Abstract P1-01-06: Ki67-positive CTCs are associated with early disease relapse in patients with early breast cancer undergoing adjuvant chemotherapy

Background: The determination of Ki67 in the primary tumor has prognostic value in early breast cancer (BC). We evaluated Ki67 expression in circulating tumor cells (CTCs) from patients with early BC undergoing adjuvant chemotherapy and correlated Ki67 positivity with patient outcome.

Methods: Ki67 expression in CTCs was evaluated by immunofluorescent analysis in paired blood samples of patients with early BC (n=166) obtained before and after adjuvant chemotherapy. Ki67 expression was also evaluated in CTC-positive patients at 6 - 24 months after the end of chemotherapy (n=31). Cytospins of peripheral blood mononuclear cells were double stained with A45-B/B3 cytokeratin and Ki67 antibodies. The proliferation index (PI) of CTCs was defined as the ratio of Ki67-positive CTCs/total CTCs.

Results: CTCs were detected in 53 (32%) patients before and/or after chemotherapy. Ki67-positive [Ki67(+)] CTCs were identified in 79% of CTC-positive patients, 25% presenting exclusively Ki67(+) CTCs and 21%, exclusively Ki67(-) CTCs. The mean value of Ki67(+) CTCs/patient remained unchanged pre- and post-chemotherapy [(mean±SE): pre- vs post-chemotherapy 2.5±0.7 vs 4.2±2, respectively; p= 0.900]. Similarly, the PI among the total CTCs detected pre- and post-chemotherapy was 59% and 60%, respectively. Ten (19%) of 53 CTC-positive and 9 (8%) of 113 CTC-negative patients relapsed (p = 0.039). In addition, all CTC-positive patients who relapsed harbored Ki67(+) CTCs before and/or after chemotherapy. Interestingly, 70% of them experienced early disease recurrence, ranging from 6-29 months after the initiation of adjuvant chemotherapy. Furthermore, 38.5% of patients with exclusively Ki67(+) CTCs relapsed compared to none among patients with exclusively Ki67(-) CTCs (p = 0.041). Of the 31 CTC-positive patients evaluated during follow-up, 39% remained CTC-positive. However, only 33.3% of them harbored Ki67(+) CTCs, 8.3% had exclusively Ki67(+) CTCs and 66.7% exclusively Ki67(-) CTCs. The mean value of Ki67(+) CTCs/patient was significantly reduced on the follow-up samples [(mean±SE): follow-up vs pre-chemotherapy, 1.35±1.3 vs 2.5±0.7, respectively; p=0.014 and follow-up vs post-chemotherapy, 1.35±1.3 vs 4.2±2, respectively; p= 0.026].

Conclusions: Ki67 expression on CTCs is predictive of early relapse in patients with early BC. Ki67 expression is not decreased by adjuvant chemotherapy, whereas it is reduced early during follow-up, possibly due to adjuvant hormone therapy and/or anti-HER2 therapy. The above results suggest that additional therapy is needed for patients with early BC and Ki67(+) CTCs to prevent early disease recurrence.

Citation Format: Agelaki S, Spiliotaki M, Politaki E, Spanaki A, Kassiou L, Koinis F, Georgoulias V, Mavroudis D. Ki67-positive CTCs are associated with early disease relapse in patients with early breast cancer undergoing adjuvant chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-01-06.

Lung cancer and tobacco smoking in Crete, Greece: reflections from a population-based cancer registry from 1992 to 2013

Background

The Cancer Registry of Crete is a regional population database that collects cancer morbidity/mortality data along with several risk factors. The current study assessed the geographical variation of lung cancer among ever and never smokers in Crete during the last 20 years.

Method

Lung cancer patient records (1992–2013) including information on medical history and smoking habits were obtained from the Cancer Registry of Crete. Age-Adjusted Incidence Rates (AAIR), prevalence of smoking among lung cancer patients and the Population-Attributable Fraction (PAF%) of tobacco smoking were estimated. Kaplan-Meier curves, grouped per smoking status were constructed, and spatio-temporal analyses were carried out to assess the geographical variations of lung cancer and smoking (a = 0.05).

Results

New lung cancer cases in Crete accounted for 9% of all cancers (AAIR_{both genders} = 40.2/100,000/year, AAIR_males = 73.1/100,000/year, AAIR_females = 11.8/100,000/year). Ever smokers presented significantly higher incidence compared to ex-smokers (p = 0.02) and never smokers (p < 0.001). The highest increase was observed in ever smokers (AAIR₁₉₉₂ = 19.2/100,000/year, AAIR₂₀₁₃ = 25.4/100,000/year, p = 0.03), while never smokers presented the lowest increase from 1992 to 2013 (AAIR₁₉₉₂ = 5.3/100,000/year, AAIR₂₀₁₃ = 6.8/100,000/year, p = 0.2). The PAF% of lung cancer mortality is 86% for both genders (males: 89%, females: 78%). AAIRs ranged from 25 to 50/100,000/year, while significant geographical differences were observed among the municipalities of Crete (p = 0.02). Smokers living in the south-east urban regions presented higher risk of dying from lung cancer (RR = 2.2; 95%CI = 1.3–3.5).

