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IMPORTANCE: Indoleamine 2,3-dioxygenase 1 (IDO1) causes tumor immune suppression. The IDO1 pathway inhibitor indoximod combined with a taxane in patients with ERBB2-negative metastatic breast cancer was tested in a prospective clinical trial. OBJECTIVE: To assess clinical outcomes in patients with ERBB2-negative metastatic breast cancer treated with indoximod plus a taxane. DESIGN, SETTING, AND PARTICIPANTS: This phase 2 double-blinded randomized 1:1 placebo-controlled clinical trial enrolled patients at multiple international centers from August 26, 2013, to January 25, 2016. Eligibility criteria included ERBB2-negative metastatic breast cancer, ability to receive taxane therapy, good performance status, normal organ function, no previous immunotherapy use, and no autoimmune disease. The study was discontinued in June 2017 because of lack of efficacy. Data analysis was performed from February 2019 to April 2020. INTERVENTIONS: A taxane (paclitaxel [80 mg/m2] weekly 3 weeks on, 1 week off, or docetaxel [75 mg/m2] every 3 weeks) plus placebo or indoximod (1200 mg) orally twice daily as first-line treatment. MAIN OUTCOMES AND MEASURES: The primary end point was progression-free survival (PFS); secondary end points were median overall survival, objective response rate, and toxic effects. A sample size of 154 patients would detect a hazard ratio of 0.64 with 1-sided α = .1 and β = .2 after 95 events. Archival tumor tissue was stained with immunohistochemistry for IDO1 expression as an exploratory analysis. RESULTS: Of 209 patients enrolled, 169 were randomized and 164 were treated (85 in the indoximod arm; 79 in the placebo arm). The median (range) age was 58 (29-85) years; 166 (98.2%) were female, and 135 (79.9%) were White. The objective response rate was 40% and 37%, respectively (indoximod vs placebo) (P = .74). The median (range) follow-up time was 17.4 (0.1-39.4) months. The median PFS was 6.8 months (95% CI, 4.8-8.9) in the indoximod arm and 9.5 months (95% CI, 7.8-11.2) in the placebo arm (hazard ratio, 1.2; 95% CI, 0.8-1.8). Differences between the experimental and placebo arms in median PFS (6.8 vs 9.5 months) and overall survival (19.5 vs 20.6 months) were not statistically significant. Grade 3 or greater treatment-emergent adverse events occurred in 60% of patients in both arms. CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that, among patients with ERBB2-negative metastatic breast cancer, addition of indoximod to a taxane did not improve PFS compared with a taxane alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01792050

Venous thromboembolism (VTE) complicates several anticancer regimens including chemotherapy and antiangiogenic agents. Cyclin‐dependent kinase inhibitors (CDKIs) are a new approach for hormone receptor‐positive metastatic breast cancer (mBC). Reported VTE rates in randomized trials range from 0.6% to 5%, but these may underestimate actual rates observed in clinical practice.

Mammary ductal carcinoma in situ (DCIS) is classically treated by combinations of excision, radiation, and endocrine therapy, based upon the specific needs of individual patients. Estrogen receptor (ER) status is generally assessed by immunohistochemistry (IHC) in newly diagnosed cases of DCIS, and endocrine therapy in this setting is thought to be chemopreventive. The potential impact of androgens on mammary carcinogenesis has been studied in recent years, and several authors have proposed androgen receptor (AR) IHC testing and targeted antiandrogenic therapy in patients with locally advanced or metastatic triple-negative invasive breast cancer (ie, negative for ER and progesterone receptor and HER-2). Very little has been published on AR in DCIS. We report results of AR IHC on archival tissue blocks from 221 adult female patients, each of whom underwent definitive breast resection of DCIS. Of the 221 cases, 72 (33%) were shown to express AR in their DCIS at or above the 10% threshold often used for invasive carcinoma. AR expression was seen in all grades of DCIS. Of the 72 positive AR cases, 21 (29%) were ER negative, corresponding to 10% (21/221) of all patients. The majority of the AR-positive cases were high grade, and the most common histologic subtype in this subset was a solid growth pattern with apocrine features. Early data from clinical trials evaluating AR antagonists in invasive/metastatic triple-negative breast cancer suggest that some patients may benefit from androgen blockade. IHC testing and potential clinical trials of AR antagonists for chemoprevention in patients with AR-positive and ER-negative DCIS could be considered.

