Comparing the type and severity of inflammatory bowel disease in relation to IgG4 immunohistochemical staining

BACKGROUD AND STUDY AIM

The role of immunoglobulin (Ig) G4 in the etiopathogenesis of inflammatory bowel disease (IBD) and its association with endoscopic and pathological activity are not yet completely understood. The purpose of this study was to determine the possible relationship between IgG4 status and IBD.

PATIENTS AND METHODS

Endoscopic colon biopsies of 55 patients with ulcerative colitis (UC) and of 17 patients with Crohn's disease (CD) were examined. Numbers of IgG4-positive plasma cells stained immunohistochemically were counted in a minimum of 5 high power fields (HPFs) for each specimen. The presence of > 10 cells/HPF IgG4-positive PCs was considered positive.

RESULTS

he prevalence of IgG4-positive plasma cells in the lamina propria of the colonic mucosa was significantly higher in patients with UC than in those with CD (p :0.01). Additionally, the prevalence of IgG4-positive plasma cells increased in line with endoscopic and pathological activity in UC patients. Conversely, we determined no significant correlation between IgG4 positivity and pathological activity in the CD group. IgG4-positive UC patients also exhibited findings of more severe disease compared to IgG4-negative UC patients.

CONCLUSION

Immunohistochemical IgG4 staining may predict disease severity in UC and may be a useful marker for distinguishing between UC and CD.

Abstract P6-13-06: Novel combination therapies for triple negative breast cancer identified by high-throughput screening

Background: Finding effective novel therapies for triple negative breast cancer (TNBC) remains an unmet challenge. Our objective was to assess the sensitivity of TNBC to single drugs and to combinations using a systematic screen of existing FDA approved drugs combined with other approved or experimental agents and to characterize the mechanism of action of the most promising combinations.

Methods: We conducted a comprehensive high-throughput drug combination screen in six TNBC cell lines with different genetic backgrounds. We tested a panel of 128 agents with known targets for their growth inhibitory potential individually and in pairwise combinations with six FDA approved anticancer drugs in MDA-MB-231, MDA-MB-436, MDA-MB-468, BT-20, BT-549, and HCC-38 TNBC cell lines. High-throughput assays were performed in 384-well plates and dose response curves were generated using 5 concentrations of the secondary drug, while keeping the first drug at fixed dose. Cell viability was measured 72h after treatment exposure using CellTiter-Glo®. Drug combinations were assessed for overall inhibitory effect and also for superadditivity, assessed as deviations from non-interaction using Bliss model of synergy. Selected synergistic and effective drug combinations identified from the high-throughput screen were subsequently validated in a 96-well low-throughput format in all TNBC cell lines.

Results: Cell cycle and apoptosis regulators were more inhibitory as single agents across TNBC cell lines relative to other drug classes. Bortezomib, carfilzomib, YM155, Flavopiridol, KP372-1, and dactinomycin were highly toxic to all TNBC lines as single agents. Combinations with either everolimus or erlotinib were particularly effective in BT-20 and MDA-MB-468, and combinations with crizotinib in MDA-MB-231 cells. Bay-11-7082/erlotinib and MK-1775/everolimus were few of the promising combinations that elicited potentiated response in all the cell lines. ABT-263/crizotinib was one of the top synergistic combination most effective in MDA-MB-231 cells that express highest relative mRNA and protein levels of respective drug targets, Bcl-xL, and AXL. The combination treatment with ABT-263 and crizotinib also resulted in apoptosis in MDA-MB-231 cells, indicated by marked PARP cleavage in these cells, while MDA-MB-436 cells with lowest expression of Bcl-xL were resistant to apoptosis or growth inhibition, indicating a potential efficacy of this combination in a subset of TNBCs.

Conclusions: This study reveals novel combinations of cell cycle or apoptosis regulators and crizotinib, everolimus, or erlotinib with enhanced anticancer activity. Combinations of Bay-11-7082 and erlotinib; and MK-1775 and everolimus had mild synergistic activity in all TNBC lines, while ABT-263 and Crizotinib showed large synergistic antiproliferative activity in a subset of TNBCs. These promising drug combinations have great potential to improve cure rates in TNBC patients. Since crizotinib, everolimus, and erlotinib are US FDA-approved while ABT-263 and MK-1775 are in advanced clinical trials, there is a rapid path for clinical translation for these drug-combinations after validation in animal studies.

Citation Format: Wali VB, Langdon CG, Held MA, Platt JT, Safonov A, Aktas B, Stern DF, Pusztai L, Hatzis C. Novel combination therapies for triple negative breast cancer identified by high-throughput screening. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-06.

Abstract P3-07-03: PIK3CA mutations predict resistance to trastuzumab/pertuzumab and nab-paclitaxel in primary HER2-positive breast cancer – Massive parallel sequencing analysis of 293 pretherapeutic core biopsies of the GeparSepto study

Background: Phosphatidylinositol 3-kinase mutations (PIK3CA) are common in breast cancer (BC). Mutations are predominantly found in hot-spots located in the helical and kinase domains (exons 9 and 20). We recently demonstrated that PIK3CA mutations predict lower pathological complete response (pCR) to double blockade with trastuzumab/lapatinib in HER2+ve primary BC.

Methods: We evaluated PIK3CA mutations in 293/403 HER2+ve tumors of participants of the neoadjuvant GeparSepto (G7) study (Untch et al. SABCS 2014). The G7 study investigated the effect of exchanging paclitaxel for nab-paclitaxel prior to EC. All patients received trastuzumab and pertuzumab. The G7 study showed a significantly higher pCR rate in patients receiving nab-paclitaxel. HER2, hormone receptors (HR), Ki67 and tumor infiltrating lymphocytes (TILs) were centrally assessed prior to randomization. PIK3CA mutations in exons 9 and 20 were evaluated in formalin-fixed, paraffin embedded core biopsies taken before therapy using deep targeted massive parallel sequencing with a minimum coverage of 500 and a mean coverage of 6520 and 6346 per amplicon, (exon9 and exon 20). Only non-synonymous mutations in the coding region that were called at variant allele frequency ≥10% were taken into consideration. Only cases with a tumor cell content of ≥20% were included.

Results: In the G7 study, 396 patients with HER2+ve BC have been randomized from 06/2012 to 01/2014 and started treatment. From these 293 could be sequenced. Median age in the analyzed cohort was 49 years (range 22-75); most tumors were cT1-2 (89.9%); cN0 (54.4%); ductal invasive (88.7%), grade 3 (53.9%), HR+ve (69.6%), Ki67>20% (69.3%), LPBC-negative (83.2%). Overall, 22.2% of the tumors were found to have a PIK3CA mutation, 20.1% in HR+ve and 27.0% in HR-ve. Overall, the pCR rate was significantly lower in the PIK3CA mutant tumors compared to the wild type (wt) group (47.7% vs. 66.7%; p=0.009). This effect was seen both in the HR+ve (43.9% vs. 61.3%; p=0.052) and the HR-ve population (54.2% vs. 80.0%; p=0.029). There was also a significant difference in pCR according to PIK3CA mutation status dependant on the taxane. In the nab-paclitaxel group, pCR rates were significantly lower in patients with PIK3CA mutations compared to those without PIK3CA mutations (38.7% vs. 72.0%; p=0.001), whereas in the paclitaxel group, there was no significant difference between patients with and without a PIK3CA mutation (55.9% vs. 60.9%; p=0.690). The respective interaction could be demonstrated in univariate (p=0.039) as well as multivariate regression analysis (p=0.010) after adjusting for known baseline factors.

Conclusion: Patients with PIK3CA mutant HER2+ve BC have a significantly lower pCR rate compared to patients with wt tumors. In contrast to the results with double anti-HER2 blockade consisting of trastuzumab/lapatinib, the effect was evident irrespective of the HR status. In addition, PIK3CA mutation status was significantly associated with higher pCR following nab-paclitaxel.

The project has partly been funded within the EU-FP7 project RESPONSIFY No 278659 and the German Cancer Consortium (DKTK).

Citation Format: Loibl S, Budczies J, Weichert W, Furlanetto J, Stenzinger A, Pfarr N, von Minckwitz G, Jackisch C, Schneeweiss A, Fasching P, Schmatloch S, Aktas B, Nekljudova V, Weber K, Untch M, Denkert C. PIK3CA mutations predict resistance to trastuzumab/pertuzumab and nab-paclitaxel in primary HER2-positive breast cancer – Massive parallel sequencing analysis of 293 pretherapeutic core biopsies of the GeparSepto study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-03.

Abstract P2-02-02: Predictors for discordance in HER2 phenotype between primary tumor and circulating tumor cells in women with metastatic breast cancer

Aim: The DETECT study program evaluates whether treatment efficacy in women with metastatic breast cancer (MBC) is increased by taking into account the molecular characteristics of circulating tumor cells (CTCs). Here, we present data on both prevalence and HER2 phenotype of CTCs in patients with HER2 negative MBC screened within the DETECT program. The aim of this study is to evaluate the rate of discordance in HER2 phenotype between primary tumor and CTCs and to analyze whether primary tumor and/or patient characteristics can predict discordance in HER2-status.

