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TP53, a well-known tumour suppressor gene that encodes p53, is frequently inactivated by mutation or deletion in most human tumours. A tremendous effort has been made to restore p53 activity in cancer therapies. However, no effective p53-based therapy has been successfully translated into clinical cancer treatment owing to the complexity of p53 signalling. Here we demonstrate that genomic deletion of TP53 frequently encompasses essential neighbouring genes, rendering cancer cells with hemizygous TP53 deletion vulnerable to further suppression of such genes. POLR2A is identified as such a gene that is almost always co-deleted with TP53 in human cancers. It encodes the largest and catalytic subunit of the RNA polymerase II complex, which is specifically inhibited by α-amanitin. Our analysis of The Cancer Genome Atlas (TCGA) and Cancer Cell Line Encyclopedia (CCLE) databases reveals that POLR2A expression levels are tightly correlated with its gene copy numbers in human colorectal cancer. Suppression of POLR2A with α-amanitin or small interfering RNAs selectively inhibits the proliferation, survival and tumorigenic potential of colorectal cancer cells with hemizygous TP53 loss in a p53-independent manner. Previous clinical applications of α-amanitin have been limited owing to its liver toxicity. However, we found that α-amanitin-based antibody-drug conjugates are highly effective therapeutic agents with reduced toxicity. Here we show that low doses of α-amanitin-conjugated anti-epithelial cell adhesion molecule (EpCAM) antibody lead to complete tumour regression in mouse models of human colorectal cancer with hemizygous deletion of POLR2A. We anticipate that inhibiting POLR2A will be a new therapeutic approach for human cancers containing such common genomic alterations.

Background: Patients with localized esophageal and esophagogastric junction cancer (EAC) receive chemoradiation and then surgery (trimodality, TMT) or definitive chemoradiation (bimodality, BMT). Distant metastases (DMs) are common but the details of their distribution and timing in a large cohort have not been described. Methods: 629 patients with localized EAC who had TMT or BMT were analyzed. Standard statistical methods were used to define the end points. Results: The median follow-up time was 37.2 months (interquartile range 17.8-65.0). Of 356 TMT patients, 33% (119) developed DM as their first relapse and of 273 BMT patients, 40% (109) developed DM; 91% (TMT) and 96% (BMT) of the DMs were diagnosed within 2 years of local therapy. The most common sites of DM were: lung, distant nodes, liver, peritoneal cavity, bone, brain and pleura in order of frequency. The median overall survival of TMT patients with DM was 10.2 months (95% CI 7.8-12.7) and that for BMT patients with DM was 7.8 months (95% CI 5.7-9.9). Conclusions: Following TMT or BMT, ≥33% of patients developed DMs and most of these occurred within 2 years (>90%) of local therapy. A clinical model is desirable that associates clinical parameters with a high risk for DM in TMT-eligible patients prior to surgery.

Farnesoid X receptor (FXR) is a bile acid nuclear receptor described through mouse knockout studies as a tumor suppressor for the development of colon adenocarcinomas. This study investigates the regulation of FXR in the development of human colon cancer. We used immunohistochemistry of FXR in normal tissue ( n = 238), polyps ( n = 32), and adenocarcinomas, staged I–IV ( n = 43, 39, 68, and 9), of the colon; RT-quantitative PCR, reverse-phase protein array, and Western blot analysis in 15 colon cancer cell lines; NR1H4 promoter methylation and mRNA expression in colon cancer samples from The Cancer Genome Atlas; DNA methyltransferase inhibition; methyl-DNA immunoprecipitation (MeDIP); bisulfite sequencing; and V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS) knockdown assessment to investigate FXR regulation in colon cancer development. Immunohistochemistry and quantitative RT-PCR revealed that expression and function of FXR was reduced in precancerous lesions and silenced in a majority of stage I-IV tumors. FXR expression negatively correlated with phosphatidylinositol-4, 5-bisphosphate 3 kinase signaling and the epithelial-to-mesenchymal transition. The NR1H4 promoter is methylated in ∼12% colon cancer The Cancer Genome Atlas samples, and methylation patterns segregate with tumor subtypes. Inhibition of DNA methylation and KRAS silencing both increased FXR expression. FXR expression is decreased early in human colon cancer progression, and both DNA methylation and KRAS signaling may be contributing factors to FXR silencing. FXR potentially suppresses epithelial-to-mesenchymal transition and other oncogenic signaling cascades, and restoration of FXR activity, by blocking silencing mechanisms or increasing residual FXR activity, represents promising therapeutic options for the treatment of colon cancer.

Purpose Operable thoracic esophageal/gastroesophageal junction carcinoma (EC) is often treated with chemoradiation and surgery but tumor responses are unpredictable and heterogeneous. We hypothesized that aldehyde dehydrogenase-1 ( ALDH-1 ) could be associated with response. Methods The labeling indices (LIs) of ALDH-1 by immunohistochemistry in untreated tumor specimens were established in EC patients who had chemoradiation and surgery. Univariate logistic regression and 3-fold cross validation were carried out for the training (67% of patients) and validation (33%) sets. Non-clinical experiments in EC cells were performed to generate complimentary data. Results Of 167 EC patients analyzed, 40 (24%) had a pathologic complete response (pathCR) and 27 (16%) had an extremely resistant (exCRTR) cancer. The median ALDH-1 LI was 0.2 (range, 0.01–0.85). There was a significant association between pathCR and low ALDH-1 LI ( p ≤ 0.001; odds-ratio [OR] = 0.432). The 3-fold cross validation led to a concordance index (C-index) of 0.798 for the fitted model. There was a significant association between exCRTR and high ALDH-1 LI ( p ≤ 0.001; OR = 3.782). The 3-fold cross validation led to the C-index of 0.960 for the fitted model. In several cell lines, higher ALDH-1 LIs correlated with resistant/aggressive phenotype. Cells with induced chemotherapy resistance upregulated ALDH-1 and resistance conferring genes ( SOX9 and YAP1 ). Sorted ALDH-1+ cells were more resistant and had an aggressive phenotype in tumor spheres than ALDH-1− cells. Conclusions Our clinical and non-clinical data demonstrate that ALDH-1 LIs are predictive of response to therapy and further research could lead to individualized therapeutic strategies and novel therapeutic targets for EC patients.

