Evaluation of Treatment With Talazoparib and Avelumab in Patients With Recurrent Mismatch Repair Proficient Endometrial Cancer

Question

Is treatment with combined polyadenosine diphosphate-ribose polymerase and immune checkpoint inhibition active and safe in patients with recurrent mismatch repair proficient endometrial cancer (MMRP EC)?

Findings

In this single-arm, phase 2, 2-stage, nonrandomized clinical trial of treatment with avelumab and talazoparib in recurrent MMRP EC that included 35 patients, the confirmed objective response rate was 11.4%, and the progression-free survival at 6 months rate was 22.9%. No patients discontinued therapy because of toxic effects, and immunogenomic profiling provided insights into subsets of patients who may derive benefit from this combination.

Meaning

These study findings suggest that treatment with avelumab and talazoparib has a favorable toxic effects profile and support further investigation in certain subsets of patients with recurrent MMRP EC.

Importance

Although the activity of pembrolizumab and lenvatinib (the only US Food and Drug Administration–approved immunotherapy for mismatch repair proficient endometrial cancer [MMRP EC]) is compelling, there are no biomarkers of response and most patients do not tolerate, do not respond to, or develop resistance to this regimen, highlighting the need for additional, potentially biomarker-driven therapeutic approaches for patients with recurrent MMRP EC.

Objective

To assess the potential positive outcomes and safety of the combination of the polyadenosine diphosphate-ribose polymerase inhibitor talazoparib and the programmed cell death ligand 1 (PD-L1) inhibitor avelumab in recurrent MMRP EC.

Design, Settings, and Participants

This investigator-initiated, open-label, single-arm, 2-stage, phase 2 study nonrandomized controlled trial patients at 4 institutions in the US. Key eligibility criteria included measurable disease, unlimited prior therapies, and all endometrial cancer histologies.

Interventions

Talazoparib, 1 mg, orally, daily, and avelumab, 10 mg/kg, intravenously, every 2 weeks, were administered until disease progression or unacceptable toxic effects.

Main Outcomes and Measures

Statistical considerations were developed for 2 coprimary objectives of objective response rate and rate of progression-free survival at 6 months, with a 2-stage design that allowed for early discontinuation for futility. Prespecified exploratory objectives included the association of immunogenomic features (determined by targeted-panel next-generation sequencing and immunohistochemistry) with activity.

Results

Thirty-five female patients (mean [SD] age, 67.9 [8.41] years) received protocol therapy; 9 (25.7%) derived clinical benefit after meeting at least 1 of the 2 coprimary end points. Four patients (11.4%) exhibited confirmed objective response rates (4 partial responses), and 8 (22.9%) survived progression free at 6 months. The most common grade 3 and 4 treatment-related toxic effects were anemia (16 [46%]), thrombocytopenia (10 [29%]), and neutropenia (4 [11%]); no patient discontinued receipt of therapy because of toxic effects. Tumors with homologous recombination repair alterations were associated with clinical benefit from treatment with avelumab and talazoparib. Tumor mutational burden, tumor-infiltrating lymphocytes, and PD-L1 status were not associated with clinical benefit.

Conclusions and Relevance

The results of this nonrandomized controlled trial suggest that treatment with avelumab and talazoparib demonstrated a favorable toxic effect profile and met the predetermined criteria to be considered worthy of further evaluation in MMRP EC. Immunogenomic profiling provided insights that may inform ongoing and future studies of polyadenosine diphosphate-ribose polymerase and PD-L1 inhibitor combinations in endometrial cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT02912572

Phase I dose escalation safety and feasibility study of autologous WT1-sensitized T cells for the treatment of patients with recurrent ovarian cancer

Background

This phase I dose escalation trial evaluated the feasibility of production, safety, maximum tolerated dose, and preliminary efficacy of autologous T cells sensitized with peptides encoding Wilms’ tumor protein 1 (WT1) administered alone or following lymphodepleting chemotherapy, in the treatment of patients with recurrent WT1⁺ ovarian, primary peritoneal, or fallopian tube carcinomas.

