Anaplastic Tumors Research Articles

Prognostic value and analytical performance (reproducibility) of Ki67 index in anaplastic oligodendroglial tumors: A translational study of the EORTC Brain Tumor Group.

2029 Background: The prognostic value and clinical utility of Ki67 tumor cell proliferation index in anaplastic oligodendroglial tumors is unclear. Methods: We performed anti-Ki67 immunostaining (Mib-1 antibody) of formalin-fixed and paraffin embedded tumor specimens of 70 patients that were treated in the Phase III EORTC trial 26951 investigating adjuvant chemotherapy with procarbazine, lomustine and vincristine (PVC) in newly diagnosed anaplastic oligodendroglial tumors (J Clin Oncol 2006). Ki67 index was independently assessed by 3 observers, 1 of whom performed re-assessment several weeks after initial evaluation. Lin's concordance correlation coefficient (CCC), Bland-Altman plots and Cohen′s kappa (k) were used to evaluate pair-wise observer agreement on Ki67 index values. The average Ki67 index was correlated to clinical (patient age, performance status, type of surgery and adjuvant therapy, tumor location), centrally assessed histopathological (diagnosis, presence of high cellularity, nuclear and endothelial abnormalities, mitoses, necrosis) and molecular features (1p19q loss, EGFR amplification, trisomy 7, loss of chromosome 10 or 10q). The association of Ki67 index, clinical, histopathological and molecular features with progression-free survival (PFS) and overall survival (OS) were assessed using log-rank test, cox model, and bootstrap validation. Results: Ki67 indices ranged from 0.3 to 73% (median 19%) and there was high inter- and intraobserver agreement (CCC > 0.9, k > 0.7). High Ki67 index (cut-off 19%) was significantly associated with presence of high cellularity, endothelial abnormalities, mitoses and necrosis. At multivariate analysis, low Ki67 index (cut-off 19%; p = 0.001), 1p19q loss (p = 0.01) and absence of EGFR amplification (p = 0.03) correlated significantly with favorable PFS. Low Ki67 index (p < 0.01) and 1p19q loss (p = 0.02) were independently and significantly associated with favorable OS. Conclusions: Ki67 index is a strong and reproducibly assessable prognostic factor in anaplastic oligodendroglial tumors. A cut off value of 0.19 is suggested. Validation in a prospective trial is needed. No significant financial relationships to disclose.

Effects of panobinostat, a novel deacetylase inhibitor, in primary cultures of anaplastic thyroid tumors.

e13625 Background: Anaplastic thyroid tumors (ATC) are aggressive human cancers that are resistant to conventional therapy. Panobinostat (LBH589) is a novel deacetylase inhibitor, acting at nanomolar concentrations, currently in phase I-II clinical evaluation for its anti-tumor activity in advanced refractory solid tumors and hematologic malignancies. Aims of the present work were to evaluate the cytotoxic and pro-differentiating activities of LBH589 on primary cultures derived from patients who underwent thyroidectomy for undifferentiated thyroid cancers. Methods: To these aims, we treated four primary cultures (1 sternal metastasis from a recurrent PDTC, and 3 ATC) with LBH589 (5-200nM). After treatment, we evaluated: 1) cell viability and cytotoxicity by WST-1 method; 2) mRNA NIS expression by RT-real-time PCR; 3) presence of NIS protein by indirect immunofluorescence; 3) ability of primary cultures to concentrate iodine by a I125 uptake. Results: At nanomolar concentrations, LBH589 treatment resulted in impairment of cell viability; induction of NIS mRNA and protein; up-take of iodide in all the primary cultures. Conclusions: In conclusion, data from our study on primary cultures strongly suggest that LBH589 is a very good candidate for carefully designed clinical trials for the treatment of this kind of cancer which is known not to respond to conventional therapy. Moreover, the novelty of testing the drug on primary cultures could allow an increase in the effectiveness of the treatment in single patients. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Novartis

Evaluation of age at diagnosis in breast cancer as a prognostic factor for disease-free survival.

