Phase 1/2 trial of avelumab combined with utomilumab (4-1BB agonist), PF-04518600 (OX40 agonist), or radiotherapy in patients with advanced gynecologic malignancies

BACKGROUND

Immune checkpoint blockade has shown mixed results in advanced/recurrent gynecologic malignancies. Efficacy may be improved through costimulation with OX40 and 4-1BB agonists. The authors sought to evaluate the safety and efficacy of avelumab combined with utomilumab (a 4-1BB agonist), PF-04518600 (an OX40 agonist), and radiotherapy in patients with recurrent gynecologic malignancies.

METHODS

The primary end point in this six-arm, phase 1/2 trial was safety of the combination regimens. Secondary end points included the objective response rate (ORR) according to Response Evaluation Criteria in Solid Tumors and immune-related Response Evaluation Criteria in Solid Tumors, the disease control rate (DCR), the duration of response, progression-free survival, and overall survival.

RESULTS

Forty patients were included (35% with cervical cancer, 30% with endometrial cancer, and 35% with ovarian cancer). Most patients (n = 33; 83%) were enrolled in arms A-C (no radiation). Among 35 patients who were evaluable for efficacy, the ORR was 2.9%, and the DCR was 37.1%, with a median duration of stable disease of 5.4 months (interquartile range, 4.1-7.3 months). Patients with cervical cancer in arm A (avelumab and utomilumab; n = 9 evaluable patients) achieved an ORR of 11% and a DCR of 78%. The median progression-free survival was 2.1 months (95% CI, 1.8-3.5 months), and overall survival was 9.4 months (95% CI, 5.6-11.9 months). No dose-limiting toxicities or grade 3-5 immune-related adverse events were observed.

CONCLUSIONS

The findings from this trial highlight that, in heavily pretreated patients with gynecologic cancer, even multidrug regimens targeting multiple immunologic pathways, although safe, did not produce significant responses. A DCR of 78% in patients with cervical cancer who received avelumab and utomilumab indicates that further research on this combination in select patients may be warranted.

Phase I study of sapanisertib (CB-228/TAK-228/MLN0128) in combination with ziv-aflibercept in patients with advanced solid tumors

BACKGROUND

Sapanisertib is a potent ATP-competitive, dual inhibitor of mTORC1/2. Ziv-aflibercept is a recombinant fusion protein comprising human VEGF receptor extracellular domains fused to human immunoglobulin G1. HIF-1α inhibition in combination with anti-angiogenic therapy is a promising anti-tumor strategy. This Phase 1 dose-escalation/expansion study assessed safety/ tolerability of sapanisertib in combination with ziv-aflibercept in advanced solid tumors.

METHODS

Fifty-five patients with heavily pre-treated advanced metastatic solid tumors resistant or refractory to standard treatment received treatment on a range of dose levels.

RESULTS

Fifty-five patients were enrolled and treated across a range of dose levels. Forty were female (73%), median age was 62 (range: 21-79), and ECOG PS was 0 (9, 16%) or 1 (46, 84%). Most common tumor types included ovarian (8), colorectal (8), sarcoma (8), breast (3), cervical (4), and endometrial (4). Median number of prior lines of therapy was 4 (range 2-11). Sapanisertib 4 mg orally 3 days on and 4 days off plus 3 mg/kg ziv-aflibercept IV every 2 weeks on a 28-day cycle was defined as the maximum tolerated dose. Most frequent treatment-related grade ≥2 adverse events included hypertension, fatigue, anorexia, hypertriglyceridemia, diarrhea, nausea, mucositis, and serum lipase increase. There were no grade 5 events. In patients with evaluable disease (n = 50), 37 patients (74%) achieved stable disease (SD) as best response, two patients (4%) achieved a confirmed partial response (PR); disease control rate (DCR) (CR + SD + PR) was 78%.

CONCLUSION

The combination of sapanisertib and ziv-aflibercept was generally tolerable and demonstrated anti-tumor activity in heavily pre-treated patients with advanced malignancies.

Examining Stripes on a Herd of Zebras: Impact of Genomic Matching for Ultrarare Sarcomas in Phase 1 Clinical Trials (SAMBA 102)

PURPOSE

Recently, the Connective Tissue Oncology Society published consensus guidelines for recognizing ultrarare sarcomas (URS), defined as sarcomas with an incidence ≤1 per 1,000,000. We assessed the outcomes of 56 patients with soft tissue, and 21 with bone sarcomas, enrolled in Phase 1 trials.

EXPERIMENTAL DESIGN

In this Sarcoma-Matched Biomarker Analysis (SAMBA-102 study), we reviewed records from patients on Phase 1 trials at the University of Texas MD Anderson Cancer Center between January 2013 and June 2021.

RESULTS

Among 587 sarcomas, 106 (18.1%) were classified as URS. Fifty (47%) were male, and the median age was 44.3 years (range, 19-82). The most common subtypes were alveolar soft part sarcoma (ASPS), chordoma, dedifferentiated chondrosarcoma, and sclerosing epithelioid fibrosarcoma. Compared with common sarcomas, median OS was similar 16.1 months [95% confidence interval (CI), 13.6-17.5] versus 16.1 (95% CI, 8.2-24.0) in URS (P = 0.359). Objective response to treatment was higher in URS 13.2% (n = 14/106) compared with common sarcomas 6.9% (n = 33/481; P = 0.029). Median OS for those treated on matched trials was 27.3 months (95% CI, 1.9-52.7) compared with 13.4 months (95% CI, 6.3-20.6) for those not treated on matched trials (P = 0.291). Eight of 33 (24%) molecularly matched treatments resulted in an objective response, whereas 6 of 73 unmatched treatments (8.2%) resulted in an objective response (P = 0.024). Clinical benefit rate was 36.4% (12/33) in matched trials versus 26.0% (19/73) in unmatched trials (P = 0.279).

CONCLUSIONS

The results demonstrate the benefit of genomic selection in Phase 1 trials to help identify molecular subsets likely to benefit from targeted therapy.

Validation of Prognostic Scores in Patients With Metastatic Urothelial Cancer Enrolling in Phase I Targeted Therapy or Next Generation Immunotherapy Trials

INTRODUCTION

Enrolling patients with metastatic urothelial carcinoma (mUC) in phase I trials provides an opportunity to identify biological drug activity. Developing prognostic scores may aid in patient selection for phase 1 trials.

PATIENTS AND METHODS

We analyzed records of patients with mUC who participated in targeted therapy and immunotherapy phase I clinical trials at MD Anderson Cancer Center (MDACC). The Bellmunt and Bajorin scores were calculated as bladder cancer-specific prognostic scores. The Royal Marsden Hospital (RMH) and MDACC scores were calculated as phase I prognostic scores. Hazard ratios (HR) were calculated using the Cox proportional hazard model. The prognostic value of the Bellmunt, Bajorin, RMH, and MDACC scores were assessed using the Likelihood ratio (LR) χ2 test and the c-index.

RESULTS

Between 2015 and 2019, 43 patients were enrolled in phase I trials and 12 were enrolled in >I trial leading to a total of 57 trial participants (TPs). Ninty-seven percent of TPs received prior platinum therapy and 60% received a prior checkpoint inhibitor. Median overall survival (OS) and progression-free survival (PFS) were significantly shorter with increasing Bajorin, RMH, or MDACC scores, but not with increasing Bellmunt score. The RMH (c-index=0.658, LR χ2=11.8, P=.008) and MDACC scores (c-index =0.66, LR χ2=12.76, P=.01) outperformed the Bajorin score (c-index=0.522, LR χ2=1.22, P=.5) and the Bellmunt score (c-index=0.537, LR χ2=0.36, P=.9) in predicting overall survivalover. The Bajorin, RMH, and MDACC scores, but not the Bellmunt score, were also predictive of progression-free survival (PFS)prog. The RMH and MDACC scores again outperformed the Bajorin scoreand the Bellmunt score for predicting PFS.

CONCLUSION

The RMH and MDACC phase I prognostic scores accurately predicted survival in patients with mUC and outperformed the bladder cancer-specific scores at time of enrollment on phase 1 clinical trials. The RMH and MDACC scores could optimize selection of patients with mUC for phase I clinical trials.