Methods: The number of CTCs in 7.5 ml of peripheral blood (using the FDA-cleared CellSearch® System; Janssen Diagnostics, LLC) and their HER2 status were evaluated. Patients were defined as having a positive HER2-status on CTCs if at least 1 CTC with a strong (+++) immunocytochemical HER2 staining intensity was found. To assess which factors predict discordance of HER2 phenotype between primary tumor and CTCs, we used a multivariate binary logistic regression model with backward selection procedure. Patient and primary tumor characteristics included as independent factors were patient age, time since primary diagnosis, tumor stage, nodal stage, grading, histological type, and hormone receptor status (HRS).

Results: 1123 women with HER2-negative MBC were screened for CTCs. Based on a cutoff of ≥ 1 CTC, 711 (63.3%) of 1123 screened patients were positive for CTCs, while 412 (36.7%) of the 1123 screened patients were categorized as CTC positive if a cutoff of ≥ 5 CTCs was used.

At least one HER2-positive CTC was found in 134 of the 711 HER2-negative MBC patients with one or more CTCs (median 2 HER2-positive CTCs, range 1 – 80), indicating a discordance between primary tumor and CTCs with regard to HER2-status in 18.8% of patients. If the analysis was restricted to the 412 patients with 5 or more CTCs, at least one HER2-positive CTC was found in 121 patients, resulting in 29.4% discordance rate.

A multivariate logistic regression with discordance in HER2 phenotype (yes/no) as binary response variable, including number of CTCs (1 – 4 CTCs vs. 5 or more CTCs) to account for the difference in discordance rate observed at different cutoff values for CTC positivity, showed that histological type (lobular vs. ductal, odds ratio OR 2.66, 95% confidence interval CI 1.62 – 4.37, p < 0.001), HRS (positive vs. negative, OR 2.89, 95% CI 1.16 – 7.19, p = 0.022) and CTC number (5 or more CTCs vs. 1 – 4 CTCs, OR 7.57, 95% CI 3.93 – 14.89, p < 0.001) significantly predicted discordance in HER2 phenotype between primary tumor and CTCs.

Conclusion: Our data revealed discordance in HER2 status between primary tumor and CTCs in 19% to 29% of patients with HER2 negative MBC. Discordance in HER2 status was predicted by histological type and HRS of the primary tumor, as well as by the number of CTCs detected. Individualized breast cancer treatment based on CTC phenotype is currently investigated in Phase III trials and not part of clinical routine yet. However, the knowledge of factors associated with discordance in HER2 status may be incorporated in today's clinical practice by guiding the decision process for performing a biopsy to characterize a metastatic relapse.

Citation Format: Janni W, Schramm A, Friedl TWP, Schochter F, Huober J, Rack B, Alunni-Fabbroni M, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Krawczyk N, Pantel K, Fehm T. Predictors for discordance in HER2 phenotype between primary tumor and circulating tumor cells in women with metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-02-02.

Abstract P1-13-01: Comparison of 12 weeks neoadjuvant Nab-paclitaxel combined with carboplatinum vs. gemcitabine in triple- negative breast cancer: WSG-ADAPT TN randomized phase II trial

Background: Pathological complete response (pCR) is associated with improved prognosis in TNBC, but optimal chemotherapy remains unclear. Use of weekly nab- paclitaxel (Nab-Pac) vs. conventional paclitaxel and also addition of carboplatinum(Carbo) to anthracycline-taxane(A/T) containing chemotherapy results in significantly higher pCR rates in TNBC with unclear impact on survival and increased toxicity.

The ADAPT study seeks to compare Carbo vs. gemcitabine(Gem) added to nab- paclitaxel as a short 12-week A-free regimen. It also assesses efficacy in early responders vs. non-responders by 3-week proliferation and/or imaging response.

Methods: ADAPT TN compares 12-week neoadjuvant regimens: Carbo vs. Gem combined with Nab-Pac and aims to identify early-response markers for pCR (yPN0 and ypT0/is). TNBC patients (centrally confirmed ER/PR <1%, HER2 neg.), cT1c- cT4c, cN0/+ were randomized to arm A (Nab-Pac 125/Gem 1000 d1,8 q3w) vs. B (Nab-Pac 125/Carbo AUC2 d1,8 q3w). Randomization was stratified by center and nodal status. The trial is powered for pCR comparison by therapy arm and by presence vs. absence of early response markers. Pre-planned interim analysis aimed to identify a dynamic biomarker, e.g. drop of 3-week Ki-67, and to validate trial assumptions.

Results: 336 patients were enrolled from 47 centers between 06/13-02/15 (n=182 ArmA: Nab-Pac/Gem and n=154 ArmB: Nab-Pac/Carbo). 90% and 95% completed therapy according to protocol respectively (n.s.). Median age was 50y. At baseline: A/B: 73% and 74%% had G3 tumors, median Ki-67 of 70% and 75%; 62.6% and 62.9%% had cT2-4c tumors, pN0 status prior to chemotherapy was confirmed in 50.5% and 50%, respectively.

pCR (ypT0/is/ypN0) was A: 28.7% and B: 45.9% (p<0.001). Total pCR (ypT0/ypN0) was A: 25.8% and B: 45.2% respectively (p <0.001).

Nab/Gem arm was associated with significantly higher frequency of dose reductions (20.6% vs. 11.9% (p=0.03), treatment related SAE's (13% vs. 5%, p=0.02), grade 3-4 infections (6.1% vs. 1.3%, p=0.04) and ALAT elevations (11.7 vs. 3.3%, p=0.01) compared to the Nab-Carbo arm.

Within the planned interim analysis (n=130: A/B: 69/61), baseline Ki-67 (Nab- Pac/Carbo arm), age>50 years, and low cellularity (<500 tumor cells and/or Ki-67≤10% in the 3-week biopsy) (Nab-Pac/Gem arm) were positively associated with pCR by logistic regression analysis (separately by therapy arm). In all patients, therapy arm itself was significant for pCR.

Validation of responder definitions for the whole study will be presented at the meeting.

Conclusions:

This is the first large randomized study comparing two short 12-week anthracycline- free regimens in unselected TNBC. Our results suggest superior efficacy and excellent toxicity of Nab-Pac/Carbo vs. Gem. Longer A/T-Carbo containing regimens render quite comparable pCR rates, thus overtreatment by 4xEC in unselected TNBC may be present in some patients. Early response criteria seem to differ according to regimen; their assessment may be impaired by substantial tumor necrosis already after the first therapy cycle.

Citation Format: Gluz O, Nitz U, Liedtke C, Christgen M, Sotlar K, Grischke EM, Forstbauer H, Braun M, Warm M, Hackmann J, Uleer C, Aktas B, Schumacher C, Bangemann N, Lindner C, Kuemmel S, Clemens M, Potenberg J, Staib P, Kohls A, Pelz E, Kates RE, Wuerstlein R, Kreipe HH, Harbeck N. Comparison of 12 weeks neoadjuvant Nab-paclitaxel combined with carboplatinum vs. gemcitabine in triple- negative breast cancer: WSG-ADAPT TN randomized phase II trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-13-01.

Abstract P2-02-01: In primary breast cancer patients with HER2-negative tumors, HER2-positive circulating tumor cells with stem cell character predict worse outcome

Introduction: The detection of disseminated (DTCs) and circulating (CTCs) tumor cells in patients with early stage breast cancer is a well described independent prognostic factor associated with increased risk of disease recurrence and disease-related death. We recently demonstrated that CTCs in blood of primary breast cancer patients rather than DTCs were significantly associated with reduced progression free survival (p=0.02). Using comprehensive molecular characterization, we here demonstrate that the negative prognostic impact was predominantly related to HER2-positive CTCs with stem cell character from patients with HER2-negative primary tumors.

Patients and Methods: 2 x 5 ml blood from 482 primary breast cancer patients with first diagnosis between 2006 and 2010 were analyzed for CTCs with the AdnaTest BreastCancer (QIAGEN Hannover GmbH, Germany) for the detection of EpCAM, MUC-1, HER-2, and beta-Actin transcripts. The recovered c-DNA was now additionally tested for the expression of the estrogen (ER) and progesterone receptor (PR) (single-plex RT-PCR) and stem cell like CTCs (slCTCs) applying the AdnaTest TumorStemCell (single-plex RT-PCR for ALDH1) and the AdnaTest EMT (multiplex RT-PCR for TWIST, AKT2, PI3K). The analysis of PCR products was performed by capillary electrophoresis on the Agilent Bioanalyzer 2100.

