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Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of surveillance imaging after the treatment of urothelial cancer of the urinary bladder are to detect new or previously undetected urothelial tumors, to identify metastatic disease, and to evaluate for complications of therapy. For surveillance, patients can be stratified into one of three groups: 1) nonmuscle invasive bladder cancer with no symptoms or additional risk factors; 2) nonmuscle invasive bladder cancer with symptoms or additional risk factors; and 3) muscle invasive bladder cancer. This document is a review of the current literature for urothelial cancer and resulting recommendations for surveillance imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Objective To examine whether blocking multiple points of the angiogenesis pathway by addition of sorafenib, a multi-kinase inhibitor against VEGFR2/3, Raf, c-Kit, and PDGFR, to bevacizumab would yield clinical activity in ovarian cancer (OvCa). Methods This phase II study tested bevacizumab plus sorafenib in two cohorts; bevacizumab-naive and bevacizumab-exposed patients. Bevacizumab (5 mg/kg IV every 2 weeks) was given with sorafenib 200 mg bid 5 days-on/2 days-off. The primary objective was response rate using a Simon two-stage optimal design. Progression-free survival (PFS) and toxicity were the secondary endpoints. Exploratory correlative studies included plasma cytokine concentrations, tissue proteomics and dynamic contrast-enhanced-magnetic resonance imaging (DCE-MRI). Results Between March 2007 and August 2012, 54 women were enrolled, 41 bevacizumab-naive and 13 bevacizumab-prior, with median 5 (2–9) and 6 (5–9) prior systemic therapies, respectively. Nine of 35 (26%) evaluable bevacizumab-naive patients attained partial responses (PR), and 18 had stable disease (SD) ≥ 4 months. No responses were seen in the bevacizumab-prior group and 7 (54%) patients had SD ≥ 4 months, including one exceptional responder with SD of 27 months. The overall median PFS was 5.5 months (95%CI: 4.0–6.8 months). Treatment-related grade 3/4 adverse events (≥5%) included hypertension (17/54 [31%]; grade 3 in 16 patients and grade 4 in one patient) and venous thrombosis or pulmonary embolism (5/54 [9%]; grade 3 in 4 patients and grade 4 in one patient). Pretreatment low IL8 concentration was associated with PFS ≥ 4 months (p = .031). Conclusions The bevacizumab and sorafenib combination did not meet the pre-specified primary endpoint although some clinical activity was seen in heavily-pretreated bevacizumab-naive OvCa patients with platinum-resistant disease. Anticipated class toxicities required close monitoring and dose modifications.

Background and objectives We have previously published the characteristics of kidney and liver disease in a cohort of 73 individuals with molecularly confirmed autosomal recessive polycystic kidney disease-congenital hepatic fibrosis, based upon cross-sectional data. Here, we present prospective data on the same cohort. Design, setting, participants, and measurements Comprehensive biochemical and imaging data on progression of kidney and liver disease in 60 of the 73 patients were prospectively collected at the NIH Clinical Center on multiple visits between 2003 and 2019. Results and conclusions Of the 73 patients, 23 received a renal allograft at an average age of 17.5 years and 10 underwent liver transplantation at an average age of 20.3 years. Patients who presented perinatally and those who had corticomedullary disease required kidney transplantation significantly earlier. The mean eGFR slope in patients with corticomedullary disease was −1.6 ml/min/1.73 m2/y, in comparison to −0.6 ml/min/1.73 m2/y in those with medullary disease. Kidney size remained the same over time and normalized to the upper limit of normal by 20–25 years of age. The extent of renal disease on ultrasound remained largely unchanged; no patient progressed from the “medullary” to the “corticomedullary” group. There was no correlation between eGFR slope and kidney size. The synthetic function of the liver remained largely intact even in patients with advanced portal hypertension. Based on spleen length/height ratio, two thirds of patients had portal hypertension which remained stable in 39% and worsened in 61%. Patients with portal hypertension had lower platelet counts and relatively higher levels of AST, GGT, direct bilirubin and ammonia. The progression rates of kidney and liver disease were independent of each other. Patients with bi-allelic non-truncating PKHD1 variants had similar progression of kidney and liver disease in comparison to those who were compound heterozygous for a non-truncating and a truncating variant.

Lower urinary tract symptoms due to benign prostatic enlargement have a high prevalence in men over 50 years of age. Diagnosis is made with a combination of focused history and physician examination and validated symptom questionnaires. Urodynamic studies can help to differentiate storage from voiding abnormalities. Pelvic ultrasound may be indicated to assess bladder volume and wall thickness. Other imaging modalities, including prostate MRI, are usually not indicated in the initial workup and evaluation of uncomplicated lower urinary tract symptoms from an enlarged prostate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of surveillance imaging after the treatment of urothelial cancer of the urinary bladder are to detect new or previously undetected urothelial tumors, to identify metastatic disease, and to evaluate for complications of therapy. For surveillance, patients can be stratified into one of three groups: (1) nonmuscle invasive bladder cancer with no symptoms or additional risk factors; (2) nonmuscle invasive bladder cancer with symptoms or additional risk factors; and (3) muscle invasive bladder cancer. This article is a review of the current literature for urothelial cancer and resulting recommendations for surveillance imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

INTRODUCTION AND OBJECTIVE:For patients undergoing Active Surveillance (AS) for prostate cancer, the utility of longitudinal multiparametric MRI (mpMRI) is not well characterized. Given known inter...