Immune evasion is a hallmark of cancer. While there are multiple different mechanisms that cancer cells employ, myeloid-derived suppressor cells (MDSCs) are one of the key drivers of tumor-mediated immune evasion. MDSCs begin as myeloid cells recruited to the tumor microenvironment, where they are transformed into potent immunosuppressive cells. However, our understanding of the clinical relevance of MDSCs in cancer patients has significantly lagged behind the preclinical literature in part due to the absence of a cognate molecule present in mice, as well as to the considerable heterogeneity of MDSCs. However, if one evaluates the clinical literature through the filter of clinically robust endpoints, such as overall survival, three important phenotypes emerge: promyelocytic, monocytic, and granulocytic. Based on these studies, MDSCs have clear prognostic importance in multiple solid tumors, and emerging data support the utility of circulating MDSCs as a predictive marker for cancer immunotherapy, and even as an early leading marker for predicting clinical response to systemic chemotherapy in patients with advanced solid tumors. More recent preclinical data in immunosuppressed murine models suggest that MDSCs play an important role in tumor progression and the metastatic process that is independent of their immunosuppressive properties. Consequently, targeting MDSCs either in combination with cancer immunotherapy or independently as part of an approach to inhibit the metastatic process appears to be a very clinically promising strategy. We review different approaches to target MDSCs that could potentially be tested in future clinical trials in cancer patients.

Lung cancer is the leading cause of cancer-related death and the second most often diagnosed malignancy worldwide. Males have higher incidence of lung cancer and higher mortality. It is hypothesized that the sex differences in survival are primarily driven by a better response of females to treatment. The primary objective of this work is to analyze and describe outcome differences between males and females diagnosed with having lung cancer.

nab-Paclitaxel has been shown to disrupt pancreatic cancer stroma and was effective in combination with gemcitabine in a phase III trial. This study was designed to determine the efficacy of nab-paclitaxel monotherapy in previously treated pancreatic cancer patients.

We recently demonstrated that human BM cells can be treated in vitro with defined growth factors to induce the rapid generation of myeloid-derived suppressor cells (MDSCs), hereafter defined as BM-MDSCs. Indeed, combination of G-CSF + GM-CSF led to the development of a heterogeneous mixture of immature myeloid cells ranging from myeloblasts to band cells that were able to suppress alloantigen- and mitogen-stimulated T lymphocytes. Here, we further investigate the mechanism of suppression and define the cell subset that is fully responsible for BM-MDSC–mediated immune suppression. This population, which displays the structure and markers of promyelocytes, is however distinct from physiologic promyelocytes that, instead, are devoid of immuosuppressive function. In addition, we demonstrate that promyelocyte-like cells proliferate in the presence of activated lymphocytes and that, when these cells exert suppressive activity, they do not differentiate but rather maintain their immature phenotype. Finally, we show that promyelocyte-like BM-MDSCs are equivalent to MDSCs present in the blood of patients with breast cancer and patients with colorectal cancer and that increased circulating levels of these immunosuppressive myeloid cells correlate with worse prognosis and radiographic progression.

BACKGROUND The survival benefit of adjuvant chemotherapy alone or chemoradiotherapy in patients with pancreatic cancer who have undergone surgical resection remains unclear. OBJECTIVE To identify the additional benefit of adjuvant therapy by retrospectively examining a large population-based registry of patients who underwent definitive surgical resection for pancreatic adenocarcinoma. DESIGN AND SETTING The Florida cancer registry and state inpatient and outpatient hospital data records were queried for pancreatic adenocarcinoma diagnosed between 1998 and 2002. PATIENTS A total of 2877 patients who underwent surgical resection with curative intent for pancreatic adenocarcinoma were identified. MAIN OUTCOME MEASURE Overall survival time. RESULTS Overall, 58.7% of patients were older than 65 years. Most patients were white (90.7%), were non-Hispanic (86.7%), and did not consume alcohol abusively (89.2%). Approximately half of the patients (51.9%) did not receive chemotherapy or chemoradiotherapy. Approximately 25.0% of the patients underwent chemoradiotherapy, and 10.0% received chemotherapy alone. Patients were more frequently treated at low-volume centers (57.6%) and nonteaching facilities (72.8%). Multivariate analysis correcting for patient comorbidities demonstrated that postoperative chemoradiotherapy (hazard ratio = 0.69, P = .04) and treatment at high-volume centers (hazard ratio = 0.85, P < .001) and teaching facilities (hazard ratio = 0.84, P < .001) were independent predictors of improved survival. CONCLUSIONS Adjuvant chemoradiotherapy was found to provide a significant additional survival benefit to surgical resection for patients with pancreatic adenocarcinoma. Furthermore, this benefit is independent of the additional survival advantage when patients are treated at teaching facilities or high-volume centers. Although selection bias may be contributing to the observed differences, these data nonetheless support the use of adjuvant chemoradiotherapy for pancreatic cancer.Arch Surg. 2010;145(1):49-56--

Malignant schwannomas or malignant peripheral nerve sheath tumors (MPNST) represent approximately 10% of all soft tissue sarcomas. Metastatic disease from chest wall MPNST is very rare. We present a case of a major clinical response to the tyrosine kinase inhibitor (TKI) sorafenib in a patient with metastatic MPNST. A 42-year-old female with a prior history of neurofibromas developed MPNST, which later metastasized to the lungs and brain. She was initially placed on sorafenib with significant clinical response to lung metastases. MPNST show high levels of Ras activity and hence these tumors are promising targets for TKIs. Studies are ongoing and the results are eagerly awaited regarding the responses to these medications and whether they can positively impact on the natural history of this disease.