A Phase I Dose-Escalation Study to Evaluate the Safety and Tolerability of Evofosfamide in Combination with Ipilimumab in Advanced Solid Malignancies

PURPOSE

As hypoxia can mediate resistance to immunotherapy, we investigated the safety, tolerability, and efficacy of combining evofosfamide, a prodrug that alleviates hypoxia, with ipilimumab, an immune checkpoint inhibitor, in immunologically "cold" cancers, which are intrinsically insensitive to immunotherapy, as well as in "hot/warm" metastatic cancers that are, atypical of such cancers, resistant to immunotherapy.

PATIENTS AND METHODS

In a phase I, 3+3 dose-escalation trial (NCT03098160), evofosfamide (400-640 mg/m²) and ipilimumab (3 mg/kg) were administered in four 3-week cycles. The former was administered on days 1 and 8 of cycles 1-2, while the latter was administered on day 8 of cycles 1-4. Response was assessed using immune-related RECIST and retreatment was allowed, if deemed beneficial, after completion of cycle 4 or at progression.

RESULTS

Twenty-two patients were enrolled, of whom 21 were evaluable, encompassing castration-resistant prostate cancer (n = 11), pancreatic cancer (n = 7), immunotherapy-resistant melanoma (n = 2), and human papillomavirus-negative head and neck cancer (n = 1). Drug-related hematologic toxicities, rash, fever, nausea, vomiting, and elevation of liver enzymes were observed in > 10% of patients. The most common drug-related grade 3 adverse event was alanine aminotransferase elevation (33.3%). Two patients discontinued ipilimumab and 4 required evofosfamide deescalation due to toxicity. Of 18 patients with measurable disease at baseline, 3 (16.7%) achieved partial response and 12 (66.7%) achieved stable disease. The best responses were observed at 560 mg/m² evofosfamide. Preexisting immune gene signatures predicted response to therapy, while hypermetabolic tumors predicted progression. Responders also showed improved peripheral T-cell proliferation and increased intratumoral T-cell infiltration into hypoxia.

CONCLUSIONS

No new or unexpected safety signals were observed from combining evofosfamide and ipilimumab, and evidence of therapeutic activity was noted.

Safety and activity of vandetanib in combination with everolimus in patients with advanced solid tumors: a phase I study

Background

Preclinical studies suggest that combining vandetanib (VAN), a multi-tyrosine kinase inhibitor of rearranged during transfection (RET) proto-oncogene, vascular endothelial growth factor receptor (VEGFR), and epidermal growth factor receptor (EGFR), with everolimus (EV), a mammalian target of rapamycin (mTOR) inhibitor, may improve antitumor activity. We determined the safety, maximum tolerated dose (MTD), recommended phase II dose (RP2D), and dose-limiting toxicities (DLTs) of VAN + EV in patients with advanced solid cancers and the effect of combination therapy on cancer cell proliferation and intracellular pathways.

Patients and methods

Patients with refractory solid tumors were enrolled in a phase I dose-escalation trial testing VAN (100-300 mg orally daily) + EV (2.5-10 mg orally daily). Objective responses were evaluated using RECIST v1.1. RET mutant cancer cell lines were used in cell-based studies.

Results

Among 80 patients enrolled, 72 (90%) patients were evaluable: 7 achieved partial response (PR) (10%) and 37 had stable disease (SD) (51%; duration range: 1-27 cycles). Clinical benefit (SD or PR ≥ 6 months) was observed in 26 evaluable patients [36%, 95% confidence intervals (CI) (25% to 49%)]. In 80 patients, median overall survival (OS) was 10.5 months [95% CI (8.5-16.1)] and median progression-free survival (PFS) 4.1 months [95% CI (3.4-7.3)]. Six patients (7.5%) experienced DLTs and 20 (25%) required dose modifications. VAN + EV was safe, with fatigue, rash, diarrhea, and mucositis being the most common toxicities. In cell-based studies, combination therapy was superior to monotherapy at inhibiting cancer cell proliferation and intracellular signaling.

Conclusions

The MTDs and RP2Ds of VAN + EV are 300 mg and 10 mg, respectively. VAN + EV combination is safe and active in refractory solid tumors. Further investigation is warranted in RET pathway aberrant tumors.

•

VAN + EV is safe, active and provides clinical benefit in some patients with refractory solid cancers.

•

Dual therapy is superior to monotherapy at inhibiting proliferation and intracellular signaling of RET mutant cancer cells.

•

This study highlights the importance of identifying novel combination therapies to overcome therapeutic resistance.

•

Next-generation sequencing of advanced solid tumors may inform treatment strategies and guide future drug development.

Molecular Profiling of Metastatic Bladder Cancer Early-Phase Clinical Trial Participants Predicts Patient Outcomes

Prognosis for patients with metastatic bladder carcinoma (mBC) remains limited and in need of novel therapies. We retrospectively analyzed medical records of 43 patients with platinum-refractory metastatic bladder cancer (mBC) who participated in one or more phase I trials of various investigational therapies. Patients' tumors or circulating tumor DNA were analyzed by next-generation sequencing. The median progression-free survival was 4.2 months, the median overall survival was 9.6 months, and the overall response rate was 17.5%. TP53, ERBB2, PI3KCA, FGFR3, and ARID1A alterations were detected in 66%, 29%, 27%, 24%, and 22% of all patients, respectively. Alterations in FGFR3 were almost mutually exclusive of TP53. More than half (64%) of patients with an FGFR alt received an FGFR inhibitor, 67% of which achieved disease control. Among patients with urothelial carcinoma histology, those harboring a TP53 alteration had a shorter median progression-free survival (PFS) compared with those whose tumors carry wild-type TP53. The reverse relationship was observed in patients harboring an FGFR alteration. IMPLICATIONS: Patients with platinum-refractory mBC derive clinical benefit from participating in early-phase clinical trials and their survival outcomes correlate with the genetic profile of the tumor. VISUAL OVERVIEW: http://mcr.aacrjournals.org/content/molcanres/19/3/395/F1.large.jpg.

Abstract CT163: Temsirolimus in combinaton with metformin in patients with advanced or refractory endometrial cancers

Purpose: There is limited success with chemotherapeutic agents in women with advanced or recurrent endometrial cancer. Dysregulation of the PI3K/RAS signaling pathways in endometrial cancer have been well documented. However, responses with mTOR inhibitor such as temsirolimus have been modest. Previously we have shown that metformin prevents temsirolimus-induced AKT activation. Therefore, we enrolled patients with advanced endometrial carcinoma in the expansion cohort of a phase I study of temsirolimus in combination with metformin. Methods: Patients with advanced endometrial cancer refractory to or relapse after standard therapies, ECOG performance status 0 or 1, and with significant organ function reserve were enrolled. Patients were administered intravenous temsirolimus 25mg weekly and oral metformin 2000 mg daily in 28-day cycles. Response was assessed every 2 cycles by clinical evaluation, tumor markers, and imaging per RECIST 1.1. All toxicities were graded using NCI CTCAE, version 4.0. Results: Forty patients were treated. Median age is 67 years (range, 33-78). Drug-related adverse events of any grade were reported in 34 patients. The most common toxicities were mucositis (n=13), AST increase (n=13), anorexia (n=12), diarrhea (n=12) and anemia (n=10). Eleven grade 3 drug-related adverse events were reported. They were anemia (n=2), thrombocytopenia (n=2), mucositis, fatigue, weight loss, hypokalemia, hypophosphatemia, AST increase and ALT increase (n=1 each). Of the 33 patients evaluable for response, objective response was seen in 2 (6%) patients. Both had partial response (PR) and were on the study for 8.7 and 18.2 months respectively. In addition, 13 (39%) patients had stable disease (SD), including 11 with SD ≥4 months, representing a clinical benefit rate of 39%. Molecular characterization of tumor was available for 35 patients. Thirty of 35 patients had molecular alterations in the PI3K and/or RAS pathway. Of the 30 patients, 1 had benign PI3K mutation and 4 were not evaluable for response. Of the remaining 25 patients with PI3K and/or KRAS pathway, 11 (44%) had either objective response or SD ≥4 months. Eighteen of them had molecular alteration only in the PI3K pathway. Seven of 18 (39%) had objective response or SD ≥4 months. Importantly, all 3 patients who had molecular alterations in both the PI3K and RAS pathway achieved SD ≥4 months, while 3 of the 4 patients with exclusive resistant KRAS mutation had progressive disease. Collectively, of the 13 patients with either objective response or SD ≥4 months, 11 (85%) patients had molecular alteration in the PI3K and/or RAS pathway. Conclusion: Temsirolimus in combination with metformin was well tolerated. Anti-tumor activity was seen in patients with advanced/refractory endometrial cancer, particularly in patients with molecular alterations in the PI3K and/or RAS pathway that warrants further study.