ObjectiveTo determine the impact of RAS mutation status on survival and patterns of recurrence in patients undergoing curative resection of colorectal liver metastases (CLM) after preoperative modern chemotherapy.BackgroundRAS mutation has been reported to be associated with aggressive tumor biology. However, the effect of RAS mutation on survival and patterns of recurrence after resection of CLM remains unclear.MethodsSomatic mutations were analyzed using mass spectroscopy in 193 patients who underwent single-regimen modern chemotherapy before resection of CLM. The relationship between RAS mutation status and survival outcomes was investigated.ResultsDetected somatic mutations included RAS (KRAS/NRAS) in 34 (18%), PIK3CA in 13 (7%), and BRAF in 2 (1%) patients. At a median follow-up of 33 months, 3-year overall survival (OS) rates were 81% in patients with wild-type versus 52.2% in patients with mutant RAS (P = 0.002); 3-year recurrence-free survival (RFS) rates were 33.5% with wild-type versus 13.5% with mutant RAS (P = 0.001). Liver and lung recurrences were observed in 89 and 83 patients, respectively. Patients with RAS mutation had a lower 3-year lung RFS rate (34.6% vs 59.3%, P < 0.001) but not a lower 3-year liver RFS rate (43.8% vs 50.2%, P = 0.181). In multivariate analyses, RAS mutation predicted worse OS [hazard ratio (HR) = 2.3, P = 0.002), overall RFS (HR = 1.9, P = 0.005), and lung RFS (HR = 2.0, P = 0.01), but not liver RFS (P = 0.181).ConclusionsRAS mutation predicts early lung recurrence and worse survival after curative resection of CLM. This information may be used to individualize systemic and local tumor-directed therapies and follow-up strategies.

Background The contribution of induction chemotherapy (IC) before preoperative chemoradiation for esophageal cancer (EC) is not known. We hypothesized that IC would increase the rate of pathologic complete response (pathCR). Methods Trimodality-eligibile patients were randomized to receive no IC (Arm A) or IC (oxaliplatin/FU; Arm B) before oxaliplatin/FU/radiation. Surgery was attempted ∼5–6 weeks after chemoradiation. The pathCR rate, post-surgery 30-day mortality, overall survival (OS), and toxic effects were assessed. Bayesian methods and Fisher's exact test were used. Results One hundred twenty-six patients were randomized dynamically to balance the two arms for histology, baseline stage, gender, race, and age. Fifty-five patients in Arm A and 54 in Arm B underwent surgery. The median actuarial OS for all patients (54 deaths) was 45.62 months [95% confidence interval (CI), 27.63–NA], with median OS 45.62 months (95% CI 25.56–NA) in Arm A and 43.68 months (95% CI 27.63–NA) in Arm B (P = 0.69). The pathCR rate in Arm A was 13% (7 of 55) and 26% (14 of 54) in Arm B (two-sided Fisher's exact test, P = 0.094). Safety was similar in both arms. Conclusions These data suggest that IC produces non-significant increase in the pathCR rate and does not prolong OS. Further development of IC before chemoradiation may not be beneficial. Clinical trial no.: NCT 00525915 ( www.clinicaltrials.gov ).

Background: It is unclear whether patients undergoing trimodality therapy (TMT) should be screened or surveyed for brain metastases. Methods: We retrospectively analyzed esophageal cancer (EC) patients who underwent TMT between the years 2000 and 2010. All were systematically staged and surveyed but none had screening or surveillance brain imaging. Results: The median follow-up time for 518 patients was 29.3 months (range 1-149.2); all patients had adenocarcinoma of the esophagus. Of 188 (36.3%) patients who developed distant metastases, 20 (10.6% of 188 patients or 3.9% of 518 patients) had brain metastases. A higher baseline clinical stage (stage III or IVa) was associated with brain metastases. Most (90%) patients with brain metastases were diagnosed within 24 months of surgery. Sixteen patients had central nervous system symptoms at diagnosis. Twelve (60%) patients had solitary metastasis and 8 (40%) patients had multiple metastases. Although 17 patients received therapy for brain metastases, the median overall survival time of 20 patients was only 10.5 months (95% CI 6.6-14.0). Conclusion: After TMT, 3.9% of EC patients developed brain metastases and their prognosis was poor. Our data suggest that screening and/or surveillance for brain metastases in the EC population undergoing TMT is not warranted.

Therapy targeting VEGF has become the standard of care in several solid malignancies. Early investigations attempting to identify predictive markers for the efficacy of therapy failed to identify any predictive markers that could help oncologists decide who should—and, more importantly, who should not—receive VEGF-targeted therapies. However, interest has been renewed in predictive biomarkers for VEGF-targeted therapies, especially in light of the fact that the U.S. Food and Drug Administration withdrew approval for use of bevacizumab, an antibody to VEGF, in patients with metastatic breast cancer. In a recent publication in the Journal of Clinical Oncology, investigators identified circulating VEGF and tumor neuropilin-1 expression as potential predictive biomarkers for bevacizumab. From this perspective, we provide a critical evaluation of the use of these markers and the need for validation in prospective clinical trials. Clin Cancer Res; 19(11); 2824–7. ©2013 AACR.

