Identifying prognostic biomarkers for palbociclib add-on therapy in fulvestrant-resistant breast cancer using cell-free DNA sequencing.

BACKGROUND: The FUTURE trial (UMIN000029294) demonstrated the safety and efficacy of adding palbociclib after fulvestrant resistance in patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) advanced and metastatic breast cancer (ABC/MBC). In this planned sub-study, cancer panel sequencing of cell-free DNA (cfDNA) was utilized to explore prognostic and predictive biomarkers for further palbociclib treatment following fulvestrant resistance. MATERIALS AND METHODS: Herein, 149 cfDNA samples from 65 patients with fulvestrant-resistant disease were analysed at the time of palbociclib addition after fulvestrant resistance (baseline), on day 15 of cycle 1, and at the end of treatment using the assay for identifying diverse mutations in 34 cancer-related genes. RESULTS: During the course of treatment, mutations in ESR1, PIK3CA, FOXA1, RUNX1, TBX3, and TP53 were the most common genomic alterations observed. Analysis of genomic mutations revealed that before fulvestrant introduction, baseline PIK3CA mutations were marginally lower in metastatic aromatase inhibitor (AI)-treated patients compared to adjuvant AI-treated patients (P = 0.063). Baseline PIK3CA mutations were associated with poorer progression-free survival [hazard ratio: 1.62, P = 0.04]. Comparative analysis between baseline and early-changing gene mutations identified poor prognostic factors including early-changing MAP3K1 mutations (hazard ratio: 4.66, P = 0.04), baseline AR mutations (hazard ratio: 3.53, P = 0.04), and baseline PIK3CA mutations (hazard ratio: 3.41, P = 0.02). Notably, the relationship between ESR1 mutations and mutations in PIK3CA, MAP3K1, and TP53 weakened as treatment progressed. Instead, PIK3CA mutations became correlated with TP53 and FOXA1 mutations. CONCLUSIONS: Cancer panel testing for cfDNA identified prognostic and predictive biomarkers for palbociclib add-on therapy after acquiring fulvestrant resistance in patients with HR+/HER2- ABC/MBC.

Navigation surgery for intraoperative sentinel lymph node detection using Indocyanine green (ICG) fluorescence real-time imaging in breast cancer.

A new sensitive fluorescence imaging system was developed for the real-time identification of sentinel lymph nodes (SLNs) in patients with early breast cancer. The purpose of this study was to evaluate the utility of a color charge-coupled device camera system for the intraoperative detection of SLNs and to determine its clinical efficacy and sensitivity in patients with operable breast cancer. We assessed a total of 168 patients diagnosed with or suspected of having early-stage breast cancer without metastasis in SLNs. The intraoperative detection of SLNs was performed using the conventional Indigo Carmine dye (indigotindisulfonate sodium) technique combined with a new Indocyanine green (ICG) imaging system (HyperEye Medical System: HEMS, MIZUHO IKAKOGYO, Japan) to map SLNs, in which the lymphatic vessels and SLNs were visualized transcutaneously with illuminating ICG fluorescence. Between January 2012 and May 2013, SLNs were successfully identified in all 168 patients (detection rate: 100%). By histopathology, the sensitivity was 93.8% for the detection of the metastatic involvement of SLNs (15 of 16 nodal-positive patients). After a median follow-up of 30.5 months, none of the patients presented with axillary recurrence. These results suggest that the HEMS imaging system is a feasible and effective method for the detection of SLNs in breast cancer. Furthermore, the HEMS device permitted the transcutaneous visualization of lymphatic vessels under light conditions, thus facilitating the identification and detection of SLNs without affecting the surgical procedure, together with a high sensitivity and specificity.

[Cellular immunotherapy for local recurrence of rectal cancer after surgery by activated lymphocyte administration--a case report].