An acute scrotum is defined as testicular swelling with acute pain and can reflect multiple etiologies including epididymitis or epididymo-orchitis, torsion of the spermatic cord, or torsion of the testicular appendages. Quick and accurate diagnosis of acute scrotum and its etiology with imaging is necessary because a delayed diagnosis of torsion for as little as 6 hours can cause irreparable testicular damage. Ultrasound duplex Doppler of the scrotum is usually appropriate as the initial imaging for the acute onset of scrotal pain without trauma or antecedent mass in an adult or child. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

BackgroundClinical trials have shown the ability of therapeutic vaccines to generate immune responses to tumor-associated antigens (TAAs). What is relatively less known is if this translates into immune-cell (IC) infiltration into the tumor microenvironment. This study examined whether neoadjuvant prostate-specific antigen (PSA)-targeted vaccination with PROSTVAC could induce T-cell immunity, particularly at the tumor site.MethodsAn open-label, phase II study of neoadjuvant PROSTVAC vaccine enrolled 27 patients with localized prostate cancer awaiting radical prostatectomy (RP). We evaluated increases in CD4 and CD8 T-cell infiltrates (RP tissue vs baseline biopsies) using a six-color multiplex immunofluorescence Opal method. Antigen-specific responses were assessed by intracellular cytokine staining after in vitro stimulation of peripheral blood mononuclear cells with overlapping 15-mer peptide pools encoding the TAAs PSA, brachyury and MUC-1.ResultsOf 27 vaccinated patients, 26 had matched prevaccination (biopsy) and postvaccination (RP) prostate samples available for non-compartmentalized analysis (NCA) and compartmentalized analysis (CA). Tumor CD4 T-cell infiltrates were significantly increased in postvaccination RP specimens compared with baseline biopsies by NCA (median 176/mm² vs 152/mm²; IQR 136–317/mm² vs 69–284/mm²; p=0.0249; median ratio 1.20; IQR 0.64–2.25). By CA, an increase in both CD4 T-cell infiltrates at the tumor infiltrative margin (median 198/mm² vs 151/mm²; IQR 123–500/mm² vs 85–256/mm²; p=0.042; median ratio 1.44; IQR 0.59–4.17) and in CD8 T-cell infiltrates at the tumor core (median 140/mm² vs 105/mm²; IQR 91–175/mm² vs 83–163/mm²; p=0.036; median ratio 1.25; IQR 0.88–2.09) were noted in postvaccination RP specimens compared with baseline biopsies. A total of 13/25 patients (52%) developed peripheral T-cell responses to any of the three tested TAAs (non-neoantigens); five of these had responses to more than one antigen of the three evaluated.ConclusionNeoadjuvant PROSTVAC can induce both tumor immune response and peripheral immune response.Trial registration numberNCT02153918.

There is great a potential for mpMRI to improve outcomes and quality of treatment. The major roles of MRI will continue to expand and its emerging use in standard of care approaches becomes more clearly defined and supported by increasing levels of data. Active surveillance has gained popularity as an acceptable management option for men with low-risk prostate cancer. Successful utilization of this strategy can delay or prevent unnecessary interventions - thereby reducing morbidity associated with overtreatment. The usefulness of active surveillance primarily depends on correct identification of patients with low-risk disease. However, current population-wide algorithms and tools do not adequately exclude high-risk disease, thereby limiting the confidence of clinicians and patients to go on active surveillance. Novel imaging tools such as mpMRI provide information about the size and location of potential cancers enabling more informed treatment decisions. The term "multiparametric" in prostate mpMRI refers to the summation of several MRI series into one examination whose initial goal is to identify potential clinically-significant lesions suitable for targeted biopsy. The main advantages of MRI are its superior anatomic resolution and the lack of ionizing radiation. Recently, the Prostate Imaging-Reporting and Data System has been instituted as an international standard for unifying mpMRI results. The imaging sequences in mpMRI defined by Prostate Imaging Reporting and Data System version 2 includes: T2-weighted MRI, diffusion-weighted MRI, derived apparent-diffusion coefficient from diffusion-weighted MRI, and dynamic contrast-enhanced MRI. The use of mpMRI prior to starting active surveillance could prevent those with missed, high-grade lesions from going on active surveillance, and reassure those with minimal disease who may be hesitant to take part in active surveillance. Although larger validation studies are still necessary, preliminary results suggest mpMRI has a role in selecting patients for active surveillance. Less certain is the role of mpMRI in monitoring patients on active surveillance, as data on this will take a long time to mature. The biggest obstacles to routine use of prostate MRI are quality control, cost, reproducibility, and access. Nevertheless, there is great a potential for mpMRI to improve outcomes and quality of treatment. The major roles of MRI will continue to expand and its emerging use in standard of care approaches becomes more clearly defined and supported by increasing levels of data.