Conclusions

The constant increase of lung cancer rates among both genders, especially in females, outlines the need for targeted, geographically-oriented, life-style preventive measures. Design of population-based screening programs, tobacco awareness campaigns and smoking cessation programs in lung cancer hot spots could be guide by these findings.

The role of docetaxel in the treatment of non-small cell lung cancer lung cancer: an update

INTRODUCTION

Non-small cell lung cancer lung cancer (NSCLC) is a devastating disease, with poor prognosis for patients with metastatic disease. The management of these patients has evolved during the past decade, challenging the role of cytotoxic chemotherapy as the only available treatment option. Nevertheless, chemotherapy still retains a dominant position for the majority of both treatment naïve and pretreated patients. Among the chemotherapeutic agents, docetaxel is one of the most commonly used in 1st and subsequent treatment lines, even in the current era of precision medicine. Areas covered: We searched Medline, Embase, Scopus and Cochrane Library for randomized phase III trials that evaluated docetaxel in various clinical settings of NSCLC and for meta-analyses of such trials and we present all relevant data regarding the pharmacology and clinical use of docetaxel in NSCLC. Expert commentary: Despite its diminishing role, docetaxel in combination with novel targeted agents remains an important option of the therapeutic armamentarium in advanced NSCLC.

Salvage treatment with irinotecan/cisplatin versus pemetrexed/cisplatin in patients with non-small cell lung cancer pre-treated with a non-platinum-based regimen in the first-line setting: a randomized phase II study of the Hellenic Oncology Research Group (HORG)

BACKGROUND

Platinum-based chemotherapy is the standard front-line treatment for patients with advanced non-small cell lung cancer (NSCLC). However, non-platinum combinations of third-generation chemotherapeutic agents are considered an alternative therapeutic option for patients who cannot tolerate the toxic effects of platinum compounds. In this study, the efficacy and toxicity of the combination of irinotecan plus cisplatin (IC) was compared to pemetrexed plus cisplatin (PC) regimen, in platinum-naïve patients with advanced NSCLC, who had been previously treated with the combination of a taxane plus gemcitabine.

PATIENTS AND METHODS

A total of 124 patients with locally advanced or metastatic NSCLC were randomly assigned to either irinotecan 110 mg/m² on day 1 and 100 mg/m² on day 8 plus cisplatin 80 mg/m² on day 8 every 3 weeks (IC arm) or pemetrexed 500 mg/m² plus cisplatin 80 mg/m² on day 1 every 3 weeks (PC arm). The primary endpoint of the study was the overall response rate (ORR).

RESULTS

The ORR and median progression-free survival (PFS) in the IC arm were 18 % and 3.3 months, respectively, while in the PC arm were 19 % and 4.2 months (p = ns). Median overall survival (OS) was significantly higher in patients with PC (6.9 vs. 10.9; p = 0.013). PC regimen had a better toxicity profile compared to IC, with a statistically significant lower incidence of grade 3/4 neutropenia (3 vs. 31 %; p = 0.0001) and diarrhea (1.6 vs. 14.7 %, p = 0.018).

CONCLUSIONS

In patients with advanced NSCLC pretreated with docetaxel/gemcitabine, the combination of pemetrexed/cisplatin is associated with increased OS and is better tolerated than the combination of irinotecan/cisplatin and should be considered as a valid therapeutic option for platinum-naive, previously treated patients. CLINICALTRIALS.

GOV IDENTIFIER

NCT00614965.

Efficacy and tolerance of frontline bevacizumab-based chemotherapy for advanced non-small cell lung cancer patients: a multicenter, phase IV study of the Hellenic Oncology Research Group (HORG)

INTRODUCTION

The addition of bevacizumab to the first-line chemotherapy of advanced non-small cell lung cancer (NSCLC) of non-squamous histology has been shown to improve survival. A multicenter, single-arm, phase IV study was conducted in order to evaluate the efficacy and toxicity of frontline bevacizumab-based chemotherapy regimens in real life.

METHODS

Patients with previously untreated recurrent or metastatic non-squamous, NSCLC, with no contraindications for bevacizumab, were enrolled. Bevacizumab (15 mg/kg every 3 weeks) was administered in combination with both platinum- and non-platinum-based chemotherapy doublets or with single-agent chemotherapy plus bevacizumab. Treatment with bevacizumab was continued until disease progression. The primary end point of the study was the safety profile of bevacizumab regimens, whereas the secondary end points included overall survival, progression-free survival, and overall response rate.