Results: CTCs were detected in 103/482 (21%) of the patients expressing EpCAM (27%), MUC-1 (26%), HER-2 (75%), ER (14%) and PR (8%), respectively. Notably, in 49/103 (48%) of the CTC-positive patients, HER2 was the only marker expressed. slCTCs could be analyzed in 72/103 CTC-positive patients. At least one of the EMT markers was expressed in 56/72 patients (78%), ALDH1 was present in 32/72 patients (44%) and 31/72 (44%) were positive for both, ALDH1 and EMT markers, respectively. Comparisons of expression profiles on CTCs with those on the primary tumor were only performed in CTC-positive patients. Primary tumors and CTCs displayed a concordant HER2, ER and PR status in 37% (p=0.81), 24% (p=0.257) and 27% (p=0.876) of cases, respectively. Most interestingly, in 60/75 (80%) patients with HER2-positive CTCs, primary tumors were HER2-negative. In contrast, the percentage of patients with ER- and PR-positive CTCs but negative ER/PR primary tumors was 29% and 25%, respectively. When the presence of HER2-positive CTCs was correlated with the presence of slCTCs (ALDH1-and/or EMT-positive), the concordance was 83% (p=0.0019). In detail, the concordances were HER2+ vs ALDH1+ (54%, p=0.037), HER2+ vs EMT+ (85%, p=0.0002) and HER2+ vs ALDH1+/EMT+ (80% p=0.00053), respectively.

Conclusion: Our results provide evidence that a) the negative prognostic impact of CTCs in our patient cohort is related to HER2-positive CTCs with EMT and tumor stem cell characteristics which indicate therapy resistant tumor cell populations and, therefore, an inferior prognosis and b) “secondary” adjuvant treatment with HER2-targeting agents, alone or in combination, may probably be effective to eliminate these cells and thus, lead to an overall decreased relapse rate. This study further confirms that the molecular characterization of CTCs might help to stratify patients for individual treatment options.

Citation Format: Kasimir-Bauer S, Bittner A-K, Aktas B, Hauch S, Kimmig R, Hoffmann O. In primary breast cancer patients with HER2-negative tumors, HER2-positive circulating tumor cells with stem cell character predict worse outcome. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-02-01.

Abstract P1-14-11: nab-paclitaxel at a dose of 125 mg/m2 weekly is more efficacious but less toxic than at 150 mg/m2. Results from the neoadjuvant randomized GeparSepto study (GBG 69)

Background: We previously reported that nab-paclitaxel (nP) increases the pathological complete response (pCR, ypT0 ypN0) rate when it replaces solvent-based paclitaxel (P) as part of a sequential taxane followed by epirubicin/cyclophosphamide (EC) neoadjuvant chemotherapy for patients with early breast cancer (Untch et al. SABCS 2014). Here, we report efficacy and safety of patients being treated either with 150 mg/m2 nab-paclitaxel (nP150) before an amendment or with 125 mg/m2 nab-paclitaxel (nP125) thereafter in comparison to solvent-formulated paclitaxel at 80 mg/m2 (P80).

Methods: In the GeparSepto study (NCT01583426), 1207 patients were randomized to either nP150 or P80 q1w for 12 weeks followed by 4 cycles of conventionally dosed EC (E: 90mg/m2; C: 600 mg/m2) q3w. The primary objective of the study was to compare the pCR rate (pCR, ypT0 ypN0). Patients with untreated, histologically confirmed uni- or bilateral, cT2- cT4d carcinoma, and no clinically relevant cardiovascular and other co-morbidities were included. Patients with HER2+ tumors received trastuzumab (loading dose 8mg/kg; 6 mg/kg) plus pertuzumab (loading dose 840 mg; 420 mg) q3w concomitantly to all chemotherapy cycles. After a safety analysis showed a higher rate of dose reductions and treatment discontinuations with nP150 compared to P80, weekly dose of nP was reduced to 125 mg/m2.

Results: nP was given for the majority of cycles at a dose of 150 mg/m2 to 179 patients and at a dose of 125 mg/m2 to 426 patients. Treatment characteristics were fairly balanced between these two sequential cohorts as well as compared to 601 patients receiving P80 except for HER2 status (HER2-positive: nP150 22%, nP125 37% and P80 33%) and Ki67 (<20%: nP150 60%, nP125 73% and P80 69%). Taxane treatment was discontinued in 16% (nP150), 11% (nP125) and 6% (P80) of patients, respectively. Median dose per cycle (based on relative total dose intensity (RTDI)) was 129 mg/m2 with nP150, 119 mg/m2 with nP125 and 78 mg/m2 with P80, respectively. Peripheral sensory neuropathy (PNP) grade 3/4 (NCI-CTCAE v4.0) was observed in 15% with nP150, 8% with nP125 and 3% with P80, respectively. pCR was 32% with nP150, 41% with nP125 and 29% with P80 in all patients and 46% with nP150, 49% with nP125 and 26% with P80 in 277 patients with triple-negative breast cancer, respectively.

Conclusions: Risk-benefit ratio of nP125 was improved over nP150 with better drug adherence and RTDI, lower frequency of PNP but a higher pCR rate. It should therefore be considered as the preferred schedule when nP is used as neoadjuvant treatment for primary breast cancer.

The trial was financially supported by Celgene and Roche.

Citation Format: von Minckwitz G, Untch M, Jakisch C, Schneeweiss A, Conrad B, Aktas B, Denkert C, Eidtmann H, Weibringhaus H, Kümmel S, Hilfrich J, Warm M, Paepke S, Just M, Hanusch C, Hackmann J, Blohmer J-U, Clemens M, Costa SD, Gerber B, Nekljudova V, Loibl S. nab-paclitaxel at a dose of 125 mg/m2 weekly is more efficacious but less toxic than at 150 mg/m2. Results from the neoadjuvant randomized GeparSepto study (GBG 69). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-11.

Abstract P4-13-26: Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC)

Background: In Europe, BEV is approved as first-line therapy for metastatic breast cancer in combination with either paclitaxel (PAC) or capecitabine (CAP).

Methods: The ongoing multicenter non-interventional AVANTI study aims to determine the safety and efficacy of first-line BEV–PAC or BEV–CAP in the context of routine oncology practice in Germany and to assess selection criteria that influence therapy choice. Eligible patients (pts) have previously untreated aBC and no contraindications for BEV. Chemotherapy schedule, diagnostics, and frequency of follow-up visits are at the physician's discretion. Data are collected for 1 year after the start of BEV, with 6-monthly follow-up for 1.5 years after the end of documented observation or BEV discontinuation, whichever occurs first.

Results: Between Oct 2009 and Feb 2015, 2168 pts treated at 331 German centers received BEV–PAC (N=1774) or BEV–CAP (N=394). The most common reasons driving treatment choice were efficacy (66% BEV–PAC, 60% BEV–CAP), guidelines (55% BEV–PAC, 50% BEV–CAP), and tolerability (40% BEV–PAC, 45% BEV–CAP). Compared with pts receiving BEV–PAC, the BEV–CAP subgroup included relatively fewer pts with ≥3 metastatic sites, visceral metastases, and stage IV disease at diagnosis, and relatively more pts with triple-negative aBC (TNBC) and prior (neo)adjuvant chemotherapy. At the time of data cut-off for this interim analysis (Mar 1, 2015), median duration of observation was 10.8 months (range <0.1–47.5). BEV was typically continued for longer than chemotherapy (median 5.9 months [95% CI 5.6–6.3] vs 4.6 months [95% CI 4.4–4.9], respectively). Among pts with hormone receptor-positive disease, only 9% received concurrent endocrine therapy with BEV. The most common reason for stopping treatment was disease progression (483 of 1529 [32%] who had stopped BEV–PAC; 157/345 [46%] who had stopped BEV–CAP). At data cut-off, 1245 pts (57%) had experienced a PFS event. Median PFS was 10.1 months (95% CI 9.6–10.7) overall, 10.7 months (95% CI 10.1–11.3) for BEV–PAC, and 8.1 months (95% CI 6.6–9.0) for BEV–CAP. Median PFS in clinically important subgroups was: TNBC 7.1 months (95% CI 6.2–8.0); ≥3 metastatic sites 9.7 months (8.7–11.2); anthracycline- and/or taxane-pretreated 9.2 months (8.5–9.9); ≥65 years old 9.9 months (9.1–10.7). Safety was consistent with the well-established safety profiles of the two regimens. Grade ≥3 adverse events occurred in 17% of pts (16% BEV–PAC, 18% BEV–CAP). There were no new safety signals.

Conclusions: Interim results of this large non-interventional study indicate that first-line BEV-containing regimens represent an active and well-tolerated therapy option for aBC. Data collection in non-inferiority studies based on routine clinical practice typically differs from that in prospective clinical trials. Nevertheless, these results from AVANTI suggest that the efficacy and tolerability of BEV–PAC and BEV–CAP seen in the E2100, RIBBON-1, and TURANDOT trials can be replicated in routine oncology practice. Further analyses focusing on the incidence, management, and potential risk factors for elevation of blood pressure are ongoing.

Citation Format: Müller V, Jakob A, Aktas B, Grafe A, Fett W, März W, Bruch H, Pott D, Klare P, Boller E, Kiewitz C, Schneeweiss A. Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-26.