e11105 Background: Women diagnosed with breast cancer, who are younger than 35 years-old, and older than 65 years-old seem to have a poorer prognosis. Younger women with breast cancer are more likely to have affected lymph nodes, to be negative for estrogen receptors, and to have larger and anaplastic tumors. On the contrary, women older than 65 years-old, usually are considered as a fragile patients, with co-morbidities (obesity, renal failure and diabetes), and could not receive chemotherapy at full doses. Methods: To investigate whether age at diagnosis is an independent negative prognostic factor in primary breast cancer. Design: Retrospective cohort study based on a population-based database of patients diagnosed with breast cancer in the period from January 1998 to December 1999. Results: Patients were staged I, II or III and were treated with at least four cycles of doxorubicin-based neoadjuvant or adjuvant chemotherapy. We defined younger patients, those aged less than 35 years-old, middle age those having between 35 to 64 years-old and older women those aged more than 64 years. The median follow-up time was 91 months interpercentile interval was 46 to 102 months. The distribution of the groups according stage, tumor grade, presence of lymphatic permeation and treatment were not different. We estimated disease free-survival with the Kaplan-Meier method and compared with the log-rank test. At 91 months, the median disease-free survival for age group was 68, 93 and 91 months respectively (p = 0.047). In the multivariate Cox analysis, besides stage, age at diagnosis but no treatment was an independent prognostic factor for disease free survival p = 0.001. There were not differences in overall survival among the groups. Conclusions: Age and stage at diagnosis are independent prognostic factor for disease free-survival. Younger women have poor prognosis in comparison with middle age and older women when treated with doxorubicin-based chemotherapy No significant financial relationships to disclose.

Thyroid cancer incidence and survival in the national cancer institute surveillance, epidemiology, and end results race/ethnicity groups.

Thyroid cancer incidence has continuously increased for decades and the causes of this increase are still controversial. The objective of this study was to examine if the increased trend is different among the different National Cancer Institute (NCI) Race/Ethnicity Groups (REGs) within the NCI surveillance epidemiology and end results database for the United States. Using recent 13-year surveillance epidemiology and end results data, we described the specific incidence trend of thyroid cancer for the REGs by tumor size, tested the statistical significance of the trend of incidence, and estimated the annual percentage change (APC) and 95% confidence interval. In addition, we compared the difference of 5-year survival rate among the REGs. Papillary thyroid cancer incidence significantly increased over 13 years from 1992 to 2004 among the five major REGs. The estimated APC was 5.6% (95% confidence interval = 5.1%-6.1%, p < 0.01) for the non-Hispanic whites group, 4.3% (3.0-5.5, p < 0.01) for the Blacks group, 2.8% (1.5-4.2, p < 0.01) for the Hispanic whites group, 1.5% (0.5-2.5, p < 0.01) for the Asians group, and 1.1% (-2.2-4.6, p = 0.477) for the American Indians/Alaska Natives group, respectively. The APCs among the REGs were significantly different (Z = 7.89, p < 0.001). The upward incidence trend could be seen in all small or large tumors as well as in women or in men. The proportion of local staged thyroid cancer increased by 24% in the Blacks group, 14.4% in the Hispanic whites group, 14.3% in the non-Hispanic whites group, and only 4.0% in the Asians group between two periods of 1992-1996 and 2000-2004. Five-year survival rates of patients with papillary tumor were about 95%, but that of anaplastic tumor ranged from 5.6% to 11.4% among REGs. The time trend of incidence of thyroid cancer is different among the different NCI REGs. Differences in diagnostic scrutiny may explain the differences in the REG-related trend, but this cannot easily explain the relatively small degree of increase in the trend in the Asian and the Indians/Alaska Natives groups nor can it explain the increase in the trend of large tumors that are likely to be discovered by self-palpation by patients.

Glutathione S‐transferase polymorphisms are associated with survival in anaplastic glioma patients

Glutathione S-transferases (GSTs) are polymorphic enzymes that are responsible for glutathione conjugation of alkylators and scavenging of free radicals created by radiation. GST polymorphisms may result in altered or absent enzyme activity and have been associated with survival in patients with cancer. The authors of this report hypothesized that patients with anaplastic glioma (AG) who have GST genotypes that encode for lower activity enzymes will have longer survival than similar patients who have higher activity genotypes. The current study was performed to investigate the role of GST enzyme polymorphisms in predicting the survival of patients with AG. The medical records of 207 patients with AG from a single cancer center were reviewed retrospectively. Polymorphisms for the GST micro1 (GSTM1), GST theta1 (GSTT1), and GST pi1 (GSTP1) enzymes were identified. Overall survival was compared using the Kaplan-Meier method and Cox proportional hazards analyses adjusting for age, sex, histology, and therapy. Among the patients with oligodendroglial tumors (n = 94), patients who had the GSTT1 null genotype had a 2.9 times increased risk of death (95% confidence interval [CI], 1.3-6.3) compared with patients who had the GSTT1 non-null genotype. Adjustment for 1p/19q status did not change the finding. In the patients who had anaplastic astrocytoma (n = 113), the patients with all GSTP1 genotypes except GSTP1 *B/*B had a 3.8 times increased risk of death (95% CI, 0.5-29.6) compared with patients who had the GSTP1 *B/*B genotype. In patients with anaplastic oligodendroglial tumors, the GSTT1 null genotype may be associated with poor survival, possibly because of modifications in therapy secondary to increased toxicity. This hypothesis is under investigation. In patients with anaplastic astrocytoma, the GSTP1 *B/*B genotype may confer a survival advantage.