RESULTS

From February 2010 to April 2014, a total of 314 patients were enrolled in the study; the median age was 63, 74.8 % were men, 95.9 % had a performance status of 0-1, 90.4 % had metastatic disease, and 94.3 % had adenocarcinoma. Grade ≥3 neutropenia occurred in 11.5 % of the patients, 1.3 % experienced febrile neutropenia, 2.6 % grade ≥3 thrombocytopenia, 2.8 % thromboembolism, and 1.6 % severe bleeding. Treatment discontinuation occurred in 7.0 % of patients because of adverse events. There were three toxic deaths. Median progression-free survival was 7.7 months, and median overall survival was 17.6 months.

CONCLUSION

The combination of bevacizumab with chemotherapy in the first-line setting of NSCLC is safe and active when used in appropriately selected patients. CLINICALTRIALS.

GOV IDENTIFIER

NCT01934465.

A phase II, open-label trial of bortezomib (VELCADE(®)) in combination with gemcitabine and cisplatin in patients with locally advanced or metastatic non-small cell lung cancer

BACKGROUND

Bortezomib is a selective reversible proteasome inhibitor with proapoptotic effects. Preclinical and phase I clinical data suggest activity of bortezomib in NSCLC, either as monotherapy or in combination with chemotherapeutic agents including gemcitabine and cisplatin.

METHODS

Chemotherapy-naïve patients with inoperable stage IIIB or IV NSCLC were administered bortezomib 1 mg/m(2) i.v. on days 1 and 8, and starting on day 21 (cycle 2), bortezomib (days 1 and 8) in combination with gemcitabine 1000 mg/m(2), (days 1 and 8), and cisplatin 70 mg/m(2) (day 1) in cycles of 21 days. Up to 8 cycles of combination therapy could be administered; single-agent bortezomib was continued until disease progression or unacceptable toxicity.

RESULTS

Fifty-three patients [median age 66 years; 79.2 % male; 96.2 % stage IV; performance status (ECOG) 0/1 73.6/26.4 %; adenocarcinoma 45.3 %, squamous cell carcinoma 41.5 %] were enrolled. All patients were evaluable for toxicity and 43 for efficacy. Grade 3-4 hematologic toxicity consisted of neutropenia (22.6 %) and thrombocytopenia (17 %). Grade 2-4 non-hematologic adverse events were fever (9.4 %), fatigue (20.8 %), infection (18.9 %), and dyspnea (15.1 %). There was no >grade 2 neurotoxicity. Febrile neutropenia occurred in two (1.9 %) patients, and there were three possibly treatment-related deaths (5.4 %). In the intention-to-treat population, the objective response rate was 17 % (95 % CI 6.9-27.1 %). No difference in response rate was observed for squamous versus other histology (18.2 vs. 16.1 %, p = 0.845). The median progression-free survival was 2.5 months, the median overall survival 10.6 months and the 1-year survival rate 38.1 %.

CONCLUSION

The incorporation of bortezomib into the gemcitabine/cisplatin regimen, in the dose and schedule used in this study, could not improve the efficacy of the chemotherapy regimen and has not to be further investigated.

Abstract P2-02-16: The proliferation index of circulating tumor cells (CTCs) is not influenced by the administration of adjuvant chemotherapy in early breast cancer (BC) and seems to reflect Ki67 expression of the primary tumor

Background: The assessment of Ki67 in the primary tumor represents a prognostic marker with potential predictive implications in early BC. We evaluated Ki67 expression in CTCs from patients with early BC and assessed the effect of adjuvant chemotherapy as well as Ki67 expression in the primary tumor.

Methods: Ki67 was evaluated in CTCs of 97 patients with early BC pre- and post- adjuvant chemotherapy by the use of immunofluorescence analysis. Cytospins of peripheral blood mononuclear cells were double stained with A45-B/B3 cytokeratin mouse antibody and a Ki67 rabbit antibody. Ki67 staining of the primary tumor was also performed for 13 CTC-positive patients. A proliferation index (PI) in CTCs was considered as the ratio of Ki67-positive CTCs/total CTCs. A PI of up to 14% was defined as 'low' whereas a PI above 14% was defined as 'high'.