UNLABELLED: Intrapelvic recurrence of the rectal cancer after surgery is a challenging status. We report here a case of intrapelvic tumor due to the recurrence of rectal cancer postoperatively treated by adoptive cellular immunotherapy. CASE REPORT: A 57-year-old Japanese man with an intrapelvic tumor showing bone destruction due to the recurrence of rectal cancer after abdomino-peritoneal resection was diagnosed by CT scan. He consented to simultaneous adaptive cellular immunotherapy for local recurrent lesions by administration of the activated lymphocytes. The tumor sample used for the activation of PBMC was obtained by operation. Tumor cells were prepared by mincing and enzymatic digestion of the tumor sample, and they were irradiated with a dosage of 50 Gy. Peripheral blood samples were collected from the same patient. PBMC for about 2 weeks to prepare cells for treatment were obtained from the blood sample. One million PBMC were incubated in 2 ml of the culture medium containing 10(5) irradiated autologous tumor cells and 100 IU/ml recombinant IL-2. The activated PBMCs, as autologous cancer specific killer T cells, were administered by direct regional injection (from 2 million to 8 x 10(7) cells). These injections were given repeatedly about once a week at 2-week intervals for three months. The surface phenotypes of activated PBMC or PBMC were tested by two color immunostaining technique with anti-CD3, -CD4, -CD8 and also anti-CD16, -CD25 or -CD56. Natural killer cell activity was also investigated. The clinical outcome was evaluated by CT scan and serum CEA levels. In the cultured activated PBMCs, NK cell activity was 40%, both CD3 and CD4 positive cells was 30%, and both CD3 and CD8 positive cells was 48%. There were far more CD8 cells than CD4 cells. In the PBMC, NK cell activity had increased, both CD3 and CD4 positive cells had decreased and both CD3 and CD8 positive cells had increased. There were then predominantly more CD8 cells than CD4 cells by repeated administration of the cultured activated PBMCs. The only adverse effect was grade 2 fever. Serum CEA levels fell from 293.7 ng/ml to 160 ng/ml, but the tumor size on the CT scan was slightly increased except for the directly administered region. We have been observing him as an outpatient.

Optimum treatment strategy for superficial esophageal cancer: endoscopic mucosal resection versus radical esophagectomy.

This study was designed to determine the optimum treatment for a superficial esophageal cancer involving the mucosal or submucosal layer of the esophagus. The subjects were 150 patients with a superficial esophageal cancer who underwent endoscopic mucosal resection (EMR) or esophagectomy in Kurume University Hospital from 1981 to 1997. The mortality and morbidity rates, survival rate, and recurrence rate were retrospectively compared for (1) 35 patients who underwent EMR and 37 patients who underwent esophagectomy for a mucosal esophageal cancer and (2) 45 patients who underwent extended radical esophagectomy and 33 patients who underwent less radical esophagectomy for a submucosal esophageal cancer. Among the 72 patients with a mucosal cancer, lymph node metastasis/recurrence was observed in only one (1%); whereas of 78 patients with a submucosal cancer it was observed in 30 (38%). Among patients with a mucosal cancer the mortality and morbidity rates after EMR were lower than for those after esophagectomy. The survival rate after EMR was the same as that after esophagectomy. No recurrence was observed after either treatment modality. Among the patients with a submucosal cancer, the survival rate was higher and the recurrence rate lower after extended radical esophagectomy; than after less radical esophagectomy; the mortality and morbidity rates after extended radical esophagectomy were the same as those after less radical esophagectomy. Multivariate analysis demonstrated that the treatment modality (EMR versus esophagectomy) did not influence the survival of patients with a mucosal esophageal cancer, whereas it strongly influenced the survival of patients with a submucosal esophageal cancer. We concluded that EMR was the mainstay of treatment for a mucosal esophageal cancer, and extended radical esophagectomy was the mainstay of treatment for a submucosal esophageal cancer.

[New trends in neoadjuvant chemoradiotherapy for locally-advanced esophageal cancer: esophagectomy--is it necessary?].

In responders to neoadjuvant chemoradiotherapy for locally-advanced esophageal cancer, there was no significant difference in the long-term outcome between patients who underwent esophagectomy and those who did not. Esophagectomy might be unnecessary for patients who achieve a complete response with chemoradiotherapy for an esophageal cancer, in cases when salvage surgery is considered in order to treat any future recurrence.