IDH1 and IDH2 Mutations Are Prognostic but not Predictive for Outcome in Anaplastic Oligodendroglial Tumors: A Report of the European Organization for Research and Treatment of Cancer Brain Tumor Group

Recent studies have shown the prognostic significance of IDH1 mutations in glioma. It is yet unclear if IDH1 mutations are predictive for outcome to chemotherapy. We determined the effect of IDH1 mutations on progression-free survival and overall survival (OS), and its correlation with other clinical and molecular features in the prospective randomized European Organization for Research and Treatment of Cancer study 26951 on adjuvant procarbazine, 1-(2-chloroethyl)-3-cyclohexyl-l-nitrosourea, and vincristine (PCV) in anaplastic oligodendroglioma. IDH1 and IDH2 alterations of the mutational hotspot codons R132 and R172 were assessed by the bidirectional cycle sequencing of PCR-amplified fragments. MGMT promoter methylation was assessed using methylation-specific multiplex ligation-dependant probe amplification based on methylation-sensitive restriction analysis. Loss of chromosomes 1p, 19q, 10, and 10q and the gain of 7 and the EGFR gene were assessed with fluorescence in situ hybridization. From 159 patients, sufficient material was available for IDH1 analysis. In 151 and 118 of these patients, respectively, the 1p/19q status and the MGMT promoter methylation status were known. In 73 cases (46%), an IDH1 mutation was found and only one IDH2 mutation was identified. The presence of IDH1 mutations correlated with 1p/19q codeletion and MGMT promoter methylation, and inversely correlated with loss of chromosome 10, EGFR amplification, polysomy of chromosome 7, and the presence of necrosis. IDH1 mutations were found to be prognostic in the radiotherapy- and the radiotherapy/PCV-treated patients, for both progression-free survival and OS. With Cox proportional hazard modeling for OS with stepwise selection, IDH1 mutations and 1p/19q codeletion but not MGMT promoter methylation were independent prognostic factors. In this homogeneously treated group of anaplastic oligodendroglioma patients, the presence of IDH1 mutations was found to carry a very strong prognostic significance for OS but without evidence of a predictive significance for outcome to PCV chemotherapy. IDH1 mutations were strongly associated with 1p/19q codeletion and MGMT promoter methylation.

Intra-arterial chemotherapy with osmotic blood-brain barrier disruption for aggressive oligodendroglial tumors: results of a phase I study.

Refractory anaplastic oligodendroglioma and oligoastrocytoma tumors are challenging to treat. This trial primarily evaluated toxicity and estimated the maximum tolerated dose of intra-arterial (IA) melphalan, IA carboplatin, and intravenous (IV) etoposide phosphate in conjunction with blood-brain barrier disruption in these tumors. The secondary measure was efficacy.Thirteen patients with temozolomide-refractory anaplastic oligodendroglioma (11 patients) or oligoastrocytoma (2 patients) underwent blood-brain barrier disruption with carboplatin (IA, 200 mg/m(2)/d), etoposide phosphate (IV, 200 mg/m(2)/d), and melphalan (IA, dose escalation) every 4 weeks, for up to 1 year. Patients underwent melphalan dose escalation (4, 8, 12, 16, and 20 mg/m(2)/d) until the maximum tolerated dose (1 level below that producing grade 4 toxicity) was determined. Toxicity and efficacy were assessed.Two of 4 patients receiving IA melphalan at 8 mg/m(2)/d developed grade 4 thrombocytopenia; thus, the melphalan maximum tolerated dose was 4 mg/m/d. Adverse events included asymptomatic subintimal tear (1 patient) and grade 4 thrombocytopenia (3 patients). Two patients demonstrated complete response, 3 had partial responses, 5 demonstrated stable disease, and 3 progressed. Median overall progression-free survival was 11 months. Patients with complete or partial response demonstrated deletion of chromosomes 1p and 19q. In the 5 patients with stable disease, 2 demonstrated 1p and 19q deletion, and 3 demonstrated 19q deletion only.In patients with anaplastic oligodendroglioma or oligoastrocytoma tumors in whom temozolomide treatment has failed, osmotic blood-brain barrier disruption with IA carboplatin, IV etoposide phosphate, and IA melphalan (4 mg/m(2)/d for 2 days) shows acceptable toxicity and encouraging efficacy, especially in patients demonstrating 1p and/or 19q deletion.