Citation Format: Aung Naing, Daniel Karp, Sarina A. Piha-Paul, Shubham Pant, Vivek Subbiah, Diane C. Bodurka, Siqing Fu, Amir A. Jazaeri, Shumei Kato, Kathleen Schmeler, Alpa Nick, Yali Yang, Fechukwu O. Akhmedzhanov, Senait Fessahaye, Jing Gong, Bettzy Stephen, Amber M. Johnson, Pamela T. Soliman, Anil K. Sood, Funda Meric-Bernstam, Karen H. Lu. Temsirolimus in combinaton with metformin in patients with advanced or refractory endometrial cancers [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT163.

Outcome analysis of Phase I trial patients with metastatic KRAS and/or TP53 mutant non-small cell lung cancer

KRAS and TP53 mutations, which are the most common genetic drivers of tumorigenesis, are still considered undruggable targets. Therefore, we analyzed these genetic aberrations in metastatic non-small cell lung cancer (NSCLC) for the development of potential therapeutics. One hundred eighty-five consecutive patients with metastatic NSCLC in a phase 1 trial center were included. Their genomic aberrations, clinical characteristics, survivals, and phase 1 trial therapies were analyzed. About 10%, 18%, 36%, and 36% of the patients had metastatic KRAS+/TP53+, KRAS+/TP53-,KRAS-/TP53+, and KRAS-/TP53- NSCLC, respectively. The most common concurrent genetic aberrations beside KRAS and/or TP53 (>5%) were KIT, epidermal growth factor receptor, PIK3CA, c-MET, BRAF, STK11, ATM, CDKN2A, and APC. KRAS+/TP53+ NSCLC did not respond well to the phase 1 trial therapy and was associated with markedly worse progression-free (PFS) and overall (OS) survivals than the other three groups together. KRAS hotspot mutations at locations other than codon G12 were associated with considerably worse OS than those at this codon. Gene aberration-matched therapy produced prolonged PFS and so was anti-angiogenesis in patients with TP53 mutations. Introduction of the evolutionary action score system of TP53 missense mutations enabled us to identify a subgroup of NSCLC patients with low-risk mutant p53 proteins having a median OS duration of 64.5 months after initial diagnosis of metastasis. These data suggested that patients with metastatic dual KRAS+/TP53+ hotspot-mutant NSCLC had poor clinical outcomes. Further analysis identified remarkably prolonged survival in patients with low-risk mutant p53 proteins, which warrants confirmatory studies.

Abstract CT024: Results of a phase I dose escalation study of ARQ 751 in adult subjects with advanced solid tumors with AKT1, 2, 3 genetic alterations, activating PI3K mutations, PTEN-null, or other known actionable PTEN mutations

Background: Dysregulation of the PI3K-AKT signaling pathway is associated with a number of cancers. and plays a critical role in cancer initiation and progression. AKT can be activated through activated receptor tyrosine kinases, gain-of-function mutations of PIK3CA, PTEN deficiency, and AKT amplification or activating mutations such as AKT1E17K. As the second generation of allosteric AKT inhibitor, ARQ 751 potently inhibits AKT1, 2 and 3 with biochemical IC50 values of 0.55 nM, 0.81 nM and 1.31 nM receptively. In addition, ARQ 751 is very selective; it does not inhibit any other kinase (out of the 245 tested) by greater than 50% at 5 µM. The objective of this study is to determine maximum tolerated dose in patients with advanced solid tumors.

Material and Methods: This is Phase 1 Dose Escalation Study to assess the safety and tolerability of ARQ 751 in subjects with advanced solid tumors with AKT1, 2, 3 genetic alterations, activating PI3K mutations, PTEN-null, or other known actionable PTEN mutations. Treatment emerging adverse events (TEAE) were assessed per NCI CTCAE v. 4.03. Tumor response were evaluated per RECIST 1.1. Blood samples were collected for PK.

Results: A total of 15 pts have been enrolled [73% female; median age 61 years; 5 Breast (5), endometrial (2), and others (9); activating PI3K mutation (9), PTEN null/other known actionable PTEN mutations (5), AKT 1 mutation (1)] and treated at dose levels of 5 mg QD, 10 mg QD, 20 mg QD, 25 mg QOD and 25 mg QD. There have been no DLTs reported so far. ARQ 751 related TEAEs included nausea (27%), stomatitis, vomiting, fatigue, mucosal inflammation, white blood cell count decreased, hyperkalaemia, cough, oropharyngeal pain, sinus congestion, pain of skin, puritus and hot flushes (7% each). All these TEAEs were grade 1 or 2. There was no ≥ Grade 3 drug related TEAEs or any grade drug-related SAEs. Four pts achieved a best response of stable disease (SD) including 1 with breast cancer treated at 25 mg QOD for 42+ weeks, 1 with head and neck cancer treated at 20 mg QD for 16 weeks, 1 with breast cancer treated at 25 mg QD for 12+, and 1 with endometrial cancer treated at 25 mg QD for 10+ weeks. 3 of 4 SD pts are currently on therapy.

Conclusions: ARQ 751 demonstrated a manageable safety profile at Dose level up to 25 mg QD. The dose escalation is ongoing. PK and updated safety, efficacy data will be presented.

Citation Format: Shubham Pant, Vivek Subbiah, Jordi Rodon, Filip Janku, David Hong, Daniel Karp, Sarina Piha-Paul, Apostolia M. Tsimberidou, Aung Naing, Siqing Fu, Ron E. Savage, Feng Chai, Yi Yu, Brian Schwartz, Funda Meric-Bernstam, Tim Yap. Results of a phase I dose escalation study of ARQ 751 in adult subjects with advanced solid tumors with AKT1, 2, 3 genetic alterations, activating PI3K mutations, PTEN-null, or other known actionable PTEN mutations [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT024.

Predicting outcomes in patients with advanced non-small cell lung cancer enrolled in early phase immunotherapy trials

OBJECTIVES

Immunotherapy (IO) has altered the non-small cell lung cancer (NSCLC) therapeutic landscape. However, the majority of patients do not respond to immune-checkpoint blockade, and subsequently either receive further chemotherapy or are referred for clinical trials. Here we examined the outcomes and predictors of response to IO in early phase clinical trials.

MATERIALS AND METHODS

We analyzed the records of 74 patients with metastatic NSCLC that were enrolled on phase 1 IO trials within MD Anderson Cancer Center from 1/2010 to 7/2017.

RESULTS

The median age was 68, with a median follow-up of 12.3 months. The median lines of prior therapy was three. There were 53 patients who did not receive any IO as a prior line of treatment with a mOS of 8.2 months and mPFS of 3.4 months. There were 21 patients who progressed on a prior IO agent and subsequently went on an IO study with a mOS of 10.5 months and mPFS of 4.3 months, which was similar to patients who did not receive IO OS HR 0.81 (P = .51) and PFS HR 0.85 (P = .59). Royal Marsden Hospital (RMH) prognostic score >1 was predictive of decreased OS HR 3.59 (P = .014) although PFS was not statistically different. MDACC prognostic score was predictive of both OS HR 3.39 (P = .0002) and PFS HR 1.9 (P = .030). ANC/ALC ratio (NLR) of >6 was predictive of decreased survival mOS 3.2 months compared to NLR <6 mOS 11 months; HR 3.0 (P = .0023).