Abstract OT1-02-02: The DETECT study program – Personalized treatment in metastatic breast cancer based on circulating tumor cells

Circulating tumor cells (CTCs) are found in patients with primary and metastatic breast cancer (MBC), respectively, and discordance in HER2 and hormone-receptor status between primary tumor, metastases and CTCs is well described. Treatment decisions are still based on the expression profile of solid tumor samples whereas CTCs are thought to cause tumor progression by blood-derived metastases. Nevertheless, targeted therapy based on expression profile of CTCs is not established in clinical routine. Individualized treatment decisions based on presence and phenotype of CTCs will be analyzed within the DETECT study program.

Metastatic breast cancer patients with HER2-negative MBC are screened in DETECT III and IV for presence of CTCs by using the CellSearch System (Janssen Diagnostics) which is FDA approved for enumeration of CTCs. Patients are enrolled into the different cohorts according to HER2-phenotype of CTCs. Since February 2012, women with HER2-negative MBC and HER2-positive CTCs are treated in the multicenter randomized Phase III study DETECT III with standard therapy with or without additional HER2-targeted therapy with Lapatinib. For standard therapy, physicians can choose between exemestane, letrozole and anastrozole for endocrine therapy, or docetaxel, paclitaxel, capecitabine, vinorelbine and non-pegylated liposomal doxorubicin for chemotherapy. Efficacy of CTC-based anti-HER2 treatment is evaluated by analyzing CTC-clearance rate after treatment.

Patients with only HER2-negative CTCs are recruited for the multicenter open-label phase II study DETECT IV. Since December 2013, women with hormone-receptor positive MBC receive endocrine therapy (tamoxifen, exemestane, letrozole or anastrozole) plus everolimus in DETECT IVa. In February 2015, DETECT IV was extended by the eribulin-cohort which offers a cytotoxic treatment with eribulin for women with triple-negative or hormone-receptor positive, chemotherapy demanding MBC (DETECT IVb). Progression free survival is used for assessment of clinical efficacy with overall survival and disease control rate as secondary objectives.

DETECT V, a multicenter open-label phase III study starting in summer 2015, randomizes patients with hormone-receptor positive, HER2-positive MBC to a dual HER2 targeted therapy (Trastuzumab and Pertuzumab) combined with either endocrine therapy or cytotoxic treatment. Quality of life determined by occurrence of adverse events is compared between both treatment arms. For prediction of endocrine treatment response, an "Endocrine Responsiveness Score" is calculated based on expression of estrogen-receptor and HER2 on detected CTCs.

More than 1200 patients are already screened in the DETECT study concept. Thus, it is the worldwide largest study concept with therapy decisions resulting from CTC-testing and CTC-phenotypization. The accompanying translational research programs evaluates further markers for molecular characterization of CTCs and prediction of therapy response.

Conclusion and Contact

The value of CTC phenotypes for making decisions on therapy interventions and predicting treatment responses in patients with MBC is tested in the DETECT study concept. The findings will help to move a step forward towards a more personalized anti-cancer therapy.

Citation Format: Schramm A, Friedl TWP, Huober J, Jäger B, Rack B, Trapp E, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Pantel K, Meier-Stiegen F, Wimberger P, Kümmel S, Gebauer G, Müller L, Janni W, Fehm T. The DETECT study program – Personalized treatment in metastatic breast cancer based on circulating tumor cells. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-02-02.

Depression and socio-economical burden are more common in primary caregivers of patients who are not aware of their cancer: TURQUOISE Study by the Palliative Care Working Committee of the Turkish Oncology Group (TOG)

In this study, we aimed to determine the personal, social and economic burden and the frequency of depression, as well as in caregivers of cancer patients who are being treated with chemotherapy in Turkey. The study is designed as a cross-sectional survey study using a 5-point Likert-type response scale, and the last part of the questionnaire includes the Beck Depression Inventory. The depression rate was found to be 64% (n = 476) among all subjects (n = 968), with 91% of those with depression demonstrating signs of mild depression. In this study, a significant difference was found between the presence of depression and age (young), sex (female), educational level (high), economic status (low), financial loss during treatment, patient's lack of knowledge about his/her diagnosis, metastatic disease and short survival time. In addition, 64% of all subjects had concerns of getting cancer, and 44% of all subjects had feelings of anger/rage against other people. In a multivariate regression analysis, the patient's lack of knowledge of the diagnosis was the independent risk factor. In conclusion, depression incidence and burden rate increased among cancer caregivers, and care burden was highly associated with depression. Accordingly, approaches to reducing the psycho-social effects of cancer should focus intensively on both the patients and their caregivers in Turkey.

Metabolic isoenzyme shifts in cancer as potential novel therapeutic targets

The functional redundancy of metabolic enzyme expression may present a new strategy for developing targeted therapies in cancer. To satisfy the increased metabolic demand required during neoplastic transformations and proliferation, cancer cells may rely on additional isoforms of a metabolic enzyme to satisfy the increased demand for metabolic precursors, which could subsequently render cancer cells more vulnerable to isoform-specific inhibitors. In this review, we provide a survey of common isoenzyme shifts that have been reported to be important in cancer metabolism and link those to metabolic pathways that currently have drugs in various stages of development. This phenomenon suggests a potentially new therapeutic strategy for the treatment of cancer by identifying shifts in the expression of metabolic isoenzymes between cancer and normal cells. We also delineate other putative metabolic isoenzymes that could be targets for novel targeted therapies for cancer. Changes in isoenzyme expression that occur during neoplastic transformations or in response to environmental pressure in cancer cells may result in isoenzyme diversity that may subsequently render cancer cells more vulnerable to isoform-specific inhibitors due to reliance on a single isoform to perform a vital enzymatic function.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

Abstract P4-14-04: AVANTI: A non-interventional study examining the combination of bevacizumab with paclitaxel or capecitabine in metastatic breast cancer

Background: We initiated a large, multicentre, non-interventional study (NIS) to determine the safety and efficacy of treatment, as well as the selection criteria that influence choice of therapy (bevacizumab plus paclitaxel or capecitabine), for patients with metastatic breast cancer (MBC) treated in the context of routine oncology practice in Germany. The study also aimed to gather information on patient-reported quality of life and treatment satisfaction. Here we present an interim analysis of the safety and efficacy data.

Methods: Pre- or postmenopausal female patients aged ≥18 years with previously untreated locally advanced, recurrent, or MBC were enrolled if they were considered eligible for treatment with a combination of bevacizumab and either paclitaxel or capecitabine. Endocrine pretreatment was allowed. Patients with contraindications to bevacizumab were excluded. Kaplan-Meier estimates and Cox-regression were used to model survival data.

Results: Since October 2009, 1,807 patients have been recruited; this analysis includes data for 1,464 patients with a median age of 60.4 years (range: 23.6–86.4). Most patients had a performance status of 1 (43.1%) and HER2-negative (83.5%), hormone receptor-positive (70.2%) disease. The most common sites of metastasis were bone (52.3%), liver (39.3%) and lungs (33.4%); 736 patients (50.3%) had at least two documented metastatic sites. Bevacizumab plus paclitaxel (68.5% of patients) and bevacizumab plus capecitabine (12.0%) were the most frequently prescribed therapies. Other bevacizumab-containing combination regimens were prescribed to the remaining 19.5% of patients. The treatment decision factors cited most often were efficacy of therapy (62.4%), therapy guidelines (49.7%), tolerability of therapy (40.6%) and HER2 status (38.1%). The overall response rate (complete response [CR] + partial response [PR]) was 48.5% with 5.9% of patients achieving a CR. The disease control rate (CR + PR + stable disease) was 72.7%. At the time of data cut-off, 414 patients (28.3%) had experienced a progression-free survival (PFS) event. Median PFS was 9.5 months (95% CI: 8.8–10.1). Adverse events (AEs) and serious AEs were reported in 457 (31.2%) and 109 patients (7.4%), respectively. The most frequently reported AEs were hypertension (6.1% of patients), fatigue (5.5%), sensory neuropathy (4.6%), leukopenia (4.0%), nausea (4.2%) and diarrhoea (3.6%). Treatment was discontinued due to AEs in 72 patients (4.9%).

Conclusions: Interim results of this large NIS demonstrate that bevacizumab plus either paclitaxel or capecitabine combination therapy is well tolerated and active in patients with MBC representative of those treated in routine oncology practice. Follow-up is ongoing and final results of this interim analysis, as well as subgroup analyses, will be reported at the meeting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-14-04.

Abstract P2-16-03: Mature results on metastatic breast cancer patients with prolonged (≥1 year) exposure to first-line bevacizumab combined with paclitaxel from a large observation study

Background: Bevacizumab (BEV) combined with chemotherapy (CT) significantly improves progression-free survival (PFS) and response rate (RR) vs CT alone in the 1st-line treatment of HER2-negative metastatic breast cancer (mBC). BEV was continued for ≥1 year in 20% of patients (pts) in the global ATHENA safety study. We examined a similar subgroup of pts with long-term antibody treatment in a large German observation study. Meanwhile, long-term follow-up of up to 4.5 years allows to present the final results, including mature data on overall survival.

Methods: Pts who had received no prior CT for their mBC received BEV-PAC per the European label. Efficacy and safety were documented in detail for up to 1 year (or until progression, death, or BEV discontinuation if earlier), with subsequent retrieval of long-term follow-up.

