Genome-Wide Association Studies for Taxane-Induced Peripheral Neuropathy in ECOG-5103 and ECOG-1199

PURPOSE

Taxane-induced peripheral neuropathy (TIPN) is an important survivorship issue for many cancer patients. Currently, there are no clinically implemented biomarkers to predict which patients might be at increased risk for TIPN. We present a comprehensive approach to identification of genetic variants to predict TIPN.

EXPERIMENTAL DESIGN

We performed a genome-wide association study (GWAS) in 3,431 patients from the phase III adjuvant breast cancer trial, ECOG-5103 to compare genotypes with TIPN. We performed candidate validation of top SNPs for TIPN in another phase III adjuvant breast cancer trial, ECOG-1199.

RESULTS

When evaluating for grade 3-4 TIPN, 120 SNPs had a P value of <10(-4) from patients of European descent (EA) in ECOG-5103. Thirty candidate SNPs were subsequently tested in ECOG-1199 and SNP rs3125923 was found to be significantly associated with grade 3-4 TIPN (P = 1.7 × 10(-3); OR, 1.8). Race was also a major predictor of TIPN, with patients of African descent (AA) experiencing increased risk of grade 2-4 TIPN (HR, 2.1; P = 5.6 × 10(-16)) and grade 3-4 TIPN (HR, 2.6; P = 1.1 × 10(-11)) compared with others. An SNP in FCAMR, rs1856746, had a trend toward an association with grade 2-4 TIPN in AA patients from the GWAS in ECOG-5103 (OR, 5.5; P = 1.6 × 10(-7)).

CONCLUSIONS

rs3125923 represents a validated SNP to predict grade 3-4 TIPN. Genetically determined AA race represents the most significant predictor of TIPN.

Abstract P6-13-01: Local excision without radiation for ductal carcinoma in situ: 12-year results from the ECOG E5194 study

Background: The ECOG E5194 study was a prospective trial designed to evaluate surgical excision (lumpectomy) without radiation for selected women with ductal carcinoma in situ (DCIS) of the breast with low risk clinical and pathologic features.

Methods: Eligible patients were enrolled on two study cohorts (not randomized): (1) low or intermediate grade DCIS, tumor size &lt; 2.5 cm; or (2) high grade DCIS, tumor size &lt; 1.0 cm. Cohort assignment was based on pathology assessment from the treating institution. Protocol specifications included surgical excision of the DCIS tumor with a minimum negative margin width of at least 3 mm or no tumor on re-excision. Radiation treatment was not allowed. From April 1997 to October 2002, 665 evaluable patients were enrolled through ECOG or NCCTG (561 in Cohort 1; 104 in Cohort 2). Tamoxifen was optional (not randomized) beginning in May 2000, and was given to 30% of the patients. The primary study endpoint was the rate of developing an ipsilateral breast event (IBE), defined as local recurrence of DCIS or invasive carcinoma in the treated breast. The median follow-up was 12.3 years. We have previously reported 7-year results (L. Hughes, J Clin Oncol 27:5319, 2009; median follow-up 6.3 years; 66 IBE’s), and we herein provide 12-year results.

Results: Median patient age was 60 years and 58 years for Cohort 1 and Cohort 2, respectively. Tumor size was &lt; 10 mm for 79% and 80% of patients, respectively. The minimum negative margin width was &gt; 5 mm for 64% and 69% of patients, respectively. There were 99 IBE’s, of which 51 (52%) were an invasive IBE. The IBE and invasive IBE rates increased over time in both cohorts (see Table). The 12-year rates of an IBE were 14.4% for Cohort 1 and 24.6% for Cohort 2 (p = 0.003), and for an invasive IBE, 7.5% and 13.4%, respectively (p = 0.08). No difference was seen for the 12-year rates of overall survival (84.0% vs 82.8%; p = .96) or contralateral breast events (6.7% vs 12.0%; p = 0.16). On multivariate analysis, study cohort (hazard ratio = 1.81; p = 0.01) and tumor size (p = 0.01) were statistically significant for an IBE, and study cohort was borderline statistically significant for an invasive IBE (p = 0.08). On central pathology review (75% of cases), neither grade nor comedo necrosis was associated with the risk of an IBE or invasive IBE (all p &gt; 0.15). Salvage treatment at the time of an IBE included mastectomy for 42% (31/74) and 64% (16/25) of the patients, respectively.

Conclusions: For these selected patients with favorable DCIS based on clinical and pathologic characteristics treated with surgical excision without radiation, the rates of an IBE and an invasive IBE continued to increase through at least 12 years of follow-up.

IBE Rates According To Study Cohort. Cohort 1 (Low or Intermediate Grade)Cohort 2 (High Grade)TimeIBEInvasive IBEIBEInvasive IBEAt 5 years6.0% (4.0%, 8.1%)2.7% (1.3%, 4.1%)15.0% (7.7%, 21.7%)5.3% (0.8%, 9.7%)At 7 years9.5% (7.0%, 12.0%)4.8% (2.9%, 6.6%)18.2% (10.6%, 25.8%)7.6% (2.2%, 13.0%)At 10 years12.5% (9.5%, 15.4%)6.4% (4.2%, 8.6%)24.6% (15.7%, 33.4%)13.4% (5.9%, 20.9%)At 12 years14.4% (11.2%, 17.6%)7.5% (5.1%, 10.0%)24.6% (15.7%, 33.4%)13.4% (5.9%, 20.9%)

Citation Format: Lawrence J Solin, Robert Gray, Lorie L Hughes, William C Wood, Mary Ann Lowen, Sunil Badve, Frederick L Baehner, James N Ingle, Edith A Perez, Abram Recht, Joseph Sparano, Kathy Miller, Nancy E Davidson. Local excision without radiation for ductal carcinoma in situ: 12-year results from the ECOG E5194 study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-13-01.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Chronic thalidomide and chemoembolization for hepatocellular carcinoma

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has been used to curtail tumor vasculature and delay tumor progression in hepatocellular carcinoma (HCC). We conducted a phase I trial to evaluate the efficacy and toxicity of thalidomide when combined with TACE in patients with advanced HCC.

METHODS

Between June 2000 and November 2003, 56 patients with unresectable HCC and amenable to TACE were enrolled. The starting dose of thalidomide was 200 mg/day and was escalated every 2 weeks as tolerated to a maximum dose of 1,000 mg/day. Dose reductions and discontinuation were determined by toxicity. TACE was performed 4 weeks after initiation of thalidomide therapy and repeated as necessary.

RESULTS

Overall, 47 and 55 patients were evaluable for response and toxicity, respectively; the median dose of thalidomide given was 200 mg/day. Three patients (6.38%) patients achieved complete responses, whereas 10 (21.3%) had partial responses, for an overall response rate of 27.7%, and 27 (57.5%) had stable disease. Median progression-free survival was 7 months (95% confidence interval [CI]: 5-10 months), and median OS was 21 months (95% CI: 16-28 months) (Fig. 1). Fatigue and lethargy (49.1%), constipation (47.3%), and nausea (43.6%) were common. Grade 3-4 toxicities consisted mostly of increased aspartate aminotransferase (43.6%) and elevated alanine aminotransferase (38.2%) (Table 1).

CONCLUSION

Thalidomide and TACE were commonly associated with nonhematologic side effects, with fatigue and constipation being prominent. With a lack of clear therapeutic benefit, this combination is unlikely to be pursued for HCC.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Genetic variant predicts bevacizumab-induced hypertension in ECOG-5103 and ECOG-2100

BACKGROUND

Bevacizumab has broad anti-tumour activity, but substantial risk of hypertension. No reliable markers are available for predicting bevacizumab-induced hypertension.

