Patients (pts) with HCC and poorly functioning livers (Child Pugh (CP) B-C) face dual challenges of tumor progression and declining liver function with few options for downstaging, bridge to transplant, or local control and are increasingly referred for stereotactic body radiation therapy (SBRT). Proper patient and dose selection is challenging as clinical trials often exclude these patients and liver function may decline after treatment. To better define patients who are at risk for hepatic decompensation after SBRT, we report the outcome of SBRT in a cohort of HCC pts with poor liver function with regards to dosimetry (mean liver and prescribed dose), baseline liver function (total bilirubin [tBili], INR, and MELD) and radiographic features (cirrhosis, tumor thrombus, portal vein patency [pPat], portal hypertension [pHTN], ascites) at the time of treatment. Twenty-one HCC pts treated with SBRT with a median 30 Gy (range 5.5-50) in 5 fractions (range 2-7) with >45 days of follow-up, were reviewed with IRB approval. Poor responders (PR) met any of the following criteria: decompensated on treatment (N = 2), died within 6 months of SBRT (N = 5), increase in either MELD >5 (N = 5), INR > 0.5 (N = 2), or tBili > 2.1 (N = 4). Very poor responders (VPR) met additional criteria of death within 3 months of SBRT (N = 2), increased MELD>10, INR>0.75, or tBili >3 (N = 1, 2 and 4 respectively). Good responders (GR) did not meet any of these criteria for PR or VPR. Data were analyzed for significance using a generalized linear regression model. Median follow-up was 6 months. Nine of 21 pts died by last follow-up, all within 207 days after SBRT. At baseline, median MELD score was 13 (range 7.4-21.9, N = 20), tBili 1.4 (0.5-7.5, N = 21), INR 1.2 (0.9-2, N = 21). There were 12 GR and 9 PR, of which 6 were VPR. Elevated tBili and ascites were associated with PR (P<0.05), and elevated INR (P = 0.02) was also significant for VPR. Six of 9 PR had tBili > 2, while 10 of 12 GR had tBili < 2. Similarly, 10 of 12 pts alive at last follow-up had tBili < 2, while 7 of 9 pts deceased at last follow-up had tBili > 2. Six of 7 pts who lived > 207 days had tBili <2. Variables associated with death <207 days from SBRT were pHTN (P = 0.02), ascites (P < 0.001), and tBili (P = 0.03), while pPat (P < 0.001) was associated with being alive at last follow-up. Higher SBRT dose was associated with GR (P = 0.03). Pts with tBili < 2 and >2 had a mean liver dose (mLD) of 13.4 Gy [range 2.4-15.5], and 6.6 Gy [range 1.3-13.6], respectively. Pts with elevated tBili (>2), INR and ascites at baseline are at risk for being a PR after SBRT. Multiple radiographic features (lack of pPat, pHTN, and ascites) and elevated tBili are associated with death < 207 days after SBRT. While higher dose was associated with GR, pts with good liver function tended to receive higher doses. Further study and longer follow-up is needed to stratify the dose-volume-liver function relationship to identify patients with poor liver function who may benefit from halting local progression with SBRT.

To determine if use of the statin class of HMG-CoA reductase inhibitors is associated with outcomes in patients with colorectal cancer (CRC). We obtained clinical data from 250 consecutive patients with CRC who underwent upfront colon resection between 2005 and 2009. Clinicopathologic records were obtained for all patients. Standard clinical and pathological risk factors including age at diagnosis, gender, T/N/M staging, tumor size, lymph node status, margin status, and tumor grade, as well as statin use at the time of diagnosis, were individually correlated with overall survival (OS) and progression free survival (PFS) using the Cox proportional hazards model. Multivariate analyses were performed using covariates that had a statistically significant effect in univariate analysis. Of the 250 patients included in this study, 54 patients (21.6%) used statin therapy at the time of diagnosis of colon cancer. Among all patients, the median survival for those on statin therapy was 32.4 months compared with 22.7 months for those not on statin therapy (p = 0.0091). Among only stage I-III patients, the median survival for those on statin therapy was 33.9 months compared with 23.2 months for those not on statin therapy (p = 0.037). In multivariate analysis of patients with stages I-IV disease using all statistically significant variables in univariate analysis, statin use was significantly associated with improved survival (p = 0.0042), and all covariates, including age, lymph node status, margin status, and N stage, remained significant. In patients stages I-III, statin use was associated with improved survival in multivariate analysis (p = 0.048), and all covariates, including age, lymph node status, margin status, and N stage, remained statistically significant. Statin use was associated with improved PFS in patients with stages I-IV disease in univariate analysis (HR 2.85, p = 0.05) and trended toward significance (HR 2.496, p = 0.090) in multivariate analysis. In this cohort, statin use was associated with improved overall and progression free survival in patients with colorectal cancer. Further study is needed to evaluate the protective effect of statin therapy in patients with colorectal cancer.