CONCLUSIONS

In our heavily pretreated patient population with NSCLC, early phase clinical trials with IO demonstrated similar outcomes to those seen in larger clinical studies that also used immune checkpoint inhibitors. The addition of NLR to RMH and MDACC prognostic scores can identify patients with poor overall outcomes treated with early phase IO studies.

Abstract A096: Phase II study of the PARP inhibitor talazoparib in advanced cancer patients with somatic alterations in BRCA1/2, mutations/deletions in PTEN or PTEN loss, aberrations in other BRCA pathway genes, and germline mutations in BRCA1/2 (not breast or ovarian cancer)

Background: Cancer cells deficient in BRCA1/2 are selectively sensitive to the double-stranded DNA breaks induced by poly (ADP-ribose) polymerase (PARP) inhibitors. Multiple ongoing trials are evaluating PARP inhibitors in patients with breast, ovarian, and prostate cancers and germline or somatic BRCA1/2 mutations. There is, however, a great need to determine if the benefit of PARP inhibition can be extended to other tumor types. We sought to assess the efficacy of talazoparib, a potent oral PARP1/2 inhibitor, in patients with germline BRCA mutations in cancer types other than breast and ovarian cancer, and in patients with somatic BRCA alterations or aberrations in other homologous repair genes or PTEN. Methods: This was a single-center, phase II trial in patients with measurable advanced solid tumors. Patients were enrolled on one of four cohorts: 1) somatic alterations of BRCA1/2, 2) mutations/deletions in other BRCA pathway genes, 3) mutations/deletions in PTEN and/or PTEN loss by IHC, and 4) germline BRCA1/2 mutations (not breast/ovarian cancer). Patients were treated with talazoparib at 1 mg PO daily. Response was assessed per RECIST v1.1. Primary end point was clinical benefit rate (CBR; complete response [CR], partial response [PR] or stable disease [SD]&gt;6m). Patients were enrolled based on standard of practice molecular testing. Patients underwent pretreatment biopsies with whole exome sequencing (WES) of tumor and normal DNA. Results: 35 patients (pts) (30 evaluable) were enrolled. Pts had a median of 4 prior lines of treatment. Grade 3-4 treatment-related AEs occurred in 37% of pts, and the most common was thrombocytopenia (23%). The median follow-up was 15.8 mo. CBR was 0%, 44%, 8%, and 29% for cohorts 1-4, respectively. In cohort 1, one patient with a somatic BRCA2 mutation enrolled and did not respond. In cohort 2, two of 9 evaluable pts had a PR: cholangiocarcinoma [CCA] with ATM mutation and bladder cancer with PALB2 mutation, and 2 of 9 pts had prolonged SD (one pt with ovarian cancer and BRIP1 mutation, and one pt with sarcoma and FANCC mutation). Among 13 evaluable pts in the PTEN mutation/loss cohort (cohort 3), one patient with PTEN mutation had prolonged SD. Among 7 evaluable pts with germline BRCA1/2 mutations (cohort 4), one pt with carcinoma of ampulla of Vater had a durable CR, and one pt with CCA had SD for 8 months. WES was performed on 28 evaluable patients. Alterations in two genes, POLQ and PTEN, were significantly associated with progressive disease. PTEN mutations were associated with shorter time to progression (p=0.004) and lower overall survival (p=0.02). Conclusion: Talazoparib demonstrated clinical benefit in selected patients with germline as well as somatic alterations in BRCA pathway genes. Patients with PTEN mutations/loss did not derive significant clinical benefit from PARP inhibition. Further study is needed to confirm these findings and determine implications for patient selection and combination therapy. Clinical trial information: NCT 02286687.

Citation Format: Sarina A. Piha-Paul, Wendy Wen Xiong, Tyler Moss, Rosa M. Mostorino, Shelby Sedelmeier, Kenneth Hess, Siqing Fu, David Hong, Filip Janku, Daniel Karp, Aung Naing, Shubham Pant, Jordi Rodon, Vivek Subbiah, A M. Tsimberidou, Timothy Yap, Milind Javle, Coya Tapia, Kenna R. Shaw, Karina Eterovic, Gordon B. Mills, Funda Meric-Bernstam. Phase II study of the PARP inhibitor talazoparib in advanced cancer patients with somatic alterations in BRCA1/2, mutations/deletions in PTEN or PTEN loss, aberrations in other BRCA pathway genes, and germline mutations in BRCA1/2 (not breast or ovarian cancer) [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A096.

Abstract 3291: Development of a novel prognostic scoring system for patient selection in immune checkpoint inhibitor phase 1 clinical trials

Purpose: To develop a prognostic scoring system for selecting patients for immune checkpoint inhibitor (ICI) phase 1 clinical trials.

Background: The Royal Marsden Hospital (RMH) and MD Anderson (MDA) prognostic scoring systems have been validated for patients in phase 1 clinical trials treated with cytotoxic chemotherapy and targeted therapy, but no such scoring system has been validated to help select patients entering ICI clinical trials.

Methods: We analyzed clinical data from patients treated in phase 1 ICI clinical trials (with anti-CTLA4 and anti-PD1 antibody therapy) at the MD Anderson Center for Targeted Therapy. Sixteen clinical factors were studied. Recursive partitioning analysis identified cut-points for each clinical factor and a Cox proportional hazards regression model was used to identify factors independently affecting overall survival.

Results: Among 172 patients treated with ICI therapy (105 CTLA4-based and 67 PD1-based) between January 2013 and November 2015, the median age was 60 years (range: 19-86 years) and 87 (51%) were male. The most common tumor types treated included renal cell carcinoma (n = 25; 15%), non-small cell lung cancer (n = 21; 12%), melanoma (n = 17; 10%), sarcoma (n = 14; 8%), gastrointestinal stromal tumors (n = 10; 6%), prostate cancer (n = 6; 3%), and colorectal cancer (n = 6; 3%). Seven factors were independently associated with significantly worse overall survival: age &gt;52 years (hazard ratio [HR] 1.59, 95% confidence interval [CI] 1.1-2.4), Eastern Cooperative Oncology Group performance status &gt;1 (HR 2.81, 95% CI 1.3-6.3), lactate dehydrogenase &gt;466 U/L (HR 2.1, 95% CI 1.4-3.2), platelet count &gt;300 × 109/L (HR 1.8, 95% CI 1.2-2.8), absolute neutrophil count &gt;4.9 × 109/L (HR 2.3, 95% CI 1.5-3.5), absolute lymphocyte count &lt;1.8 × 109/L (HR 3.3, 95% CI 1.9-5.7), and liver metastases (HR 1.8, 95% CI 1.2-2.6). An index was created whereby the cohort was divided into four risk groups based on the number of factors present: 0-2, 3, 4, or 5-6. Median overall survival was 24.2 months (0-2), 11.6 months (3), 8.0 months (4), and 3.8 months (5-6); log rank test, p &lt; 0.0001. The Harrell c-index of this scoring system was 0.72, indicating significant predictability.

Conclusion: We have developed a novel “MDA ICI” prognostic scoring system incorporating seven clinical parameters with prognostic significance for patients in phase 1 clinical trials treated with immune checkpoint inhibitors. Unlike in the RMH and MDA prognostic scoring systems, albumin level and number of metastatic sites did not independently correlate with overall survival. Prospective evaluation and external validation of our novel prognostic scoring system is warranted and may help better select patients for future clinical trials of checkpoint inhibitors.

Citation Format: Shiraj Sen, Kenneth Hess, David Hong, Aung Naing, Sarina Piha-Paul, Filip Janku, Siqing Fu, Holly Liu, Yunfang Jiang, Rahil Khanji, Daniel Karp, Apostolia Tsimberidou, Nizar Tannir, Funda Meric-Bernstam, Vivek Subbiah. Development of a novel prognostic scoring system for patient selection in immune checkpoint inhibitor phase 1 clinical trials [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3291. doi:10.1158/1538-7445.AM2017-3291

Phase I clinical trial of combination imatinib and ipilimumab in patients with advanced malignancies

Background

Imatinib mesylate can induce rapid tumor regression, increase tumor antigen presentation, and inhibit tumor immunosuppressive mechanisms. CTLA-4 blockade and imatinib synergize in mouse models to reduce tumor volume via intratumoral accumulation of CD8+ T cells. We hypothesized that imatinib combined with ipilimumab would be tolerable and may synergize in patients with advanced cancer.