The role of oestrogen receptor α in human thyroid cancer: contributions from coregulatory proteins and the tyrosine kinase receptor HER2

Epidemiological, clinical, and molecular studies suggest a role for oestrogen in thyroid cancer. How oestrogen mediates its effects and the consequence of it on clinical outcome has not been fully elucidated. The participation of coregulatory proteins in modulating oestrogen receptor (ER) function and input of crosstalk with the tyrosine kinase receptor HER2 was investigated. Oestrogen induced cell proliferation in the follicular thyroid cancer (FTC)-133 cells, but not in the anaplastic 8305C cell line. Knockdown of the coactivator steroid receptor coactivator (SRC)-1 inhibited FTC-133 basal, but not oestrogen induced, cell proliferation. Oestrogen also increased protein expression of SRC-1 and the ER target gene cyclin D1 in the FTC-133 cell line. ERalpha, ERbeta, the coregulatory proteins SRC-1 and nuclear corepressor (NCoR), and the tyrosine kinase receptor HER2 were localised by immunohistochemistry and immnofluorescence in paraffin-embedded tissue from thyroid tumour patients (n=111). ERalpha was colocalised with both SRC-1 and NCoR to the nuclei of the tumour epithelial cells. Expression of ERalpha and NCoR was found predominantly in non-anaplastic tumours and was significantly associated with well-differentiated tumours and reduced incidence of disease recurrence. In non-anaplastic tumours, HER2 was significantly associated with SRC-1, and these proteins were associated with poorly differentiated tumours, capsular invasion and disease recurrence. Totally, 87% of anaplastic tumours were positive for SRC-1. Kaplan-Meier estimates of disease-free survival indicated that in thyroid cancer, SRC-1 strongly correlates with reduced disease-free survival (P<0.001), whereas NCoR predicted increased survival (P<0.001). These data suggest opposing roles for the coregulators SRC-1 and NCoR in thyroid tumour progression.

Molecular analysis of anaplastic oligodendroglial tumors in a prospective randomized study: A report from EORTC study 26951

Recent studies have shown that the clinical outcome of anaplastic oligodendroglial tumors is variable, but also that the histological diagnosis is subject to interobserver variation. We investigated whether the assessment of 1p/19q codeletion, polysomy of chromosome 7, epidermal growth factor receptor (EGFR) gene amplification (EGFR(amp)), and loss of chromosome 10 or 10q offers additional prognostic information to the histological diagnosis and would allow molecular subtyping. For this study, we used the clinical data and tumor samples of the patients included in multicenter prospective phase III European Organisation for Research and Treatment of Cancer (EORTC) study 26951 on the effects of adjuvant procarbazine, chloroethyl cyclohexylnitrosourea (lomustine), and vincristine chemotherapy in anaplastic oligodendroglial tumors. Fluorescence in situ hybridization was used to assess copy number aberrations of chromosome 1p, 19q, 7, 10, and 10q and EGFR. Three different analyses were performed: on all included patients based on local pathology diagnosis, on the patients with confirmed anaplastic oligodendroglial tumors on central pathology review, and on this latter group but after excluding anaplastic oligoastrocytoma (AOA) with necrosis. As a reference set for glioblastoma multiforme (GBM), patients from the prospective randomized phase III study on GBM (EORTC 26981) were used as a benchmark. In 257 of 368 patients, central pathology review confirmed the presence of an anaplastic oligodendroglial tumor. Tumors with combined 1p and 19q loss (1p(loss)19q(loss)) were histopathologically diagnosed as anaplastic oligodendroglioma, were more frequently located in the frontal lobe, and had a better outcome. Anaplastic oligodendroglial tumors with EGFR(amp) were more frequently AOA, were more often localized outside the frontal lobe, and had a survival similar to that for GBM. Survival of patients with AOA harboring necrosis was in a similar range as for GBM, while patients with AOA with only endothelial proliferation had better overall survival. In univariate analyses, all molecular factors except loss of 10q were of prognostic significance, but on multivariate analysis a histopathological diagnosis of AOA, necrosis, and 1p(loss)19q(loss) remained independent prognostic factors. AOA tumors with necrosis are to be considered WHO grade IV tumors (GBM). Of all molecular markers analyzed in this study, especially loss of 1p/19q carried prognostic significance, while the others contributed little prognostic value to classical histology.