Reliable identification of patients likely to benefit from primary or adjuvant local therapy for pancreatic adenocarcinoma (PAC) remains elusive. This is in part due to the prevalence of radiographically occult micrometastases, and limitations of available biomarkers to detect residual disease. Therefore, novel biomarkers for PAC that reliably assess for the presence of micrometastatic or residual disease are needed. We recently developed Cancer Personalized Profiling by Deep Sequencing (CAPP-Seq), a novel next-generation sequencing based technique that allows for the ultrasensitive and specific detection of circulating tumor DNA (ctDNA) in plasma. The objective of this study was to determine the feasibility of applying CAPP-Seq for quantitation of ctDNA in patients undergoing primary and adjuvant therapy for PAC. CAPP-Seq employs a hybrid capture technique, using a "selector" that is tailored to the cancer type of interest. To design a PAC-specific CAPP-Seq selector we used a custom bioinformatics approach to identify recurrently mutated genomic regions in PAC using publically available whole exome sequencing data. Biotinylated DNA oligonucleotides targeting these mutated regions were synthesized. Next, we tested the feasibility of extracting sufficient genomic DNA for tumor genotyping (criterion: ≥ 4ng) from PAC formalin fixed paraffin embedded (FFPE) specimens collected via fine needle aspirates (FNAs), core biopsies, or surgical resection. CAPP-Seq was then used to identify tumor-specific mutations in these PACs. Finally, ctDNA levels were quantitated from pre- and post-treatment blood samples prospectively collected from patients undergoing therapy for PAC at our institution using a customized bioinformatics pipeline. The PAC-specific CAPP-Seq selector covered ∼135 kb and targeted 979 genomic regions from 925 recurrently mutated genes. Although comprising <0.005% of the human genome, the selector identified a median of 11 mutations per tumor and was able to identify multiple mutations in >96% of PACs. Using an optimized protocol, we extracted adequate tumor genomic DNA for CAPP-Seq genotyping from 95% of FFPE samples, including 13 of 13 FNA/core samples (mean = 178 ng; range = 4-1075 ng) and 9 of 10 surgical samples (mean = 680 ng; range = 3-2351 ng). Finally, we used CAPP-Seq to identify tumor-specific mutations and to quantitate ctDNA in pre- and post-treatment plasma samples. CAPP-Seq is a promising method for the ultrasensitive and specific quantification of ctDNA in patients with PAC. Isolation of tumor DNA from PAC FFPE FNA/core biopsy specimens using our optimized protocol provides sufficient tumor DNA for genotyping using CAPP-Seq. Ongoing analyses are exploring the prognostic and predictive utility of ctDNA analysis in PAC.

OBJECTIVES:The prognostic value of several hematologic parameters, including platelet, lymphocyte, and neutrophil counts, has been studied in a variety of solid tumors. In this study, we examined the significance of inflammatory markers and their prognostic implications in patients with colorectal cancer (CRC).MATERIALS AND METHODS:Patients with stage I-III CRC who underwent surgical resection at the Stanford Cancer Institute between 2005 and 2009 were included. Patients were excluded if they did not have preoperative complete blood counts performed within 1 month of surgical resection, underwent preoperative chemotherapy or radiation, had metastatic disease at diagnosis, or had another previous malignancy. We included 129 eligible patients with available preoperative complete blood counts in the final analysis.RESULTS:A preoperative neutrophil-to-lymphocyte ratio of>3.3 was significantly associated with worse disease-free (DFS) and overall survival (OS) (P=0.009, 0.003), as was a preoperative lymphocyte-to-monocyte ratio of ≤2.6 (P=0.01, 0.002). Preoperative lymphopenia (P=0.002) was associated with worse OS but not DFS (P=0.09). In addition, preoperative thrombocytosis was associated with worse DFS (P=0.006) and OS (P=0.010). Preoperative leukocytosis was associated with worse OS (P=0.048) but not DFS (P=0.49). Preoperative hemoglobin was neither associated with OS (P=0.24) or DFS (P=0.15).CONCLUSIONS:Pretreatment lymphopenia, thrombocytosis, a decreased lymphocyte-to-monocyte ratio, and an elevated neutrophil-to-lymphocyte ratio independently predict for worse OS in patients with CRC.