Continuous intra-arterial 5-FU chemotherapy in a patient with a repeated recurrence of rectal cancer: report of a case.

PURPOSE: We report a patient with a recurrent pelvic tumor after abdominoperineal resection of a rectal carcinoma who was treated sufficiently by repeated intra-arterial infusions of 5-fluorouracil. METHODS: A continuous, 24-hour 5-fluorouracil administration was made through the bilateral internal iliac artery at a dosage of 250 mg/m2/day by the subcutaneous reservoir located at both upper legs using a Baxter infusor. RESULTS: In this patient pain in the hip and pelvis was relieved. A complete regression in the infused field of pelvic tumor was observed not only with computed tomography and magnetic resonance imaging but also confirmed by operative findings at the seventh month after the intra-arterial infusion. The abnormal serum level of carcinoembryonic antigen and carbohydrate antigen 19-9 was decreased to within the normal range at the 19th and 3rd week respectively. When the repeated recurrence was suspected in follow-up, normalization of the re-elevated carcinoembryonic antigen and carbohydrate antigen 19-9 levels was also obtained by repeating the same treatment. The side effects and complications were tolerable, consisting of local skin erosion on the hips and lower extremity neuropathy caused by the 5-fluorouracil. CONCLUSIONS: Clinical local regression of a pelvic recurrence was observed in a patient with rectal recurrent tumor who received continuous intra-arterial chemotherapy. Local recurrence of rectal cancer may be controlled effectively and safely by repeating long-term, continuous, intra-arterial 5-fluorouracil infusion.

Induction of human leukocyte antigen-A26-restricted and tumor-specific cytotoxic T lymphocytes by a single peptide of the SART1 antigen in patients with cancer with different A26 subtypes.

Peptide antigens available for use in specific immunotherapy of patients with cancer have not been fully determined. Although the authors have reported the SART1 gene encoding epitopes recognized by HLA-A2601-restricted and tumor-specific cytotoxic T lymphocytes (CTLs), the HLA-A26 allele is mainly subdivided into A2601, A2602, and A2603 subtypes. In this study, the authors attempted to determine whether the SART1-derived peptide at position 736-744 (KGSGKMKTE) is suitable to induce HLA-A26-restricted and tumor-specific CTLs in patients with cancer who have these subtypes. This peptide induced the HLA-A26 subtype-restricted and tumor-specific CTLs in HLA-A2601+ or HLA-A2603+ peripheral blood mononuclear cells, respectively. It also induced the HLA-A26-restricted CTL activity in HLA-A2602+ peripheral blood mononuclear cells. Therefore, this peptide could be useful for specific immunotherapy of patients with cancer who have any of the three HLA-A26 subtypes.

Locoregional cellular immunotherapy for patients with advanced esophageal cancer.

The objectives of the present study were to determine the safety of locoregional administration of autologous lymphocytes stimulated with autologous tumor cells and interleukin (IL) 2 in vitro and to find laboratory markers to predict either clinical toxicity or clinical response. Eleven patients with advanced (n = 4) or recurrent (n = 7) esophageal cancers received the locoregional administration of these activated lymphocytes every 2 weeks for two to nine times (mean, 5.6 times), and mean numbers of the administered cells were 0.8 x 10(9) cells per treatment. The activated lymphocytes that were pretested for their surface markers and CTL activity were endoscopically injected into primary tumor sites (n = 4) or directly injected into metastatic lymph nodes (n = 2), pleural (n = 4) or ascitic (n = 1) regions. Grade 3 hypotension, grade 2 diarrhea, and grade 1 fever were observed in 1, 1, and 6 patients, respectively, and there was no adverse effect in the remaining three patients. The clinical outcome was as follows: one, complete response (CR); three, partial response (PR); two, stable response (SR); and five, progressive disease (PD). CTL activity in the administered cells was observed in 5 of the 11 patients (1 CR, 3 PR, and 1 PD) and was not observed in the remaining 6 patients (2 SR and 4 PD). Percentages of CD16+ cells in the peripheral blood of the responder group (CR+PR) significantly increased when compared with those before treatment or with those of the nonresponder group before as well as after treatment. Because the clinical toxicity was moderate and tolerable, this new method of locoregional immunotherapy will be applicable for use in treatment of patients with advanced and recurrent esophageal cancers. Both CTL activity in the administered cells and the percentages of CD16+ cells in the peripheral blood may be useful laboratory markers for predicting of clinical response.