Classification and management of anaplastic gliomas

To summarize findings, discuss problems and define new questions from the past phase III trials in anaplastic gliomas. The current standard of care for first-line treatment in anaplastic gliomas is radiotherapy or chemotherapy. The next steps are to define the role and optimal sequencing of combined modality treatment focusing on radiotherapy and temozolomide and to develop trials with novel targeted treatments. The feature of necrosis in oligodendroglial tumors needs to be further studied, and molecular prognosticators will take more room. These include O⁶-methylguanylmethyltransferase promoter methylation, isocitrate dehydrogenase mutations and epidermal growth factor receptor amplification. Further, the notion that all anaplastic oligodendroglial tumors with or without a relevant astrocytic component fall into the same prognostic category and the obvious difficulties to type and to grade anaplastic gliomas pose an enormous burden on local diagnosis. The current and upcoming trials including the European Organization for Research and Treatment of Cancer 26053/22054 trial aim at solving some of these issues with an initial central pathology review. Anaplastic gliomas are an important group of brain tumors to develop future molecularly targeted therapies and should therefore be in the main focus of academic and industrial drug development, which aims at efficacy and avoiding long-term side effects.

Glioblastoma with signet-ring morphology: a case report and review of the literature

Primary central nervous system tumors with signet-ring morphology are exceedingly rare. We report an unusual case of glioblastoma with signet-ring cell features in an 81-year-old woman. Microscopic examination revealed a highly anaplastic tumor, with a prominent proportion of tumor cells exhibiting signet-ring appearance characterized by classic round cytoplasmic inclusions and eccentrically positioned nuclei. The tumor cells were immunoreactive for glial fibrillary acidic protein and S100, and negative for cytokeratins, confirming their glial origin. Ultrastructurally, the tumor cells were noted to contain intermediate filaments, and by fluorescence in-situ hybridization analysis, they demonstrated intact 1p/19q. The presence of signet-ring cells in the central nervous system should immediately raise the suspicion of metastatic carcinoma, particularly from the upper gastrointestinal tract. In the present case, however, the morphological and immunohistochemical features were diagnostic of a malignant primary glial neoplasm (glioblastoma). This case highlights the diagnostic difficulties that can arise in such instances, given the rarity of signet-ring morphology in primary central nervous system tumors.

Prognosis and patterns of care in elderly patients with glioma

The current study was conducted to evaluate the patterns of care and survival of older adults with oligodendroglioma (OLI) and astrocytoma (AST) from a large population-based registry. The authors identified a cohort of OLI and AST patients aged >or=65 years from Surveillance, Epidemiology and End Results (SEER) cancer registry data linked with Medicare claims between 1994 and 2002. Patients with a diagnosis of glioblastoma were excluded. The impact of demographic characteristics and comorbidities on the probability of undergoing surgical resection, radiotherapy (RT), and chemotherapy within 6 months of diagnosis was assessed using multivariate logistic regression. A total of 1067 patients (891 with AST and 176 with OLI) were included; the median survival was 9 months for patients with low-grade AST, 4 months for patients with anaplastic AST, 57 months for patients with low-grade OLI, and 9 months for patients with anaplastic OLI. Approximately 54% of patients underwent resection at the time of diagnosis; 66% received RT, and 13% received chemotherapy within 6 months of diagnosis. In a multivariate regression analysis, age and tumor grade were found to be the most significant predictors of resection, RT, or chemotherapy. Patients with anaplastic tumors were treated with resection, RT, and chemotherapy more often than patients with low-grade tumors, and OLI patients received chemotherapy more frequently than AST. Data from the current study suggested that histologic diagnosis and tumor grade retained significant prognostic value in this elderly AST and OLI population. Furthermore, age and tumor grade were found to influence the probability of undergoing surgery, RT, and chemotherapy in this cohort.

Large cell/anaplastic medulloblastoma: Outcome according to myc status, histopathological, and clinical risk factors

To evaluate the prognostic impact of large cell/anaplastic (LC/A) histology together with molecular and clinical risk factors in childhood medulloblastoma. Three consecutive prospective medulloblastoma trials were screened for patients with the histological diagnosis of LC/A medulloblastoma. Tumors were considered as LC/A if they displayed areas of severe cytological anaplasia or a significant or predominant large cell component. Histology was centrally confirmed. Genomic DNA amplification of c-myc and n-myc, and mRNA expression of c-myc and trkC were analyzed. Twenty-eight patients with LC/A medulloblastoma with a median age of 6.1 years (1.4-16.5 years) and a median follow-up of 4.5 years were identified (5% of all medulloblastoma). Four-year event-free (EFS) and overall survival (OS) were 58% and 67%. Young age and metastases (n = 13, 4-year EFS 31% vs. 82% in 15 children >4 years and without metastases, P = 0.001), large cell histology (n = 9, 4-year EFS 22% vs. 75%, P = 0.005) and c-myc amplification (n = 9, 4-year EFS 22% vs. 89%, P < 0.0001) were negative prognostic factors. C-myc amplification was highly correlated with young age (P < 0.001), metastases (P = 0.002) and large cell histology (P = 0.007). Outcome of 12 patients with severely anaplastic tumors without these risk factors was not impaired (4-year EFS 86%). In a subgroup of patients without clinical and molecular risk factors outcome was favorable despite severely anaplastic histology. In contrast, c-myc amplification and large-cell histology were associated with an inferior outcome. Intensified treatment strategies should be considered for children with LC/A medulloblastoma and these characteristics.