Lower urinary tract injury is most commonly the result of blunt trauma but can also result from penetrating or iatrogenic trauma. Clinical findings in patients with a mechanism of penetrating trauma to the lower urinary tract include lacerations or puncture wounds of the pelvis, perineum, buttocks, or genitalia, as well as gross hematuria or inability to void. CT cystography or fluoroscopy retrograde cystography are usually the most appropriate initial imaging procedures in patients with a mechanism of penetrating trauma to the lower urinary tract. CT of the pelvis with intravenous contrast, pelvic radiography, fluoroscopic retrograde urethrography, and CT of the pelvis without intravenous contrast may be appropriate in some cases. Arteriography, radiographic intravenous urography, CT of the pelvis without and with intravenous contrast, ultrasound, MRI, and nuclear scintigraphy are usually not appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

BACKGROUND: Alström syndrome (AS), a monogenic form of obesity, is caused by recessive mutations in the centrosome- and basal body–associated gene ALMS1. AS is characterized by retinal dystrophy, sensory hearing loss, cardiomyopathy, childhood obesity, and metabolic derangements. OBJECTIVE: We sought to characterize the endocrine and metabolic features of AS while accounting for obesity as a confounder by comparing patients with AS to body mass index (BMI)–matched controls. METHODS: We evaluated 38 patients with AS (age 2 to 38 years) who were matched with 76 controls (age 2 to 48 years) by age, sex, race, and BMI. Fasting biochemistries, mixed meal test (MMT), indirect calorimetry, dual-energy X-ray absorptiometry, and MRI/magnetic resonance spectroscopy were performed. RESULTS: Frequent abnormalities in AS included 76% obesity, 37% type 2 diabetes mellitus (T2DM), 29% hypothyroidism (one-third central, two-thirds primary), 3% central adrenal insufficiency, 57% adult hypogonadism (one-third central, two-thirds primary), and 25% female hyperandrogenism. Patients with AS and controls had similar BMI z scores, body fat, waist circumference, abdominal visceral fat, muscle fat, resting energy expenditure (adjusted for lean mass), free fatty acids, glucagon, prolactin, ACTH, and cortisol. Compared with controls, patients with AS were shorter and had lower IGF-1 concentrations (Ps ≤ 0.001). Patients with AS had significantly greater fasting and MMT insulin resistance indices, higher MMT glucose, insulin, and C-peptide values, higher HbA1c, and higher prevalence of T2DM (Ps < 0.001). Patients with AS had significantly higher triglycerides, lower high-density lipoprotein cholesterol, and a 10-fold greater prevalence of metabolic syndrome (Ps < 0.001). Patients with AS demonstrated significantly greater liver triglyceride accumulation and higher transaminases (P < 0.001). CONCLUSION: Severe insulin resistance and T2DM are the hallmarks of AS. However, patients with AS may present with multiple other endocrinopathies affecting growth and development.

PURPOSE: We summarize the available data about the clinical and economic effectiveness of magnetic resonance imaging in the diagnosis and management of prostate cancer, and provide practical recommendations for its use in the screening, diagnosis, staging and surveillance of prostate cancer. MATERIALS AND METHODS: A panel of clinicians with expertise in the diagnosis and management of prostate cancer evaluated the current published literature on the use and effectiveness of magnetic resonance imaging for this disease. When adequate studies were available for analysis, recommendations were made on the basis of data and when adequate studies were not available, recommendations were made on the basis of expert consensus. RESULTS: At this time the data support the use of magnetic resonance imaging in patients with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. The data regarding its usefulness for initial biopsy suggest a possible role for magnetic resonance imaging in some circumstances. There is currently insufficient evidence to recommend magnetic resonance imaging for screening, staging or surveillance of prostate cancer. CONCLUSIONS: Although it adds cost to the management of prostate cancer, magnetic resonance imaging offers superior anatomic detail, and the ability to evaluate cellular density based on water diffusion and blood flow based on contrast enhancement. Imaging targeted biopsy may increase the diagnosis of clinically significant cancers by identifying specific lesions not visible on conventional ultrasound. The clinical indications for the use of magnetic resonance imaging in the management of prostate cancer are rapidly evolving.

Background The incidence of pancreatic neuroendocrine tumors (PNETs) is increasing, but only a subset of these heterogeneous tumors will progress to malignant disease, which is associated with a poor prognosis. Currently, there are limited data on the natural history of these tumors and it is difficult to determine which patients require surgical intervention because the risk of metastatic disease cannot be accurately determined. Study Design We conducted a prospective study of 87 patients with von Hippel Lindau syndrome-associated solid pancreatic lesions to determine the natural history of these tumors with biochemical testing, follow-up anatomic and functional imaging, and advanced imaging analysis, with a median follow-up of 4 years. Results Approximately 20% of consecutive tumor measurements during follow-up were decreased in size and 20% showed no change. This included 2 of 4 surgically proven malignant tumors, which had a net decrease in tumor size over time. Tumor volume, as derived from greatest diameter and volumetric measurements, showed good correlation to pathology tumor measurement of surgically resected tumors (Spearman rank correlation ρ = 0.72, p = 0.0011, and ρ = 0.83, p Conclusions Pancreatic neuroendocrine tumors demonstrate a nonlinear growth pattern, which includes periods of no growth and apparent decrease in size by imaging. These growth patterns are variable and are not associated with tumor grade and malignancy. Tumor density, as measured in this cohort, may offer a specific diagnostic tool for malignant disease.