METHODS

A genome-wide association study (GWAS) was performed in the phase III bevacizumab-based adjuvant breast cancer trial, ECOG-5103, to evaluate for an association between genotypes and hypertension. GWAS was conducted in those who had experienced systolic blood pressure (SBP) >160 mm Hg during therapy using binary analysis and a cumulative dose model for the total exposure of bevacizumab. Common toxicity criteria (CTC) grade 3-5 hypertension was also assessed. Candidate SNP validation was performed in the randomised phase III trial, ECOG-2100.

RESULTS

When using the phenotype of SBP>160 mm Hg, the most significant association in SV2C (rs6453204) approached and met genome-wide significance in the binary model (P=6.0 × 10(-8); OR=3.3) and in the cumulative dose model (P=4.7 × 10(-8); HR=2.2), respectively. Similar associations with rs6453204 were seen for CTC grade 3-5 hypertension but did not meet genome-wide significance. Validation study from ECOG-2100 demonstrated a statistically significant association between this SNP and grade 3/4 hypertension using the binary model (P-value=0.037; OR=2.4).

CONCLUSIONS

A genetic variant in SV2C predicted clinically relevant bevacizumab-induced hypertension in two independent, randomised phase III trials.

Abstract P2-16-05: Efficacy of ABT-888 (veliparib) in patients with BRCA-associated breast cancer

Background: The potential for exploiting BRCA deficiencies with DNA repair inhibitors has both pre-clinical and clinical support. ABT-888 (veliparib), a DNA repair inhibitor initially thought to target Poly(ADP-Ribose) Polymerases (PARP), has demonstrated in vitro inhibition of BRCA1 and BRCA2 deficient mouse embryonic stell cells, with a larger effect on BRCA1 cells. We report on the pre-planned interim analysis of the efficacy of single agent veliparib in patients with either BRCA1 or BRCA2-associated stage IV breast cancer. Methods: BRCA 1 or 2 carrier patients with stage IV breast cancer, with measurable disease, without prior exposure to a PARP inhibitor or a platinum compound in the metastatic setting, were eligible. Velapirib was administered orally, at doses of 400 mg twice daily. Dose adjustments based on toxicity were permitted. Patients progressing on velapirib alone received carboplatin at an AUC of 5, IV, given Q 21 days, and velapirib 150 mg twice daily (the maximum tolerated dose [MTD] of the combination from our completed Phase I study: J Clin Oncol 30, 2012 [suppl; abstr 1024]). Patients were to be accrued from 7 NCI NO1- supported consortia. Initially 10 patients were to be accrued to each stratum (BRCA1 and BRCA2) to provide evidence of single agent activity. If there was sufficient activity to warrant consideration of velapirib as single agent therapy (defined as 2 or more confirmed partial [PR] or better responses out of 10 per stratum), an additional 12 patients would be accrued per stratum. Results: 20 evaluable patients (11 BRCA1 and 9 BRCA2 [1 in screening]) have been accrued, the majority with lung or liver as visceral metastatic sites of disease. Median age (range) is 46 (29-68) years. Tumors from 9 patients were hormone receptor positive. BRCA1 cohort: 4 of 11 patients are off treatment at a median of 2 months (1-4); 1 patient stopped velapirib due to toxicity (grade 2 rash/pruritus, grade 2 vomiting), 3 stopped for progressive disease (one with an unconfirmed PR). Seven patients are still on single agent veliparib with 1 unconfirmed PR, and 1 patient with two evaluations showing stable disease. BRCA2 cohort: 2 patients are off treatment at 2 months for progressive disease, 7 are still on treatment with 1 confirmed PR, and 3 unconfirmed PRs. Data on patients receiving combination of velapirib and carboplatin after progression is too early. Treatment-related toxicity is being updated and has so far been reported from 14 patients: 1 patient had grade 3 fatigue, 1 patient with liver metastasis had both grade 3 alanine aminotransferase elevation and grade 3 abdominal pain. Grade 2 toxicities occurring in more than 1 patient included nausea/vomiting (6 patients), chills (2 patients), and fatigue (2 patients). Conclusion: Velapirib has single agent activity in both BRCA1 and BRCA2-associated stage IV breast cancer patients, and is well-tolerated. Mature response, treatment, and toxicity data will be presented.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-05.

Abstract P1-08-08: Tumor infiltrating lymphocytes (TILs) in breast cancer: A meta-analysis of response to neoadjuvant chemotherapy based on TIL status

Background:

TILs involving tumor and/or its associated stroma may be indicative of an immune response that may either facilitate anti-tumor immunity and clearance or immune tolerance and evasion. In this study we performed a meta-analysis evaluating the relationship between TILs and pathologic response to neoadjuvant chemotherapy (NAC) since this is considered as a surrogate endpoint of disease outcomes in ER negative or Her2 positive tumors.

Methods:

We searched PubMed and Embase (1991-May 2013), and ASCO abstracts (2009-2012), using a combination of free text search and controlled vocabulary search. We identified 1147 reports which met our initial search criteria, and they were reviewed to identify those which met the following criteria: (1) evaluated the presence of TILs, defined as tumor and/or stromal lymphocytes (CD4, CD8 or FOXP3) identified by H&E, IHC or gene expression before NAC, (2) classified TIL's “high/low” or “positive/negative”, and (3) correlated TILs with pathological complete response (pCR) or near pCR after NAC. Standard anthracycline-containing regimens were used as NAC in most studies, and anti-HER2 therapy was not used in most studies with HER2-positive disease. Results are presented as pooled odds ratios (OR) with 95% confidence intervals (CI), based on random-effects (to account for between study variance and heterogeneity due to different cutoffs and subtypes of T lymphocytes). Sensitivity analysis was done and publication bias was investigated using a funnel plot. We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity. Meta-analysis statistics were calculated using StatsDirect Version 2.7.9.

Results:

Seven studies including 1641 patients met our criteria for inclusion in this analysis. A TIL ratio classified as either high or positive was associated with a significantly higher likelihood of achieving a pCR/near pCR after NAC (OR 3.68; 95% CI 1.93–7.01. p&lt;0.0001) [Table 1]. This effect was driven mainly by a difference in ER negative tumors (OR 4.04, 95% CI 2.16-7.57. p&lt;0.0001) and Her2 positive tumors (OR 5.61, 95% CI 1.8–17.47, p = 0.0007); the association was present, but nonsignificant, in ER positive tumors (OR 2.17, 95% CI 0.95-4.98). Sensitivity analyses did not change the inference. Funnel plots suggested low likelihood of publication bias (Harbord Egger test, p = 0.604) for all studies, and the I(2) statistic was 67.5%.

Table 1. Characteristics and Odds ratio for individual subtypesSubtypeNNo of studiesTIL low pCR%TIL high pCR%OR95% CIAll1641712.5%28.6%3.681.93 -7.01ER-/PR- and HER2- [except one study defined by ER-/PR-]403423.6%41.3%4.042.16 - 7.57Her2+326316.9%23.4%5.611.80 - 17.47ER/PR+55825.6%11.5%2.170.95 - 4.98

Conclusions:

In this systematic review and meta-analysis, high or positive TIL status before NAC was associated with a significantly better pathologic response to NAC (surrogate for DFS and OS), particularly in patients with ER/PR-negative or HER2-overexpressing disease. Patients with tumors characterized by low or absent TILs require novel therapeutic approaches, and may be candidates for immunotherapeutic approaches to enhance innate immunity or reverse immune tolerance.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-08.