Results: CTCs were detected in 26 (26.8%) patients before and/or after chemotherapy. Seven (27%) of 26 CTC-positive and 8 (11%) of 74 CTC-negative patients relapsed (p = 0.047). Ki67-positive CTCs were identified in 20 (76.9%) of 26 patients, whereas in 1 (3.9%) and 5 (19.2%) patients, exclusively Ki67-positive and Ki67-negative CTCs, respectively, were detected. Seven (33%) of 21 Ki67-positive patients relapsed in contrast to none among the exclusively Ki67-negative patients (p = 0.13). A total of 154 and 161 CTCs were detected pre- and post-chemotherapy, respectively; the PI in CTCs was 56% and 55%, respectively. In 8 patients with detectable CTCs at both time points, the PI was 65% and 49% pre- and post-chemotherapy, respectively. In 5 (62.5%) out of 8 patients, the PI remained high, in 2 (25%) increased and in 1 patient no Ki67–positive CTCs were detected post-chemotherapy. Seventeen patients were CTC-positive at baseline [HER2 positive, n=5; triple negative, n=1; hormone receptor positive, n=11]. A concordance in Ki67 staining between the primary tumor and CTCs was recorded in 10 (77%) out of 13 patients. Moreover, in 2 (67%) of 3 patients with exclusively Ki67-negative CTCs, low Ki67 expression was also observed in the primary tumor. Interestingly, 2 out of 5 patients with HER2 positive primary relapsed and both had high PI in their CTCs, whereas 2 out the 3 HER2 positive patients that did not relapse had low CTC proliferation index. Similarly, the triple negative patient had low PI in her CTCs and has not relapsed after 4 years of follow up.

Conclusions: Adjuvant chemotherapy fails to decrease the proliferation index in CTCs. Ki67 expression in CTCs seems to reflect Ki67 expression in the primary tumor and could be predictive of patient outcome.

Citation Format: Agelaki S, Spiliotaki M, Spanaki A, Kassiou L, Tzardi M, Koinis F, Kafousi M, Georgoulias V, Mavroudis D. The proliferation index of circulating tumor cells (CTCs) is not influenced by the administration of adjuvant chemotherapy in early breast cancer (BC) and seems to reflect Ki67 expression of the primary tumor. [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 P2-02-16.

Abstract P1-12-02: Sequential versus concurrent administration of epirubicin and docetaxel as adjuvant chemotherapy in women with high-risk axillary lymph node negative early breast cancer. An interim analysis of a multicenter randomized study from the Hellenic oncology research group

Purpose: To compare the sequential versus the concurrent administration of epirubicin and docetaxel as adjuvant therapy in high risk axillary node negative women with early breast cancer.

Patients and treatment: Women 18-75 years old with invasive breast adenocarcinoma surgically resected with no infiltrated axillary lymph nodes and absence of metastatic disease were randomized to receive 4 cycles of epirubicin 90mg/m2 followed by 4 cycles of docetaxel 75mg/m2 (sequential regimen) or 6 cycles of epirubicin 75mg/m2 followed by docetaxel 75mg/m2 (concurrent regimen). All chemotherapy cycles were administered every 21 days with prophylactic G-CSF support for days 3-10 only for the concurrent regimen. Stratification was based on menopausal status, tumor size and hormone receptor expression. By protocol amendment in 2008 women with HER2 positive tumors were excluded. The primary endpoint of the study was to compare the disease-free survival (DFS) at 5 years and 329 patients were scheduled to enroll on each arm.

Results: Between 2001-2013, 658 women were randomized and received the sequential (n=329) or the concurrent (n=329) regimen. The median age was 53 and 52 years, premenopausal status 43.8% versus 44.1%, tumor size &lt;2cm in 44.1% versus 44.4%, histological grade 3 tumor in 52% versus 53.5% and hormone receptor negative disease in 33.1% versus 37.4% of patients in the sequential and concurrent regimens, respectively. After a median follow up of 70.5 and 70 months, there were 29 (8.8%) versus 42 (12.8%) disease relapses (p=0.102) and 11 (3.3%) versus 19 (5.8%) deaths (p=0.135), in the sequential and concurrent arms, respectively. The median DFS has not yet been reached in either arm (p=0.053) and the 5-year DFS rates were 92.6% versus 88.2% for sequential and concurrent arms, respectively. Dose reduction was required in 1.2% versus 3% (p=0.001) of the treatment cycles in the sequential and concurrent arms, respectively. Toxicity included grade 2-4 neutropenia in 54% versus 41% (p=0.001), febrile neutropenia 2.7% versus 6.1% (p=0.06), anemia 12% versus 17% (p=0.07), nausea/vomiting 18.5% versus 12.4% (p=0.03) of patients in the sequential and concurrent arms, respectively. There were no toxic deaths.

Conclusion: In this interim analysis both the efficacy and the toxicity profile seem to favor the sequential over the concurrent regimen.

Citation Format: Mavroudis D, Saloustros E, Boukovinas I, Papakotoulas P, Kakolyris S, Ziras N, Christophylakis C, Kentepozidis N, Timotheadou E, Rigas G, Varthalitis I-I, Kalbakis K, Agelaki S, Georgoulias V. Sequential versus concurrent administration of epirubicin and docetaxel as adjuvant chemotherapy in women with high-risk axillary lymph node negative early breast cancer. An interim analysis of a multicenter randomized study from the Hellenic oncology research group. [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 P1-12-02.