Objective To assess the efficacy and toxicity of cediranib, a highly potent inhibitor of vascular endothelial growth factor receptor tyrosine kinases, in patients with metastatic castration-resistant prostate cancer (CRPC) previously treated with docetaxel-based therapy. Patients and Methods The study used a Simon two-stage trial design, which required at least two of 12 patients in the first cohort to be progression-free at 6 months. We enrolled a total of 35 evaluable patients who all received cediranib 20 mg orally daily. In a second cohort, 23 additional patients received prednisone 10 mg daily with cediranib. Endpoints included tumour response, progression-free survival (PFS), overall survival (OS), vascular permeability via dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), and toxicity. Results A total of 59 patients were enrolled, of whom 67% had received two or more previous chemotherapy regimens. Six of 39 patients with measurable disease had confirmed partial responses and one had an unconfirmed partial response. At 6 months, 43.9% of patients were progression-free; the median PFS and OS periods for all patients were 3.7 months and 10.1 months, respectively. We found that the DCE-MRI variables baseline transport constant (Ktrans) and rate constant at day 28 were significantly associated with PFS in univariate analyses, but only baseline Ktrans remained significant when considered jointly. The most frequent toxicities were hypertension, fatigue, anorexia and weight loss; the addition of prednisone reduced the incidence of constitutional toxicities. Conclusion This study demonstrated that cediranib was generally well tolerated with some anti-tumour activity in highly pretreated patients with metastatic CRPC who had progressive disease after docetaxel-based therapy. Keywords: castration-resistant prostate cancer, angiogenesis inhibitors, cediranib, AZD2171 Introduction Prostate cancer is the most common non-dermatological cancer in men and has the second highest cancer-related death rates in men [1]. Docetaxel and prednisone are currently the standard of therapy for patients with symptomatic metastatic castration-resistant prostate cancer (CRPC). Cabazitaxel and abiraterone are approved as second-line treatment options for patients with post-docetaxel progressive metastatic disease, but the duration of response is generally short-lived with a modest survival benefit; therefore, more effective therapeutic approaches are still needed, especially in the post-docetaxel setting. Vascular endothelial growth factor (VEGF), a pro-angiogenic factor, and its receptors have been shown to be important in promoting tumour angiogenesis, playing a critical role in prostate cancer development and progression [2–4]. In preclinical models, inhibition of angiogenesis has been shown to be an effective target in CRPC. VEGF expression is observed in prostate tumours and in plasma and urine from patients with metastatic disease, where increased expression is associated with disease progression [5, 6]. The fms-like tyrosine kinase/kinase insert domain receptor receptors are expressed in human prostate cancers and are correlated with higher grade lesions and outcome [7]. While targeting angiogenesis appears to be a rational and therapeutic approach for CRPC [8), recent phase III trial results of VEGF pathway inhibitors bevacizumab [9] and sunitinib [10] have shown no clinical benefit, suggesting the need for predictive biomarkers to identify appropriate subgroups that may more likely benefit from this targeted therapy. Cediranib (AZD2171) is a potent oral small molecule inhibitor of VEGFR-1, VEGFR-2 and VEGFR-3 [11, 12] and also of c-kit, to a lesser extent [12]. Cediranib has been investigated in clinical trials with multiple cancers including colorectal [13], lung [14, 15], ovarian [16] and renal [17] cancer, and glioblastoma [18, 19]. Cediranib has been reported to show activity in prostate cancer. Ryan et al. [20] reported a phase I trial that established a maximum tolerated dose of 20 mg with the dose-limiting toxicities of muscle weakness and hypertension. We conducted a phase II trial using cediranib 20 mg orally, once daily to assess the clinical efficacy and side-effect profile in patients with metastatic CRPC who have progressed after therapy with docetaxel. Previous studies have reported that serum PSA level has not been a dependable marker in assessing response using non-cytotoxic drugs [21, 22]. The present study used clinical and radiographical criteria to assess response. A second part of the study added prednisone in an attempt to limit the constitutional side effects that were associated with cediranib.

Purpose: Hypoxia-inducible factor 1 (HIF-1) α is frequently overexpressed in human tumors and is associated with angiogenesis and metastasis. Topotecan, a topoisomerase I inhibitor, has been shown to inhibit HIF-1α expression in preclinical models. We designed a pilot trial to measure HIF-1α inhibition in tumor biopsies from patients with advanced solid tumors overexpressing HIF-1α, after treatment with oral topotecan. Experimental Design: Topotecan was administered orally at 1.6 mg/m2 once daily for 5 days/week for 2 weeks, in 28-day cycles. Objectives were to determine inhibition of expression of HIF-1α and HIF-1 target genes in tumor; to assess tumor blood flow by dynamic contrast–enhanced magnetic resonance imaging (DCE-MRI); and to measure pharmacokinetics. Tumor biopsies were collected at baseline and during the second cycle of treatment. Results: Sixteen patients were enrolled. The dose of topotecan was reduced to 1.2 mg/m2/day due to myelosuppression. Seven patients had paired tumor biopsies. In 4 patients, HIF-1α nuclear staining became undetectable after treatment (7.5%–50% staining at baseline). Decreased levels of VEGF and GLUT-1 mRNA were measured in 4 patients; the changes were concordant with reduction in HIF-1α in 3 patients. Decreased tumor blood flow and permeability were observed by DCE-MRI in 7 of 10 patients after 1 cycle. One patient had a partial response accompanied by inhibition of HIF-1α in tumor and reduction in tumor blood flow on DCE-MRI. Conclusions: This multihistology, target assessment trial of a small molecule inhibitor of HIF-1α showed that topotecan could decrease HIF-1α expression in advanced solid tumors. Clin Cancer Res; 17(15); 5123–31. ©2011 AACR.