Association of a compact 13-gene VEGF signature with OS in E2100

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Background: E2100, an open-label, randomized, phase III trial, demonstrated a significant improvement in progression free survival and overall response rate with paclitaxel plus bevacizumab compared with paclitaxel alone as initial chemotherapy for patients with HER2-negative metastatic breast cancer. Genentech completed additional clinical trials and submitted these data to the FDA. On 18 Nov, 2011, the FDA Commissioner revoked the agency’s approval of bevacizumab for the breast cancer indication because of the lack of evidence of an improvement in overall survival or a clinical benefit to patients sufficient to outweigh the risks. However, the Commissioner “encouraged Genentech to consider additional studies to identify if there are select subgroups of women who might benefit from this drug”. Hu et al. (BMC Medicine 2009) published a compact 13 gene VEGF-signature associated with distant metastases and poor outcomes. Supervised analyses comparing patients with distant metastases versus primary tumors or regional metastases showed that the distant metastases were distinct and distinguished by the lack of expression of fibroblast/mesenchymal genes, and by the high expression of a 13 gene profile that included VEGF, ANGPTL4, ADM and the monocarboxylic acid transporter SLC16A3. Methods: We have investigated the VEGF signature in silico on Illumina DASL analysis of 122 FFPE samples remaining from E2100. Results: PFS benefit is seen for pacli + bev vs pacli in both treatment arms with the low VEGF signature (HR 0.45 95% CI .27-.77 p .009 n 67) and with the high VEGF signature (HR 0.57 95% CI .32-1.0 p .015 n 55). However, OS benefit is only seen for pacli + bev vs pacli in the high VEGF group (HR 0.56 95% CI .30-1.05 p .02 n 52) and not in patients with the low VEGF signature (HR 1.12 95% CI .66-1.90 p .81 n 67). Conclusions: Hence, this signature, which suggests that the response to hypoxia includes the ability to promote new blood and lymphatic vessel formation, shows great potential as a predictive biomarker of those patients to whom bevacizumab would convey an OS advantage benefit. We note with great caution that this exploratory analysis of trial subset is underpowered, hence, this compact VEGF signature is being pursued in other bevacizumab trial sets.

Patient-reported cognitive impairments among women with breast cancer randomly assigned to hormonal therapy (HT) alone versus chemotherapy followed by hormonal therapy (C+HT): Results from the Trial Assigning Individualized Options for Treatment (TAILORx)

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Background: Cognitive impairment is a complication of chemotherapy. Perceived cognitive impairments (PCI) were prospectively assessed among TAILORx participants randomized to HT alone versus chemotherapy followed by HT (C+HT). Methods: TAILORx participants with an OncoType DX Recurrence Score 11-25 were randomly assigned to HT or C+HT. PCI, fatigue, endocrine symptoms and health-related quality of life (HRQL) were assessed at baseline, 3, 6, 12, 24, and 36 months, using the Functional Assessment of Cancer Therapy (FACT) in 455 patients enrolled after 1/15/10. PCI change scores > 4.5 from baseline were defined a priori as clinically meaningful. Linear regression (LR) was used to model PCI scores on baseline PCI, treatment and other factors. Results: PCI scores were significantly worse at 3, 6, and 12 months compared to baseline for both groups (Table). The decline was greater for C+HT than HT at 3 months, but scores were similar at 12 months. Tests of an interaction between menopausal status and treatment were non-significant. PCI correlated with fatigue (r = 0.57-0.64) but not FACT Emotional well-being (EWB; r = 0.28-0.38); controlling for EWB did not account for differences in PCI change scores between treatment arms. Conclusions: Our study is the first to examine PCI among breast cancer patients randomized to receive C+HT vs. HT alone. C+HT was associated with greater declines in PCI at 3 months, but at 12 months PCI was similar in the C+HT and HT groups. PCI was associated with fatigue but not EWB. Pre- and post-menopausal groups demonstrated the same pattern of change. Since this study did not include a control group of patients not treated with HT, further study is required to determine if and to what extent HT contributes to PCI. [Table: see text]

OT3-01-17: Randomized, Double-Blind, Placebo-Controlled Phase II Trial of Low-Dose Metronomic Cyclophosphamide Alone or in Combination with Veliparib (ABT-888) in Chemotherapy-Resistant ER and/or PR-Positive, HER2/neu-Negative Metastatic Breast Cancer: New York Cancer Consortium Trial P8853

Background: Veliparib is an orally available, small molecule inhibitor of poly(ADP-ribose) polymerase (PARP). PARP is an essential nuclear enzyme that plays a role in recognition of DNA damage and facilitation of DNA repair. PARP inhibitors potentiate the cytotoxicity of DNA-damaging agents, including cyclophosphamide (C). The rationale for the proposed trial is as follows: (1) low-dose, continuous metronomic C (50 mp PO daily) has activity in refractory metastatic breast cancer (MBC), (2) PARP is induced by DNA damaging agents, (3) PARP expression is comparable in ER-positive and ER-negative disease, (4) some ER-positive breast cancers exhibit defective homologous recombination pathway repair genes (eg, RAD51 and XRCC3), (5) the PARP inhibitor iniparib appears to be more effective when used in chemotherapy resistant disease. Taken together, these findings suggest that veliparib-C combination may be more effective than metronomic C alone in chemotherapy resistant MBC. Trial design: A randomized Phase II trial design 1:1. S. Blocked randomization will be performed at all participating sites. Patients are randomized to oral C (50mg PO daily) plus either veliparib (60mg PO daily) or matching placebo.

Eligibility criteria:(1) ER- and or PR-positive, HER2−negative MBC, (2) ECOG PS 0–1, (3) at least 2 prior chemotherapy regimens for MBC, including a taxane and capecitabine. 4) at least 1 line of endocrine therapy for metastatic disease (includes relapse while receiving endocrine therapy).

Specific aims: Primary: To determine if the addition of veliparib to metronomic dose C improves median progression free survival (PFS) compared with C alone in patients with ER and/or PR-positive, Her2-negative MBC who progressed on at least two lines of prior chemotherapy and one line of prior endocrine therapy.

Secondary: 1)To determine if the addition veliparib to C chemotherapy improves a) response rate b) clinical benefit rate (defined as objective response plus stable disease for at least 24 weeks from day +1) 2) Survival in patients treated with C alone and C plus veliparib. 3) Adverse event profile in patients treated with C alone and C plus veliparib.

Translational: Exploratory analyses will evaluate whether the macroH2A1.1 and PARP1 expression status in archival paraffin, or veliparib-induced PAR downregulation in peripheral blood mononuclear cells, is predictive of benefit from veliparib.

Statistical methods: The primary endpoint is PFS, and the trial is powered to detect an increase in median PFS from 3 to 6 months (alpha=0.10, beta=0.10), which will require enrollment of 62 eligible patients over 12 months.

Enrollment: The study is active and open to enrollment.

Clinical trials.gov NCT01351909

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-17.

OT3-01-01: Randomized Phase II Study of Fulvestrant Versus Fulvestrant Plus Bortezomib in Postmenopausal Women with Estrogen Receptor (ER) Positive, Aromatase-Inhibitor (AI) Resistant Metastatic Breast Cancer (MBC): New York Cancer Consortium Trial P8457

Background: Bortezomib ia proteasome inhibitor that enhances fulvestrant-mediated aggregation of the ER in the cytoplasm without blocking ER degradation in the nucleus in ER+ human breast cancer cell lines, thereby promoting cytoplasmic ER aggresomes which activate a sustained unfolded protein response leading to apoptotic cell death; the combination also induces tumor regression in a tamoxifen resistant T47D-cyclin D1 xenograft model more effectively than either agent alone (Clin Cancer Res 2011; 17: 2292–2300).