TGF-β and Notch signaling pathways play important roles in regulating self-renewal of stem cells and gastrointestinal carcinogenesis. Loss of TGF-β signaling components activates Notch signaling in esophageal adenocarcinoma, but the basis for this effect has been unclear. Here we report that loss of TGF-β adapter β2SP (SPNB2) activates Notch signaling and its target SOX9 in primary fibroblasts or esophageal adenocarcinoma cells. Expression of the stem cell marker SOX9 was markedly higher in esophageal adenocarcinoma tumor tissues than normal tissues, and its higher nuclear staining in tumors correlated with poorer survival and lymph node invasion in esophageal adenocarcinoma patients. Downregulation of β2SP by lentivirus short hairpin RNA increased SOX9 transcription and expression, enhancing nuclear localization for both active Notch1 (intracellular Notch1, ICN1) and SOX9. In contrast, reintroduction into esophageal adenocarcinoma cells of β2SP and a dominant-negative mutant of the Notch coactivator mastermind-like (dnMAN) decreased SOX9 promoter activity. Tumor sphere formation and invasive capacity in vitro and tumor growth in vivo were increased in β2SP-silenced esophageal adenocarcinoma cells. Conversely, SOX9 silencing rescued the phenotype of esophageal adenocarcinoma cells with loss of β2SP. Interaction between Smad3 and ICN1 via Smad3 MH1 domain was also observed, with loss of β2SP increasing the binding between these proteins, inducing expression of Notch targets SOX9 and C-MYC, and decreasing expression of TGF-β targets p21(CDKN1A), p27 (CDKN1B), and E-cadherin. Taken together, our findings suggest that loss of β2SP switches TGF-β signaling from tumor suppression to tumor promotion by engaging Notch signaling and activating SOX9. Cancer Res; 73(7); 2159–69. ©2013 AACR.

Objective: Major limitation of successful implementation of targeted therapy in esophageal adenocarcinoma (EAC) is low frequency of target specific biomarker alteration and intratumoral heterogeneity. Cyclin dependent kinase 9 (CDK9) is a ubiquitous serine threonine kinase whoseinhibition has been used as a therapeutic option in other solid tumors. However, critical in vitro and in vivo information about the efficacy and mechanism of CDK9 inhibition in EAC is lacking and needs to be generated before a clinical trial is proposed. Design: We assessed the CDK9 protein expression in EAC cell lines and in patient tissue samples of Barrett's esophagus and EAC. Subsequently, we studied effects of genetic downregulation (shCDK9) in SKGT4 and chemical inhibition of CDK9 by CDK9 inhibitor II, a specific, potent competitive inhibitor of CDK9 (Santa Cruz Biotechnology, CA) on proliferation, apoptosis, and cell cycle of SKGT4, FLO-1 and OE33. In vivo effects of shCDK9 and CDK9 inhibitor II was analyzed in xenografts experiments performed on nude mice after injection of FLO-1 or shCDK9-SKGT 4 and control cells in right flank or abdomen. We also assessed the effects of shCDK9 and CDK9 inhibitor II on expression of MCL-1 and phosphorylation of RNA polymerase II in EAC cells. Results: Higher expression of CDK9 was observed in all EAC cell lines and in tumor samples of patients with EAC as compared to normal squamous epithelium and Barrett's Esophagus. shCDK9 in SKGT4 cells induced significant reduction in proliferation, increase in apoptosis and G1 arrest as compared to control cells in vitro. In vivo experiment with SKGT4-shCDK9 demonstrated no tumor growth in 4 of 10 mice and tumor volume was significantly smaller in SKGT4-shCDK9 as compared to control SKGT4 cells (72.89 ± 12.88 mm3 v.270 ± 64.07 mm3, p< 0.01) in other mice. Treatment with CDK9 inhibitor II demonstrated dose dependent reduction in proliferation, increased apoptosis and G1 arrest in all three cell lines in vitro and more than 50% reduction in tumor volume in xenografts as compared to control. CDK9 inhibitor II reduced RNA Pol II phosphorylation and expression of MCL-l and up-regulation of MCL-1 expression induced resistance to CDK9 inhibitor II in all three EAC cell lines.. Conclusions: CDK9 inhibition has strong anti-EAC properties in vitro and in vivo. These properties along with strong diffuse expression of CDK9 in human EAC support further exploration of CDK9 as a potential therapeutic target for EAC. Citation Format: Zhimin Tong, Devkumar Chatterjee, Defeng Deng, Omkara Veeranki, Alicia Mejia, Jaime Rodriguez, Jaffer Ajani, Wayne Hofstetter, Steven Lin, Sushovan Guha, Scott Kopetz, Sunil Krishnan, Dipen Maru. Cyclin-dependent kinase 9: a potential therapeutic target for esophageal adenocarcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3815.

3607Background: FBXW7 functions as a ubiquitin ligase tagging dominant oncogenic proteins such as cyclin E, MYC, Jun and Notch for degradation by the proteasome system. FBXW7mt are noted throughout...

4029Background: Older patients with localized gastric adenocarcinoma (LGAC) have substantial postoperative morbidity and mortality; however, postoperative outcomes of these patients who receive pre...

3506Background: CRCs originating in the right colon (RC) have features distinct from those in the rectum/left colon, including more frequent CpG island methylator phenotype (CIMP-High) and BRAF mut...

3520Background: While checkpoint blockade therapy has shown promise in mismatch repair-deficient CRC, these represent a small fraction of overall cases. Limited data exists regarding the immune mic...