Purpose Inhibition of epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) pathways may result in synergistic antitumour activity. We designed a phase I study to evaluate the combination of vandetanib, an investigational agent with activity against EGF receptor and VEGF receptor 2, and bevacizumab, a monoclonal antibody against VEGF. Experimental design Patients with advanced solid tumours and lymphomas were enrolled. Objectives were to determine the safety and maximum tolerated dose of the combination, characterise pharmacokinetics, measure angiogenic marker changes in blood, and assess tumour blood flow using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Vandetanib was given orally once daily and bevacizumab intravenously once in every 3 weeks in 21-day cycles utilising a standard dose-escalation design. Results Fifteen patients were enrolled, and a total of 94 cycles of therapy were administered. No protocol-defined dose-limiting toxicities were observed; due to toxicities associated with chronic dosing, hypertension, proteinuria, diarrhoea and anorexia, dose escalation was stopped at the second dose level. We observed one partial response and one minor response; 9 patients experienced stable disease. There were significant changes in plasma VEGF and placental-derived growth factor levels, and decreases in K trans and k ep were observed by DCE-MRI. Conclusion In this trial, we safely combined two targeted agents that cause dual blockade of the VEGF pathway, demonstrated preliminary evidence of clinical activity, and conducted correlative studies demonstrating anti-angiogenic effect. The recommended phase II dose was established as vandetanib 200 mg daily and bevacizumab 7.5 mg/kg every 3 weeks.

Objective Olaparib (O), a polyADPribose polymerase (PARP) inhibitor, and cediranib (C), a VEGF receptor (VEGFR)1–3 inhibitor together had greater activity than O alone in women with recurrent platinum-sensitive ovarian cancer (OvCa). The objective of this study is to identify potential lead biomarker candidates for response to O + C in the setting of a multi-institutional phase II study of O with and without C in recurrent platinum-sensitive OvCa. Methods A self-selected group of patients participated in a prospectively planned exploratory biomarker substudy of the randomized phase II study of O versus O + C. Whole blood for peripheral blood mononuclear cell (PBMC) and plasma isolation was collected prior to and on day 3 of treatment. Quantitation of circulating endothelial cells (CEC), IL-6, IL-8, VEGF, and soluble VEGFR-2 plasma concentrations, and polyADPribose (PAR) incorporation were performed. Single nucleotide polymorphism analysis of XRCC1 280H, R194W, and Q399R was done. Dynamic contrast-enhanced-magnetic resonance imaging (DCE-MRI) was performed at baseline and day 3 of treatment. Parameter changes were compared between the two arms using an exact Wilcoxon rank sum test. Kaplan–Meier and log-rank tests were used to examine survival outcome. Results Thirteen patients elected to participate in the translational substudy, seven patients on O and six patients on O + C. Patients on O + C had a greater decrease in IL-8 concentration and larger CEC fold increase compared with those on O alone (p = 0.026, p = 0.032). The fold increase in CEC on day 3 was associated with duration of progression-free survival (PFS) (R2 = 0.77, 95% CI 0.55–0.97, p

Purpose Alveolar soft part sarcoma (ASPS) is a rare, highly vascular tumor, for which no effective standard systemic treatment exists for patients with unresectable disease. Cediranib is a potent, oral small-molecule inhibitor of all three vascular endothelial growth factor receptors (VEGFRs). Patients and Methods We conducted a phase II trial of once-daily cediranib (30 mg) given in 28-day cycles for patients with metastatic, unresectable ASPS to determine the objective response rate (ORR). We also compared gene expression profiles in pre- and post-treatment tumor biopsies and evaluated the effect of cediranib on tumor proliferation and angiogenesis using positron emission tomography and dynamic contrast-enhanced magnetic resonance imaging. Results Of 46 patients enrolled, 43 were evaluable for response at the time of analysis. The ORR was 35%, with 15 of 43 patients achieving a partial response. Twenty-six patients (60%) had stable disease as the best response, with a disease control rate (partial response + stable disease) at 24 weeks of 84%. Microarray analysis with validation by quantitative real-time polymerase chain reaction on paired tumor biopsies from eight patients demonstrated downregulation of genes related to vasculogenesis. Conclusion In this largest prospective trial to date of systemic therapy for metastatic ASPS, we observed that cediranib has substantial single-agent activity, producing an ORR of 35% and a disease control rate of 84% at 24 weeks. On the basis of these results, an open-label, multicenter, randomized phase II registration trial is currently being conducted for patients with metastatic ASPS comparing cediranib with another VEGFR inhibitor, sunitinib.