Hypothesis: We hpothesize that the combination of fulvestrant and bortezomib will be more effective than fulvestrant alone in ER+, AI-resistant MBC.

Trial design: This is an open-label randomized phase II design in which patients with MBC are randomized to receive fulvestrant alone (500 mg IM day −14, day +1, and day +14 during cycle 1, then 500 mg every 4 weeks on day +1 during cycle 2 and thereafter) or in combination with bortezomib (1.6 mg/m2 IV days +1, +8, +15 every cycle). Stratification factors for randomization include performance status (ECOG 0 vs. 1–2), measurable disease (yes vs. no), and prior chemotherapy for MBC (yes vs. no). Patients who progress on fulvestrant alone may cross over to the combination.

Eligibility criteria: Postmenopausal women with ER+, Her2-negative, MBC who have progressive disease during AI therapy for metastatic disease, or relapse while receiving adjuvant AI therapy. Up to one prior chemotherapy regimen for metastatic disease is permitted.

Specific aims: Primary Objective: To determine if the addition of bortezomib to fulvestrant significantly improves median progression-free survival (PFS), defined as the time from cycle 1, day 1 of therapy until disease progression or death from any cause.

Secondary Objectives: To determine: (1) adverse event rates in both arms, (2) the clinical benefit rate (CBR — objective response [by RECIST 1.1] and/or progression free at 24 weeks), (3) the objective response and CBR after crossover from fulvestrant to fulvestrant plus bortezomib.

Translational Objectives: To perform an exploratory analysis of the effects of the combination on intratumoral nuclear/cytoplasmic ER ratio, unfolded protein response (BiP), apoptotis (cleaved caspase 3, Bc1-2 phospho JNK.)

Statistical methods: he median PFS for patients receiving fulvestrant alone is expected to be approximately 5.4 months based upon patients with AI-resistant disease enrolled on the CONFIRM trial ( J Clin Oncol 2010; 28: 4594–4600). The trial is designed to detect a 70% improved in median PFS to 9.0 months (alpha=0.10, beta =0.10), which will require 59 eligible patients in each arm.

Present accrual and target accrual: 24/118

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-01.

A phase 2 trial of dasatinib in patients with advanced HER2-positive and/or hormone receptor-positive breast cancer

PURPOSE

SRC-family kinases (SFK) are involved in numerous oncogenic signaling pathways. A phase 2 trial of dasatinib, a potent oral tyrosine kinase inhibitor of SFKs, was carried out in patients with human epidermal growth factor receptor 2-positive (HER2+) and/or hormone receptor-positive (HR+) advanced breast cancer.

EXPERIMENTAL DESIGN

Patients with measurable tumors and progression after chemotherapy and HER2 and/or HR-targeted agents in adjuvant or metastatic settings (maximum of two prior metastatic setting regimens) received twice daily dasatinib. Primary endpoint was Response Evaluation Criteria in Solid Tumors-defined response rate. Secondary endpoints included toxicity and limited pharmacokinetics.

RESULTS

Seventy patients (55 years median age) were treated, 83% of HER2+ patients had received prior HER2-directed therapy, and 61% of HR+ patients had received prior endocrine therapy in the advanced setting. Dasatinib starting dose was reduced from 100 to 70 mg twice daily to limit toxicity. Median therapy duration was 1.8 months in both dose groups and most discontinuations were due to progression. Of 69 evaluable patients, three had confirmed partial responses and six had stable disease for 16 weeks or more (disease control rate = 13.0%); all nine of these tumors were HR+ (two were also HER2+). The most common drug-related toxicities were gastrointestinal complaints, headache, asthenia, and pleural effusion. Grade 3-4 toxicity occurred in 37% of patients and was comparable between doses; drug-related serious adverse events were less frequent with 70 mg twice daily than 100 mg twice daily.

CONCLUSION

Limited single-agent activity was observed with dasatinib in patients with advanced HR+ breast cancer.

Gene Expression Profiling of Phenotypically-Defined Hormone-Receptor Positive Breast Cancer: Evidence for Increased Transcriptional Activity of the Insulin Growth Factor Receptor Pathway and Other Pathways

Background: Approximately 70% of all breast cancers are hormone receptor (HR)-positive tumors that are sensitive to endocrine therapy, but some patients have recurrence despite adjuvant endocrine therapy. We performed an exploratory analysis of gene expression in HR-pos operable breast cancer in order to identify potential novel therapeutic targets and biomarkers associated with recurrence. Methods: RNA was extracted from primary tumor samples obtained from 776 patients with stage I-III breast cancer treated with adjuvant chemohormonal therapy in trial E2197 (JCO 2008; 26: 4092-4099), of whom 458 had HR-pos disease (defined in a central lab; JCO 2008; 26: 2473). We evaluated RNA expression patterns (by quantitative RT-PCR using a panel of 371 rationally selected genes) in HR-pos cases compared with the HR-neg cases using weighted T statistics, and determined which genes in the HR-pos, HER2-neg group were associated with recurrence (using Cox proportional hazards model score test, Korn's adjusted P value &lt;5% with false discovery rate &lt; 10%).Results: The top 10 genes exhibiting significantly higher expression in the HR-pos group (p≤ 6.17e-160) included ESR1 plus 5 estrogen regulated genes, confirming our approach of evaluating gene expression in phenotypically-defined subsets. Other pathways that exhibited higher expression in the HR-pos group (among the 40 top genes with higher expression, p&lt;8.66e-53) included the insulin growth factor (IGF) (IRS1, IGFR1, IGFB2), Ras (RhoB, RhoC, RAB27B, GGPS1), and HER pathways (ERBB2, ERBB3, ERBB4), and other genes involved in apoptosis (BCL2, BCL2L1, BAG1, NME6, BBC3), signaling (MAPK3, SEMA3F, RXRA), mismatch repair (MSH3), cell cycle regulation (CCND1), stress response (HSPB1), and tumor suppressor genes (TP53BP1, APC). These patterns were similar in HER2-pos cases. Pathway analysis (Ingenuity) revealed substantial interconnectivity among these genes, especially between IGFR1, ERB2/3/4, MAPK3, BCL2, and CCND1, but not RhoB/RhoC. Genes for which increased expression was associated with increased recurrence included those associated with proliferation (TOP2A, AURKB, PLK1) and apoptosis (BIRC5 - survivin).Conclusions: This exploratory analysis reveals several pathways that exhibit higher transcriptional expression in HR-pos disease, some of which are also associated with a higher risk of recurrence, suggesting that they may be potential therapeutic targets. This provides rationale for testing agents currently available in the clinic that inhibit the IGF and other pathways.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5165.

