A phase I radiation dose-escalation study to determine the maximal dose of radiotherapy in combination with weekly gemcitabine in patients with locally advanced pancreatic adenocarcinoma

<p>Abstract</p> <p>Background</p> <p>The primary objective of this study was to determine the maximum tolerated dose (MTD) of escalating doses of radiotherapy (RT) concomitantly with a fixed dose of gemcitabine (300 mg/m²/week) within the same overall treatment time.</p> <p>Methods</p> <p>Thirteen patients were included. Gemcitabine 300 mg/m²/week was administered prior to RT. The initial dose of RT was 45 Gy in 1.8 Gy fractions, escalated by adding 5 fractions of 1.8 Gy (one/week) to a dose of 54 Gy with a total duration kept at 5 weeks. All patients received a dynamic MRI to assess the pancreatic respiratory related movements. Toxicity was scored using the RTOG-EORTC toxicity criteria.</p> <p>Results</p> <p>Three of six patients experienced an acute dose limiting toxicity (DLT) at the 54 Gy dose level. For these patients a grade III gastro-intestinal toxicity (GI) was noted. Patients treated at the 45 Gy dose level tolerated therapy without DLT. The 54 Gy dose level was designated as the MTD and was deemed not suitable for further investigation.</p> <p>Between both dose levels, there was a significant difference in percentage weight loss (p = 0.006) and also in cumulative GI toxicity (p = 0.027). There was no grade 3 toxicity in the 45 Gy cohort versus 4 grade 3 toxicity events in the 54 Gy cohort. The mean dose to the duodenum was significantly higher in the 54 Gy cohort (38.45 Gy vs. 51.82 Gy; p = 0.001).</p> <p>Conclusion</p> <p>Accelerated dose escalation to a total dose of 54 Gy with 300 mg/m²/week gemcitabine was not feasible. GI toxicity was the DLT. Retrospectively, the dose escalation of 9 Gy by accelerated radiotherapy might have been to large. A dose of 45 Gy is recommended. Considering the good patient outcomes, there might be a role for the investigation of a fixed dose of gemcitabine and concurrent RT with small fractions (1.8 Gy/day) in borderline resectable or unresectable non-metastatic locally advanced pancreatic cancer.</p

G-8 indicates overall and quality-adjusted survival in older head and neck cancer patients treated with curative radiochemotherapy

Background: Evidence-based guidelines concerning the older head and neck cancer (HNCA) patient are lacking. Accurate patient selection for optimal care management is therefore challenging. We examined if geriatric assessment is indicative of long-term health-related quality of life (HRQOL) and overall survival in this unique population. Methods: All HNCA patients, aged >= 65 years, eligible for curative radio(chemo) therapy were evaluated with the Geriatric-8 (G-8) questionnaire and a comprehensive geriatric assessment (CGA). Euroqol-5 dimensions (EQ-5D) and survival were collected until 36 months post treatment start. Repeated measures ANOVA was applied to analyse HRQOL evolution in 'fit' and 'vulnerable' patients, defined by G-8. Kaplan-Meier curves and cox proportional hazard analysis were established for determination of the prognostic value of geriatric assessments. Quality-adjusted survival was calculated in both patient subgroups. Results: One hundred patients were recruited. Seventy-two percent of patients were considered vulnerable according to CGA (>= 2 abnormal tests). Fit patients maintained a relatively acceptable long-term HRQOL, whilst vulnerable patients showed significantly lower median health states. The difference remained apparent at 36 months. Vulnerability, as classified by G-8 or CGA, came forward as independent predictor for lower EQ-5D index scores. After consideration of confounders, a significantly lower survival was observed in patients defined vulnerable according to G-8, compared to fit patients. A similar trend was seen based on CGA. Calculation of quality-adjusted survival showed significantly less remaining life months in perfect health in vulnerable patients, compared to fit ones. Conclusions: G-8 is indicative of quality-adjusted survival, and should be considered at time of treatment decisions for the older HNCA patient

The prognostic value of the hypoxia markers CA IX and GLUT 1 and the cytokines VEGF and IL 6 in head and neck squamous cell carcinoma treated by radiotherapy ± chemotherapy