62 Background: Multiparametric MRI (mpMRI) and fusion biopsy (FBx) detect more high risk prostate cancer (CaP) and less low risk CaP than standard systematic biopsy (SBx). However, there remains a small subset of patients where SBx captures higher grade disease than FBx. We aim to identify potential reasons for failure of FBx biopsy in detection of clinically significant (CS) CaP. Methods: A review was performed of a prospectively maintained database of patients undergoing mpMRI followed by FBx and SBx in the same session from 2007−2014. Patients upgraded to higher risk disease based on SBx results relative to FBx were identified. Independent re−review of MR imaging in this subset was conducted to identify potential proximity between MR targets and SBx region which revealed higher risk CaP. Univariate analysis was performed to determine association of patient, MRI, and pathologic characteristics with upgrading by SBx. Results: We identified 1003 total patients who underwent mpMRI and biopsy, of which 564 were found to have CaP (56.2%). Upgrading based on SBx occurred in 137/564 (24.3%) patients, of which only 55 (9.8%) were to intermediate (high volume 3+4) [N = 37, 6.5%] or high risk CaP ( ≥ 4+3) [N = 18, 3.2%]. 41 of 55 patients (75%) had a lesion identified by mpMRI with FBx in the same sextant in which SBx biopsy revealed intermediate or high risk CaP. On univariate analysis, higher prostate volume (48cc vs 42cc, p < 0.001) and lower percent core involvement (20% vs. 58%, p < 0.001) were associated with upgrading by SBx. Conclusions: MRI rarely misses CS CaP and FBx, if accurate, should reflect the true disease state. Most gleason upgrades by SBx were to low risk, low volume CaP. In patients upgraded by SBx to CS CaP, mpMRI identified a targetable lesion in proximity to the SBx sextant in a majority of patients. FBx failure may be related to suboptimal imaging or biopsy related inaccuracy including registration error, miscalculation of target location, or inadequate lesion sampling. Other possibilities include presence of tumor heterogeneity, multi−focality within the same sextant, or low volume disease. Future studies with biopsy mapping on MRI will provide insight into mechanisms of failure in patients with overlapping target and sextant sampling.

291 Background: Endoglin (CD105) is an endothelial cell membrane receptor highly expressed on proliferating tumor vasculature, including HCC. CD105 is essential for angiogenesis and its expression is upregulated by hypoxia and VEGF inhibition. TRC105 is a chimeric IgG1 anti-CD105 monoclonal antibody that inhibits angiogenesis and causes ADCC and apoptosis of proliferating endothelium. Sorafenib is the only FDA-approved drug in HCC. Methods: Preclinical: Murine BNL HCC cells were grown subcutaneously in wildtype Balb/c mice and treated with antibody to murine CD105, (clone MJ7/18; 10-200ug) + sorafenib (10 mg/kg daily p.o.) or sorafenib alone with assessment for CD105 expression, tumor size. Clinical: Patients with HCC (Childs Pugh A/B7), ECOG 0/1, were enrolled in a phase I study of TRC105 at 3, 6, 10, 15mg/kg q 2wks plus sorafenib 400mg bid. Correlative biomarkers included DCE-MRI, color Doppler ultrasonography, circulating endothelial and endothelial progenitor cells, plasma levels of angiogenic factors, soluble CD105 and tumor IHC for CD105. Samples were also collected for immunogenicity and pharmacokinetics. Results: Preclinical studies: CD105 expression was increased in BNL HCC tumors by sorafenib. Anti-CD105 antibody + sorafenib reduced tumor volume compared to sorafenib alone. Clinical trial: 19 pts were enrolled; Hep B/C/NA: 2/10/7; M:F 13:6; Mean age of 60 (range 18-76); 1 DLT (increased AST) occurred at 10mg/kg. Three of 14 (21%) evaluable pts achieved PR by RECIST. Four patients had confirmed stable disease, one of whom was treated for 22 months. Median time on study was 4 months (range 2 to 22 months). Conclusions: TRC105 combined with sorafenib was well tolerated at the recommended single agent doses of both drugs. Encouraging evidence of activity was observed and the study is proceeding to the phase 2 stage. Full correlative and clinical data will be presented. Clinical trial information: NCT01306058.

5535 Background: O and C have single agent activity in recurrent platinum-sensitive high-grade serous ovarian cancer (HGSOC). A multi-institutional phase 2 open label study evaluated the efficacy o...