Radical esophagectomy and secondary anastomosis for high-risk patients with intrathoracic esophageal carcinoma.

OBJECTIVE: We have often conducted esophageal reconstruction via a thoracic subcutaneous route in high-risk patients to avoid major complications following anastomotic leakage. This type of reconstruction is nonphysiological, however, and presents a poor cosmetic appearance. In better risk patients, therefore, we usually conduct gastric-tube replacement via a posterior mediastinal route. We have recently begun gastric-tube replacement via the posterior mediastinal route with secondary anastomosis for high-risk patients to avoid anastomotic leakage. RESULTS: From 1996 to 1999, secondary anastomosis was conducted in 25 patients with different degrees of risk--10 with diabetes mellitus, 7 with liver dysfunction, 3 with simultaneous laryngeal and/or pharyngeal cancer, 2 each with induction chemoradiotherapy, cardiac failure, renal dysfunction, respiratory failure, and cardiorespiratory dysfunction, and 1 with cerebral infarction. 6 patients had with multiple combined diseases. Secondary anastomosis was conducted 3-12 weeks (mean: 5.5 weeks) after esophagectomy. Stomach-tube necrosis was not seen in any of the 25 patients undergoing this 2-step procedure. Anastomosis leakage was seen in 5 of the 25 patients (20%), but was slight, in all but 1. CONCLUSION: Our 2-step procedure has the following advantages: low risk of anastomotic leakage, radical surgery for esophageal cancer, the potential for early adjuvant therapy after esophagectomy, easy and early training in swallowing, and no cosmetic problem. Its disadvantages are prolonged hospitalization, multiple surgery, and esophageal stoma formation. Secondary anastomosis thus appears helpful in treating high-risk patients with advanced esophageal cancer.

Histopathological analysis of non-malignant and malignant epithelium in achalasia of the esophagus.

We studied the premalignant nature of achalasia using anti-Ki-67 and anti-p53 monoclonal antibodies immunohistochemically. In this study, four patients with esophageal carcinoma and achalasia were investigated. Three tumors were pT4 (UICC pTNM) and one tumor was pT1. The majority of non-malignant esophageal epithelium showed esophagitis and/or dysplasia histologically. Esophageal epithelial cells in the lesions of esophagitis and/or dysplasia had a higher number of Ki-67-positive cells than normal epithelial cells. p53 protein was expressed in two tumors and it was not expressed in non-malignant epithelium. From these results, we found that esophageal epithelium in achalasia lesions is changed to varying degrees of esophagitis and/or dysplasia by stagnation of intake foods, and these abnormal epithelial cells showed a high proliferative state compared with the normal cells without the p53 gene mutation. We suggest that the distinct proliferative status is a cause of carcinogenesis.

Effect of combination therapy with a methionine-mitomycin C conjugate and a methionine-deficient diet on tumor growth.

BACKGROUND: We investigated effects of a combination therapy of a methionine-mitomycin C conjugate (M-M conj) and methionine-free nutrition both in vitro and in vivo, compared to mitomycin C (MMC) administration alone. MATERIALS AND METHODS: The human esophageal cancer cell line, KE-3, incubated in either standard or methionine-free media, was treated with phosphate buffered saline (PBS), M-M conj in PBS, or MMC in PBS. The rate of cell survival was determined. The tumor bearing mice were maintained on either a standard or methionine-free diet (MFD) and treated with PBS, MMC, or M-M conj. RESULTS: The lowest tumor cell survival rate was found with the M-M conj plus methionine-free media at every dose tested (p < 0.05). Tumor weight was significantly lower with the M-M conj plus MFD than in any other group (p < 0.003). CONCLUSION: Methionine targets MMC to tumor during administration of MFD.

Clinical aspects of total colectomy--laparoscopic versus open technique for familial adenomatous polyposis and ulcerative colitis.