Results: By April 2013, final data were available for 865 pts, of whom 167 (20%) were recorded to have received BEV for ≥1 year. Baseline characteristics of this subset relative to the overall population are summarized in the table.

CharacteristicOverall population (n = 865)Subgroup treated with BEV for ≥1 year (n = 167)Median age, years (range)58(26-87)57(28-79)Age ≥65 years,%3230Metastatic at diagnosis,%2018Disease-free inreval <12 months,%24*14#Liver metastasis,%4235≥3 metastatic sites,%3329Triple-negative disease,%1812ECOG performance status >1,%98Prior (neo)adjuvant chemotherapy,%6661*n = 591, initially M0. #n = 113

Dose reductions of long-term BEV occurred in only 3% of cycles and (at least once) in 17% of pts. In the majority of pts treated for ≥1 year, BEV was continued as a single agent after discontinuation of CT. The overall best RR in pts treated for ≥1 year was 80% (complete response in 19%). Median PFS, based on observed events in 83% of all pts, was 18.4 months compared to 9.6 months in the overall population. Overall survival data, based on 524 deaths (61%), show a median of 21.6 months. In the subgroup with prolonged therapy, median OS amounts to 35.7 months with 40% of pts still alive after 4 years. Safety of long-term BEV is as previously reported with only a slightly increased hypertension rate (35%, grade ≥3: 11%), and no cases of gastrointestinal perforation, arterial thromboembolic event, or reversible posterior leukoencephalopathy syndrome.

Conclusions: According to the mature data of this study, including those on OS, a notable proportion of pts appear to derive benefit from prolonged exposure to first-line BEV-containing therapy. Although baseline characteristics exhibited only moderate indicators for an a priori more favorable prognostic profile in the subset of pts treated for ≥1 year, of course one has to keep in mind, that time-related efficacy data are biased towards improved outcome in those able to continue BEV for ≥1 year. However, the median survival of almost 3 years suggests that in a considerable number of pts continued first-line BEV-PAC correlates to favorable outcomes with limited adverse effects.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-03.

Abstract P6-05-11: Run-in phase of prospective WSG-ADAPT HR+/HER2- trial demonstrates feasibility of early endocrine sensitivity prediction by recurrence score and conventional parameters in clinical routine

Background: Despite promising evidence regarding outcome prediction, endocrine sensitivity, as determined by proliferation response to short-term preoperative endocrine therapy, is currently not included in adjuvant chemotherapy decisions in early HR+/HER2- breast cancer (BC).

Methods: The prospective WSG-ADAPT HR+/HER2- trial includes early BC patients with 0-3 positive LN who are candidates for adjuvant chemotherapy based on clinical-pathological criteria alone; it aims to spare chemotherapy in a substantial proportion utilizing a combination of genomic assessment by Oncotype DX and endocrine sensitivity testing. All patients received 3-week preoperative endocrine induction therapy (ET): aromatase inhibitors (AI) if postmenopausal, tamoxifen if premenopausal. Patients with low (0-11) Recurrence Score (RS) or intermediate RS (12-25) and ET response (centrally tested, post-therapy Ki-67 <10%) are recommended to forego adjuvant chemotherapy (“low-risk” patients). Distribution of RS, responder percentages in each group, and impacts of RS, ET regimen, and initial Ki-67 on post-therapy Ki-67 are reported here.

Results: As of 6/2013, 380 patients from 30 study centers had been enrolled in the ADAPT HR+/HER2- trial. Median age was 54 years. At first pre-planned analysis (5/2013), paired Ki-67 measurements (pre-/post-therapy) were available in 241 patients; RS was available in 208 cases (201 with paired Ki-67). RS was low in 21.6%, intermediate in 57.7%, and high in 20.7%; the respective risk group responder percentages (post-treatment Ki 67 <10%) were 84.1%, 73.9%, and 40.0% (p<0.001 when comparing low/intermediate vs. high, chi-square). In particular, these percentages support the pre-trial estimate of >70% endocrine responders in the intermediate genomic risk group, who could potentially be spared adjuvant chemotherapy. Median Ki 67 level decreases (as percentage of pre-treatment value) were 25% in premenopausal patients (tamoxifen, n = 101) vs. 75% in postmenopausal patients (AI, n = 115) (p<0.001, Mann-Whitney); median decreases by RS group were similar, 61% (low), 53% (intermediate) and 56% (high), respectively (p = 0.81, Kruskal-Wallis). In linear regression, pre-treatment Ki-67, endocrine regimen/menopausal status, and RS were all independent predictors for post-treatment Ki 67. Final run-in-phase analysis and validation will be presented after completion of endocrine induction therapy in 400 patients.

Conclusions: The Run-In Phase of the WSG ADAPT HR+/HER2- trial confirms trial design estimates of RS and proliferation response to induction ET. It indicates that the multicenter prospective ADAPT concept combining static and dynamic biomarker assessment for individualized therapy decisions in early BC is feasible. Proliferation response was strongly associated with therapy group (AI/post-menopausal vs. tamoxifen/pre-menopausal). Survival non-inferiority of intermediate Recurrence Score proliferation responders vs. low Recurrence Score patients (active control) will be tested in the ADAPT main phase to determine if adjuvant chemotherapy can be spared in 70% of patients with 0-3 positive LN classified as “intermediate risk” by conventional factors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-11.

Abstract OT1-1-10: DETECT III - A multicenter, randomized, phase III study to compare standard therapy alone versus standard therapy plus lapatinib in patients with initially HER2-negative metastatic breast cancer but with HER2-positive circulating tumorcells

Background: Despite a HER2-negative primary tumor approximately 20–30% of patients develop HER2-positive metastases (Zidan et al. 2005; Tewes et al. 2009). As previously described in the DETECT I trial (Fehm et al. 2010) determination of HER2 status on circulating tumor cells (CTCs) is one option for re-evaluating HER2-status in the metastatic setting. Currently it is unclear if HER2-targeted therapy based on the assessment of HER2-status of CTCs reveals a clinical benefit.

Trial design: DETECT III is a randomized, open-label, two arm phase III study comparing standard treatment alone vs. standard treatment plus HER2-targeted therapy with lapatinib in HER2-negative metastatic breast cancer patients with HER2-positive CTCs. Choices of chemotherapy and endocrine therapy include: docetaxel, paclitaxel, capecitabine, vinorelbine, non pegylated liposomal doxorubicin, letrozole, exemestane and anastrozole.

Main eligibility criteria: 1. metastatic breast cancer with HER2-negative primary tumor tissue and/or biopsies from metastatic sites or locoregional recurrences2. evidence of ≥ 1 HER2-positive CTC3. ≥ 1 evaluable metastatic lesion according to RECIST4. Tumor evaluation within 6 weeks before randomization

Specific aims: Objective: The objective of the trial is to prove the clinical efficacy of lapatinib in patients with metastasizing breast cancer who exhibit HER2-positive circulating tumor cells (CTC) although the primary tumor tissue and/or biopsies from metastatic sites were investigated for HER2 status and showed HER2-negativity.

Primary endpoint: Progression free survival

Secondary endpoints: Overall response rateClinical benefit rateOverall survivalDynamic of CTCQuality of lifeSafety and tolerability of lapatinib

Statistical methods: The primary endpoint will be analyzed by Kaplan-Meier method using the logrank test in order to compare the PFS distributions of the two arms. Efficacy, toxicity and other event rates are calculated, providing confidence intervals. In case of comparison between patient groups, these rates will be analyzed by Fisher's exact test or test. The Kaplan Meier analysis for all event related data will be carried out overall for the whole patient population. Furthermore a Cox regression analysis will be done using the following covariates Hormone receptor status (positive/negative)Number of prior chemotherapy lines for metastatic diseasePrior endocrine therapy for metastatic diseaseEndocrine treatment vs. cytotoxic treatmentOne metastatic site vs. multiple metastatic sitesBone metastases vs. no bone involvementPerformance status ECOG Score (0/> 0)

Present accrual and target accrual: As only half of the patients with HER2-negative metastatic breast cancer show CTC-positivity and of those approximately 32% will exhibit HER2-positive CTC (Fehm et al. 2010), screening of about 1420 patients is required to enroll 228 patients. First patient was screened in February 2012. As of July 27th 2012 117 patients were screened and 21 were found to have HER2-positive CTCs

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT1-1-10.

Abstract P1-14-05: Phase I/II Trial of primary chemotherapy with non-pegylated liposomal doxorubicin, paclitaxel and lapatinib in patients with HER2-positive, early stage breast cancer

Background: Several studies showed that pathologic complete response (pCR) is a surrogate for disease free survival (DFS) and overall survival (OS). Combinations of trastuzumab and anthracyclines in HER2-positive breast cancer are highly active but associated with a high incidence of cardiotoxicity. The risk of cardiac damage can be significantly reduced through liposomal encapsulation of anthracyclines. This phase I/II study was initiated to evaluate the combination of non-pegylated liposomal doxorubicin (NPLD), paclitaxel and lapatinib as primary treatment for patients with early stage, HER2-positive primary breast cancer.