3605Background: Response to nCRT is a key prognostic indicator for rectal cancer and may be influenced by the systemic inflammatory response. The purpose of this study was to determine the relation...

3517Background: HER2 amplification (HERamp), seen in 5% of KRAS wildtype (WT) metastatic colorectal cancers (mCRC), is associated with resistance to anti-epidermal growth factor receptor antibodies...

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

51 Background: Biomarker or biomarker signature(s) is needed to help optimize therapy of GEAC patients undergoing multimodality therapy. p63 is a transcription factor important in the development of squamous epithelial lineage and mediating ectodermal-mesenchymal interactions. Methods: Primary objective of this study was to study the predictive value of p63-associated subtype for pathCR. Other outcomes were also studied. Results: Unsupervised cluster analysis of gene expression data from 185 GEAC patients uncovered two distinct subtypes of GEAC with differences in expression of p63 mRNA: p63-positive and p63-negative. All patients had chemoradiation and surgery. Most were men (88%), all had adenocarcinoma, and most were p63-negative (69%). 25% of patients achieved a pathCR. The median follow-up for all patients was 3.9 years (range, 0.1 – 11.5). p63-positive subtype was associated with pathCR in both a univariate and multivariate analyses (p = 0.04 and p = 0.02, respectively). Female patients with p63-positive subtype, lower no. of ypNodes, and low grade GEACs had a higher probability of pathCR. However, p63-positive subtype was not prognostic (PFS, p = 0.26 or OS, p = 0.80). The median OS for all patients was 4.8 years (95% CI, 3.3 – 6.7 years). Higher no. of ypNodes, higher histologic grade, and mid- or higher esophageal primary were associated with shorter OS (with p-values of < 0.0001, 0.0004 and 0.0001, respectively). Conclusions: Our data suggest that pretreatment p63-positive subtype of GEAC highly correlates with pathCR. Further refinement/validation and combination with other biomarkers is warranted.

Purpose The purposes of this study were to confirm the prognostic value of an optimal morphologic response to preoperative chemotherapy in patients undergoing chemotherapy with or without bevacizumab before resection of colorectal liver metastases (CLM) and to identify predictors of the optimal morphologic response. Patients and Methods The study included 209 patients who underwent resection of CLM after preoperative chemotherapy with oxaliplatin- or irinotecan-based regimens with or without bevacizumab. Radiologic responses were classified as optimal or suboptimal according to the morphologic response criteria. Overall survival (OS) was determined, and prognostic factors associated with an optimal response were identified in multivariate analysis. Results An optimal morphologic response was observed in 47% of patients treated with bevacizumab and 12% of patients treated without bevacizumab (P < .001). The 3- and 5-year OS rates were higher in the optimal response group (82% and 74%, respectively) compared with the suboptimal response group (60% and 45%, respectively; P < .001). On multivariate analysis, suboptimal morphologic response was an independent predictor of worse OS (hazard ratio, 2.09; P = .007). Receipt of bevacizumab (odds ratio, 6.71; P < .001) and largest metastasis before chemotherapy of ≤ 3 cm (odds ratio, 2.12; P = .025) were significantly associated with optimal morphologic response. The morphologic response showed no specific correlation with conventional size-based RECIST criteria, and it was superior to RECIST in predicting major pathologic response. Conclusion Independent of preoperative chemotherapy regimen, optimal morphologic response is sufficiently correlated with OS to be considered a surrogate therapeutic end point for patients with CLM.

Approximately 25% of patients with esophageal cancer (EC) who undergo preoperative chemoradiation, achieve a pathologic complete response (pathCR). We hypothesized that a model based on clinical parameters could predict pathCR with a high (≥60%) probability.We analyzed 322 patients with EC who underwent preoperative chemoradiation. All the patients had baseline and postchemoradiation positron emission tomography (PET) and pre- and postchemoradiation endoscopic biopsy. Logistic regression models were used for analysis, and cross-validation via the bootstrap method was carried out to test the model.The 70 (21.7%) patients who achieved a pathCR lived longer (median overall survival [OS], 79.76 months) than the 252 patients who did not achieve a pathCR (median OS, 39.73 months; OS, P = 0.004; disease-free survival, P = 0.003). In a logistic regression analysis, the following parameters contributed to the prediction model: postchemoradiation PET, postchemoradiation biopsy, sex, histologic tumor grade, and baseline (EUS)T stage. The area under the receiver-operating characteristic curve was 0.72 (95% confidence interval [CI] 0.662-0.787); after the bootstrap validation with 200 repetitions, the bias-corrected AU-ROC was 0.70 (95% CI 0.643-0.728).Our data suggest that the logistic regression model can predict pathCR with a high probability. This clinical model could complement others (biomarkers) to predict pathCR.

Background: For patients with localized esophageal cancer (EC) who can withstand surgery, the preferred therapy is chemoradiation followed by surgery (trimodality). However, after achieving a clinical complete response [clinCR; defined as both post-chemoradiation endoscopic biopsy showing no cancer and physiologic uptake by positron emission tomography (PET)], some patients decline surgery. The literature on the outcome of such patients is sparse. Method: Between 2002 and 2011, we identified 622 trimodality-eligible EC patients in our prospectively maintained databases. All patients had to be trimodality eligible and must have completed preoperative staging after chemoradiation that included repeat endoscopic biopsy and PET among other routine tests. Results: Out of 622 trimodality-eligible patients identified, 61 patients (9.8%) declined surgery. All 61 patients had a clinCR. The median age was 69 years (range 47–85). Males (85.2%) and Caucasians (88.5%) were dominant. Baseline stage was II (44.2%) or III (52.5%), and histology was adenocarcinoma (65.6%) or squamous cell carcinoma (29.5%). Forty-two patients are alive at a median follow-up of 50.9 months (95% CI 39.5–62.3). The 5-year overall and relapse-free survival rates were 58.1 ± 8.4 and 35.3 ± 7.6%, respectively. Of 13 patients with local recurrence during surveillance, 12 had successful salvage resection. Conclusion: Although the outcome of 61 EC patients with clinCR who declined surgery appears reasonable, in the absence of a validated prediction/prognosis model, surgery must be encouraged for all trimodality-eligible patients.