Methods

Primary objective of the dose-escalation study (3 + 3 design) was to establish the maximum tolerated dose (MTD) and recommended phase II dose. Secondary objectives included evaluation of antitumor activity of the combination based on KIT mutation status and the capacity of tumor-associated immune biomarkers to predict response.

Results

The primary objective to establish the maximum tolerated dose (MTD) was achieved, and the recommended phase II doses are ipilimumab at 3 mg/kg every 3 weeks and imatinib 400 mg twice daily. Of the 35 patients treated in the escalation and GIST expansion, none experienced dose-limiting toxicities. The most common grade 1/2–related adverse events (AEs) were fatigue (66%), nausea (57%), anorexia, vomiting (each 31%), edema (29%), and anemia, diarrhea, and rash (each 23%). Grade 3 AEs occurred in 6 patients (17%) and included fatigue, anemia, fever, rash, and vomiting. There were no grade 4 AEs. In general, the combination was well tolerated. Among all patients, 2 responses were seen: 1 partial response (GIST) and 1 partial response (melanoma). Stable disease was seen in 6 patients lasting an average of 6 months. The melanoma responder was KIT mutated and the GIST responder was wild-type.

Conclusions

Our findings suggest that this combination of a targeted agent with checkpoint blockade is safe across multiple tumor types. Low activity with no clear signal for synergy was observed in escalation or GIST expansion cohorts. Assessment of antitumor activity of this combination in the KIT-mutant melanoma population is being evaluated.

Trial registration

Clinicaltrials.gov NCT01738139, registered 28 November 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s40425-017-0238-1) contains supplementary material, which is available to authorized users.

Post-Discharge Survival Outcomes of Patients with Advanced Cancer from the University of Texas MD Anderson Cancer Center Investigational Cancer Therapeutics (Phase I Trials) Inpatient Unit

BACKGROUND

Patients with advanced cancer who progress on standard therapy are potential candidates for phase I clinical trials. Due to their aggressive disease and complex comorbid conditions, these patients often need inpatient admission. This study assessed the outcomes of such patients after they were discharged to hospice care.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with solid tumor malignancies who were discharged to hospice care from the inpatient service.

RESULTS

One hundred thirty-three patients were included in the study cohort. All patients had metastatic disease and an Eastern Cooperative Oncology Group performance status ≥3. The median survival after discharge to hospice from an inpatient setting was 16 days, with a survival rate of 5% at 3 months after discharge. The median survival after the last cancer treatment was 46 days, with survival of 17% at 3 months, and 5% at 6 months. Patients with lactate dehydrogenase (LDH) >618 IU/L had a median post-discharge survival of 11 days versus 20 days for patients with LDH ≤618 IU/L.

CONCLUSIONS

Patients with metastatic cancer participating in phase I trials who have poor performance status and require inpatient admission have a very short survival after discharge to hospice. A high LDH level predicts an even shorter survival.

Incidence of infusion reactions to anti-neoplastic agents in early phase clinical trials: The MD Anderson Cancer Center experience

Infusion reactions (IRs) to anti-neoplastic agents require prompt recognition and immediate treatment to avert significant complications. We conducted a retrospective review of the medical records of consecutive patients who received anti-neoplastic therapy in the outpatient treatment center of the Department of Investigational Cancer Therapeutics from January 1, 2013 to November 30, 2013. Of the 597 patients who received treatment, 9 (1.5 %) had IRs (all ≤ grade 2). The most common IRs observed on first occurrence were chills (n = 5), itching, rash, and facial flushing (n = 3 each). There were no IR-related deaths. All the IRs were reversible with appropriate symptomatic treatment and the therapy was completed after temporary cessation of infusion in 7 of the 9 patients. The infusion was stopped in 2 patients due to symptoms suggestive of IgE-mediated allergic reaction and cytokine storm. Five of the 8 patients who were re-challenged with the same therapy developed a similar reaction. However, the infusion was completed in 4 of the 5 patients after administration of intravenous diphenhydramine and/or hydrocortisone, or slowing the rate of infusion. And, subsequent cycles with the same agents were uneventful. IRs to anti-neoplastic agents are rare. Though the clinical presentations are overlapping, most IRs are not IgE-mediated allergic reactions. Appropriate premedication and slow rate of infusion facilitates uneventful administration of the anti-neoplastic agents in subsequent cycles. Further study in a larger cohort of patients to identify biomarkers of hypersensitivity is warranted.

Ipilimumab with Stereotactic Ablative Radiation Therapy: Phase I Results and Immunologic Correlates from Peripheral T Cells

Purpose: Little prospective data are available on clinical outcomes and immune correlates from combination radiation and immunotherapy. We conducted a phase I trial (NCT02239900) testing stereotactic ablative radiotherapy (SABR) with ipilimumab.Experimental Design: SABR was given either concurrently (1 day after the first dose) or sequentially (1 week after the second dose) with ipilimumab (3 mg/kg every 3 weeks for 4 doses) to five treatment groups: concurrent 50 Gy (in 4 fractions) to liver; sequential 50 Gy (in 4 fractions) to liver; concurrent 50 Gy (in 4 fractions) to lung; sequential 50 Gy (in 4 fractions) to lung; and sequential 60 Gy (in 10 fractions) to lung or liver. MTD was determined with a 3 + 3 dose de-escalation design. Immune marker expression was assessed by flow cytometry.Results: Among 35 patients who initiated ipilimumab, 2 experienced dose-limiting toxicity and 12 (34%) grade 3 toxicity. Response outside the radiation field was assessable in 31 patients. Three patients (10%) exhibited partial response and 7 (23%) experienced clinical benefit (defined as partial response or stable disease lasting ≥6 months). Clinical benefit was associated with increases in peripheral CD8⁺ T cells, CD8⁺/CD4⁺ T-cell ratio, and proportion of CD8⁺ T cells expressing 4-1BB and PD1. Liver (vs. lung) irradiation produced greater T-cell activation, reflected as increases in the proportions of peripheral T cells expressing ICOS, GITR, and 4-1BB.Conclusions: Combining SABR and ipilimumab was safe with signs of efficacy, peripheral T-cell markers may predict clinical benefit, and systemic immune activation was greater after liver irradiation. Clin Cancer Res; 23(6); 1388-96. ©2016 AACR.

TP53 Alterations Correlate with Response to VEGF/VEGFR Inhibitors: Implications for Targeted Therapeutics

TP53 tumor-suppressor gene mutations are among the most frequent abnormalities in cancer, affecting approximately 40% of patients. Yet, there is no accepted way to target these alterations in the clinic. At the same time, antagonists of VEGFR or its ligand are best-selling oncology drugs, with multiple, expensive compounds approved. Although only a subset of patients benefit from these antiangiogenesis agents, no relevant biomarker has been identified. Interestingly, TP53 mutations upregulate VEGF-A and VEGFR2. We prospectively enrolled 500 patients, to be interrogated by comprehensive genomic profiling (CGP) (next-generation sequencing, 236 genes), and to be matched, whenever possible, with targeted agents. Herein, we analyze outcomes based on VEGF/VEGFR inhibitor treatment and presence of TP53 mutations. Of the 500 patients, 188 (37.6%; with ≥1 alteration) were treated; 106 (56% of 188) had tumors that harbored TP53 mutations. VEGF/VEGFR inhibitor therapy was independently associated with improvement in all outcome parameters [rate of stable disease (SD) ≥6 months/partial and complete remission (PR/CR); (31% versus 7%; TP53-mutant patients (who received no other molecular-matched agents) treated with versus without VEGF/VEGFR inhibitors), time-to-treatment failure, and overall survival (multivariate analysis: all P ≤ 0.01)] for the patients harboring TP53-mutant cancers, but improvement was not seen in any of these parameters for patients with TP53 wild-type neoplasms. We conclude that TP53 mutations predict sensitivity to VEGF/VEGFR inhibitors in the clinic. TP53 alterations may therefore be a ready biomarker for treatment with antiangiogenesis agents, a finding of seminal importance across the cancer field. Mol Cancer Ther; 15(10); 2475-85. ©2016 AACR.