Relationship of Anthracycline-Free Interval to Outcomes in a Phase 3 Trial of Pegylated Liposomal Doxorubicin Plus Docetaxel Compared with Docetaxel Monotherapy in Patients with Advanced Breast Cancer Treated with Adjuvant Anthracycline

Background: An earlier report showed that pegylated liposomal doxorubicin (PLD) + docetaxel (D) improved time to progression (TTP) vs D alone in patients (pts) with advanced breast cancer (ABC) who had relapsed at least 1 year after adjuvant or neoadjuvant anthracycline therapy. (Sparano et al., SABC 2008, #80) This analysis evaluated whether the time between completion of adjuvant anthracycline therapy until relapse impacts overall outcome. We retrospectively examined outcomes in pts with an anthracycline-free (A-F) interval of 1 to 2 years and pts with an A-F of &gt;2 years.Methods: 751 pts were randomly assigned to receive either D 75 mg/m2 (N=373) or PLD 30 mg/m2 followed by D 60 mg/m2 (N=378) every 21 days. Treatment was continued until disease progression or the occurrence of unacceptable toxicity. The primary endpoint was TTP and secondary endpoints included overall survival (OS), progression free survival (PFS), objective response rate (ORR), and safety. Pts were categorized into groups by anthracycline-free interval of 1-2 years or &gt;2 years. Relationship between the interval and outcomes was examined by proportional hazards model for TTP, OS (updated as of 1-Dec-2008), and PFS.Results: Approximately 60% of pts in both treatment groups had A-F intervals of &gt;2 years. Median TTP, OS, and PFS (months) by A-F interval groups are listed in the Table. A-F interval 1-2 years  A-F interval &gt;2 years   D, n=151PLD+D, n=155HR (CI)*; P**D, n=221PLD+D, n=221HR (CI)*; P**TTP5.77.80.67 (0.52, 0.87); .0027.710.60.63 (0.50, 0.79); &lt;.001OS15.817.90.90 (0.69, 1.16); .40424.722.91.10 (0.86, 1.40); .448PFS5.57.70.67 (0.52, 0.87); .0027.710.00.65 (0.51, 0.81); &lt;.001ORR25%34%P=.086†27%36%P=.042† A-F interval 1-2 years, N=306  A-F interval &gt;2 years, N=442 HR (CI)***; P**TTP6.6  8.9 0.74 (0.63, 0.88); .001OS17.2  23.4 0.63 (0.52, 0.75); &lt;.001PFS6.5  8.7 0.74 (0.62, 0.87); &lt;.001ORR30%  31% P=.826†*Proportional hazard model for PLD+D vs D; **Log-rank test; ***Proportional hazard model for &gt;2 years vs ≤2 years A-F; †Cochran-Mantel-Haenszel test.Overall, HFS and stomatitis occurred more often in pts treated with PLD+D. The overall incidence of CHF was 1%.Conclusions: An A-F interval of &gt;2 years reduced the risk for TTP, OS, and PFS, regardless of treatment. However, similar to results of the overall study, treatment with the combination PLD+D resulted in statistically significant improvement of TTP and PFS, but not OS, compared with D among pts with ABC, regardless of A-F interval. The addition of PLD to a D-based regimen is an active option for pts with ABC previously treated with adjuvant anthracycline regimens.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2095.

Dasatinib in advanced HER2/neu amplified and ER/PR-positive breast cancer: Phase II study CA180088

1011

Background: SRC family kinases (SFKs) are involved in numerous signaling pathways including from ER and HER-2 receptors, as well as osteoclast function. Dasatinib is a potent oral inhibitor of SFKs. A phase II trial was performed in patients (pts) with ER+ and/or PR+ and/or HER-2-amplified progressive advanced breast cancer. Subsequent to study initiation, dasatinib demonstrated similar efficacy with a lower incidence of key side-effects at 100 mg once daily in CML and prostate cancer. Methods: Pts with measurable disease and progression after chemotherapy and other targeted agents were treated with dasatinib on a continuous twice-daily (BID) schedule; RECIST-defined response rate was primary endpoint. Results: Sixty-eight pts, 24 with HER-2-amplified and 44 with HER-2-normal, ER+ and/or PR+ disease, were treated. Original starting dose of 100 mg BID (23 pts) was reduced to 70 mg BID (45 pts) due to fluid retention, fatigue, or GI toxicity. Median age was 55 years; nearly all pts (93%) had prior therapy in advanced setting. 59 were radiographically-evaluable (8 discontinued for toxicity and 1 inevaluable). We observed 3 partial responses lasting 9, 9 and 8+ mos plus 6 stable disease ≥16 weeks (range 24–33 wks). All 9 controlled tumors were ER/PR+, 2 were also HER-2-amplified; thus, disease control rate was 19% in the 47 radiographically-evaluable pts with ER/PR+ disease. Median dose intensity was 136 mg/day at 70 mg BID and 175 mg/day at 100 mg BID; median duration of therapy was 1.8 mos in both dose groups. Most pts (75%) discontinued for disease progression. The most common drug-related AEs were diarrhea (49%), headache (34%), nausea (34%), asthenia (32%), pleural effusion (31%), musculoskeletal pain (25%), and vomiting (24%). Drug-related grade 3–4 AEs were reported in 37% of pts and comparable between doses, but related serious AEs were less frequent at 70 mg BID than 100 mg BID (16% vs 26%). Grade 3–4 laboratory abnormalities were uncommon. PK and biomarker analyses will be presented. Conclusions: Encouraging single-agent activity was observed with dasatinib in pts with advanced ER+ breast cancers. Future studies will address the combination of dasatinib with hormonal therapies using a better-tolerated once daily schedule.

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Human T cell leukemia virus reactivation with progression of adult T-cell leukemia-lymphoma

BACKGROUND

Human T-cell leukemia virus-associated adult T-cell leukemia-lymphoma (ATLL) has a very poor prognosis, despite trials of a variety of different treatment regimens. Virus expression has been reported to be limited or absent when ATLL is diagnosed, and this has suggested that secondary genetic or epigenetic changes are important in disease pathogenesis.

METHODS AND FINDINGS

We prospectively investigated combination chemotherapy followed by antiretroviral therapy for this disorder. Nineteen patients were prospectively enrolled between 2002 and 2006 at five medical centers in a phase II clinical trial of infusional chemotherapy with etoposide, doxorubicin, and vincristine, daily prednisone, and bolus cyclophosphamide (EPOCH) given for two to six cycles until maximal clinical response, and followed by antiviral therapy with daily zidovudine, lamivudine, and alpha interferon-2a for up to one year. Seven patients were on study for less than one month due to progressive disease or chemotherapy toxicity. Eleven patients achieved an objective response with median duration of response of thirteen months, and two complete remissions. During chemotherapy induction, viral RNA expression increased (median 190-fold), and virus replication occurred, coincident with development of disease progression.

CONCLUSIONS

EPOCH chemotherapy followed by antiretroviral therapy is an active therapeutic regimen for adult T-cell leukemia-lymphoma, but viral reactivation during induction chemotherapy may contribute to treatment failure. Alternative therapies are sorely needed in this disease that simultaneously prevent virus expression, and are cytocidal for malignant cells.

Phase II trial of dasatinib in triple-negative breast cancer: results of study CA180059

Abstract #3118

Background: Dasatinib (SprycelR; BMS-354825) is a potent orally-available inhibitor of Src-family kinases and other kinases with anti-proliferative, anti-osteoclastic and anti-metastatic activity demonstrated pre-clinically. Expression profiling suggested that basal-like cancers may be preferentially sensitive to dasatinib. Methods: A Phase II single-agent trial of dasatinib, using a continuous schedule, was performed in patients with advanced triple-negative (as proxy for basal-like) breast cancers. Subjects were required to have measurable locally-advanced or metastatic triple-negative (ER/PR-negative, Her2-normal) disease and prior anthracycline and/or taxane therapy. A 2-stage Gehan design was adopted, with RECIST-defined response as primary endpoint; subjects discontinued for toxicity were considered non-responders. The original dasatinib dose of 100 mg BID (n=21) was reduced to 70 mg BID (n=23) to improve tolerability. Biomarkers were analyzed in tumor and plasma samples obtained for PK analysis. Results: From 12/06 through 12/07, 44 subjects were treated at 14 institutions: median age 55 yrs, median time from diagnosis 30 mo, prior therapy for advanced disease in 29 (66%). Of 43 response-evaluable subjects, 7 discontinued for toxicity prior to on-study assessment. Of 36 subjects with radiographic assessment, there were 2 confirmed PR [1 continues &gt;1 year + 1 discontinued for intolerance at week 16] plus 2 SD lasting &gt;16 weeks. Four additional subjects had transient clinical benefit reflected by improvement in bone pain (anecdotal) or short-term tumor shrinkage (reductions of 11 - 29%). Tolerability was improved at a dose of 70 mg compared with 100 mg BID. In preliminary analysis, fewer subjects experienced any serious adverse event (13% at 70 mg BID vs 48% at 100 mg BID), fewer reported Grade 3 toxicity, including gastrointestinal (10% vs 26%), pleural effusion (4% vs 9%), generalized edema (0% vs 9%) or pericardial effusion (0% vs 9%), and fewer had dasatinib dose reduction (24% vs 61%). Fatigue, myalgia/arthralgia and headache were comparable at the two doses. No Grade 4 drug-related events occurred. Grade 3-4 abnormal laboratory values were uncommon. Biomarker and PK data will be presented. Conclusions: Modest but encouraging single-agent activity was observed with dasatinib in patients with advanced triple-negative breast cancers, with clinical benefit rate of 9.3% (4/43). Future studies are warranted to address optimal dose and schedule of dasatinib in combination with chemotherapy for this challenging tumor type.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3118.