The presence of malignant lymph nodes (+ypNodes) in the surgical specimen after preoperative chemoradiation (trimodality) in patients with oesophageal cancer (EC) portends a poor prognosis for overall survival (OS) and disease-free survival (DFS). Currently, none of the clinical variables highly correlates with +ypNodes. We hypothesised that a combination of clinical variables could generate a model that associates with high likelihood of +ypNodes after trimodality in EC patients.We report on 293 consecutive EC patients who received trimodality therapy. A multivariate logistic regression analysis that included pretreatment and post-chemoradiation variables identified independent variables that were used to construct a nomogram for +ypNodes after trimodality in EC patients.Of 293 patients, 91 (31.1%) had +ypNodes. OS (p=0.0002) and DFS (p0.0001) were shorter in patients with +ypNodes compared to those with -ypNodes. In multivariable analysis, the significant variables for +ypNodes were: baseline T-stage (odds ratio [OR], 7.145; 95% confidence interval [CI], 1.381-36.969; p=0.019), baseline N-stage (OR, 2.246; 95% CI, 1.024-4.926; p=0.044), tumour length (OR, 1.178; 95% CI, 1.024-1.357; p=0.022), induction chemotherapy (OR, 0.471; 95% CI, 0.242-0.915; p=0.026), nodal uptake on post-chemoradiation positron emission tomography (OR, 2.923; 95% CI, 1.007-8.485; p=0.049) and enlarged node(s) on post-chemoradiation computerised tomography (OR, 3.465; 95% CI, 1.549-7.753; p=0.002). The nomogram after internal validation using the bootstrap method (200 runs) yielded a high concordance index of 0.756.Our nomogram highly correlates with the presence of +ypNodes after chemoradiation, however, considerably more refinement is needed before it can be implemented in the clinic.

OBJECTIVE. The purpose of this article is to provide a practical review of newly established morphologic tumor response criteria for hepatic colorectal metastasis treated with bevacizumab-containing chemotherapy and a description of the patterns of early recurrence. We also discuss the respective value of these criteria and the Response Evaluation Criteria in Solid Tumors (RECIST). CONCLUSION. RECIST alone are not sufficient to assess response after bevacizumab-containing chemotherapy for hepatic colorectal metastasis. The combined use of RECIST and morphologic criteria is mandatory for optimal evaluation in this population.

The availability of confocal endomicroscopy motivates the development of optical contrast agents that can delineate the morphologic and metabolic features of gastrointestinal neoplasia. This study evaluates 2-NBDG, a fluorescent deoxyglucose, the uptake of which is associated with increased metabolic activity, in the identification of Barrett's-associated neoplasia. Surveillance biopsies from patients with varying pathologic grades of Barrett's esophagus were incubated ex vivo at 37°C with 2-NBDG and imaged with a fluorescence confocal microscope. Images were categorized as neoplastic (high grade dysplasia, esophageal adenocarcinoma) or metaplastic (intestinal metaplasia, low grade dysplasia) based on the degree of glandular 2-NBDG uptake. Classification accuracy was assessed using histopathology as the gold standard. Forty-four biopsies were obtained from twenty-six patients; 206 sites were imaged. The glandular mean fluorescence intensity of neoplastic sites was significantly higher than that of metaplastic sites (p < 0.001). Chronic inflammation was associated with increased 2-NBDG uptake in the lamina propria but not in glandular epithelium. Sites could be classified as neoplastic or not with 96% sensitivity and 90% specificity based on glandular mean fluorescence intensity. Classification accuracy was not affected by the presence of inflammation. By delineating the metabolic and morphologic features of neoplasia, 2-NBDG shows promise as a topical contrast agent for confocal imaging. Further in vivo testing is needed to determine its performance in identifying neoplasia during confocal endomicroscopic imaging.

Background Confocal endomicroscopy has revolutionized endoscopy by offering subcellular images of the GI epithelium; however, the field of view is limited. Multiscale endoscopy platforms that use widefield imaging are needed to better direct the placement of high-resolution probes. Design Feasibility study. Objective This study evaluated the feasibility of a single agent, proflavine hemisulfate, as a contrast medium during both widefield and high-resolution imaging to characterize the morphologic changes associated with a variety of GI conditions. Setting The University of Texas MD Anderson Cancer Center, Houston, Texas, and Mount Sinai Medical Center, New York, New York. Patients, Interventions, and Main Outcome Measurements Resected specimens were obtained from 15 patients undergoing EMR, esophagectomy, or colectomy. Proflavine hemisulfate, a vital fluorescent dye, was applied topically. The specimens were imaged with a widefield multispectral microscope and a high-resolution microendoscope. The images were compared with histopathologic examination. Results Widefield fluorescence imaging enhanced visualization of morphology, including the presence and spatial distribution of glands, glandular distortion, atrophy, and crowding. High-resolution imaging of widefield abnormal areas revealed that neoplastic progression corresponded to glandular heterogeneity and nuclear crowding in dysplasia, with glandular effacement in carcinoma. These widefield and high-resolution image features correlated well with the histopathologic features. Limitations This imaging approach must be validated in vivo with a larger sample size. Conclusions Multiscale proflavine-enhanced fluorescence imaging can delineate epithelial changes in a variety of GI conditions. Distorted glandular features seen with widefield imaging could serve as a critical bridge to high-resolution probe placement. An endoscopic platform combining the two modalities with a single vital dye may facilitate point-of-care decision making by providing real-time, in vivo diagnoses.