Abstract CT052: A phase I dose escalation trial of vemurafenib in combination with the mTOR inhibitor everolimus for melanoma and non-melanoma cancers with a BRAF aberration

Background: Vemurafenib (Vem) is approved by the US Food and Drug Administration for the treatment of BRAF V600-mutant melanoma. Vem also has demonstrated activity in BRAF V600-mutant non-melanoma cancers. However, with monotherapy, all patients eventually experience disease progression, and more effective treatments are needed. On the basis of preclinical studies showing that combined inhibition of the BRAF and PI3K/mTOR pathways may overcome the primary or innate resistance mechanisms in BRAF-mutant malignancies, we conducted a phase I trial combining Vem with the mTOR inhibitor everolimus (Eve).

Objectives: Primary objectives of this open-label phase I trial were to evaluate safety and tolerability, and to determine the maximum tolerated dose (MTD) of the Vem and Eve combination in patients with BRAF-mutant advanced cancers; the secondary objective was to assess efficacy.

Methods: Escalating doses of Vem twice daily (BID) and Eve once daily (QD) were combined using the standard 3 + 3 design, and then an expansion cohort was enrolled and treated at the MTD. Treatment was administered in 28-day cycles. MTD was defined as the highest dose studied in which incidence of dose-limiting toxicity (DLT) was less than 33%. Younger patients were enrolled at the accruing dose level, with body surface area-based dose adjustments for smaller children.

Results: Twenty patients (14 male, 6 female) with BRAF-mutant (18 V600E, 1 V600K, 1 G469A) melanoma (n = 7) or central nervous system (n = 5), thyroid (n = 4), non-small cell lung (n = 1), colorectal (n = 1), appendiceal (n = 1), or unknown primary (n = 1) cancer were enrolled. The median age of the 18 adult patients was 64 years (range 16-85 years); the 2 pediatric patients were aged 10 and 13 years. Prior therapies included surgery (n = 18, 90%), radiation (n = 11, 55%), cytotoxic chemotherapy (n = 14, 70%), and a prior phase I trial (n = 10, 50%). Ten patients (50%) had prior treatment with BRAF/MEK inhibitor(s). Ten patients had received 2 or more lines of systemic therapies. No dose-limiting toxicity was observed at dose level 1 (Vem 720 mg BID, Eve 5 mg QD). Two DLTs (rash, fatigue) were observed at dose level 2 (Vem 720 mg BID, Eve 10 mg QD). Dose level 1 was determined to be the MTD. Grade &gt;3 toxic effects included rash (n = 4), fatigue (n = 4), photosensitivity (n = 1), anemia (n = 1), hyperglycemia (n = 1), and hypertriglyceridemia (n = 1). After excluding 1 patient who withdrew consent before restaging, we found that 5 patients (26%) had a partial response (melanoma = 1, non-melanoma = 4), 9 (47%) had stable disease, and 5 (26%) had progression as the best response. Among 9 evaluable patients with a history of prior treatment with BRAF/MEK inhibitors, 2 had a partial response and 5 had stable disease. Two patients are continuing the treatment after 5 and 16 cycles.

Conclusion: The combination of Vem (720 mg BID) and Eve (5 mg QD) is safe, well-tolerated, and has activity in patients with BRAF-mutant advanced cancers, including those previously treated with a BRAF/MEK inhibitor.

Citation Format: Muhammad Rizwan Khawaja, Soumen Khatua, Daniel Karp, Filip Janku, David Hong, Javier Munoz, Apostolia Tsimberidou, Wafik Zaky, Steven I. Sherman, Patrick Hwu, Funda Meric-Bernstam, Vivek Subbiah. A phase I dose escalation trial of vemurafenib in combination with the mTOR inhibitor everolimus for melanoma and non-melanoma cancers with a BRAF aberration. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT052.

Abstract LB-C17: A phase I study of everolimus (mTOR inhibitor) in combination with vandetanib (multikinase inhibitor of VEGFR, EGFR, and RET) in advanced solid tumors including molecularly matched aberrations

Background: RET gene aberrations including fusions have been identified across several types of solid malignancies, including lung adenocarcinomas, thyroid, colorectal and invasive breast cancers. Preclinical models has shown that the combination of vandetanib (VAN), a multi tyrosine kinase inhibitor of VEGFR2/EGFR and RET pathways) and everolimus (EV), an mTOR pathway inhibitor, overcomes intrinsic and /or acquired tumor resistance to either agent alone, suggesting a rationale for investigating this combination in cancer patients, including those harboring aberrations in the drug targets.

Methods: We designed a dose escalation and expansion trial with “3+3” design to determine the safety, maximum tolerated dose (MTD), recommended Phase II dose (RP2D), dose-limiting toxicities (DLTs) and activity of the combination. During the escalation phase, the study drugs (VAN, EV) were given at the following doses, respectively: level 0 (100 mg, 2.5 mg), level 1 (200mg, 2.5mg), level 2 (200mg, 5mg), level 3 (300 mg, 5mg), and level 4 (300mg, 10mg). Both study drugs are given continuously on a 28 day schedule. Tumor responses are assessed using RECIST v1.1. Tumor molecular aberrations were detected by Next Generation Sequencing (NSG) and/or Fluorescence In Situ Hybridization (FISH).

Results: To date, 72 adult patients have been treated. Median age was 56 years (range 18-82 years) and 38 patients (53%) were male. The most common diagnoses were sarcoma (n = 15); renal cell carcinoma (n = 11); thyroid cancer (n = 10; n = 3 medullary) lung cancer (n = 10). Thirty patients (41%) had 3 or more sites of metastases. Nine patients were treated at dose level 0 (VAN 100 mg daily + EV 2.5 mg daily), five at dose level 1 (VAN 200 mg daily + EV 2.5 mg daily), and 6 patients at dose level 4 (highest dose VAN 300 mg daily + EV 10 mg daily). The most common adverse events observed in patients across different dose levels included G1 rash (n = 10), G1-G3 diarrhea (n = 21); G1-G4 thrombocytopenia (n = 9); G1-G2 hypertriglyceridemia/hypercholesterolemia (n = 8); G1-G2 hypertension (n = 6), G1-G2 QTc prolongation (n = 4); G1-G transaminitis (n = 4). Dose escalation has been completed and the expansion phase is currently ongoing in patients with advanced malignancies harboring RET, or P13K, PIK3R1, TSC1/2 and AKT genomic aberrations. The best responses were PR (n = 7), and SD (n = 33). Ten patients with reported SD (30.3%) experienced durable responses (&gt; 6 months). One RET M918T mutant medullary thyroid cancer patient, who developed acquired resistance to VAN, achieved a 25% reduction on this combination. Three NSCLC patients with RET fusions (100%) responded with one reaching 48% decrease per RECIST. In addition there was evidence of blood-brain barrier penetration in 2 patients with RET fusion patients who had brain metastases.

Conclusions: The combination of VAN and EV was reasonably well tolerated at the highest doses of each of the drugs. Evidence of response was noted in heavily pre-treated patients with refractory solid tumors and targetable genomic aberrations specifically RET. The combination has CNS penetration in RET fusion NSCLC.

Citation Format: Tina Cascone, Kenneth R. Hess, Sarina Piha-Paul, David S. Hong, Michael Roxas, Ishwaria M. Subbiah, Siquing Fu, Aung Naing, Filip Janku, Daniel Karp, Steven I. Sherman, Funda Meric-Bernstam, John V. Heymach, Vivek Subbiah. A phase I study of everolimus (mTOR inhibitor) in combination with vandetanib (multikinase inhibitor of VEGFR, EGFR, and RET) in advanced solid tumors including molecularly matched aberrations. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr LB-C17.

Abstract C44: Phase I dose escalation study of temsirolimus in combination with metformin in patients with advanced cancers

Background: The mTOR inhibitors may result in upregulation of Akt, leading to undesirable cell proliferation. Metformin inhibits mTOR through different mechanisms and may enhance antitumor activity of Temsirolimus.