Methods

A 3+3 dose escalation design was used to determine dose-limiting toxicity (DLT). In cohort I, patients received WT1-sensitized T cells dosed at 5×10⁶/m² (level I) without cyclophosphamide lymphodepletion. In cohorts II–IV, patients received lymphodepleting chemotherapy (a single intravenous dose of cyclophosphamide 750 mg/m²), 2 days prior to the first intravenous infusion of WT1-sensitized T cells administered at escalating doses (2×10⁷/m² (level II), 5×10⁷/m² (level III), and 1×10⁸/m² (level IV)).

Results

Twelve patients aged 23–72 years, with a median of 7 prior therapies (range 4–14), were treated on the study. No DLT was observed, even at the highest dose level of 1×10⁸/m² WT1-sensitized T cells tested. Common adverse events reported were grade 1–2 fatigue, fever, nausea, and headache. Median progression-free survival (PFS) was 1.8 months (95% CI, 0.8 to 2.6); 1 year PFS rate 8.3% (95% CI, 0.5 to 31.1). Median overall survival (OS) was 11.0 months (95% CI, 1.1 to 22.6); OS at 1 year was 41.7% (95% CI, 15.2% to 66.5%). Best response was stable disease in one patient (n=1) and progressive disease in the others (n=11). We observed a transient increase in the frequencies of WT1-specific cytotoxic T lymphocyte precursors (CTLp) in the peripheral blood of 9 of the 12 patients following WT1-sensitized T-cell infusion.

Conclusion

We demonstrated the safety of administration of WT1-sensitized T cells and the short-term increase in the WT1 CTLp. However, at the low doses evaluated we did not observe therapeutic activity in recurrent ovarian cancer. In this heavily pretreated population, we encountered challenges in generating sufficient numbers of WT1-reactive cytotoxic T cells. Future studies employing WT1-specific T cells generated from lymphocytes are warranted but should be done earlier in the disease course and prior to intensive myelosuppressive therapy.

Trial registration number

NCT00562640.

One-sentence summary

The authors describe the first human application of autologous WT1-sensitized T cells in the treatment of patients with recurrent ovarian, primary peritoneal, and fallopian tube carcinomas.

Abstract 1837: A human artificial chromosome (HAC)-based system as a powerful tool for stable co-expression of multiple proteins and therapeutic IgGs in mammalian cells

Background: Currently, there is increasing demand for recombinant therapeutic proteins produced in mammalian cell lines, especially therapeutic antibodies. MUC16-directed IgG and bispecific diabodies are one such example that represents a promising strategy for treatment of ovarian cancer. HEK293 and CHO cells are mostly used for large-scale stable expression of therapeutic proteins, however low protein yield, transgene silencing, cell line instability, and the time-consuming process of cell line development represent serious challenges. Here, we are presenting an alternative system for stable, high yield expression of multiple genes including complex therapeutic antibodies (HC and LC genes) and other proteins within single HAC. HAC vector propagate independently in cells without integration in the host chromosomes and has unlimited cloning capacity. Furthermore, this particular HAC can be targeted by transcriptional transactivators like tetR-VP16, eliminating transgene silencing, thereby providing stable long-term high yield protein production in mammalian cells.

Methods: The targeting vector containing single or multiple genes is loaded at the unique LoxP site of tetO-HAC propagated in HPRT-deficient CHO cells by Cre-LoxP mediated recombination. As a result of recombination, functional HPRT gene will be reconstituted and HPRT-positive colonies are selected after 3 weeks growth in HAT medium. In the next step, HAC with therapeutic transgene(s) is transferred to the different high productive cell lines via MMCT technique following by high yield protein(s) expression in spinner flask. The alphoid tetO-HAC carries Bsr gene, so Blasticidin is used to select for the recipient cells that have taken up the HAC after Microcell-mediated chromosome transfer (MMCT).