Patients and Methods: Patients with newly diagnosed HER2-positive (IHC 3+ or FISH+) early stage (T1c N1-2 or T2 N0-2) breast cancer were treated with NPLD (60mg/m2; day 1), paclitaxel (175mg/m2, day 1) and lapatinib (750–1500 mg orally daily) in 3-week intervals for up to 6 cycles. The primary endpoints were dose-limiting toxicities (DLT) and pathological complete response (pCR). Secondary endpoints include safety, incidence of cardiac events, and clinical response. Exploratory endpoints include molecular markers for sensitivity or resistance to chemotherapy and/or lapatinib evaluated.

Results: A total of 84 patients have been included. No dose-limiting toxicity were observed and the maximum tolerated doses were NPLD 60mg/m2, paclitaxel 175mg/m2 and lapatinib 1500mg. Recommended phase 2 doses (P2D) were NPLD 60mg/m2, paclitaxel 175mg/m2 and lapatinib 1250mg. The treatment was generally well tolerated and associated with toxicities that were consistent with the known side-effects of the individual agents. No cardiac event has been observed to date. Preliminary efficacy data confirm a pCR breast rate of 41.7% and pCR rate in breast and lymph nodes of 37.5%, in 32 evaluable patients treated at ≥P2D.

Conclusions: The combination of NPLD, paclitaxel and lapatinib is well tolerated and has high antitumor activity in patients with HER2-positive primary breast cancer. Updated results of all 84 patients will be presented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-05.

Association of methylenetetrahydrofolate reductase C677T-A1298C polymorphisms with risk for esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis

Incidence of the esophagus adenocarcinoma has been dramatically increasing in Western countries since the last decade. Gastroesophageal reflux disease and Barrett's esophagus are risk factors for adenocarcinoma. Methylenetetrahydrofolate reductase (MTHFR) genes play a key role not only in folate metabolism but also in esophagus, stomach, pancreatic carcinoma, and acute leukemias. Studies have suggested that genetic polymorphisms of MTHFR (C677T) may clarify the causes and events involved in esophageal carcinogenesis. In this study, we evaluated MTHFR C677T and A1298C polymorphisms, and vitamin B12, folate, and plasma homocystein levels in patients with esophageal adenocarcinoma (EAC), Barrett's esophagus (BE), chronic esophagitis, and healthy controls (n = 26, n = 14, n = 30, and n = 30, respectively). The mean age of patients in the EAC and BE groups was significantly higher compared with the control group (P < 0.001, P = 0.003, respectively). In all patient groups, serum folate levels were significantly lower than that of the control group (P < 0.01, P < 0.05, and P < 0.01, respectively). There was no statistically significant association between folate levels and MTHFR gene polymorphisms. No differences were found in terms of MTHFR gene polymorphisms, homocystein, and B12 levels among the groups. MTHFR gene polymorphisms and folate deficiency are not predictors of early esophageal carcinoma. However, further studies using larger series of patients are needed to evaluate the effect of genetic polymorphisms in the folate metabolic pathway and to clarify the role of folate deficiency and folate metabolism in the development of esophagus adenocarcinoma.

P4-07-05: Comparison of PIK3CA Hot Spot Mutations in the Primary Tumor or Metastases with PIK3CA Mutations or PIK3CA Over-Expression in Circulating Tumor Cells of Metastatic Breast Cancer Patients under Sequential Palliative Therapy

Background: Stem cell like tumor cells have been implied as the active source of metastatic spread in primary tumors. To disseminate and metastasize, these cells may undergo phenotypic changes, known as epithelial-mesenchymal transition (EMT). The PI3K/AKT signaling pathway has been identified as one of the most important and most frequently mutated pathways involved in these processes. Assuming that metastasis requires a dissemination of tumor stem cells or tumor cells showing EMT, we studied 174 blood samples of 43 metastatic breast cancer patients under follow-up of palliative chemo-, antibody - or antihormonal therapy for the presence of sternness like circulating tumor cells (slCTCs). Further, we correlated these data with the occurrence of PIK3CA mutations in slCTCs and with the detection of hot spot mutations as well as PTEN loss in primary tumors or metastases.

Materials and Methods: All blood samples underwent immunomagnetic enrichment using the ***AdnaTest ***BreastCancerSelect (AdnaGen AG, Germany). RNA was recovered and reverse transcribed for analysis using the AdnaTest EMT (multiplex RT-PCR for TWIST, AKT2, PI3K), and separately for the stem cell marker ALDH1 applying the AdnaTest TumorStemCell. The identification of EMT markers was considered positive if at least one of the three markers was detected in the sample. The expression of CD34 was analyzed in a subset of samples to exclude potential interference of normal hematopoietic stem cells. The analysis of PCR products was performed by capillary electrophoresis on the Agilent Bioanalyzer 2100. The PIK3CA 3140 G/A mutation in slCTC-derived cDNA was identified by direct sequencing. PIK3CA hot spot mutations in primary tumors or metastases were identified by direct sequencing from microdissected FFPE tumor tissue. PTEN loss (as defined as &lt;10% of cells exhibiting positive staining) was detected by immunohistochemistry.

Results: During follow up, slCTCs were detected in 23/43 (53%) of the patients at least at one time point. ALDH1 was present in 18/43 (42%) patients, and at least one of the EMT markers was detected in 22/43 (51%) of the patients with the over-expression of PI3K (87%), AKT (96%) and TWIST (22%), respectively. Positivity for both, ALDH1 and EMT markers, was found in 15/23 (65%) of the patients. So far, analyzing one sample of each slCTC-positive patient during follow-up of the disease, there seems to be an occurrence of PIK3CA 3140 G/A mutation in slCTCs in about 25% of the patients. Examining the tissue samples, PTEN loss was found in 3/43 (7%) patients, in two of which slCTCs were present. DNA has been extracted from the dissected tumor tissues of all patients and is currently analyzed for PIK3CA mutations. The results will be available for presentation during the SABCS.

Conclusion: This study provides evidence for the presence of therapy-resistant breast cancer stemness like cells in the blood, possibly derived from the tumor or the metastases. Specific PI3K pathway inhibitors, alone or in combination therapy, may provide a therapeutic strategy for eliminating these cells to improve the prognosis of these patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-05.

P4-07-13: Prognostic Impact of Circulating Tumor Cells Assessed with the Cell Search Assay and Adna Test Breast in Metastatic Breast Cancer Patients – The DETECT Study

Background

Over the last decade circulating tumor cells (CTC) were established as a prognostic factor in breast cancer patients. However, there are very limited studies comparing different test methods, although several are available.The DETECT trial for metastatic breast cancer patients was designed to investiate the prognostic impact of CTC. Here, we report on the prognostic relevance of CTC testing with different detection methods.

Material and Methods: Patients with primary metastatic breast cancer or metastatic recurrence were prospectively enrolled in this multicenter trial. CTC were detected using the FDA-approved Cell Search® assay applying immunocytochemistry and the RNA-based Adna Test Breast Cancer™. After a median follow-up of 11 months the first survival data are now presented.

Results: Both methods could be performed in 221 patients. Using the CellSearch™ assay 116 of 221 patients were CTC-positive based on the cut-off level of 5 cells. Presence of CTC was associated with the site of metastatic disease. The OS was 15.4 months in CTC positive pts. (95%-CI: 13.5−17.1 mths) compared to 20.4 mths. in CTC negative pts. (19.1−21.9 mths.; p&lt;0.001). In the multivariate analysis presence of CTC was the only independent predictor for overall survival (HR: 3.4, 95%-CI: 1.7−6.3) including tumorbiological factors, menopausal status, number and sites of metastatic disease. The progression-free survival was not correlated with CTC status in our cohort receiving different types of systemic treatment (p=0.197). When the AdnaTest Breast was performed, 88 of 221 (40%) patients were CTC positive. Except for HER2 status, no correlation could be observed between CTC positivity and any of the clinicopathological factors. CTC positivity assessed by the AdnaTest Breast has no impact on PFS and OS. A multivariate analysis was therefore not performed.

Conclusions: Currently, several different tests are available for CTC detection. Only a few tests have been approved by the FDA and been validated in large clinical trials. Therfore, it will be important to compare new techniques with the Cell Search assay.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-13.

OT3-01-15: Phase III Trial Evaluating the Addition of Bevacizumab to Endocrine Therapy as First-Line Treatment for Advanced Breast Cancer: The LEA Study

Background

Retrospective clinical data suggest that high vascular endothelial growth factor (VEGF) levels in breast tumors are associated with a decreased response to endocrine therapy. We designed the randomized phase III LEA study of first-line bevacizumab in combination with endocrine therapy, to address the hypothesis that anti-VEGF treatment can prevent resistance to endocrine therapy in patients with advanced breast cancer sensitive to such treatment.