Phase II clinical trial of ixabepilone (BMS-247550), an epothilone B analog, as first-line therapy in patients with metastatic breast cancer previously treated with anthracycline chemotherapy

PURPOSE

There is a need for new agents to treat metastatic breast cancer (MBC) in patients for whom anthracycline therapy has failed or is contraindicated. This study was conducted to assess the efficacy and safety of the novel antineoplastic, the epothilone B analog ixabepilone, in patients with MBC previously treated with an adjuvant anthracycline.

PATIENTS AND METHODS

Patients were age >or= 18 years and had received a prior anthracycline-based regimen as adjuvant treatment. Ixabepilone as first-line metastatic chemotherapy was administered as a 40 mg/m(2) intravenous infusion during 3 hours every 3 weeks. The primary efficacy end point was objective response rate (ORR). Secondary efficacy end points included duration of response, time to response, time to progression, and survival.

RESULTS

All 65 patients were assessable for response. Their median age was 52 years (range, 33 to 80 years). ORR was 41.5% (95% CI, 29.4% to 54.4%), median duration of response was 8.2 months (95% CI, 5.7 to 10.2 months), and median time to response was 6 weeks (range, 5 to 17 weeks). Median survival was 22.0 months (95% CI, 15.6 to 27.0 months). Treatment-related adverse events were manageable and mostly grades 1/2: the most common of these (other than alopecia) was mild to moderate neuropathy, which was primarily sensory and mostly reversible in nature.

CONCLUSION

Ixabepilone is efficacious and has a predictable and manageable safety profile in women with MBC previously treated with an adjuvant anthracycline.

Phase III study of paclitaxel (Pac) versus pegylated liposomal doxorubicin (PLD) for the treatment of advanced human immunodeficiency virus (HIV)-associated Kaposi's sarcoma (KS): An Eastern Cooperative Oncology Group (ECOG) and AIDS Malignancy Consortium

20503

Background: PLD (doxorubicin HCL liposome injection, Doxil®, Tibotec Therapeutics, Raritan, NJ) and paclitaxel (Taxol®, Bristol Myers, Inc, New York, NY) are active in the treatment of HIV-associated KS; however, optimal therapy is undefined. Methods: A randomized phase III, multicenter trial was initiated to compare the efficacy of Pac (100 mg/m2) every 2 weeks to PLD (20 mg/m2) every 3 weeks for chemotherapy-naïve AIDS-related KS. Treatment continued until disease progression or unacceptable toxicity; concurrent antiretrovirals were permitted. 216 pts were required to detect at least a 3-month improvement in median progression free survival (PFS) for Pac compared with PLD (80% power, 2-sided alpha 0.05). Response was assessed using KS response and clinical benefit criteria, and global assessment of quality of life (QOL) using the Functional Assessment of Health Index (FAHI; version 3) plus 3 supplemental questions concerning pain, swelling, and satisfaction with physical appearance (measured at baseline and during/after treatment). Results: The trial was terminated early due to poor accrual; 46 pts were randomized to PLD, 43 to Pac. 11 pts were ineligible, 4 never started therapy and 6 lacked disease assessment or progression data, resulting in 68 pts for the efficacy analysis (34 in each arm) and 82 in the toxicity analysis. After a median follow-up of 35.8 months (mo.), there was no significant difference in PFS, response rate, or overall survival. Due to early termination, the study was not adequately powered to detect the hypothesized difference in PFS. There was no significant difference in QOL between the two arms. Grade 3–4 toxicity was comparable, including grade 4 neutropenia (34% vs. 27%) and infection (13% vs. 11%). Conclusions: Paclitaxel and PLD have comparable efficacy and toxicity in patients with HIV-associated KS.

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Concordance of local and central laboratory hormone and HER2 receptor status in ECOG 2197

21022

Background: Central and local laboratory concordance for hormone and HER2 receptor measurement is of national interest. This study compares ER/PR/HER2 by local laboratories using immunohistochemistry (IHC) and central laboratories (IHC & quantitative RT-PCR). Methods: Of 2952 patients in E2197, a case-cohort sample of 776 patients who either did (N=179) or did not recur was studied. Central IHC for ER/PR/HER2 was performed using single 0.6 mm microarrays; Allred score (AS) was used for ER/PR (AS>2 = positive). Positive HER2 was 3+ staining in >10% cells for Central IHC and 2+ or 3+ for Local IHC. RT-PCR analysis by Oncotype DX™ for ER/PR/HER2 was performed using pre-defined cutoffs of 6.5, 5.5 and 11.5 units, respectively. Hormone receptor (HR) pos was defined as ER &/or PR pos. Results: Results from Local IHC (ER/PR in 776 & HER2 in 517 pts) were compared with Central IHC (760 pts) and RT-PCR results (776 pts). The discordance between HR positivity by Local IHC and RT-PCR was very low. However, 12% of HR neg pts by Local IHC (38/321) & Central IHC (39/326) were HR pos by RT-PCR. The relationship between ER and recurrence as a function of AS was examined. Patients with AS of 3–4 were found to be closer to the AS=2 group than to the AS>4 group Patients with AS of 3–4 were found to be closer to the AS ÿ 2 group than to the AS > 4 group (Est.HR for ER 0.97 for AS 3–4 vs. 0–2 and 0.46 for AS 5–8 vs. 0–2, and for PR were 0.84 for AS 3–4 vs. 0–2 and 0.41 for AS 5–8 vs. 0–2). Conclusions: There is a high degree of overall concordance among Local IHC, Central IHC, and Central RT-PCR for ER and PR. The degree of concordance is even greater for HR compared to ER or PR alone. Although the concordance with local labs for HER2 testing was poor, the concordance between Central IHC and RT-PCR was very high. The relatively high incidence (12%) of IHC HR neg pts who are HR pos by RT- PCR is notable.