TPS4701 Background: In high-risk prostate cancer, radiation therapy (RT) + androgen deprivation therapy (ADT) improve survival. Nonetheless, 10-year disease specific mortality is about 25%. L-BLP25 is a cancer vaccine containing the BLP25 lipopeptide that targets MUC1 tumor antigen. It may enhance immune targeting of cells that express MUC1 (e.g. prostate cancer). In murine models, RT synergizes with vaccine-induced anti-cancer immunity (augments T-cell mediated cancer cytolysis, up-regulates cellular Fas and co-stimulatory/adhesion molecules). ADT augments T-cell trafficking to prostate. Immune response to combining the three (L-BLP25 + RT + ADT) is not known. The current trial intends to study this immune response to L-BLP25 + RT + ADT and compare it to RT+ADT alone. Using ELISPOT, endo-rectal MRI and serial prostate biopsies, this trial was designed to correlate systemic immune response with changes in tumor imaging and/or tumor microenvironment after treatment with L-BLP25. This trial may provide insight into immune response biomarkers that are most appropriate in this setting. Methods: A randomized (1:1), open-label, phase II trial of 42 pts is planned. Eligibility: Adult males with newly diagnosed high-risk prostate cancer (T3 or Gleason ≥ 8 or seminal vesicle involvement or N1 or PSA>20) and HLA-A2/A3 positivity (to allow for ELISPOT analysis). The vaccine arm will receive RT + 2-year ADT + L-BLP25. Standard arm will receive RT + 2-year ADT. L-BLP25 vaccine schedule: biweekly X 5 starting with neo-adjuvant ADT, then 6 weekly X 4 starting with RT. A single 300mg/m2 cyclophosphamide infusion (decreases suppressor T-cells) will be given 3 days before L-BLP25 to enhance immune response in the vaccine arm. The impact of L-BLP25 + RT+ADT on MUC-1-specific systemic immune response will be determined using interval peripheral blood ELISPOT assays. Endo-rectal coil MRI will be done before and after treatment to study prostate signal changes for correlative and predictive analysis. MRI-UltraSound guided lesion-targeted serial prostate biopsies will be obtained to assess immune response in tumor microenvironment. Two pts have been enrolled.

10001 Background: ASPS accounts for < 1% of soft tissue sarcomas. ASPS is associated with the t(X;17)(p11;q25) translocation, ASPL-TFE3 fusion protein. There is no effective systemic treatment for metastatic ASPS. Cediranib (C) is a potent oral inhibitor of vascular endothelial growth factor receptor (VEGFR-1,-2,-3) tyrosine kinases. Methods: Phase II trial to determine the response rate (PR + CR) of patients (pts) with ASPS to C; assess the effect of C on tumor angiogenesis using DCE-MRI and proliferation using FDG-PET; and compare gene expression profiles in pre- and post-treatment tumor biopsies. Eligible pts (≥ 18 years) had documented metastatic ASPS; ECOG 0-2; and adequate bone marrow, hepatic, and renal function. Pts received 30 mg C by mouth, once a day in 28-day cycles. Tumor response was assessed using RECIST 1.1. Biopsies were performed at baseline and after 3-5 days of treatment. Results: A total of 36 pts have been enrolled since July 2009; age range 19-59 yrs. Twenty-eight pts are evaluable ...

Background: The presence of K-ras mutation predicts for a lack of response to EGFR-directed therapies in CRC. We hypothesized that a drug capable of inhibiting Raf kinase, which is downstream of Ras, could restore tumor sensitivity to cetuximab. We conducted a Phase II single-arm optimal two-stage design trial of cetuximab, a monoclonal antibody directed against EGFR, in combination with sorafenib, a small molecule inhibitor of VEGFR2 and Raf kinase, in patients with EGFR-positive (+) CRC bearing K-ras mutations. Trial Design: Objectives were to determine clinical benefit rate (CBR) (CR+PR+SD for 4 months) and PFS. Eligible patients were ≥ 18 years old and had histologically documented EGFR+ metastatic CRC bearing K-ras mutations which had recurred or progressed following at least one prior chemotherapy regimen; measurable disease; ECOG PS 0-1; adequate bone marrow, hepatic and renal function. Patients previously treated with an EGFR inhibitor were excluded. Cetuximab was given IV at 400 mg/m2 initially as a loading dose on week 1, followed by 250 mg/m2 weekly, in 28-day cycles. Sorafenib was self-administered orally at 400 mg BID. Radiologic assessment was performed at baseline and every 2 cycles; response was determined based on RECIST criteria. Changes in tumor vascularity were evaluated by dynamic contrast-enhanced MRI (DCE-MRI) at baseline and after 2 cycles. Results: A total of 9 patients received at least 2 cycles of therapy and were evaluable for response. The median age was 51 years (range 21-81 years), and all patients had an ECOG PS of 1 and had received prior FU, oxaliplatin, irinotecan, and bevacizumab. Rash, electrolyte abnormalities, hypertension, and diarrhea were the most common toxicities. Grade 2 and 3 toxicities (number of patients in parentheses) were hypophosphatemia (5), hypokalemia (1), hypomagnesemia (1), acneiform rash (2), hand-foot syndrome (1), diarrhea (3), transaminitis (2), hyperbilirubinemia (1), lymphopenia (6), hypertension (1), anemia (1), and hypoalbuminemia (4). The only grade 4 events were lymphopenia (1) and hypokalemia (1). Although no patients had objective responses, 3 patients had stable disease for 6, 6 and 4 months respectively. DCE-MRI results showed reduction in the parameters of permeability, with decrease in ktrans and kep values. Quantitative biomarker analysis with determination of plasma angiogenic factors is ongoing. Conclusions: Sorafenib in combination with cetuximab is well tolerated in CRC patients and was associated with disease stabilization in 3 of 9 patients with EGFR+ CRC bearing K-ras mutations. Sorafenib plus cetuximab may have a role in the treatment of patients with CRC bearing Kras mutations. We have met the response goals for the first stage of the trial, and accrual continues for the second stage. Funded by NCI Contract No. HHSN261200800001E. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3718.