Results: Targeting vector with His-tagged MUC16 BiTEs gene (or iBAC caring HC and LC of anti-MUC16 IgG) was inserted into the HAC propagated in CHO cells. HPRT gene reconstitution was confirmed by PCR using a set of specific primers. Expression of His-tagged MUC16 BiTEs or anti-MUC16 IgG in CHO cells was confirmed by western blot and SDS-PAGE analysis. The yield of Ni- purified MUC16 BiTEs was up to 6 mg/l in original CHO cells. Our data from cellular models confirmed high efficacy of Ni- purified MUC16 BiTEs against OVCAR3 tumor cells, - up to 80% of the tumor cells were killed by T-cells in the presence of MUC16 BiTEs protein. After that, HAC/MUC16 BiTEs was successfully transferred to high productive ExpiHEK293F cells by MMCT. Therapeutic HAC transferring was confirmed by expression DsRed transgene linked with MUC16BiTEs through IRES and FISH analysis. FISH reveals the HAC propagated independently in ExpiHEK293F cells.

Conclusions: Our data shows that the HAC is the new promising system for stable, high yield production of multiple therapeutic proteins.

Citation Format: Artem Kononenko, Ian Laster, Oladapo Yeku, David Spriggs. A human artificial chromosome (HAC)-based system as a powerful tool for stable co-expression of multiple proteins and therapeutic IgGs in mammalian cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1837.

Bispecific T-Cell Engaging Antibodies Against MUC16 Demonstrate Efficacy Against Ovarian Cancer in Monotherapy and in Combination With PD-1 and VEGF Inhibition

Immunotherapy for ovarian cancer is an area of intense investigation since the majority of women with relapsed disease develop resistance to conventional cytotoxic therapy. The paucity of safe and validated target antigens has limited the development of clinically relevant antibody-based immunotherapeutics for this disease. Although MUC16 expression is almost universal in High Grade Serous Ovarian Cancers, engagement of the shed circulating MUC16 antigen (CA-125) presents a theoretical risk of systemic activation and toxicity. We designed and evaluated a series of bispecific tandem single-chain variable fragments specific to the retained portion of human MUC16 ectodomain (MUC16^ecto) and human CD3. These MUC16^ecto- BiTEDs retain binding in the presence of soluble MUC16 (CA-125) and show cytotoxicity against a panel of ovarian cancer cells in vitro. MUC16^ecto- BiTEDs delay tumor progression in vivo and significantly prolong survival in a xenograft model of ovarian peritoneal carcinomatosis. This effect was significantly enhanced by antiangiogenic (anti-VEGF) therapy and immune checkpoint inhibition (anti-PD1). However, the combination of BiTEDs with anti-VEGF was superior to combination with anti-PD1, based on findings of decreased peritoneal tumor burden and ascites with the former. This study shows the feasibility and efficacy of MUC16^ecto- specific BiTEDs and provides a basis for the combination with anti-VEGF therapy for ovarian cancer.

Abstract 3374: Development of novel and improved monoclonal antiMUC16 antibodies for the targeted therapy of ovarian cancer

There is a need for the development of better targeted therapies in the treatment of ovarian cancer. Monoclonal antibodies directed towards MUC16, a diagnostic and prognostic marker for ovarian cancer, with improved selectivity and specificity would be an instrumental component in the construction of novel methods of drug delivery and immunotherapies. C57BL/6 mice were immunized with various MUC16 peptides and truncated MUC16 constructs to extend the scope of MUC16 epitopes within the proximal COOH portion of the retained elements. Three rounds of hybridomas were made from harvested murine splenocytes, and subsequent rounds of peptide-based ELISA and cell-based flow cytometry were performed to select the most promising subclones from each of the fusions. Over 50 hybridomas producing antibodies against MUC16 have been identified and screened for reactivity with MUC16 peptide sequences and native, full-length MUC16 protein presented on the surface of ovarian cancer cell line cells. The antibodies were isotyped, and 10 have been selected for initial characterization. Non-overlapping epitopes were mapped via sequential and tandem peptide-based ELISA. With improved selectivity and specificity, these monoclonal antibodies will be used in the construction of antibody drug conjugates (ADCs) as potential targeted therapies in the treatment of ovarian cancer. Efficacy testing of the candidate antibodies in Matrigel invasion and direct growth inhibition assays is underway. Comparative effectiveness of the binding, internalization, and killing by ADCs in ovarian cancer cell lines will be presented. Antibodies against key MUC16 epitopes may have value in the development of antigen directed therapy.