ObjectivesThe incidence and consequence of an isolated involved circumferential radial margin (CRM) after resection for esophageal adenocarcinoma in the setting of neoadjuvant chemoradiotherapy (CRT) has not been reported. We aimed to determine the frequency and significance of a close (

BACKGROUND: Metabolic imaging is of interest in esophageal cancer; however, the usefulness of initial standardized uptake value (SUV) in positron emission tomography (PET) is unknown in patients with esophageal or gastroesophageal carcinoma treated with definitive chemoradiotherapy. The authors hypothesized that initial SUV would correlate with patient outcome. METHODS: The authors retrospectively analyzed esophageal or gastroesophageal carcinoma patients who had baseline PET and endoscopic ultrasonography in addition to other routine staging. All patients received definitive chemoradiotherapy. Multiple statistical methods were used. RESULTS: The authors analyzed 209 consecutive esophageal or gastroesophageal carcinoma patients treated with definitive chemoradiation for outcome; of these, 180 had baseline PET for additional analyses. The median overall survival (OS) for all patients was 20.7 months (95% confidence interval, 18.8-26.3). Patients with clinical complete response (CR) lived longer than those with less than clinical CR (P < .0001). The median initial SUV was 12.7 (range, 0-51). Higher initial SUV was associated with longer tumors (P = .0001), higher T-stage status (P < .0001), positive N-stage status (P = .0001), higher overall stage (P < .0001), lack of clinical CR (P = .0002), and squamous cell histology (P < .0001). In the univariate analysis, initial SUV was associated with OS (Cox model, P = .016; log-rank test, P = .002). In the multivariate analysis, initial SUV dichotomized by the median value (P = .024) and tumor grade (P = .016) proved to be independent OS prognosticators. Median initial SUV for clinical CR patients was 10.2, compared with 15.3 for less than clinical CR patients (P = .0058). CONCLUSIONS: The data indicate that a higher initial SUV is associated with poorer OS in patients with esophageal or gastroesophageal carcinoma receiving definitive chemoradiation. Upon validation, baseline PET may become a useful stratification factor in randomized trials and for individualizing therapy. Cancer 2011;. © 2011 American Cancer Society.

Background Despite many attempts to establish pre-treatment prognostic markers to understand the clinical biology of esophageal adenocarcinoma (EAC), validated clinical biomarkers or parameters remain elusive. We generated and analyzed tumor transcriptome to develop a practical biomarker prognostic signature in EAC. Methodology/Principal Findings Untreated esophageal endoscopic biopsy specimens were obtained from 64 patients undergoing surgery and chemoradiation. Using DNA microarray technology, genome-wide gene expression profiling was performed on 75 untreated cancer specimens from 64 EAC patients. By applying various statistical and informatical methods to gene expression data, we discovered distinct subgroups of EAC with differences in overall gene expression patterns and identified potential biomarkers significantly associated with prognosis. The candidate marker genes were further explored in formalin-fixed, paraffin-embedded tissues from an independent cohort (52 patients) using quantitative RT-PCR to measure gene expression. We identified two genes whose expression was associated with overall survival in 52 EAC patients and the combined 2-gene expression signature was independently associated with poor outcome (P

Nonspecific sequestration of nanoparticles by the reticulo-endothelial system (RES) results in the degradation of image quality of nanoparticle-based imaging. We demonstrate that gadolinium chloride (GdCl3) pretreatment inactivates RES macrophages, thereby increasing circulatory time and amplifying the tumor-specific signal of conjugated nanoparticles in vivo. The experimental results were validated using compartmental modeling, and the rate parameters for the observed kinetics pattern were estimated. This pretreatment strategy could have broad applicability across biomedical applications utilizing theranostic nanoparticles that are sequestered by the RES.

Protein kinase D (PKD) family members are increasingly implicated in multiple normal and abnormal biological functions, including signaling pathways that promote mitogenesis in pancreatic cancer. However, nothing is known about the effects of targeting PKD in pancreatic cancer. Our PKD inhibitor discovery program identified CRT0066101 as a specific inhibitor of all PKD isoforms. The aim of our study was to determine the effects of CRT0066101 in pancreatic cancer. Initially, we showed that autophosphorylated PKD1 and PKD2 (activated PKD1/2) are significantly upregulated in pancreatic cancer and that PKD1/2 are expressed in multiple pancreatic cancer cell lines. Using Panc-1 as a model system, we showed that CRT0066101 reduced bromodeoxyuridine incorporation; increased apoptosis; blocked neurotensin-induced PKD1/2 activation; reduced neurotensin-induced, PKD-mediated Hsp27 phosphorylation; attenuated PKD1-mediated NF-κB activation; and abrogated the expression of NF-κB-dependent proliferative and prosurvival proteins. We showed that CRT0066101 given orally (80 mg/kg/d) for 24 days significantly abrogated pancreatic cancer growth in Panc-1 subcutaneous xenograft model. Activated PKD1/2 expression in the treated tumor explants was significantly inhibited with peak tumor concentration (12 μmol/L) of CRT0066101 achieved within 2 hours after oral administration. Further, we showed that CRT0066101 given orally (80 mg/kg/d) for 21 days in Panc-1 orthotopic model potently blocked tumor growth in vivo. CRT0066101 significantly reduced Ki-67–positive proliferation index (P < 0.01), increased terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling–positive apoptotic cells (P < 0.05), and abrogated the expression of NF-κB–dependent proteins including cyclin D1, survivin, and cIAP-1. Our results show for the first time that a PKD-specific small-molecule inhibitor CRT0066101 blocks pancreatic cancer growth in vivo and show that PKD is a novel therapeutic target in pancreatic cancer. Mol Cancer Ther; 9(5); 1136–46. ©2010 AACR.