3522 Background: (V), a small molecule tyrosine kinase inhibitor, has strong inhibitory activity against VEGFR-2 and the EGF RTK. (B), a humanized anti-VEGF monoclonal antibody, blocks the binding of human VEGF to its receptors. We proposed that dual blockade of the VEGF pathway provides an added therapeutic effect compared with either agent alone. Methods: A standard 3–6 pt/cohort design, dose-escalation Phase I study was performed. (V) was self-administered PO, days 1–21 of each 21-day cycle. (B) was administered by IV infusion Q 3 wks. Objectives: Determine the toxicity profile and the MTD of the combination of (V+B); evaluate (V) pharmacokinetics, changes in tumor vascularity by dynamic contrast enhanced MRI (DCE-MRI) and effects of (V+B) treatment on circulating endothelial progenitors and mature circulating endothelial cells. Eligibility: ECOG ≤ 2, adequate organ function. The MTD is the dose level at which no more than 1 of 6 patients experience DLT during the first 2 cycles of treatment, and the dose below at which at least 2 (of ≤6) patients have DLT due to drug treatment. Results: 9 pts have been accrued to date. Diagnosis: pancreatic-1, NSCLC-1, colorectal-3, peritoneal mesothelioma-1, melanoma-1, NHL-1, jejunal adenocarcinoma (JAC)-1. 1 DLT (gr 3 Allergic reaction) was observed at DL 2. HTN was the most common toxicity at DL 2. Other gr 2–3 toxicities seen beyond 2 cycles included: diarrhea, elevated creatinine, leucopenia, anemia, thrombocytopenia, hemorrhage, prolonged QTc interval, proteinuria, rash (hand-foot syndrome / acneiform). Partial Response (PR) was achieved in 2 pts (pancreatic 14 mos + and JAC 6 mos); disease stabilization in 5 pts (4 mos +). DCE-MRI results showed a reduction in the parameters of permeability, (ktrans and kep), associated with one PR. Conclusions: We decided not to escalate beyond DL 2 due to the gr 2–3 toxicities observed with chronic therapy. We recommend (V): 200mg daily and (B): 5mg/kg IV q3 weeks as the Phase II dose. [Table: see text] No significant financial relationships to disclose.

5141 Background: There is no standard therapy for prostate cancer patients who have progressed following docetaxel therapy. VEGF is implicated in tumor blood vessel formation and in disease progression in several solid tumors. Cediranib is an oral, small molecule inhibitor of receptor tyrosine kinases which influence VEGF. Methods: Patients must have clinical and/or radiographic evidence of progression on docetaxel with no limit on the number of prior chemotherapy regimens or radioisotopes. The starting dose is 20 mg daily, imaging is every 2 months. The primary objective is a 30% 6 month probability of progression free survival as determined by clinical (not by PSA rise alone) and radiographic criteria Simon two stage optimal design is being utilized with twelve patients enrolled in the first cohort. If 2 or more patients are progression-free at 6 months, the cohort will be expanded to 35 evaluable patients. Patients receiving cediranib were scanned by DCE-MRI pre- and post-treatment. A two compartment model was used to analyze the volume transfer. Results: Thirty-four of a planned 35 patients have been enrolled and 4 remain on active treatment (2–7 months). There have been 13 of 23 evaluable patients with tumor shrinkage and 4 have met the criteria for partial response. Decreases in lymph node metastases as well as in lung, liver and bone lesions have occurred. PSA levels have not corresponded well with imaging responses. Adverse events have been similar to other drugs in this class including hypertension, dysphonia and fatigue. Grade 3 toxicities included vomiting (2), prolonged QTc interval (1) and muscle weakness (3), weight loss (3), dehydration (4), fatigue (6), hypoxia (1), renal failure (1), transaminitis (3), and anorexia (1). There have been 30 patients who were evaluated by DCE-MRI. Targeted lesions included bone (17) and soft tissue (15). Conclusions: The safety profile and early activity makes cediranib a promising drug in CRPC post docetaxel. Preliminary data suggests that cediranib does have direct effect on the microcirculation and vasculature. Additional accrual is required to better characterize the response rate, the discrepancy between PSA and standard imaging changes and establish evidence of clinical correlation for DCE-MRI. No significant financial relationships to disclose.

5136 Introduction: There is no standard therapy for prostate cancer patients who have progressed following docetaxel therapy. VEGF is implicated in tumor blood vessel formation and disease progression in solid tumors. Cediranib, an oral, small molecule inhibitor of VEGF receptor tyrosine kinases, is being evaluated at a dose of 20 mg daily in patients with prostate cancer resistant to docetaxel and hormonal therapy. Methods: Patients have clinical and/or radiographic evidence of progression on docetaxel with no limit on the number of prior chemotherapy regimens or radioisotopes. Response imaging is assessed every 2 months. Simon two stage optimal design was utilized. Primary objective is a 30% 6 month probability of progression free survival as determined by clinical (not PSA rise alone) and radiographic criteria. If 2 or more patients are progression-free at 6 months, the cohort will be expanded to 35 evaluable patients. Patients receiving cediranib were scanned by DCE-MRI pre- and post-treatment. A two ...