MGMT Promoter Methylation Is Prognostic but Not Predictive for Outcome to Adjuvant PCV Chemotherapy in Anaplastic Oligodendroglial Tumors: A Report From EORTC Brain Tumor Group Study 26951

O6-methylguanine-methyltransferase (MGMT) promoter methylation has been shown to predict survival of patients with glioblastomas if temozolomide is added to radiotherapy (RT). It is unknown if MGMT promoter methylation is also predictive to outcome to RT followed by adjuvant procarbazine, lomustine, and vincristine (PCV) chemotherapy in patients with anaplastic oligodendroglial tumors (AOT). In the European Organisation for the Research and Treatment of Cancer study 26951, 368 patients with AOT were randomly assigned to either RT alone or to RT followed by adjuvant PCV. From 165 patients of this study, formalin-fixed, paraffin-embedded tumor tissue was available for MGMT promoter methylation analysis. This was investigated with methylation specific multiplex ligation-dependent probe amplification. In 152 cases, an MGMT result was obtained, in 121 (80%) cases MGMT promoter methylation was observed. Methylation strongly correlated with combined loss of chromosome 1p and 19q loss (P = .00043). In multivariate analysis, MGMT promoter methylation, 1p/19q codeletion, tumor necrosis, and extent of resection were independent prognostic factors. The prognostic significance of MGMT promoter methylation was equally strong in the RT arm and the RT/PCV arm for both progression-free survival and overall survival. In tumors diagnosed at central pathology review as glioblastoma, no prognostic effect of MGMT promoter methylation was observed. In this study, on patients with AOT MGMT promoter methylation was of prognostic significance and did not have predictive significance for outcome to adjuvant PCV chemotherapy. The biologic effect of MGMT promoter methylation or pathogenetic features associated with MGMT promoter methylation may be different for AOT compared with glioblastoma.

Dual Inhibition of Mitogen-Activated Protein Kinase Kinase and Mammalian Target of Rapamycin in Differentiated and Anaplastic Thyroid Cancer

ABSTRACT Context Differentiated thyroid cancer and anaplastic thyroid cancer tumors frequently have activation of the ras/raf /MAPK kinase (MEK)/ERK and phosphatidylinositol 3-kinase (PI-3K)/AKT/mammalian target of rapamycin (mTOR) signaling pathways. Objective The objective of the study was to investigate the efficacy of MEK and mTOR inhibitors in preclinical thyroid cancer treatment models with defined mutation status. Experimental Design The MEK inhibitor AZD6244 (ARRY-142886) and mTOR inhibitor rapamycin were tested separately and in combination in 10 differentiated thyroid cancer and anaplastic thyroid cancer cell lines and in a xenograft model for evidence of pathway inhibition, growth inhibition, apoptosis, and long-range adaptation and resistance. Results Seven of 10 tested lines had evidence of significant basal activity of the PI-3K/AKT/mTOR pathway, with elevated phosphorylated AKT and phosphorylated p70 S6 kinase. Activation of ras/RAF/MEK/ERK was equally common in this panel. All 10 lines exhibited better than 60% growth inhibition with combined MEK and mTOR inhibition, including lines with BRAF, Ret-PTC, ras, and PTEN mutations. Rapamycin or AZD6244 alone achieved this threshold in six and two lines, respectively. Dual-pathway inhibition in the Ret-PTC mutant cell line TPC1 caused an intense G1 arrest in cell culture and reversible cytostatic inhibition in a xenograft model. We did not observe significant feedback up-regulation of AKT activation in either acute or prolonged exposures. Conclusion These preclinical results support the inclusion of thyroid cancer patients in early-phase clinical trials combining ras/RAF/MEK/ERK and PI-3K/AKT/mTOR pathway inhibition.