Citation Format: Ian Laster, Oladapo Yeku, David Spriggs. Development of novel and improved monoclonal antiMUC16 antibodies for the targeted therapy of ovarian cancer [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 3374.

Abstract LB-229: Utilizing a novel highly specific sialyl-Tn ELISA as a diagnostic for ovarian cancer

Sialyl-Thomsen-nouveau antigen (STn), a tumor-associated carbohydrate antigen (TACA) is elevated in several solid tumors. In ovarian cancer, increased STn levels correlate with chemo-resistance and decreased suvival. Our recent studies suggest that many of STn antibodies utilized previously were not as specific as originally proposed so through a proprietary platform, a highly specific anti-STn antibody with high binding affinity was developed. Subsequent study of this antibody as an antibody-drug conjugate (ADC) demonstrated reduced tumor growth in patient derived xenograft models of high grade serous OvCa, an effect that positively correlated with tumor STn levels. Collectively, these findings and those by others suggest that STn might serve as relevant OvCa therapeutic target and could play a role as a biomarker for discriminating malignant from benign ovarian tumors. In this investigation, we designed and optimized a custom ELISA to detect STn levels in human serum. Our objective was to determine whether we could distinguish between benign and malignant serum samples. The assay was employed on retrospective serum samples derived from patients diagnosed with benign gynecologic disease (n =62) and serum from patients diagnosed with high grade OvCa (n =200). Serum samples were all collected from consented patients under an approved IRB protocol. Based on our analysis, we determined the areas under the receiver operating characteristic curves (AUC of ROC) to compare how STn values associated with malignant or benign conditions. Our STn assay demonstrated an AUC of 0.74 at an STn value of 0.025. Of the 8 patients with malignancy and a CA-125 < 35 mIU/ml, 6 were found to have elevated STn above the cutoff value and thus the sensitivity of CA-125 was significantly improved if elevated levels of STn were integrated as a biomarker. To determine whether circulating STn levels mirrored that which is detected in the tumor, we identified 15 samples with high (STn>0.096) and 15 samples with low (<0.096) levels and assessed STn in their matching formalin fixed, paraffin embedded tumor by immunohistochemistry (IHC). Elevated serum STn corresponded with positive STn focal 2+, 3+ staining 60% of the time while tumors with corresponding serum STn levels that were <0.096 were associated with 6.7% IHC tumor low focal 0, 1+ staining) STn staining. There was staining in tumor samples of patients that had relatively low STn levels in the serum, which is not surprising since not all STn glycosylated proteins are shed into the blood. These data suggest that serum STn levels may improve the sensitivity of CA-125 alone to detect malignancy in an adnexal mass of unknown nature making it a valuable biomarker for clinical triage. Additionally, serum STn levels have a significant correlation (Fisher exact p<0.01) with tumor expression and therefore may be useful in identifying women likely to respond to STn targeted agents.

Citation Format: Linah F. Al-Alem, Jillian Prendergast, Justin Clark, Bianca Zarrella, Dan Dransfield, Whitfield Growdon, David Spriggs, Eric Eisenhauer, Jeff Behrens, Bo R. Rueda. Utilizing a novel highly specific sialyl-Tn ELISA as a diagnostic for ovarian cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-229.