Clinical aspects of laparoscopy combined total colectomy (LTC) (n = 10) and open total colectomy (OTC) (n = 29) with ileorectal anastomosis for familial adenomatous polyposis and ulcerative colitis are compared in a retrospective study. The mean operative time was 282 (range, 169 to 420) minutes in the LTC group and 274 (range, 139 to 570) minutes in the OTC group. The mean volume of operative blood loss was 321 (range, 52 to 728) ml and 471 (range, 48 to 1040) ml for the LTC and OTC groups, respectively. Nasogastoric tube could be removed after POD 1.2 vs. 5.8 (p < 0.05), the mean time to passage of stool was 1.9 (range, 1 to 3) vs. 5.2 (range, 3 to 7) days (p < 0.01), and in the LTC group watery stool was soon made solidification after POD 23.4 vs. 84.1 (p < 0.01). Laparoscopy combined total colectomy may prove to have one-stage restorative total colectomy without a temporary ileostomy due to early solidification of watery stool and more benefits than conventional open surgery.

Functional outcome of double-stapled and transanal ileal pouch-anal anastomosis after proctocolectomy.

Improvement of functional outcome after proctocolectomy for ulcerative colitis and familial adenomatous polyposis was compared between transanal ileal pouch-anal anastomosis (T-IAA group, n = 29) and double-stapled ileal pouch-anal anastomosis (DS-IAA group, n = 8). Clinical functions were evaluated using a functional scoring system, and physiologic functions by anorectal manometry after one year postoperatively. Although in the T-IAA group 4 of the 29 patients (13.8%) displayed partial incontinence (< 9 points), all of 8 patients in the DS-IAA group showed good results referring to continence (> 10 points). The maximum resting pressure was 44.3 +/- 5.2 cmH2O in the T-IAA group vs. 56.6 +/- 5.8 cmH2O in the DS-IAA group, and postoperatively the maximum squeezing pressure was 96.8 +/- 9.2 cmH2O in the T-IAA group vs. 106.3 +/- 8.1 cmH2O in the DS-IAA group. There was a significant difference of maximum resting pressure and no significant difference of maximum squeezing pressure between the two groups. The length of the high pressure zone in the anal canal was significantly shorter in patients of the T-IAA group (2.1 +/- 0.8 cm) than in those of the DS-IAA group (3.5 +/- 1.1 cm) (p < 0.05). The DS-IAA is associated with excellent objective physiologic and subjective functional results. This reflects the sacrifice of the internal anal sphincter 1.5 cm cephalad necessary to effect this anastomosis at a mean of 1.4 cm from the dentate line.

HLA class I-restricted and tumor-specific cytotoxic T lymphocytes from metastatic lymph nodes of esophageal cancers.

This paper investigates the presence of HLA class I-restricted and tumor-specific cytotoxic T lymphocytes (CTL) in tumor sites of esophageal cancers. Five CTL lines were established from the metastatic lymph nodes or pleural effusion by incubation with interleukin-2 of tumor-infiltrating lymphocytes: cases 1 and 5, HLA-A26- and HLA-A33-restricted and squamous cell carcinoma (SCC)-specific CTL; case 2, HLA-Cw0102-restricted and esophageal SCC-specific CTL; case 3, HLA-A24- and HLA-A26-restricted CTL recognizing histologically different tumor cells; and case 4, HLA-A26-restricted and esophageal SCC-specific CTL. These results suggest the existence of HLA class I-restricted and tumor-specific CTL in metastatic esophageal SCC.

The effect of radioimmunotherapy using murine monoclonal antibody KIS1 on esophageal squamous cell carcinoma-bearing nude mice.