BACKGROUND: Several parameters of the tumor microenvironment, such as hypoxia, inflammation and angiogenesis, play a critical role in tumor aggressiveness and treatment response. A major question remains if these markers can be used to stratify patients to certain treatment protocols. The purpose of this study was to investigate the inter-relationship and the prognostic significance of several biological and clinicopathological parameters in patients with head and neck squamous cell carcinoma (HNSCC) treated by radiotherapy ± chemotherapy. METHODS: We used two subgroups of a retrospective series for which CT-determined tumoral perfusion correlated with local control. In the first subgroup (n = 67), immunohistochemistry for carbonic anhydrase IX (CA IX) and glucose transporter-1 (GLUT-1) was performed on the pretreatment tumor biopsy. In the second subgroup (n = 34), enzyme linked immunosorbent assay (ELISA) was used to determine pretreatment levels of the cytokines vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) in serum. Correlation was investigated between tumoral perfusion and each of these biological markers, as well as between the markers mutually. The prognostic value of these microenvironmental parameters was also evaluated. RESULTS: For CA IX and GLUT-1, the combined assessment of patients with both markers expressed above the median showed an independent correlation with local control (p = 0.02) and disease-free survival (p = 0.04) with a trend for regional control (p = 0.06). In the second subgroup, IL-6 pretreatment serum level above the median was the only independent predictor of local control (p = 0.009), disease-free survival (p = 0.02) and overall survival (p = 0.005). CONCLUSION: To our knowledge, we are the first to report a link in HNSCC between IL-6 pretreatment serum levels and radioresistance in vivo. This link is supported by the strong prognostic association of pretreatment IL-6 with local control, known to be the most important parameter to judge radiotherapy responses. Furthermore, the combined assessment of CA IX and GLUT-1 correlated independently with prognosis. This is a valuable indication that a combined approach is important in the investigation of prognostic markers

Serial comprehensive geriatric evaluation in older head and neck cancer patients undergoing radiotherapy

Downregulating transcription of the oncogene <i>c-MYC</i> is a feasible strategy for cancer therapy. Stabilization of the G-quadruplex structure present in the <i>c-MYC</i> promoter can suppress <i>c-MYC</i> transcription. Thus, far, several ligands targeting this structure have been developed. However, most have shown no selectivity for the <i>c-MYC</i> G-quadruplex over other G-quadruplexes, leading to uncertain side effects. In this study, through structural modification of aryl-substituted imidazole/carbazole conjugates, a brand-new, four-leaf clover-like ligand called <b>IZCZ-3</b> was found to preferentially bind and stabilize the <i>c-MYC</i> G-quadruplex. Further intracellular studies indicated that <b>IZCZ-3</b> provoked cell cycle arrest and apoptosis and thus inhibited cell growth, primarily by blocking <i>c-MYC</i> transcription through specific targeting of the promoter G-quadruplex structure. Notably, <b>IZCZ-3</b> effectively suppressed tumor growth in a mouse xenograft model. Accordingly, this work provides an encouraging example of a selective small molecule that can target one particular G-quadruplex structure, and the selective ligand might serve as an excellent anticancer agent

Echium oil is not protective against weight loss in head and neck cancer patients undergoing curative radio(chemo)therapy: a randomised-controlled trial