[Table: see text]

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Final Results of ECOG1100: A phase I/II study of combined blockade of the ErbB receptor network in patients with HER2- overexpressing metastatic breast cancer (MBC)

1033

Background: Activation of EGF receptor has been associated with resistance to trastuzumab in breast cancer cell lines. EGFR tyrosine kinase inhibitors inhibit HER2 phosphorylation and synergize with trastuzumab in HER2+ cell lines that co-express EGFR. Methods: Pts with MBC and HER2 overexpression by immunohistochemistry (3+) and/or HER2 gene-amplification by FISH, 0–2 prior chemotherapy regimens for met disease, LVEF 50%, and no prior trastuzumab were treated with trastuzumab 2 mg/kg/wk and gefitinib 250- 500 mg/day until disease progression, unacceptable toxicity or withdrawal of consent. The phase I portion of the trial used a 3+3 design to determine MTD. In the phase II portion of the trial, patients were stratified based upon prior chemotherapy exposure (Group 1= no prior exposure to chemotherapy, Group 2= prior exposure to 1–2 chemotherapy regimens). Response measured using RECIST criteria. The primary endpoint was to increase proportion progression free from 50 to 65% at 6 months in Group 1 and from 50 to 70% at 3 months in Group 2. Results: Phase I: DLT (Grade 3 diarrhea) occurred in 2/3 patients treated at the 500 mg/day dose level of gefitinib in combination with weekly trastuzumab. 0/3 patients treated at the 250 mg/day dose level experienced DLT. This was considered MTD and was the dose selected for the Phase II portion of the trial. Phase II: 36 eligible pts were enrolled. Most patients were ECOG PS of 0 and had visceral organ involvement. Of the patients enrolled in Group 1, one pt achieved a CR, one PR and 7 had SD (≥ 24 weeks). Median time to progression (TTP) was 2.9 months (95% CI, 2.5–4). In Group 2 no responses were observed with a median TTP of 2.5 months (95% CI, 1.5- 2.7). Most common severe toxicities were rash (grade 3, 14%) and diarrhea (grade 3, 30%). No grade 3 cardiac toxicity was encountered. Conclusions: Trastuzumab in combination with gefitinib at doses of 250 mg/day demonstrated an acceptable toxicity profile; however, during planned interim analysis, the TTP did not meet predetermined statistical endpoints required for study continuation. These results do not support the further use of this combination and have implications for other trials using trastuzumab and EGFR TK inhibitors simultaneously.

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AIDS and non-AIDS diffuse large B-cell lymphomas express different antigen profiles

Based on gene expression profiling, diffuse large B-cell lymphomas arising in immunocompetent patients can be divided into germinal center and activated B-cell types. Since little is known about acquired immunodeficiency syndrome associated diffuse large B-cell lymphomas, we tested whether the protein expression of germinal center and activated B-cell markers differed between acquired immunodeficiency syndrome (AIDS) vs non-AIDS diffuse large B-cell lymphomas. We immunohistochemically stained tissue microarrays of 39 de novo diffuse large B-cell lymphomas: 12 AIDS associated and 27 non-AIDS, with germinal center (BCL6, CD10, CyclinH) and activated B-cell markers (MUM1, CD138, PAK1, CD44, BCL2). We scored each case for percent positive cells (0-19%=0; 20-49%=1; 50-100%=2). The activated B-cell and germinal center summation scores of each case were used as (x, y) coordinate data points to construct two-dimensional contour-frequency plots. The contour plot of non-AIDS diffuse large B-cell lymphomas showed two distinct clusters: a cluster with a high germinal center phenotype (cluster 1) and a cluster with a high activated B-cell phenotype (cluster 3). In contrast, the AIDS-related diffuse large B-cell lymphomas formed a single aggregate (cluster 2) (P=0.02, Fisher exact test). When the contour plots of the AIDS-related and the non-AIDS cases were superimposed, cluster 2 of the AIDS cases expressed an intermediate germinal center/activated B-cell phenotype compared to clusters 1 and 3 of the non-AIDS diffuse large B-cell lymphomas. Our results confirm that non-AIDS diffuse large B-cell lymphomas segregate into two groups with either germinal center or activated B-cell phenotype. We report the new finding that the AIDS status of the patient predicts the immunophenotype of the diffuse large B-cell lymphomas.

Germinal center and activated b-cell profiles separate Burkitt lymphoma and diffuse large B-cell lymphoma in AIDS and non-AIDS cases

Morphologic features of Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL) overlap. No single phenotypic marker or molecular abnormality is pathognomonic. We tested a panel of 8 germinal center (GC) and activated B-cell (ABC) markers for their ability to separate BL and DLBCL. We diagnosed 16 BL and 39 DLBCL cases from 21 patients with AIDS and 34 without AIDS based on traditional morphologic criteria, Ki-67 proliferative index, and c-myc rearrangement (fluorescence in situ hybridization). After immunohistochemically staining tissue microarrays of BL and DLBCL for markers of GC (bcl-6, CD10, cyclin H) and ABC (MUM1, CD138, PAK1, CD44, bcl-2), we scored each case for the percentage of positive cells. Hierarchical clustering yielded 2 major clusters significantly associated with morphologic diagnosis (P < .001). For comparison, we plotted the sum of the GC scores and ABC scores for each case as x and y data points. This revealed a high-GC/low-ABC group and a low-GC/high-ABC group that were associated significantly with morphologic diagnosis (P < .001). Protein expression of multiple GC and ABC markers can separate BL and DLBCL.

Mitoxantrone, vinblastine, and lomustine (CCNU) (MVC): a highly active regimen for advanced and poor-prognosis Hodgkin's disease

PURPOSE

A new regimen, MVC (mitoxantrone, vinblastine, and CCNU [lomustine]), was studied in advanced Hodgkin's disease. This regimen combines the most effective elements of previous regimens for poor-prognosis Hodgkin's disease and eliminates agents with unnecessary toxicities and marginal activity. Initially, patients with relapsed or refractory disease were entered, and after substantial activity was observed, patients with advanced-stage, newly diagnosed Hodgkin's disease were also treated.

PATIENTS AND METHODS

Thirty-six relapsed or refractory patients were entered on this study. Prior treatment included radiotherapy alone (three patients), combined-modality treatment (n = 21), and single (n = 2) or multiple chemotherapy regimens (n = 10). Seventeen advanced-stage (bulky IIB-IVB) newly diagnosed Hodgkin's patients were also entered, with a median follow-up of 7 years.

RESULTS

Thirty-two of 36 (88%) relapsed/refractory patients responded to MVC, with 18 partial responses (50%) and 14 complete responses (39%). Median complete response duration is 20 months (range, 2 to 108+ months). The median survival of all previously treated MVC patients is 28 months (range, 4 to 127+ months). Eleven of 32 previously treated MVC responders remain alive and disease-free at 12 to 127+ months, seven after autologous bone marrow transplantation (12 to 127+ months) and four after MVC without transplantation (31 to 113+ months). Thirteen of 17 advanced-stage, newly diagnosed Hodgkin's disease patients achieved a complete response and four achieved a partial response to MVC (100% response rate). Two complete response and all partial response patients have relapsed. Eight complete responses are ongoing at 11 to 114+ months. Three patients died in complete response at 11, 42, and 43 months. Median response duration has not been reached.

DISCUSSION

MVC is a highly active regimen in relapsed and advanced-stage Hodgkin's disease, with outcome results comparable to other established regimens. Treatment is associated with myelosuppression but is otherwise well tolerated. MVC provides an effective alternative regimen for newly diagnosed patients with Hodgkin's disease and an effective salvage regimen for patients previously treated with anthracyclines.

Determination and validation of a predictive model for Clostridium difficile diarrhea in hospitalized oncology patients

BACKGROUND

Clostridium difficile colitis in the cancer patient receiving chemotherapy is a frequent cause of morbidity which may prolong hospitalization. Techniques for identifying infection often delay the initiation of therapy.

PATIENTS AND METHODS

In this retrospective case-control analysis, we identified predictors for C. difficile-associated diarrhea in 29 patients hospitalized from 1988 to 1993 on a hematologic malignancy/bone marrow transplant unit (hospital A). We then validated our model with 58 C. difficile cases and 74 controls admitted to an oncology unit from a different institution (hospital B).