Expression of hypoxia-inducible factor 1α in thyroid carcinomas

Hypoxia-inducible factor 1α (HIF-1α) is upregulated by hypoxia and oncogenic signalling in many solid tumours. Its regulation and function in thyroid carcinomas are unknown. We evaluated the regulation of HIF-1α and target gene expression in primary thyroid carcinomas and thyroid carcinoma cell lines (BcPAP, WRO, FTC-133 and 8505c). HIF-1α was not detectable in normal tissue but was expressed in thyroid carcinomas. Dedifferentiated anaplastic tumours (ATCs) exhibited high levels of nuclear HIF-1α staining. The HIF-1 target glucose transporter 1 was expressed to a similar level in all tumour types, whereas carbonic anhydrase-9 was significantly elevated in ATCs. In vitro studies revealed a functionally active HIF-1α pathway in thyroid cells with transcriptional activation observed after graded hypoxia (1% O2, anoxia) or treatment with a hypoxia mimetic cobalt chloride. High basal and hypoxia-induced expression of HIF-1α in FTC-133 cells that harbour a phosphatase and tensin homologue (PTEN) mutation was reduced by introduction of wild-type PTEN. Similarly, pharmacological inhibition of the phosphoinositide 3-kinase (PI3K) pathway using LY294002 inhibited HIF-1α and HIF-1α targets in all cell lines, including those with B-RAF mutations (BcPAP and 8505c). In contrast, the effects of inhibition of the RAF/MEK/extracellular signal-regulated kinase pathway were restricted by environmental condition and B-RAF mutation status. HIF-1 is functionally expressed in thyroid carcinomas and is regulated not only by hypoxia but also via growth factor signalling pathways and, in particular, the PI3K pathway. Given the strong association of HIF-1α with an aggressive disease phenotype and therapeutic resistance, this pathway may be an attractive target for improved therapy in thyroid carcinomas.

Dual Inhibition of Mitogen-Activated Protein Kinase Kinase and Mammalian Target of Rapamycin in Differentiated and Anaplastic Thyroid Cancer

Differentiated thyroid cancer and anaplastic thyroid cancer tumors frequently have activation of the ras/raf /MAPK kinase (MEK)/ERK and phosphatidylinositol 3-kinase (PI-3K)/AKT/mammalian target of rapamycin (mTOR) signaling pathways. The objective of the study was to investigate the efficacy of MEK and mTOR inhibitors in preclinical thyroid cancer treatment models with defined mutation status. The MEK inhibitor AZD6244 (ARRY-142886) and mTOR inhibitor rapamycin were tested separately and in combination in 10 differentiated thyroid cancer and anaplastic thyroid cancer cell lines and in a xenograft model for evidence of pathway inhibition, growth inhibition, apoptosis, and long-range adaptation and resistance. Seven of 10 tested lines had evidence of significant basal activity of the PI-3K/AKT/mTOR pathway, with elevated phosphorylated AKT and phosphorylated p70 S6 kinase. Activation of ras/RAF/MEK/ERK was equally common in this panel. All 10 lines exhibited better than 60% growth inhibition with combined MEK and mTOR inhibition, including lines with BRAF, Ret-PTC, ras, and PTEN mutations. Rapamycin or AZD6244 alone achieved this threshold in six and two lines, respectively. Dual-pathway inhibition in the Ret-PTC mutant cell line TPC1 caused an intense G(1) arrest in cell culture and reversible cytostatic inhibition in a xenograft model. We did not observe significant feedback up-regulation of AKT activation in either acute or prolonged exposures. These preclinical results support the inclusion of thyroid cancer patients in early-phase clinical trials combining RAS/RAF/MEK/ERK and PI-3K/AKT/mTOR pathway inhibition.

Expression of cytokines in the thyroid: thyrocytes as potential cytokine producers

The unstimulated and stimulated thyrocyte is able to produce more different cytokines in vitro than any other endocrine cell. Cytokines produced by thyrocytes may play a role in the local stimulation and maintenance of immune responses against autoantigens in the thyroid, in the modulation of goiter size in response to TSH, and in the clinical course of patients with thyroid tumors. This paper tries to summarize the results of relevant studies investigating cytokine production by thyrocytes. Although there is an agreement in published work that thyrocytes secrete a number of cytokines such as II-1, II-6, II-8 and TGF-beta in vitro it is unclear whether these factors are produced also by thyrocytes in vivo. By the example of GM-CSF in vitro secretion by stimulated anaplastic thyroid carcinoma cell lines and stimulated thyrocytes, the relevance of these findings during the clinical course of patients with anaplastic thyroid tumours is discussed.