Background: Therapy-induced mucositis and dysphagia puts head and neck (H&N) cancer patients at increased risk for developing cachexia. Omega-3 fatty acids (n-3 FA) have been suggested to protect against cachexia. We aimed to examine if echium oil, a plant source of n-3 FA, could reduce weight loss in H&N cancer patients undergoing radio(chemo)therapy with curative intent. Methods: In a double-blind trial, patients were randomly assigned to echium oil (intervention (I) group; 7.5 ml bis in die (b.i.d.), 235 mg/ml α-linolenic acid (ALA) + 95 mg/ml stearidonic acid (SDA) + 79 mg/ml γ-linolenic acid (GLA)) or n-3 FA deficient sunflower oil high oleic (control (C) group; 7.5 ml b.i.d.) additional to standard nutritional support during treatment. Differences in percentage weight loss between both groups were analysed according to the intention-to-treat principle. Erythrocyte FA profile, body composition, nutritional status and quality of life were collected. Results: Ninety-one eligible patients were randomised, of whom 83 were evaluable. Dietary supplement adherence was comparable in both groups (median, I: 87%, C: 81%). At week 4, the I group showed significantly increased values of erythrocyte n-3 eicosapentanoic acid (EPA, 14% vs −5%) and n-6 GLA (42% vs −20%) compared to the C group, without a significant change in n-6 arachidonic acid (AA, 2% vs −1%). Intention-to-treat analysis could not reveal a significant reduction in weight loss related to echium oil consumption (median weight loss, I: 8.9%, C: 7.6%). Also, no significant improvement was observed in the other evaluated anthropometric parameters. Conclusions: Echium oil effectively increased erythrocyte EPA and GLA FAs in H&N cancer patients. It failed however to protect against weight loss, or improve nutritional parameters. Trial registration: ClinicalTrials.gov Identifier NCT01596933