Colorectal carcinoma (CRC) metastases to the liver and lung have been shown to have poor local control to stereotactic ablative body radiation therapy. We sought to determine if similar radioresistance is seen for CRC brain metastases treated with stereotactic radiosurgery (SRS). We retrospectively evaluated the outcomes of SRS targeting 36 intact brain metastases and 18 post-resection cavities from 30 patients with evaluable follow-up with CRC treated from 2002-2012. Results were compared to 157 resection cavities from non-CRC histology as well as our previously published results of SRS for 145 intact metastases from radioresistant histologies (renal cell carcinoma [RCC] and melanoma). The Kaplan-Meier product-limit method was used to estimate rates of Local Control (LC) and Overall Survival (OS). The dose from hypofractionated SRS (1-5 fractions) was converted to a single session equivalent dose (SSED) (α/β of 10). Variables associated with LC and OS were evaluated with the Cox proportional hazards and log rank methods. Variables analyzed included Planning Target Volume (PTV) size and SSED (as continuous variables), and histology (CRC vs non-CRC). For patients with CRC, the median follow-up was 10.7 months (range, 3-55 months). The median OS for patients with CRC was 11 months (range, 3-55 months) versus 15 months (range, 1-156 months) for non-CRC. The median SSED for intact brain lesions and resection cavities was 20 Gy10 (range, 15 - 24 Gy10) and 16 Gy10 (range, 12 - 24 Gy10), respectively. For intact metastases, the 1 year LC was 48% for CRC vs 87% for RCC/melanoma. For resection cavities, the 1 year LC was 56% for CRC vs 85% for non-CRC (p < 0.001). On univariate analysis, factors predictive of LC for intact metastases were CRC histology (p < 0.001) and PTV size (HR 0.141, p = 0.002). LC at 1 year was 22% and 76% for tumor volume greater than vs less than the median PTV of 1.7 cc, respectively (p = 0.01). For resection cavities, both PTV size and SSED were predictive for LC (SSED: HR = 0.807, p = 0.025; PTV: HR = 0.667, p = 0.04). Patients with CRC brain metastases have poor rates of LC compared to non-CRC patients. Further investigation is warranted to identify methods of intensifying treatment for this radioresistant histology.

To determine if expression of SMAD4, a tumor suppressor involved in the transforming growth factor β (TGF-β) signaling pathway and found to be absent in 10% of colorectal cancer (CRC), is associated with outcomes in patients with CRC. We obtained tumor samples from 240 consecutive patients with CRC who underwent upfront colon resection between 2005 and 2009. Triplicate tissue cores from resected primary colon tumors and matched normal controls were used to construct the tissue microarrays (TMAs). We examined the expression of SMAD4 using immunohistochemistry (IHC). Clinicopathologic records were obtained for all patients. The TMAs were reviewed by a single board-certified pathologist and scored as either "positive" or "negative" for nuclear staining based on percent positive staining. In total, 22 of 240 tumors (9.2%) were SMAD4 negative. Chi-square tests were used to evaluate the relationship between SMAD expression and staging. SMAD4 staining was correlated with overall survival (OS) and progression free survival (PFS) by the Kaplan-Meier method and log-rank tests. The Cox proportional hazards model was used for multivariate analysis looking at overall stage, T-stage, patient age (≤67 years vs >67 years), and SMAD4 expression (positive vs negative). Loss of SMAD4 expression was higher in patients with stage IV disease vs stages I-III (20% vs 8% respectively, p = 0.047) and higher in patients with T3/T4 stage vs T1/T2 stage (13% vs 5%, respectively, p = 0.03). Loss of SMAD4 expression also correlated with significantly improved OS (p = 0.04) but not PFS (p = 0.29). Patients with negative expression of SMAD4 had a lower median OS compared to those with positive SMAD4 expression (21 months vs 28 months, respectively). Overall stage (p = 0.05), patient age (p = 0.01) and T-stage (p = 0.006) were also associated with OS. On multivariate analysis, overall stage (p<0.001), age (p < 0.001), significantly correlated with OS but T-stage (p = 0.10) and SMAD4 expression (p = 0.353) did not. Loss of SMAD4 expression is associated with higher disease stage and thus worse overall survival in patients with colorectal cancer. Further studies are required to validate the prognostic significance of SMAD4 and its role in disease progression.