Retrospective analysis of outcomes among more than 1,000 patients with newly diagnosed anaplastic oligodendroglial tumors

2014 Background: Treatment of anaplastic oligodendroglial tumors is controversial. Early results of randomized trials suggest chemotherapy (CT) with procarbazine-lomustine-vincristine (PCV) before or after radiotherapy (RT) improves progression-free but not overall survival (OS) versus RT alone. It is unknown if CT alone affects outcome versus CT&amp;RT, or if temozolomide (TMZ) compares favorably with PCV. Methods: We retrospectively identified adults with newly diagnosed anaplastic oligodendroglioma (AO) or oligo-astrocytoma (AOA) seen at 17 medical centers from 1981–2007 exclusive of phase III or bone marrow transplant trials. Data were updated January 1, 2009. Survivals were estimated by Kaplan-Meier method and compared with log-rank. Results: There were 1054 patients: 594 men, 460 women; median age 42 (18–88); 661 with AO, 443 with AOA. Treatment was: observation (82, 8%), RT alone (n = 210, 20%), RT then chemotherapy (283, 27%), RT + CT concurrently (118, 11%), CT alone (205, 19%), CT then RT (137, 13%), or other (19, 2%). Median time to progression (TTP) and OS were 2.8 and 6.5 years, respectively, with median follow up of 4.1 years (0.03–20.8) on surviving patients (n = 560, 53%). 1p19q co-deletion was observed in 292 (48%) and no deletion in 232 (38%) of 606 tested tumors. Co-deletion predicted longer median TTP (4.2 vs. 1.8 years for no deletion, p = 0.0002) and OS (8.4 vs. 3.3 years, p &lt; 0.0001). Median TTP was longer following CT&amp;RT (sequential or concurrent) than CT alone (3.7 vs. 2.6 years, p = 0.0007), but median OS did not differ (6.6 vs. 7.1 years, p = 0.8); co-deletion was more common with CT alone than CT&amp;RT (p &lt; 0.0001, χ2), although restricting analysis of CT&amp;RT versus CT to the co-deletion cohort yielded analogous results (median TTP 7.2 vs. 3.8 years, p = 0.011; OS 7.9 vs. 10.4 years, p = 0.26). Median TTP was longer following PCV alone (7.6 years, n = 17) than TMZ alone (3.3 years, n = 65) with co-deletion (p &lt; 0.02); median OS was also longer (not reached, vs. 7.1 years), but did not reach statistical significance (p = 0.07 log-rank). Conclusions: 1p19q co-deletion predicted improved outcome. Treatment strategies varied widely. CT alone did not appear to shorten OS versus CT&amp;RT. PCV may be superior in efficacy to TMZ. Multivariate analyses and additional 1p19q testing are in progress. [Table: see text]

Are all stage III Wilms tumors the same? Data from the Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP)

10030 Background: Criteria to classifying Wilms tumor (WT) as stage III are much heterogeneous, including factors referring both to tumor biology and surgical skills. Methods: We analyzed survival results in patients aged less than 18 years with stage III WT enrolled in the AIEOP CNR92 and TW2003 clinical trials (10/1991–10/2008). Main therapy differences across the trials were the timing of abdominal radiotherapy (RT) (anticipated to 2nd week from nephrectomy) and doxorubicin cumulative dose reduction from 360 mg/m2 to 240 in TW2003. Results: Of 553 in-study patients, 106 (19%) were classified as stage III according to NWTS4 criteria (59 patients in CNR92, 47 in TW2003; median age 49 months). Reasons for stage III as follows: lymph nodes (LN) 40 cases (alone 28 cases, combined with other factors 12); cava vein tumor thrombus 7, peritoneum involvement 8, post-operative gross or microscopic tumor remains 24, pre-operative rupture 9, surgical rupture 17. For 29 patients (27%) information on regional LN were missing. 36 patients received primary 4-week vincristine/dactinomycin regimen, while the others had up-front nephrectomy. Adjuvant therapy consisted of 8-months vincristine/dactinomycin/doxorubicin + flank 1440 cGy RT (whole abdominal 15 Gy in case of diffuse peritoneal contamination). 7 patients had intensified chemotherapy/RT for diffuse anaplasia. Interval between nephrectomy and RT was 75 days in CNR92 (median) and 33 in TW2003. Overall 16 tumor failure occurred (2 in anaplastic tumors): abdominal relapse 8 (combined to other extra-abdominal site 3), lung 5, tumor progression 2, metacronous tumor 1. After median follow-up of 49 months 5-year RFS and OS were 83% ±4 and 90% ±3 for the whole cohort of children, respectively. Noteworthy the doxorubicin dose reduction in TW2003 did not jeopardize survival (82% 4-year RFS for CNR92, 84% TW2003). Overall, RFS was 75% ±7 in patients with at least LN involvement compared to 89% ±4 in patients classified as stage III for the remaining criteria, including those without LN sampling (Logrank p.09). Conclusions: The sensible doxorubicin dose reduction did not jeopardize survival. 1440 cGy flank RT warranted satisfactory local tumor control. The worse outcome reported in LN-positive patients deserves further attention. No significant financial relationships to disclose.