The epidermal growth factor receptor (EGFR) is a member of the HER/ERB-B family of transmembrane receptor kinases. Overexpression of EGFR confers advantages in cell proliferation, survival, and migration and correlates with decreased survival in multiple solid tumors. However, a proportion of these malignancies have little or no expression of EGFR. CpG island hypermethylation and associated transcriptional silencing are common in solid tumors. The methylation status of the EGFR CpG island was examined in a series of cell lines and tissues. Dense EGFR methylation (90%) was found in the breast cancer cell line CAMA1, and a moderate degree of methylation (30-50%) was observed in the breast cancer cell lines MB435 and MB453. Transcriptional silencing of EGFR in these cell lines closely correlated with methylation. By contrast, no methylation of the HER-2/neu CpG island was detected. EGFR hypermethylation was also found in a subset of unselected primary breast (20%), head and neck squamous cell carcinoma (35%), and lung tumors (11%). Treatment with decitabine resulted in the reexpression of EGFR in CAMA1 and MB453. Both cell lines are relatively resistant to killing by the EGFR inhibitor gefitinib. However, after co-treatment with decitabine and gefitinib, a significant effect on the induction of apoptosis was observed. In conclusion, EGFR is hypermethylated and silenced in a subset of solid tumor cell lines and primary tumor specimens, and co-treatment with decitabine and gefitinib has an additive effect only in EGFR methylated breast cancer cell lines.

The majority of patients with breast carcinoma with ≥ 10 metastatic axillary lymph nodes (ALNs) develop recurrent disease within 5 years from diagnosis. The purpose of the current study, performed retrospectively, was to characterize the natural history of this subset of patients, both before and after the advent of adjuvant anthracycline‐based chemotherapy and tamoxifen.Retrospectively, patients with primary breast carcinoma (N = 882) with ≥ 10 metastatic ALNs, treated between 1954 and 1998, were selected from 3 institutions: The University of Texas M. D. Anderson Cancer Center (Houston, TX); the Institut Gustave Roussy (Villejuif, France); and Hospital Clinico Universitario (Valencia, Spain). All patient data had been registered prospectively in clinical databases. One group consisted of 314 patients treated with locoregional therapy alone (no adjuvant therapy) from 1954 to 1983. The second group included 568 patients who received adjuvant anthracycline‐based chemotherapy between 1974 and 1998 with or without adjuvant tamoxifen.The median follow‐up time was 140 months. Disease‐free survival rates at 15 and 20 years for the no adjuvant therapy and adjuvant therapy groups were 17% and 16% versus 26% and 24%, respectively. The overall survival rates at 20 years for the no adjuvant therapy and the adjuvant therapy groups were 9% and 21%, respectively. By multivariate analysis, the independent factors associated with survival in the adjuvant therapy group were tumor size and the number of metastatic lymph nodes.The retrospective analysis suggested that adjuvant anthracycline‐based chemotherapy and hormonal therapy have altered the natural history in this high‐risk group of patients. However, despite such improvements, survival rates remained low, and innovative therapeutic approaches are, therefore, needed to improve clinical outcomes. Cancer 2005. © 2005 American Cancer Society.

Rhabdomyolysis is a clinical syndrome in which skeletal muscle damage and necrosis leads to the release of intracellular muscle contents, which can ultimately lead to electrolyte disturbances, renal failure and even death. Chemotherapy is an extremely rare cause of rhabdomyolysis. Herein, we describe a fatal case of rhabdomyolysis in a patient with metastatic sarcoma after receiving the chemotherapeutic agent Ecteinascidin-743 (ET-743, trabectedin) as palliative chemotherapy treatment.

Background

Reducing unplanned hospital readmissions, defined as a hospitalization occurring within 30 days of discharge, is a national policy priority that is aimed at improving health care quality. Unplanned hospitalizations and emergency department visits are a major problem in medical oncology patients. In our cancer institute, just 6% of all discharged patients accounted for > 40% of unplanned readmissions. These patients continue to be highest risk of future admissions, ICU stay, ED visits, over use of chemotherapy and underuse of hospice resources. We hypothesized that developing individualized care plans (ICP) for patients with the highest preventable utilization will better address the complex needs of this patient population and subsequently decrease preventable admissions, readmissions, and ED visits.

Commentary to:Combination effects of bortezomib with gemcitabine and EMAP II in experimental pancreatic cancerNiranjan Awasthi, Margaret A. Schwarz and Roderich E. Schwarz