The monoclonal antibody (MoAb) KIS1 has been shown to react specifically with an antigen of human squamous cell carcinoma (SCC); however, a major problem in its clinical application is that the intact murine antibody induces a human anti-mouse antibody (HAMA). To overcome this problem, we produced the KIS1 F(ab')2 fragment, then radioiodinated the intact KIS1 antibody and its F(ab')2 fragment. Nude mice bearing human esophageal SCC implants were injected with 100 microCi of 131I-intact KIS1 or 131I-KIS1 F(ab')2, and images were obtained using a gamma camera. Radioimmunotherapy (RIT) was performed by injecting the tumor-bearing nude mice with 131I-intact KIS1 or 131I-KIS1 F(ab')2 at a dosage of 300 microCi, following which 7 or 3 days were required to produce high quality tumor images by scintigraphy. The tumor-bearing mice treated with 131I-KIS1 F(ab')2 showed significant tumor growth inhibition, about 5.4 times greater than that of the control group and 1.8 times greater than that of the 131I-intact KIS1 group 21 days after the injection. These results indicate that the KIS1 F(ab')2 fragment is superior to intact KIS1, and that it may be clinically useful for radioimmunodetection followed by tumor targeting therapy for patients with SCC of the esophagus.

A monoclonal antibody KIS-1 recognizing a new membrane antigen on human squamous-cell carcinoma.

A KIS-1 monoclonal antibody (MAb) (IgG1, kappa) recognizing a membrane antigen on human squamous-cell carcinomas (SCC) was developed to understand their antigenicity using an esophageal SCC as an immunogen. The KIS-1 MAb recognized a membrane antigen on a majority of esophageal, lung, and oral- cavity SCC by immunofluorescent and by immunohistochemical analyses. In contrast, it showed little reactivity to adenocarcinomas from different organs, and none to keratinocyte cell lines. This MAb showed reactivity to the cells in the basal layer of normal esophageal epithelium adjacent to the esophageal SCC, but none of the other normal tissues, including esophageal epithelium far from the SCC and that from patients with non-malignant disease. The KIS-1 MAb immunoprecipitated a 46-kDa membrane protein of the esophageal SCC in non-reducing and in reducing conditions. It recognized the 46- and the 40-kDa proteins of the esophageal SCC by immunoblot analysis. These results suggest that the KIS-1 MAb recognizes a new membrane antigen preferentially expressed on SCC, and that this antigenicity is shared only by the cells in the basal layer of the esophageal epithelium adjacent to SCC. The KIS-1 MAb may be a new tool for understanding the antigenicity of SCC.

HLA A2601-restricted CTLs recognize a peptide antigen expressed on squamous cell carcinoma.

The CD4-CD8+ CTL (KE-4 CTL) cell line against autologous tumor cells was established in a patient with esophageal cancer. This KE-4 CTL recognized a peptide antigen on esophageal and lung squamous cell carcinomas in an HLA A2601-restricted manner, as evaluated by cytotoxicity against a panel of tumor cells, transfection experiments with HLA A2601 cDNA, and reconstitution with eluted peptides. None of the normal cells tested was lysed by this CTL. These results suggest the existence of HLA A2601-restricted CTL precursors recognizing a peptide antigen on SCC in a patient with esophageal cancer.

Cervico-thoraco-abdominal (3-field) lymph node dissection for carcinoma in the thoracic esophagus.

The efficacy of an extended radical lymph node dissection for carcinoma in the thoracic esophagus is controversial. Results of a multivariate analysis using clinical data from 127 cases collected from 1982 to 1988 are reported. Twenty-seven of these patients underwent an extended radical (cervico-thoraco-abdominal: 3 fields) lymph node dissection which was recently developed in Japan, while others underwent a standard (thoraco-abdominal: 2 fields) lymph node dissection. They all had a locally-curative resection of the tumor through a right thoracotomy. In this study, 13 factors commonly affecting prognosis were examined: sex, age, cancer location, tumor length, radiographic type, depth of invasion, lymph node metastasis, tumor differentiation, postoperative radiotherapy, chemotherapy, operative risk, postoperative complications, and 3-field or 2-field dissection. Based on the survival-rate curves using Kaplan-Meier's statistics, the 3-field dissection was superior to the 2-field dissection. Moreover, when other prognostic factors were adjusted using Cox's proportional hazards general linear model, the same result was obtained from survival-rate curves. From this analysis, it can be concluded that a 3-field dissection is a better approach for management of carcinoma in the thoracic esophagus.