RESULTS

We found that low intensity of chemotherapy (P < 0.001), lack of parenteral vancomycin use (P = 0.03) and hospitalization within the past two months (P = 0.05) were independently predictive of C. difficile colitis by multivariate analysis. These variables were weighted for predictive capability using a receiver operator characteristic score; low intensity chemotherapy was assigned two points, lack of parenteral vancomycin received one point and prior hospitalization one point (P < 0.001 by chi 2 for trend). The receiver operating characteristic (ROC) curve areas were 0.78 for patients at hospital A and 0.70 at hospital B indicating moderate drop off in discrimination. Compared to hospital A patients, hospital B patients hospitalized between 1989 and 1994 were more often women (P = 0.04), received less systemic vancomycin (P = 0.01), were less frequently neutropenic (P < 0.05), and received less intense chemotherapy regimens (P < 0.05). Despite these differences in demographics in patients between these institutions, our predictive model was validated in hospital B patients (P = 0.02 by chi 2 for trend).

CONCLUSIONS

The results of this study may help clinicians predict the risk of C. difficile disease in the hospitalized immunocompromised oncology patient and may help guide empiric therapy while awaiting results of stool toxin assays.

Prospective randomized trial of lisofylline for the prevention of toxicities of high-dose interleukin 2 therapy in advanced renal cancer and malignant melanoma

The therapeutic application of high-dose interleukin (IL) 2 in human malignancy is limited by severe multiorgan toxicities that are mediated, in part, by tumor necrosis factor (TNF) and IL-1. CT1501R (lisofylline; LSF) is one of several methyl xanthine congeners that inhibit the effects of TNF by the interruption of specific signal transduction pathways. This randomized, placebo-controlled trial was designed to assess the activity of LSF in reducing the toxicities of high-dose IL-2 therapy. Fifty-three patients with metastatic renal cancer or malignant melanoma were treated with i.v. bolus IL-2, 600, 000 IU/kg every 8 h for 5 days (14 doses), followed by 9 days of rest and another 5-day course of IL-2. Patients were randomly assigned to LSF, 1.5 mg/kg i.v. bolus, or placebo every 6 h during IL-2 therapy. All patients were to be treated to individual maximum tolerance of IL-2 at the intensive care unit level of support. The end points for statistical analysis were the number of IL-2 doses administered during the first cycle of treatment (maximum, 28) and the toxicities experienced by each group after the first 8 planned IL-2 doses. There was no difference between the LSF and placebo groups in the mean number of IL-2 doses tolerated in the entire first cycle of therapy (19.6 +/- 5.4 versus 19.5 +/- 5.8, P = 0.86) or in the first or second 5-day course of IL-2. The only significant difference in toxicities occurring through the eighth dose of IL-2 was in the maximum elevation of serum creatinine (mean, 1.7 +/- 0.8 for placebo versus 1.5 +/- 0.6 mg/dl for LSF, P = 0.013). A Monte Carlo analysis of major toxicities over the first 14-dose course of therapy showed a statistically significant difference favoring the LSF-treated group (P = 0.025). LSF was well tolerated, associated only with mildly increased nausea (P = 0.006 after eight IL-2 doses, but not significant for the entire first cycle). The antitumor activity was comparable in both groups (objective responses, 2 of 28 with LSF versus 4 of 24 with placebo). The mean peak plasma concentrations of LSF on days 1, 5, and 19 were 6.24, 3.83, and 5.04 micromol/liter, respectively. In conclusion, with this dose and schedule, LSF did not alter the toxicities of high-dose i.v. IL-2 sufficiently to impact the overall dose intensity of IL-2. Successful IL-2 toxicity modulation may require the use of higher doses of LSF, the development of agents with more potent anti-TNF activity, and/or combined modulating agents that function via distinct mechanisms to interrupt cytokine-mediated signaling.

A distinct coagulopathy associated with interleukin-2 therapy

We studied the coagulation profiles of 14 patients with advanced malignancies treated with Interleukin-2 (IL-2). A 43% prolongation of the PTT (P < 0.001) and a significant decrease in functional levels of factors II, IX, X, XI, and XII were observed 6 h post IL-2 treatment in comparison to pretreatment values. These parameters normalized within 2-3 d following IL-2 administration. The PT, factors V, VII, VIII, fibrinogen and D-dimer levels were unchanged with IL-2 treatment. This pattern of coagulopathy has not previously been reported.

Survival after phase II treatment of advanced renal cell carcinoma with taxol or high-dose interleukin-2

From 1986 to 1989, 71 patients with advanced renal cell carcinoma were treated at one institution with either the Phase II agent, taxol, or one of several high dose interleukin-2 (IL-2) protocols. As no responses to taxol were seen, that group may represent the natural history of renal cell carcinoma in a Phase II population. The results of treatment with IL-2 were examined against this background. Concurrently, 17 patients received taxol and 14 patients IL-2. An additional 40 patients subsequently received IL-2. Five taxol patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 2 were excluded from the comparison as similar patients were ineligible for the IL-2 studies. There were more patients in the IL-2 groups with non-liver/lung metastases and ECOG PS 0 than in the taxol group. Six (43%) of concurrent IL-2 patients responded [complete response (CR) = 14%; partial response (PR) = 29%]. The response rate for all IL-2-treated patients was 22% (CR +/- 7%, PR +/- 15%). The response rate to IL-2 was higher in cases with ECOG PS 0, time to treatment < 12 months, and no prior chemotherapy. The median time to progression for the concurrent IL-2 group was 4.5 months (4.0 months for all IL-2 patients) and 2.5 months for taxol patients. Median survival for concurrent IL-2 patients was 12.5 months (12 months for all IL-2 patients) and 10 months for taxol patients. Durable remissions resulted in a 21% overall survival at 40 months for all IL-2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized phase II trial of high-dose interleukin-2 either alone or in combination with interferon alfa-2b in advanced renal cell carcinoma

PURPOSE

To determine better the activity of high-dose interleukin-2 (IL-2) either alone or in combination with interferon alfa-2b (IFN; Schering-Plough, Kenilworth, NJ) in patients with metastatic renal cell carcinoma, the IL-2 Working Group initiated a randomized phase II trial.

PATIENTS AND METHODS

Patients were randomly assigned to receive treatment with either IL-2 (Chiron Corp, Emeryville, CA) 1.33 mg/m2 (approximately 600,000 IU/kg) alone or IL-2 0.8 mg/m2 and IFN 3 x 10(6) U/m2 administered by bolus intravenous injection every 8 hours, days 1 to 5 and 15 to 19 (maximum, 28 doses). All patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 and normal organ function. After 28 patients were entered onto each arm, the IL-2/IFN arm was closed because of a failure to meet predetermined efficacy criteria. An additional 43 patients (total, 71) were assigned to receive IL-2 alone.

RESULTS

Toxicities were similar for both study arms. Hypotension requiring pressors was the most frequent dose-limiting toxicity. Only 11 of 99 patients experienced severe toxicity; there were no irreversible side effects or treatment-related deaths. Responses were seen in three of 28 patients (11%) on IL-2/IFN (three partial responses [PRs] lasting 14, 7, and 7 months) and 12 of 71 patients (17%) on IL-2 alone (four complete responses [CRs] and eight PRs). Six of the partial responders on IL-2 and two on IL-2/IFN experienced greater than 90% reduction in tumor mass. Ten of the 12 responders to IL-2 have ongoing responses of 12+ to 26+ months in duration.

CONCLUSION

We conclude that both IL-2 and IL-2/IFN therapy have activity in metastatic renal cell carcinoma. In particular, therapy with high-dose IL-2 alone produces meaningful and durable responses with manageable and reversible toxicity. This study supports the contention that high-dose IL-2 represents the treatment of choice in selected patients with advanced renal cell carcinoma.