Methods: Postmenopausal patients with evaluable locally recurrent or metastatic breast cancer, HER2−negative- and estrogen receptor (ER)-and/or progesterone receptor (PgR)-positive disease, and eligible to receive hormonal treatment are candidates for this study. Patients are randomized to receive letrozole 2.5mg daily or fulvestrant, 250mg every 4 weeks (Arm A) or the same hormonal therapy plus bevacizumab 15mg/kg every 3 weeks (Arm B). The primary objective is to compare progression-free survival (PFS) between the treatment arms. Secondary endpoints are overall survival, time to treatment failure, overall response rate, response duration, clinical benefit rate and safety. In total, 344 patients (172 in each treatment arm) will be needed to detect a hazard ratio of 0.69 (corresponding to a median PFS of 9 months in Arm A and 13 months in Arm B) with a power of 80% and a two-tailed log-rank test at 0.05. With an expected drop-out rate of 10%, 378 patients will be included. Efficacy analysis will be triggered after 270 events.

Results: Recruitment began in November 2007. To date, 348 patients have been included in the study in Spain (n=244) and Germany (n=104). We anticipate completing recruitment by September 2011. Baseline characteristics of the first 334 randomized patients are shown in the table.

P5-18-03: First Interim Toxicity Analysis of the Randomized Phase III WSG Plan B Trial Comparing 4xEC-4xDoc Versus 6xTC in Breast Cancer Patients with HER2 Negative Breast Cancer (BC)

Background: Anthracycline-taxane based adjuvant chemotherapy (cht) is considered standard in node-positive and high-risk node-negative BC. However, retrospective analyses suggest that in HER2−BC, benefit from anthracyclines may not outweigh acute and long term toxicities. Recurrence Score (RS) identifies patients who are not candidates for cht based on their low relapse risk, as well as minimal, if any, benefit of cht. The WSG Plan B trial investigates anthracycline-free cht in HER2− BC and is the first trial in Europe prospectively incorporating RS for decision making regarding adjuvant cht in both N0 and N+ BC.

Methods: Plan B trial randomizes HER2− BC patients with high-risk N0 (at least one risk factor: ≥pT2; negative HR status; G2-3; age ≤35 years old; high uPA/PAI-1) or N+ disease to 6xTC (Docetaxel 75Cyclophosphomide600) vs. 4xEC (Epirubicin90Cyclophosphomide600)-4xDocetaxel100 G-CSF prophylaxis is recommended according to current ASCO guidelines. The statistical design previews n=2.448 randomized to cht; patients with HR+ BC, N0-3 and a RS ≤11 receive endocrine therapy only.

Results: From April 2009 to June 2011, 3037 patients have been recruited and 2296 randomized (TC/EC-Doc: 1146/1150; age &lt;65 years old: 900/911; ≥65 years old: 246/239). From the patients with HR+ disease (n=2368) 18% had a RS 0–11, 61% a RS 12–25 and 21% a RS ≥ 25. In patients with 0–3 positive LN and RS of 0–11 (n=329) who opted for no cht 257 are in the observational arm. In the group with an intermediate risk (RS 12–25) 14% drop outs before start of cht have been reported. In 1172 fully monitored patients 22 toxicity-related therapy stops have been reported in the TC and 34 in the EC-Doc arm (p=0.12). 614 serious adverse events (SAE) have been reported (299 TC vs. 315 EC-Doc). There is no difference in patients &lt;65 years old (TC vs. EC-Doc: 218/218), but slightly more SAE's in patients ≥65 years old treated by EC-Doc (97 vs. 81, p=0.13).

The most frequent SAEs were: leucopenia, febrile neutropenia (TC/EC-Doc:37 (3.3%)/31 (2.7%), n.s.), infections and heart/vascular events (TC/EC-Doc 29/40, n.s.). In patients ≥65 years old, there is a trend towards more febrile neutropenia (13 vs. 5; p=0.06) in the TC, and more severe mucositis/diarrhea/nausea (3 vs. 15; p=0.007) and heart/vascular events (5 vs. 14; p=0.06) in the EC-Doc arm. There were 5 therapy related deaths (TC 5 (0.4%)/EC-Doc 0, p=0.03); 3 in patients &lt;65 years, 2 in patients ≥65 years (4 due to sepsis, 1 due to cardiac failure).

Detailed data on relationship between the protocol specified, RS-guided treatment assignment and toxicity, and use of G-CSF support will be updated for the meeting.

Conclusions: The Plan-B trial is one of the largest randomized phase III trials currently evaluating anthracycline-free adjuvant cht in HER2− BC. The cht administered within the study was generally well tolerated, but higher number of treatment-related deaths has been observed within the TC arm. The short term toxicity profile seems be different between both study arms, particularly in patients &gt;65 years old. On the basis of prognosis as determined by RS, cht has been spared after a shared decision process in a substantial group of patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-03.

Abstract P2-09-33: Validity of Bone Marker Measurements for Monitoring Response to Bisphosphonate (BP) Therapy with Zoledronic Acid (ZOL) in Metastatic Breast Cancer (mBC): Useful or Not?

BACKGROUND: Bone is the most common site of metastasis in breast cancer. The detection relies on imaging technology which is costly and can only be performed to a certain degree. Bone markers are noninvasive, inexpensive and potentially might serve as predictive and prognostive surrogate endpoints in detecting bone metastases and response to BPs. This study analyzes the value of the serum markers of type I collagen synthesis (PINP) and degradation (ICTP) as markers of bone metastases in mBC patients (pts) receiving ZOL. The results will be correlated with the levels of CEA and Ca 15-3 as well as the clinical response. MATERIALS AND METHODS: 38 mBC pts (mean age was 60 years: range, 35-86), with confirmed bone metastases who were received chemotherapy and/or hormonal therapy and ZOL iv q 4 wks were participating in our study. 5 ml blood were collected at the time of study start and q 3 months for one year for the analysis of PINP, ICTP, CEA and Ca 15-3 using radioimmunoassays and ECLIA System, respectively. Imaging of bone metastases was performed at the same time points. In this first analysis, data were correlated with the number of bone metastases at study start.

RESULTS: At study baseline, PINP, ICTP, CEA and Ca 15-3 were analyzed in all pts. In 28/38 pts (73%) more than 3 bone metastases were confirmed by imaging and 10/38 pts (27%) presented with 3 or less bone metastases. The median value for ICTP was 6 µg/l (interquartile range 3.9-12.7) and for PINP 58.7 µg/l (43.5-164). Serum PINP and ICTP concentrations were significantly different when pts were stratified into &gt; 3 bone metastases (median value ICTP 6.3 µg/l and PINP 75.3 µg/l) and 3 or less bone metastases (median value ICTP 4.1 µg/l and PINP 47 µg/l), respectively (P&lt;0.05, see Figure 1 for ICTP and 2 for PINP for logarithmized values). No significant differences were seen when tumor marker levels were correlated with the number of bone metastases (P&gt;0.2). Statistical analysis for follow-up measurements will be available after having completed sampling for all 38 pts in 5 months. Up to now, 135 samples of all patients have been analyzed and there seems to be an association between the number of bone metastases, serum levels for PINP/ICTP and response to therapy.

CONCLUSION: In contrast to serum tumor markers, the identification of PINP and ICTP permit to estimate the number of bone metastases and seems to be a useful tool for monitoring mBC pts undergoing BP therapy with ZOL for treatment of bone metastases. These results have to be confirmed in a larger prospective trial.

Abstract PD02-04: Molecular Profiling of Circulating Tumor Cells in Blood of Metastatic Breast Cancer Patients Indicates Therapy Response and Provides Information on Epithelial Mesenchymal Transition and Tumor Stem Cell Metabolism

Background: Stem cell like tumor cells may undergo phenotypic changes, known as epithelial-mesenchymal transition (EMT), for metastasis formation using different signal transduction pathways. Assuming that metastasis requires a dissemination of tumor stem cells or tumor cells showing EMT, it was the purpose of this study to evaluate the expression of the stem cell marker ALDH1 and markers involved in two different pathways for EMT in 137 blood samples of 34 metastatic breast cancer patients during a follow-up of palliative chemo-, antibody — or hormonal therapy. Results were correlated with the presence of circulating tumor cells (CTCs) and response to therapy.

Materials and Methods: 2 x 5 ml blood were analyzed for CTCs with the AdnaTest BreastCancer (AdnaGen AG). The recovered c-DNA was additionally multiplex tested for the EMT markers [Twist, Akt2, PI3K (EMT1)], [Jagged, Slug, Snail (EMT2)] and separately for the stem cell marker ALDH1. The analytical sensitivity was determined by the detection of 5 target (IGROV) cells spiked into 5 ml blood of healthy donors using the AdnaTest BreastCancer procedure. The identification of EMT markers was considered positive if at least one marker was detected in the sample. Healthy donor samples without spiked tumor cells were used to determine the specificity of the test. The expression of CD34 was analyzed in a subset of samples to exclude potential interference of normal hematopoietic stem cells.