Background Patients with esophageal carcinoma who appear to have a complete response at the primary tumor site after undergoing neoadjuvant chemoradiotherapy may still have residual disease in regional lymph nodes despite clinically negative restaging (ypT0N1). We hypothesized that these patients would have similar survival to patients with incomplete response to therapy. Methods We reviewed 336 esophageal cancer patients who received neoadjuvant chemoradiotherapy followed by complete resection. We identified 20 patients who obtained complete pathologic response at the primary tumor with persistent metastatic disease to regional lymph nodes (ypT0N1). These patients were compared to 123 patients with pathologic complete response and 193 with partial response for overall survival. Results Demographics among the three groups of patients were similar except that this cohort of patients with ypT0N1 had higher initial clinical stage (p = 0.013) and had more squamous cell carcinoma pathology (p = 0.005). Eighty-six percent of the ypT0N1 patients who had modern preoperative staging were felt to have clinical complete response. Five-year survival of ypT0N1 patients was intermediate, similar to pathologic partial response stage II patients in both the sixth and seventh editions of the American Joint Committee on Cancer staging criteria. Conclusions Clinical staging of complete response to chemoradiotherapy may not translate to pathologic complete response. Patients with ypT0N1 disease at resection have intermediate but reasonable survival, justifying an aggressive approach to curative therapy. Future revisions of the staging system should place this group of patients with patients who have metastatic regional lymph nodes, stratified by number of nodes involved.

This ex vivo study evaluates widefield and high-resolution fluorescence imaging with vital-dye enhancement to improve endoscopic evaluation of metaplasia, dysplasia, and cancer in the gastrointestinal tract. Differences in epithelial features were observed.

BACKGROUND: Postchemoradiation percentage decrease in standardized uptake value (SUV) of positron emission tomography (PET) from baseline correlates with overall survival (OS) and pathologic response. Analyses of dichotomized data are commonly reported. The authors analyzed percentage SUV decrease as both dichotomized and continuous variables. METHODS: The authors assessed 151 consecutive patients with gastroesophageal adenocarcinoma who had chemoradiation and surgery. Baseline and postchemoradiation PET/computed tomography imaging was performed. The log-rank test and Cox proportional hazards models were used to associate percentage SUV changes and OS, and logistic regression models were used to detect the association between percentage SUV changes and pathologic response. RESULTS: A >52% SUV decrease (dichotomized analysis) was associated with a longer OS (log-rank test, P = .023). The univariate Cox proportional hazards model indicated that greater percentage SUV decrease (as a continuous variable) was associated with a lower risk of death (hazard ratio [HR], 0.99; P = .01). Pathologic response (≤50% residual cancer) was associated with longer OS (P = .003). Patients with chemoradiation resistance (>50% residual cancer) tended to have a higher risk of death than those with chemoradiation sensitivity (0-50% residual cancer; HR, 2.12; P = .099). In the multivariate model, the percentage SUV decrease (as a continuous variable) was the only prognosticator of OS (P = .01). The percentage SUV decrease was nonsignificantly associated with pathologic complete response (univariate odds ratio [OR], 1.01; P = .06 and multivariate OR, 1.03; P = .07). CONCLUSIONS: The greater the decline in SUV after chemoradiation, the longer is the OS of gastroesophageal adenocarcinoma patients. The percentage SUV decrease as a continuous variable is a better prognosticator of OS than its dichotomized assessments. Cancer 2009. © 2009 American Cancer Society.

Effective systemic drugs are increasingly used to treat patients with colorectal liver metastases. Recent trials have shown that chemotherapy can reduce the size of metastases that are unresectable rendering them resectable, and decrease postoperative recurrence rates in patients with initially resectable tumours. The increasing use of chemotherapy for colorectal liver metastases has raised awareness of the potential hepatotoxicities induced by systemic drugs and the effects of these drugs on outcome after hepatic resection. In this Review, we outline the rationale for the use of perioperative chemotherapy for colorectal liver metastases, associations between specific agents and patterns of liver injury, and strategies to treat patients with suspected or known chemotherapy-associated hepatotoxicity.

Esophageal cancer staging uses tumor depth as the sole criterion for assessment of the primary tumor (pT). To the authors' knowledge the impact of esophageal tumor length on long-term outcome and the esophageal cancer staging system has not been fully evaluated in the current era.All esophageal cancer patients (n = 209) undergoing surgery from 1995 to 2005 who did not receive preoperative chemotherapy or radiotherapy were reviewed. Maximum esophageal tumor length along a craniocaudal axis was determined pathologically after surgical resection. Univariate and multivariate analyses were used to assess the impact of esophageal tumor length (or = 3 cm vs3 cm) on long-term survival.Esophageal tumor length was closely associated with long-term survival (hazards ratio [HR] of 6.14 [95% confidence interval (95% CI), 4.1-9.25]; 5-year survival:or = 3 cm = 68%,3 cm = 10% [P.001]). Multivariate Cox regression analyses demonstrated tumor length (HR of 2.13 [95% CI, 1.26-3.63]) was found to be a significant independent predictor of long-term survival even when controlled for sex, age, tumor location, histology, margin positivity, surgical procedure, and current pTNM criteria. The incorporation of tumor length in pTNM staging significantly improves the ability to predict the long-term survival of patients (5-year survival for patients with tumorsor = 3 cm and stages I, IIA, IIB, and III disease = 86%, 62%, 49%, and 22%, respectively; survival for patients with tumors measuring3 cm and stages I, IIA, IIB, and III disease = 27%, 22%, 0%, and 8%, respectively [P.1]).Esophageal tumor length is an independent predictor of long-term survival in the current era and should be considered for incorporation into the current esophageal cancer staging system to better predict long-term survival and identify high-risk patients for postoperative therapy.