Objectives: Primary objectives of this open-label phase 1 trial were to evaluate safety and tolerability, and to determine the maximum tolerated dose (MTD) of Temsirolimus plus Metformin combination in patients with advanced cancers refractory to standard therapies. Secondary objective was to assess clinical tumor response with this combination.

Methods: A fixed dose of intravenous (IV) Temsirolimus 25mg weekly was combined with an escalating dose of oral Metformin (level-1: 500mg daily, level-2: 1000mg daily, level-3: 1500mg daily, level-4: 2000g daily) by utilizing a standard 3 + 3 design. Treatment was administered in 28-day cycles following an initial 2 weeks of Metformin titration during the first cycle. MTD was defined as the highest dose studied in which the incidence of dose-limiting toxicity (DLT) was less than 33%.

Results: Twenty-one patients (male/female: 7/14) with sarcoma (n = 8), colorectal cancer (n = 3), endometrial cancer (n = 4), uterine carcinosarcoma (n = 2), ovarian cancer (n = 2) and other cancers (n = 2) were enrolled. Median age of patients was 56 (range 18-81) years. Patients had received median of 4 (range 2-11) lines of prior systemic treatments. Three DLTs were observed including one grade 3 mucositis in a patient with dose level-1, one grade 2 pneumonitis in level-2 and one grade 3 renal failure in level-4; all 3 patients who experienced DLT were able to continue treatment after dose modification. No grade 4 or 5 toxicities were observed. Patients continued treatment for a median of 11 (range 1-99; interquartile range 8-25) weeks.

Conclusion: Combination of Temsirolimus and Metformin is feasible and well tolerated. We recommend a dose of Temsirolimus 25mg IV weekly and Metformin 2000mg orally daily administered in 28-day cycles for phase 2 study. The combination showed modestly promising effectiveness among this cohort of heavily pretreated patients. Further expansion is being conducted among patients with metastatic endometrial cancer.

Citation Format: Muhammad Rizwan Khawaja, Vinu Madhusudanannair, Chaan Ng, Alpa Nick, Filip Janku, Sarina Piha-Paul, Robert Coleman, Pamela Soliman, Siqing Fu, David Hong, Daniel Karp, Vivek Subbiah, Apostolia Tsimberidou, Funda Meric-Bernstam, Karen Lu, Aung Naing. Phase I dose escalation study of temsirolimus in combination with metformin in patients with advanced cancers. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr C44.

Retreatment with anti-EGFR based therapies in metastatic colorectal cancer: impact of intervening time interval and prior anti-EGFR response

BACKGROUND

This retrospective study aims to investigate the activity of retreatment with anti-EGFR-based therapies in order to explore the concept of clonal evolution by evaluating the impact of prior activity and intervening time interval.

METHODS

Eighty-nine KRAS exon 2-wild-type metastatic colorectal patients were retreated on phase I/II clinical trials containing anti-EGFR therapies after progressing on prior cetuximab or panitumumab. Response on prior anti-EGFR therapy was defined retrospectively per physician-records as response or stable disease ≥6 months. Multivariable statistical methods included a multiple logistic regression model for response, and Cox proportional hazards model for progression-free survival.

RESULTS

Retreatment anti-EGFR agents were cetuximab (n = 76) or cetuximab plus erlotinib (n = 13). The median interval time between prior and retreatment regimens was 4.57 months (range: 0.46-58.7). Patients who responded to the prior cetuximab or panitumumab were more likely to obtain clinical benefit to the retreatment compared to the non-responders in both univariate (p = 0.007) and multivariate analyses (OR: 3.38, 95 % CI: 1.27, 9.31, p = 0.019). The clinical benefit rate on retreatment also showed a marginally significant association with interval time between the two anti-EGFR based therapies (p = 0.053). Median progression-free survival on retreatment was increased in prior responders (4.9 months, 95 % CI: 3.6, 6.2) compared to prior non-responders (2.5 months, 95 % CI, 1.58, 3.42) in univariate (p = 0.064) and multivariate analysis (HR: 0.70, 95 % CI: 0.43-1.15, p = 0.156).

CONCLUSION

Our data lends support to the concept of clonal evolution, though the clinical impact appears less robust than previously reported. Further work to determine which patients benefit from retreatment post progression is needed.

Phase I study of pazopanib and vorinostat: a therapeutic approach for inhibiting mutant p53-mediated angiogenesis and facilitating mutant p53 degradation

BACKGROUND

We carried out a phase I trial of the vascular endothelial growth factor inhibitor pazopanib and the histone deacetylase inhibitor vorinostat to determine the safety and efficacy. Because these agents are known to target factors activated by TP53 mutation and facilitate mutant p53 degradation, a subgroup analysis may be interesting in patients with TP53 mutant malignancies.

PATIENTS AND METHODS

Patients with advanced solid tumors (n = 78) were enrolled following a 3 + 3 design, with dose expansion for those with responsive tumors. Hotspot TP53 mutations were tested when tumor specimens were available.

RESULTS

Adverse events of ≥grade 3 included thrombocytopenia, neutropenia, fatigue, hypertension, diarrhea and vomiting. Overall, the treatment produced stable disease for at least 6 months or partial response (SD ≥6 months/PR) in 19% of the patients, median progression-free survival (PFS) of 2.2 months, and median overall survival (OS) of 8.9 months. In patients with detected hotspot TP53 mutant advanced solid tumors (n = 11), the treatment led to a 45% rate of SD ≥6 months/PR (1 PR and 3 SD ≥6 months), median PFS of 3.5 months, and median OS of 12.7 months, compared favorably with the results for patients with undetected hotspot TP53 mutations (n = 25): 16% (1 PR and 3 SD ≥6 months, P = 0.096), 2.0 months (P = 0.042), and 7.4 months (P = 0.1), respectively.

CONCLUSION

The recommended phase II dosage was oral pazopanib at 600 mg daily plus oral vorinostat at 300 mg daily. The preliminary evidence supports further evaluation of the combination in cancer patients with mutated TP53, especially in those with metastatic sarcoma or metastatic colorectal cancer.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, NCT01339871.

The changing face of phase I protocols: A closer look at study requirements

3061

Background: We have studied our recent experience in the MDACC Clinical Translational Research Center (CTRC), the Phase I Program, and the Dept. of Thoracic/Head & Neck Medical Oncology to compare the extent of regulatory and other requirements for current phase I and II cancer clinical trials. Methods: We developed a comprehensive database, together with a Microsoft Excel spreadsheet matrix to analyze the number and extent of diagnostic and therapeutic requirements for each protocol. We then examined the demands for pharmacokinetic (PK) sampling as well as electrocardiography (ECG) in the first cycle of a protocol as a surrogate for study complexity. Results: Since October, 2002, 250 protocols have been conducted in the CTRC; 54.6% were Phase I clinical trials. We reviewed 65 trials, approximately one quarter of the total. Of these, 48 were phase I trials carried out by the Phase I Program. For comparison, we identified 17 phase II trials managed by the Dept. of Thoracic/Head & Neck Medical Oncology during the same time period. In the phase I trials there were significantly more PKs (mean ± SE = 16.69 ± 1.93) than in the phase II trials (mean ± SE = 1.82 ± 1.17) (p<0.0001). Similarly, there were more ECGs in the phase I versus phase II trials (4.46 ± 1.18 vs. 1.41 ± 0.35; p=0.017). Conclusions: Pharmacokinetic collection and ECG monitoring in Phase I trials are complex and labor-intensive. In addition, they represent only a small portion of time-intensive requirements, with increasingly complicated correlates and monitoring (physical exams, imaging, etc.). Successful and accurate Phase I clinical trials require resources and commitment for research infrastructure considerably greater than later phase studies.

No significant financial relationships to disclose.