Background Long-term outcomes are favorable for patients with polycythemia vera (PV) and for patients with essential thrombocythemia (ET). However, hemorrhage is a significant cause of morbidity and mortality in those patients. Methods We retrospectively recruited 247 patients who had received a diagnosis of PV (n=101) or ET (n=146) during the period 20012010. Results After a median follow-up period of 36.2months, the cumulative incidence of hemorrhage was 39.6% in patients with PV (6.2% per person-year) and 29.7% in patients with ET (5.9% person-years). Episodes of major bleeding occurred in 9.9% of patients with PV and in 14.4% of patients with ET. Overall survival was significantly shorter among patients with hemorrhage than among those without said complication (P<0.001 for overall patients; P=0.002 for patients with PV; P=0.026 for patients with ET). In the univariate analysis, age 60yr (OR: 4.77, P=0.046) and WBC16x109/L (OR: 4.15, P=0.010) were predictors of hemorrhage in patients with PV, and age 60yr (OR: 3.25, P=0.040), WBC16x109/L (OR: 2.89, P=0.024), albumin <4.0g/dL (OR: 4.10, P=0.002), and splenomegaly (OR: 5.19, P=0.002) were predictors of hemorrhage in patients with ET. Multivariate analysis showed that WBC16x109/L was the only significant risk factor for hemorrhage in patients with PV (OR: 3.51, P=0.026) and that splenomegaly was the only risk factor for hemorrhage in patients with ET (OR: 3.00, P=0.048). Conclusion Leukocytosis in PV and splenomegaly in ET are independent risk factors for hemorrhage.

To report toxicities, cosmetic outcomes and local control in a series of patients treated on a pilot study of partial breast irradiation (PBI), using CT-planned high-dose-rate (HDR) multi-catheter interstitial brachytherapy. Between May 2003 and December 2005, 30 subjects with low-risk breast cancer were treated with adjuvant PBI using multi-catheter interstitial HDR brachytherapy. All subjects fulfilled the following criteria: age >50 years; invasive ductal histology; T <3cm, pN0; ER positive; LVI negative; and surgical margin >0.2cm. Pre-implant CT was performed 4-8 weeks following breast-conserving surgery. The PTV was the excision cavity + 1.5cm, excluding chest wall and 0.5 cm from skin. An ideal virtual implant was created based on the Paris System. Post-implant CT planning was performed, delivering 32.4Gy in 9 BID fractions over 5 days, using an Iridium-192 HDR after-loading system. Acute toxicity (NCI criteria), late morbidity (RTOG) and overall cosmesis (EORTC) were prospectively evaluated and recurrence rates have been updated. Mean tumor size was 1.2cm (0.4 - 2.4cm). Acute toxicities at 6 weeks and 3 months were all grade 1: fatigue (7%, 0%); pain due to radiation (4%, 7%) and radiation dermatitis (7%, 0%). Telangiectasia was observed in two subjects (7%), maximum dimension 3.5 and 2.0cm, 25 and 37 months after treatment. Fat necrosis occurred in 3 subjects (10%), 13, 16 and 68 months after treatment, one undergoing mastectomy. Cosmesis was good-excellent in 82% of patients at baseline; while 89% had stable or improved cosmesis at three years compared to baseline. At a median follow-up of 80 months (range 60-90 months), patient and disease status were as follows: 32 months after diagnosis, one subject developed an ipsilateral breast node-positive tumor in a different quadrant which was pathologically distinct from the original tumor; salvaged with mastectomy, axillary dissection and post-operative RT. Another subject developed nodal-only recurrence at 42 months, salvaged with axillary dissection and post-operative RT. A third developed lung and bone metastases 49 months after diagnosis and died 8 months later. None of the subjects experienced recurrence in the same quadrant as the index tumor. In this cohort of women with favorable-risk breast cancer, PBI with CT-planned interstitial HDR brachytherapy provided excellent local control, good-excellent cosmesis and acceptable acute and late toxicities.