Alexander , Clarke Stephen John
Published: February 2017

593

Background: The prognostic significance of systemic inflammatory markers in colorectal cancer (CRC) such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and modified Glasgow prognostic score (mGPS) have been well defined in literature. In addition, commonly utilized genetic markers such as combined BRAF-MMR status have also been found to be prognostic. Recent evidence suggests that the lymphocyte-to-monocyte ratio (LMR) may hold prognostic utility in CRC. However the LMR has still not been clearly defined in either its clinical utility or in comparsion to other established biomarkers. Methods: Consecutive patients from the Northern Sydney Local Health District undergoing curative surgical resection for colorectal cancer from January 1998 to December 2012 were collated. Of the 3281 patients identified, 1623 patients with complete pre-operative blood counts, BRAF-MMR IHC and clinicopathologic data were further analysed. Variables were analysed in univariate and then a multivariate cox regression model using forwards conditional method looking for association with overall survival (OS). Results: In multivariate analysis of 1623 patients, elevated LMR was associated with better overall survival (OS) (HR 0.565, 95% CI: 0.475-0.672, P < 0.001) independent of age (P < 0.001), T stage (P < 0.001), N stage (P < 0.001) and grade (P = 0.049). Other biomarkers such as NLR, PLR and combined BRAF-MMR status were not significantly associated with OS. In multivariate subgroup analysis of 389 patients with available mGPS data, LMR remained the only independently prognostic biomarker (HR 0.620, 95% CI: 0.437-0.880, p = 0.007). Conclusions: The LMR is an independent predictor of OS in CRC patients undergoing curative resection. Furthermore, the LMR appears to be superior to previously established biomarkers.
Histological tumor regression after preoperative chemotherapy for colorectal liver metastases: Correlations with radiological response and prognosis.
Authors: Inada Ryo , Iwamoto Shigeyoshi , Kaibori Masaki , Ishizaki Morihiko , Iida Hiroya , Matsui Kosuke , Oishi Masaharu , Matsumoto Tomoko , Michiura Taku , Inoue Kentaro , Kon Masanori , Hamada Madoka
Published: February 2017

609

Background: The purpose of this study was to characterize histological tumor regression grade (TRG) to colorectal liver metastases (CLM) treated with preoperative chemotherapy followed by liver surgery, and to evaluate whether TRG correlates with radiological response and prognosis. Methods: This study included 30 patients with CLM treated by surgical resection after preoperative chemotherapy with oxaliplatin- or irrinotecan-based regimens with or without molecular target agents. TRG was determined by the amount of fibrosis and necrosis replaced from tumor cells, ranging TRG 0 (0%), 1 (1-24%), 2 (25-50%), 3 (51-99%), and 4 (100%). Results: TRG 0, 1, 2, 3, and 4 were observed in 0%, 6.7%, 10.0%, 66.7%, and 16.6% of the patients, respectively. There were no relations between TRG and regimen, including molecular target agents. As shown in the table, radiological response was not significantly correlated with TRG. Patients with histological major response (TRG 3+4) had better prognosis (MST; TRG 1+2 vs. 3+4: 20.0 vs. 50 months, P= 0.007), and a multivariate analysis identified histological major response as an independent good prognostic factor. Conclusions: In this analysis, histological TRG predicted survival after preoperative chemotherapy and resection for CLM. Preoperative radiological response could not evaluate TRG. [Table: see text]
Methylation profiling of locally advanced rectal cancer (LARC): Exploration of potential predictive markers for neoadjuvant chemoradiation (NACR).
Authors: Guo Songchuan , Melamed Jonathan , Eze Ogechukwu , Bowman Christopher , Ahmed Sunjida , Moore Harvey G. , Loomis Cynthia , Heguy Adriana , Brody Rachel , Morrison Debra J. , Serrano Jonathan , Du Kevin Lee , Wu Jennifer J. , Ryan Theresa , Cohen Deirdre Jill , Gu Ping , Goldberg Judith D , Snuderl Matija , Leichman Lawrence P. , Leichman Cynthia G.
Published: February 2017

614

Background: NACR followed by total mesorectal excision (TME) is standard of care for LARC. However, only 10-20% of patients achieve complete pathologic response with associated optimal clinical outcome. No predictive biomarker is currently available. Aberrant DNA methylation is well known for its key role in the pathogenesis of colorectal cancer. Previous rectal cancer methylation studies were conducted in patients without NACR or inconclusive. We hypothesized a correlation between methylation status and pathologic outcome following NACR. Methods: This is an IRB approved, retrospective, translational study of patients with LARC who received identical NACR before TME at New York University hospitals. Ten micron sections from FFPE tissue blocks underwent laser capture microdissection (LCM) followed by genome DNA isolation. Illumina Infinium 450k methylation array was used to assess 485,000 methylation sites. Methylation profiles and copy number changes were analyzed using in-house bioinformatics. Histone H3K27me, a global methylation marker, was assessed using immunohistochemistry (IHC) and expression quantified in carcinoma cells, normal epithelium, inflammatory cells, stromal cells and endothelial cells. Results: Tumor specimens from 52 patients were collected. Analyzed specimens of stromal and cancer cells showed distinct methylation profiles pre- and post- therapy. The histone H3K27me3 mark was markedly increased in carcinoma compared to normal epithelium and strong trimethyl mark expression persisted in invasive carcinoma after the therapy including single cells. We obtained adequate DNA to demonstrate differences between pre- and post- NACR specimens and tissue sites. Full data set, including the known clinical and pathologic results, is to be presented. Conclusions: This is the first study to combine LCM and high throughput quantitative methylation profiling in rectal cancer to correlate with NACR outcome. Histone H3K27me3 IHC can be used to identify high-grade and invasive carcinoma with high specificity. Data from our annotated clinical cohort and correlative molecular results can inform a future prospective trial.