Results: 97% of 30 healthy donor samples investigated were negative for EMT1, 90% for EMT2 and 95% for ALDH1 transcripts, respectively. The spiking experiments revealed 80% recovery of the IGROV cells. In total, CTCs were detected in 35/137 (26%) blood samples. In 13/14 (93%) patients responding to a given therapy, no CTCs were detected or dissapeared in the course of the therapy. In contrast, 10/20 patients (50%) not responding to therapy were detected positive for CTCs. All samples were further examined for EMT1, EMT2 and ALDH1, respectively. A subset of samples was tested for CD34 expression with none of the samples found positive. Interestingly, EMT2 markers were only detected in 2/34 (5%) patients. Thus, the following calculations refer to EMT1. In the CTC (+) group, 59% (20/34) of the samples were positive for at least one of the EMT markers or ALDH1 but also in the CTC (-) group, EMT1 or ALDH1 were found in 34% (31/90) of the samples investigated, respectively. In patients diagnosed as non-responders and found positive for EMT markers and ALDH1 during therapy, persistence or reappearance of CTCs was found in 8/9 cases (88%) whereas in the responder group negative for EMT1 and ALDH1, CTCs persisted in only 10% (1/10) of the cases. Conclusion: In metastatic breast cancer (1) a major proportion of CTCs shows EMT and tumor stem cell characteristics (2) the PI3K/AKT pathway and TWIST as a transcription factor seem to be dominant (3) EMT markers or ALDH1 were also detectable in a group of patients negative for CTCs assuming that such markers could indicate a tumor cell phenotype that is not anymore detectable by epithelial markers and thus, could add additional sensitivity for CTC detection.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD02-04.

ER and PR Expression Profile of Circulating Tumor Cells in Metastatic Breast Cancer Patients in Comparison to the Primary Tumor

Background: Introduktion: Several studies have indicated that the expression of predictive markers including ER and PR can change during course of disease. Therefoore, reassesment of of the prediktive markers at the time of disease progression might help to optimize treatment decisions. Metastatic tissue may be difficult to obtain for repeated analysis. In this context, characterization of circulating tumor cells (CTCs) could be of relevance. Therefore, the purpose of the present study was: (1) to reevaluate the ER/PR expression by circulating tumor cells and (2) to compare the hormone receptor status expression profile of CTC with the primary tumor. Materials and Methods: We ecaluated, 166 blood samples from metastatic breast cancer patients at the time of first diagnosis of first metastatic disease or disease progression. All samples underwent immunomagnetic enrichment using the AdnaTest BreastCancerSelect (AdnaGen AG, Germany) within 4 hours after blood withdrawal followed by RNA isolation and subsequent gene expression analysis by reverse transcription and Multiplex-PCR in separated tumor cells using the AdnaTest BreastCancerDetect. CTC were analyzed for the three breast cancer associated markers: GA733-2, Muc-1, Her-2 and β-actin as an internal PCR control. Expression of the estrogen (ER) and progesterone (PR) receptor was assessed in an additional RT-PCR. The analysis of PCR products was performed by capillary electrophoresis on the Agilent Bioanalyzer 2100. Results: The overall detection rate for CTC was 38% (63/166 patients) with the expression rates of 79% for EpCAM (50/63 patients), 77% for MUC1 (49/63 patients), 49% for HER2 (31/63 patients), 23% for ER (15/65 patients) and 11% for PR (7/65 patients), respectively. Comparisons with the primary tumor were only performed in CTC+ patients (n=65). In 41 of 65 (63%) patients with ER+ tumors, CTC were ER- and 38/65 (58%) patients with PR+ tumors did not express PR on CTC. Primary tumors and CTC displayed a concordant ER and PR status in only 34% and 61% of cases, respectively. Conclusion: Most of the CTC were ER/PR-negative despite the presence of an ER/PR-positive primary tumor. The predictive value of hormone receptor status expression profile of CTC for palliative endocrine therapy has to be prospectively evaluated.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3009.

Prospective Evaluation of Serum HER2 and HER2 Expression on Circulating Tumor Cells in Patients with Metastatic Breast Cancer within the DETECT Study

Background: Assessment of HER2 status at the time of metastatic disease might help to optimize treatment decisions in patients with no HER2 status determined at first diagnosis and could also be helpful since HER2 status may change during disease progression. In this context, determination of serum HER2 or the evaluation of HER2 status on circulating tumor cells (CTC) is of potential relevance especially for optimizing HER2-directed therapy. The aim of this study was therefore to determine the serum HER2 status and the HER2 status of CTC from corresponding patients.Methods: Blood samples were obtained in a prospective multicenter setting from 251 patients with metastatic breast cancer at the time of disease progression. Serum HER2 was determined using the commercial HER2 ELISA-kit (Oncogene Science). CTC were detected and HER2 expression was assessed with the CellSearch™ system (Veridex).Results: 119 of 251 (47%) metastatic patients had elevated serum HER2 levels above 15 ng/mL. Serum HER2 was elevated in 49 (66%) of 74 patients with HER2 positive primary tumors, in 57 of 148 (39%) with HER2 negative primary tumors and in 13 of 29 (45%) patients with unknown HER2 primary tumor status. CTC were detected in 133 of 243 evaluable patients (5 or more cells), in these HER2 overexpression on CTC (strong overexpression in at least one cell) was detected in 52 cases (39%). Only 20 of these patients had a HER2 positive primary tumor. In patients with HER2 positive CTC, serum levels were above the cut off in 34 of 52 (65%), while in those with HER2 negative CTC 44 of 81 (54%) showed elevated HER2 serum levels. Concordance between HER2 status of circulating tumor cells and elevated serum HER2 was seen in 71 of 133 patients (53%).Conclusions: Our study demonstrates with a prospective design that also in patients with initially negative HER2 tumor status elevated serum HER2 levels and/or HER2 positive CTC can be detected at the time of metastatic disease. This is of clinical relevance since these patients in current practice do not have access to HER2 targeted therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3050.

Expression profile of CTC and corresponding tumors in primary breast cancer patients

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Background: The target of adjuvant therapy in breast cancer is minimal residual disease (MRD). However, treatment decisions are based on expression of predictive markers (ER; PR, HER-2) of the primary tumor. Based on current studies, presence of MRD may be reflected by the detection of circulating tumor cells (CTC). Therefore, the aim of the study was to characterize CTC by multiplex-PCR for the expression of HER-2, ER, and PR and compare the expression profiles of CTCs with those of the corresponding primary tumors. Methods: CTC from blood of 431 patients with primary breast cancer were analyzed for EpCAM, MUC1, and HER-2 transcripts with the AdnaTest BreastCancer (AdnaGen AG, Germany). A blood samples was CTC positive when at least one of the markers was detected. Expression of the ER and PR receptor was assessed in an additional RT-PCR. The ER, PR and HER2 receptor status of the primary tumors was determined by immunohistochemistry. The DAKO-Score for the expression of HER-2 was determined with the HercepTest. Results: The overall detection rate for CTC was 13% (58/431 patients) with the expression rates of 38% for HER-2 (22/58 patients), 25% for ER (12/48) and 4% for PR (2/48), respectively. ER positivity of the primary tumor was demonstrated in 45/58 (78%) of these patients, PR positivity in 41/58 (71%) patients and HER-2 in 9/58 (16%) patients, respectively. The concordance rate between ER, PR, and HER-2 status of CTCs and the primary tumor was 29%, 25%, and 53%, respectively Interestingly, the spread of CTC was mostly found in triple negative tumors (p = 0.01) and CTC in general were mostly found to be triple-negative regardless of the ER, PR, and HER-2 status of the primary tumor. Conclusions: Since the expression profile between CTC and the primary tumor differs, the consequence for the selection of adjuvant treatment targeting minimal residual disease has to be further evaluated in clinical trials.

No significant financial relationships to disclose.

Platelets in atherothrombosis: lessons from mouse models

Platelets play a central role in hemostasis and thrombosis but also in the initiation of atherosclerosis, making platelet receptors and their intracellular signaling pathways important molecular targets for antithrombotic and anti-inflammatory therapy. Historically, much of the knowledge about hemostasis and thrombosis has been derived from patients suffering from bleeding and thrombotic disorders and the identification of the underlying molecular defects. In recent years, the availability of genetically modified mouse strains with defined defects in platelet function and the development of in vivo models to assess platelet-related physiologic and pathophysiologic processes have opened new ways to identify the individual roles and the interplay of platelet proteins in adhesion, activation, aggregation, secretion, and procoagulant activity in vitro and in vivo. This review will summarize key findings made by these approaches and discuss them in the context of human disease.

Thermal, vibrational and EPR studies of Cu(II) bromide bis(p-methylaniline) and bis(m-methylaniline) complexes

[CuBr(2)(pMA)(2)] and [CuBr(2)(mMA)(2)] complexes (pMA: p-methylaniline, mMA: m-methylaniline) have been prepared and characterized by elemental analyses, thermogravimetric analyses, magnetic moment measurements, and IR, Raman and EPR spectroscopic studies. Coordination effects on the vibrational spectra of the ligands have been investigated. The room temperature EPR spectra of the complexes and their simulated spectra are also discussed in detail. The vibrational and EPR spectral studies suggest that the coordination sphere around Cu(II) consist of a distorted tetragonal structure.