Clinicopathologic features of esophageal neuroendocrine carcinoma (NEC), apart from those of small-cell carcinoma, have not been characterized. We evaluated the clinicopathologic features and prognosis including overall survival of NEC of the esophagus. We identified 40 patients with esophageal NEC from our institutional database. All cancers had been clinically staged using endoscopic ultrasonography, computed tomography, and positron emission tomography. Neuroendocrine differentiation was confirmed by immunohistochemical staining. The NEC component was classified into small-cell and large-cell subtypes, and non-neuroendocrine components were evaluated. Patients with locoregional disease were treated with chemoradiation with or without surgery or with surgery only. Patients with distant metastasis were treated with systemic therapy. The extent of residual tumors was evaluated in esophagectomy specimens after preoperative chemoradiation. Twenty-seven patients had large-cell NEC, and 13 had small-cell neuroendocrine carcinoma. An adenocarcinoma component was present in 15 patients and squamous carcinoma component in 1 patient. Synaptophysin was positive in all cases, and chromogranin was positive in 31 cases. Seventeen patients had distant metastasis, and 21 had locoregional disease. Seventeen patients with locoregional disease received preoperative chemoradiation. Disease progressed in 7 patients, and 10 had residual tumor in resection specimens. Overall survival was better with locoregional disease than with distant metastasis (P=0.006). Overall survival was better in patients with non-neuroendocrine component than in patients with pure NEC (P=0.031). There was no difference in prognosis between patients with large-cell NEC and those with small-cell neuroendocrine carcinoma. Esophageal NEC is an aggressive tumor, and patients with mix NEC have better outcome.

BACKGROUND. Patients with localized esophageal cancer (LEC) have diverse outcomes (post‒therapy pathologic response, disease‒free survival [DFS], and overall survival [OS]) after preoperative chemoradiation (P‒CTRT), dictated also by inherent molecular heterogeneity. Whether the type of therapy influences the outcomes remains largely unanswered. It is hypothesized that induction chemotherapy (IC) or the type of cytotoxics used would not influence patient outcomes. METHODS. In this retrospective analysis, consecutive patients with LEC who had P‒CTRT were analyzed. Data were collected regarding age, sex, baseline clinical stage, location, type of cytotoxics, post‒therapy pathology, DFS, and OS. IC and the type of cytotoxics used were found to be correlated with DFS, OS, and post‒therapy pathologic response. RESULTS. A total of 180 patients with LEC (119 had IC before P‒CTRT, all had received 5‒fluorouracil, 87 had received a taxane, and 57 had received a platinol) were analyzed. The median survival (MS) of all patients was 57.7 months and the 3‒year and 5‒year OS rates were 65.4% and 46.5%, respectively. The type of therapy appeared to have no influence on the outcome: IC versus no IC (P = .58) or platinol versus taxane versus platinol plus taxane (P = .63). Similarly, the type of pathologic response was not found to be influenced by IC (P = .18) or the type of cytotoxics used (P = .42). The data were similar for DFS. CONCLUSIONS. IC or the type of cytotoxics used with radiation for patients with LEC does not appear to influence OS, DFS, or the type of pathologic response after therapy, suggesting that a plateau has been reached. It remains to be seen whether the use of biochemoradiotherapy can provide an advantage in outcome. Cancer 2008. © 2008 American Cancer Society.

Esophageal pre-cancer biomarkers can be optically detected in tissue using confocal microscopy and specific stains. Developing and characterizing these optical biomarkers ex vivo is necessary to be able to detect them in vivo.

Purpose We retrospectively analyzed treatment outcomes among resectable gastric cancer patients treated preoperatively with chemoradiation therapy (CRT) but rendered ineligible for planned surgery because of clinical deterioration or development of overt metastatic disease. Methods and Materials Between 1996 and 2004, 39 patients with potentially resectable gastric cancer received preoperative CRT but failed to undergo surgery. At baseline clinical staging, 33 (85%) patients had T3–T4 disease, and 27 (69%) patients had nodal involvement. Most patients received 45 Gy of radiotherapy with concurrent 5-fluorouracil-based chemotherapy. Twenty-one patients underwent induction chemotherapy before CRT. Actuarial times to local control (LC), distant control (DC), and overall survival (OS) were calculated by the Kaplan-Meier method. Results The cause for surgical ineligibility was development of metastatic disease (28 patients, 72%; predominantly peritoneal, 18 patients), poor performance status (5 patients, 13%), patient/physician preference (4 patients, 10%), and treatment-related death (2 patients, 5%). With a median follow-up of 8 months (range, 1–95 months), actuarial 1-year LC, DC, and OS were 46%, 12%, and 36%, respectively. Median LC and OS were 11.0 and 10.1 months, respectively. Conclusions Patients with potentially resectable gastric cancer treated with preoperative CRT are found to be ineligible for surgery principally because of peritoneal progression. Patients who are unable to undergo planned surgery have outcomes comparable to that of patients with advanced gastric cancer treated with chemotherapy alone. CRT provides durable LC for the majority of the remaining life of these patients.