Predictive and/or prognostic markers in rectal adenocarcinomas

Introduction Nowadays, patients with a locally advanced colorectal tumour are treated preoperatively either with radiotherapy alone or with a combination of chemo- and radiotherapy. However, the response of individual tumours to the neoadjuvant therapies is not uniform, making the search for predictive and/or prognostic markers of cancer response to neoadjuvant treatments of significant clinical relevance. This thesis attempts to identify some of these markers by immunohistochemically defined patterns of protein expression, which includes spatial location, and to correlate responses with outcome. Immunohistochemistry using whole tissue sections has the disadvantage of being time consuming and expensive when screening large patient groups. We therefore used a new tissue microarray (TMA) technique (1). In this technique, cylindrical tissue samples are taken from up to 1000 different archival tissue blocks and subsequently placed onto one empty “recipient” paraffin block. Sections from TMA blocks can be used for all different types of in situ tissue analyses including immunohistochemistry. Validation of the scoring procedures and the TMA technique. Semiquantitative analyses of immunohistochemically stained sections require a reliable scoring methodology. Therefore, an experiment was set up where totally artificially images were generated and scored by a human observer. The scoring was done as real tissue sections are: for the amount of tumour present and for the positivity of the stain, so the weighted mean percentage positivity of areas within the tumour could be calculated. The conclusion was that the amount of tumour per image was slightly underestimated and the percentage positivity of the tumour slightly overestimated, which negated each other, validating the methodology. Working with TMAs instead of with whole tissue sections has the advantage of performing uniform stainings, reducing the costs of antibodies, reducing manual interactions and guaranteeing more uniform scorings, but at the expense of losing some information since only parts of the tumours are analysed. It has the possibility of missing information since only a small amount of tissue is studied, compared to the study of whole tissue sections. Therefore the calculation of the number of core biopsies needed to account for tumour heterogeneity is crucial. Ten immunohistochemical sections were digitized and used to generate artificial core biopsies. These core biopsies (500 in total) were all scored as described above. Powerful mathematical methods were used to calculate the standard deviation in percentage positivity for increasing number (n) of core biopsies (n varying between 1 and 10). The recommendations are: one should take at least four biopsies where possible, keeping in mind that the standard deviation increases as the mean percentage positivity increases to 50% and decreases again as the mean percentage positivity reaches 100%. The search for clinical prognosticators. Prognosticators or predictors can only be studied in a patient population for which clinical as well as pathological data are available. Therefore a retrospective study was set up where 110 consecutive patients treated with either radiotherapy only (30Gy/10fr) or treated with a combination of radio– and chemotherapy (45Gy/25fr + 5FU/LV) were studied. Patient characteristics for both groups were homogeneously distributed except for the cN status, with more node positive patients in the chemoradiation group. No differences concerning outcomes, or toxicity were found between the two treatment arms. Both preoperative treatment schemes caused downstaging of T-stage and of N-stage. Moreover, patients with tumours that showed T-downstaging had a significantly better disease-free and overall survival compared to those who did not. Multivariate analysis showed that ypN-stage (p<0.01) was an independent predictor of local recurrence, ypT-stage (p<0.01) was an independent predictor of disease recurrence and resection margins and ypN-stage were independent predictors for overall survival. Is hypoxia present in colorectal tumours? Hypoxia is one of the causes of tumour treatment resistance. The hypoxic fraction in solid tumours reduces sensitivity to conventional treatment modalities, influences growth, and may increase malignant progression. Hypoxia can be broadly categorized into two main types: “chronic” or “diffusion-limited” hypoxia and “acute” or “transient” hypoxia. Since the most quantitative and widely used method to measure hypoxia is a commercially available polarographic oxygen electrode which can only be applied to superficially accessible tumours, to date no data are available on the existence of hypoxia in colorectal tumours. Therefore a prospective study was set up where patients were injected with an extrinsic hypoxia marker (pimonidazole) and an extrinsic cell proliferation marker (IdUrd) to quantify the regions of respectively chronic and acute hypoxia. Based on the expression patterns of pimonidazole which were found around regions of debris at a certain distance from blood vessels, and the inverse relationship with the micro vessel density (R=-0.55 ; p=0.01) we do believe chronic hypoxia is present in colorectal tumours. The number of non-functioning blood vessels (determined as blood vessels surrounded by tumour cells negative for IdUrd, but positive for Ki67) representing acute hypoxic regions was low, though present (0.08% - 11%). Besides demonstrating the existence of hypoxia in colorectal tumours, we searched for potentially endogenous hypoxia markers. The relationship between Vascular Endothelial Growth Factor (VEGF), Carbonic Anhydrase IX (CA IX), Epidermal Growth Factor Receptor (EGFR) and pimonidazole-positive regions couldn’t be established. The search for biological prognosticators. In this chapter, we retrospectively analyzed tumour material from pretreatment biopsies and resection specimens from 105 patients with an advanced rectal adenocarcinoma using TMAs. TMAs were stained for EGFR, CA IX, Ki67, VEGF, Cyclo-oxygenase 2 (COX-2) and Nuclear Factor-κ-B (NF-κB) expression. Thirteen cores per patient tumour sample and a total of 1308 cores were scored semi-quantitatively for expression levels of all proteins. High COX-2 expression in the pre-treatment biopsy was a (negative) prognostic factor for overall survival in univariate analysis (p=0.04). There was no significant correlation between and with expression of any other marker. None of the studied markers had predictive value in univariate or multivariate analysis, though COX-2 expression was upregulated after neoadjuvant treatment (p=0.01) and EGFR and Ki67 expression were significantly downregulated (p<0.001). Hierarchical clustering analysis as well as factor analysis revealed that expression levels of the six studied proteins were unrelated to each other. Multivariate analysis showed that ypT-stage (p=0.003) and section margins (p=0.04) independently predicted overall survival, and cN-(p=0.04) and ypN-stage (p=0.003) disease free survival. For local control, ypN-stage (p=0.01) and section margins (p=0.01) were independently significant. Quality control on our work with TMAs was done using a 216 spot tissue microrarray using paraffin-embedded tissue from 12 colorectal cancers. Immediately after surgery, specimens from tumour rim or tumour centre were formalin-fixed individually overnight, for > 24 h, or for > 48 h, respectively. After evaluation by H&E staining, three cores from each specimen were assembled in a tissue array, i.e. 18 cores per tumour. Sections were stained for all six studied immonomarkers and scored. When average staining pattern for the three cores per location was calculated, there was no difference between tumour centre and rim (p ≥0.62 in paired t-tests for all comparisons). Most importantly, fixation time had no impact on the expression levels of the five antigens (p values from 0.12 to 0.93). In summary, pre-therapy COX-2 expression was associated with poor survival in advanced rectal cancer, but no significant correlation could be found between for Ki67, NF-κB, CA IX, COX-2, EGFR and VEGF and levels of all markers varied indepentently. Further it was proven that a quality control TMA is functional and it seems to be a good platform to test the reliability of a given antibody and staining procedure before its use in translational research.status: publishe