Risk of intracranial hemorrhage and cerebrovascular accidents in non-small cell lung cancer brain metastasis patients

7671

Background: Brain metastases confer significant morbidity and a poorer survival in non-small cell lung cancer (NSCLC). Vascular endothelial growth factor-targeted antiangiogenic therapies (AAT) have demonstrated benefit for patients with metastatic NSCLC and are expected to directly inhibit the pathophysiology and morbidity of brain metastases, yet patients with brain metastases have been excluded from most clinical trials of AAT for fear of intracranial hemorrhage (ICH). This is a low suspected risk, but needs to be quantitated to plan clinical trials of AAT for NSCLC brain metastases. Methods: Data from MD Anderson Cancer Center Tumor Registry and electronic medical records from January 1998 to March 2006 was interrogated. 2143 patients with metastatic NSCLC registering from Jan 1998 to Sept 2005 were followed till March 2006. 776 patients with and 1367 patients without brain metastases were followed till death, date of ICH, or last date of study, whichever occurred first. Results: The incidence of ICH seemed to be higher in those with brain metastasis compared to those without. However, the rates of symptomatic ICH were not significantly different. All ICH patients with brain metastasis had received radiation therapy for them and were not anticoagulated. Most of the brain metastasis-associated ICH's were asymptomatic, detected during radiologic surveillance. The rates of symptomatic ICH, or cerebrovascular accidents were similar and not significantly different between the two groups. The following table depicts the rates of CVA and/or ICH in metastatic NSCLC patients. Conclusions: In metastatic NSCLC patients, the incidence of spontaneous ICH appeared to be higher in those with brain metastases compared to those without, but was very low in both groups nonetheless without a statistically significant difference. These data suggest minimal risk of clinically significant ICH for NSCLC brain metastasis patients and justifies for them clinical trials of AAT.

No significant financial relationships to disclose.

[Table: see text]

Phase II Trial of Sequential Chemotherapy Followed by Chemoradiation, Surgery, and Postoperative Chemotherapy for the Treatment of Stage IIIA/IIIB Non-Small-Cell Lung Cancer

BACKGROUND

The optimal treatment of locally advanced non-small-cell lung cancer remains a challenge. Although the benefit of combined chemoradiation has been established, the optimal chemotherapy regimen, timing of full-dose chemotherapy, and how best to combine chemotherapy with radiation to maximize systemic and radiosensitizing effects remain unclear.

PATIENTS AND METHODS

Twenty-nine patients with pathologically confirmed stage IIIA/IIIB non-small-cell lung cancer were included in a phase II trial of sequential carboplatin/paclitaxel followed by chemoradiation, surgery, and postoperative gemcitabine. Twenty-five patients (86%) completed the concurrent chemotherapy and radiation therapy phase and were eligible for surgery. At restaging, 7 patients (21%) showed disease progression. Seventeen patients (59%) went on to surgery. Few were able to tolerate full postoperative chemotherapy.

RESULTS

The 1-year overall survival rate was 61%, with a 2-year survival rate of 56%. Median overall survival was 25.2 months. Seven of the patients are alive and without recurrence at the time of this writing. Our median follow-up time was 22.2 months. Reversible grade 3/4 toxicities were fairly common, experienced in 45% of patients.

CONCLUSION

Our results with this combined modality approach are comparable with those of previous, similar studies. Postoperative chemotherapy after initial combined modality therapy is often not feasible, reinforcing the value of initial systemic therapy. Long-term results are still suboptimal and await studies adding targeted therapies to our usual chemotherapy/radiation approaches.

Prognostic quantification of non-small cell lung cancer metastases to the lung

17080

Background: Lung is the most frequent organ site of metastases from non-small cell lung cancer (NSCLC), yet the impact of these metastases on the natural history of the disease has not been well elucidated. Part of the difficulty of evaluating the prognosis of lung metastases in NSCLC patients is the effect of metastases to other organ sites. Here we have studied the survival of patients with lung as the solitary or dominant site of metastases and correlated it with number and maximal size of tumors. Methods: Data from the M.D. Anderson Cancer Center Tumor Registry during 1998 to 2002 was interrogated. Of 1280 patients registering as new patients, 87 were evaluable as having lung as the only site of metastases on initial staging evaluation. Excluding 13 patients who had bronchioloalveolar carcinoma (BAC) or BAC features on histology, the remaining 74 patients’ baseline CT scans were reviewed and scored for 1) the maximal linear measurement of the largest lung tumor and 2) the number of lung nodules that were growing and consistent with lung metastases. Results: In non-BAC patients with lung only metastases, an inverse correlation is seen between maximal linear measurement of a patient’s largest lung metastasis on baseline staging and their subsequent survival. A similar inverse correlation is seen between the number of lung metastases and survival. When patients with subsequent development of other metastatic sites are excluded from the analysis, these correlations are strengthened. Also, in BAC patients with lung only metastases, a trend toward longer survival with fewer metastases was seen, but only 13 patients were evaluable. Formal statistical analysis of these results is pending. Conclusions: The number and size of lung metastases from NSCLC appear to be independent predictors of survival. This might be explained by lead-time bias where fewer lesions represent an earlier stage of metastatic disease, however, increasing number and size of metastases may also be multiplying the source for further metastatic spread of disease. This interpretation of data may justify the local therapy of individual lung metastases in oligometastatic disease by surgery, stereotactic radiosurgery, or radiofrequency ablation.

No significant financial relationships to disclose.

Determinants of tumor response and survival with erlotinib in patients with non--small-cell lung cancer

PURPOSE

Erlotinib is a highly specific epidermal growth factor receptor (HER1/EGFR) tyrosine kinase inhibitor. This phase II study of erlotinib in patients with HER1/EGFR-expressing non-small-cell lung cancer previously treated with platinum-based chemotherapy evaluated tumor response, survival, and symptom improvement.

PATIENTS AND METHODS

Fifty-seven patients received an oral, continuous daily dose of 150 mg of erlotinib. Assessments of objective response used WHO and Response Evaluation Criteria in Solid Tumors criteria. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, supplemented with a lung cancer module, Quality of Life Questionnaire LC13, was used to measure health-related quality of life. Additional analyses were performed to identify predictors of response and survival.

RESULTS

The objective response rate was 12.3% (95% CI, 5.1% to 23.7%). Responses were observed regardless of type or number of prior chemotherapy regimens. Median survival time was 8.4 months (95% CI, 4.8 to 13.9 months), and the 1-year survival rate was 40% (95% CI, 28% to 54%). Erlotinib therapy was associated with tumor-related symptom improvement. The drug was well tolerated; drug-related cutaneous rash and diarrhea were observed in 75% and 56% of patients, respectively. One patient experienced toxicity consisting of severe grade 3 rash and diarrhea. Time since diagnosis and good performance status were significant predictors of survival in a multivariate Cox proportional hazards model, whereas HER1/EGFR staining intensity was not. Additionally, survival correlated with the occurrence and severity of rash.

CONCLUSION

Erlotinib was active and well tolerated in this patient population, and further clinical development is clearly warranted. Cutaneous rash seems to be a surrogate marker of clinical benefit, but this finding should be confirmed in ongoing and future studies.

Phase II randomized trial of cisplatin and WR-2721 versus cisplatin alone for metastatic melanoma

This study was designed to evaluate the toxicity and efficacy of cisplatin and WR-2721 in contrast to cisplatin alone for the therapy of measurable metastatic melanoma. Ninety-four patients with metastatic melanoma were randomized to receive either cisplatin at a dose of 150 mg/m2 and WR-2721 at a dose of 910 mg/m2, or cisplatin alone at a dose of 120 mg/m2. WR-2721 did not mitigate the toxic effects of cisplatin, and toxicity was increased in the WR-2721 plus cisplatin arm compared with cisplatin alone. For patients receiving cisplatin alone, the response rate was 16.3%; for those receiving cisplatin plus WR-2721, the response rate was 23.3%. The duration of response was 7.3 months. Median survival in the intent-to-treat analysis was 7.58 months. The study was terminated after accrual of 94 patients, with inadequate power to define an effect of WR-2721 on the duration of response and survival. In conclusion, cisplatin with WR-2721 showed an improved response rate over cisplatin alone. The lack of improved duration of response or impact on survival may be the result of the limited improvement of efficacy with the higher dosage of cisplatin in conjunction with WR-2721, or the limited number of patients accrued to this study. These factors, coupled with the failure of the combination to diminish toxicity, dampen enthusiasm for this combination.