Abstract IA25: Strategies for glycosylation-based immunotargeting of MUC16

The pathobiology of MUC16 / CA125 has been of great interest for three decades. Most recently, my laboratory has been focused on the biology of MUC16, the glycoprotein encoding the CA125 antigen. In particular, we have been interested in role of the carboxyterminal elements of this tethered mucin. Our work has required the development of new reagents including multiple antibodies specific for the most proximal, non-shed sequences adjacent to the cell surface. In our studies, we have shown that few as 114 amino acids from the carboxy-terminal portion of MUC16 were sufficient to increase soft agar growth, promote matrigel invasion, and increase the rate of tumor growth in athymic nude mice. Transformation with carboxy elements of MUC16 was associated with activation of the EGFr, SRC AKT, and ERK pathways. MUC16 transformation was associated with upregulation of a number of metastases and invasion gene transcripts, including IL-1beta, MMP2, and MMP9. All observed oncogenic changes were exclusively dependent on the extracellular “ectodomain” of MUC16 and did not require the cytoplasmic domain of MUC16 for transformation. In TP53 +/- knockout mice, the most proximal 114 aa of MUC16 is sufficient to generate spontaneous tumors (primarily sarcomas) in transgenic mice (Rao TD et al. PLoS One 2015;10(5):e0126633). Subsequent experiments have shown that MUC16 oncogenic effects are mediated through tetra-antennary N-glycosylation of asparagine sites within the 58-amino-acid domain between the putative cleavage site and the cell membrane. We have also established that oncogenic signaling from the C-terminal portion of MUC16 requires the presence of Galectin-3 and growth factor receptors colocalized on lipid rafts. These effects are blocked upon loss of either Galectin-3 expression or activity of the glycosylation enzyme MGAT5. With sufficient N-glycosylation and Galectin-3 MUC16 stabilizes pro-growth receptors on the cancer cell surface and enhances signaling through decreased receptor turnover. This inhibition is dependent on Galectin-3, MGAT5-dependent glycosylation, and MUC16 interactions. Using synthetic MUC16 glycopeptides, we have developed novel N-glycosylation site directed monoclonal antibodies that block Galectin-3-mediated MUC16 interactions with cell surface signaling molecules. These antibodies inhibit invasion of ovarian cancer cells, directly blocking the in vivo growth of MUC16-bearing ovarian cancer xenografts, elucidating new therapeutic modalities (Rao TD et al. ACS Chem Biol 2017 epub). We have also examined the use of MUC16 targeted CAR-T cells. These CAR T cells, specifically directed at the most proximal portions of MUC16, are in clinical testing and early results will be discussed. Enhancements in the design of MUC16-directed T-cell vectors and therapeutic directions will be addressed as well.

Citation Format: David Spriggs, Roisin O’Cearbhaill, Oladapo Yeku, Marina Stasenko, Thapi D. Rao, Renier Brentjens. Strategies for glycosylation-based immunotargeting of MUC16. [abstract]. In: Proceedings of the AACR Conference: Addressing Critical Questions in Ovarian Cancer Research and Treatment; Oct 1-4, 2017; Pittsburgh, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(15_Suppl):Abstract nr IA25.

Absence of Potentiation with Murine Antiplatelet GPIIb/IIIa Antibody of Thrombolysis with Recombinant Tissue-Type Plasminogen Activator (rt-PA) in a Canine Venous Thrombosis Model

F(ab’)2 fragments of a murine monoclonal anti-platelet GPIIb/ IIIa antibody (7E3) are a potent platelet aggregation inhibitor, which in a canine coronary artery thrombosis model accelerate lysis with recombinant tissue-type plasminogen activator (rt-PA) and prevent reocclusion (7).

In the present study, we have investigated the potential value of platelet aggregation inhibition as adjunctive therapy to lysis of venous thrombi, by measuring the thrombolytic potency of 7E3- F(ab’)2 and rt-PA used alone or in combination, in dogs with a 125I-fibrin labeled femoral vein thrombus. The dose-response of thrombolysis with rt-PA infused over 4 hours was linear: doses of 0.075 mg/kg, 0.15 mg/kg and 0.3 mg/kg produced 37 ± 3, 57 ± 11 and 83 ± 4% lysis respectively, against a background value of 20 ± 2%. With F(ab’)2 fragments of 7E3 given as a bolus of 1.2 mg/ kg, which saturated 70% of the platelet GPIIb/IIIa receptors and prolonged the bleeding to more than 30 min, lysis was not significantly increased over background. Combination of 0.3 or 0.6 mg/kg of 7E3-F(ab’)2 with either 0.03 or 0.06 mg/kg of rt-PA did not produce more lysis than obtained with a comparable dose of rt-PA alone. No significant changes in plasma fibrinogen or α2- antiplasmin were observed with either agent alone or with the combination. It is concluded that extensive inhibition of platelet aggregation does not potentiate the thrombolytic effect of rt-PA in this venous thrombosis model.

Abstract PR08: Armored CAR T cells genetically modified to secrete IL-12 show enhanced efficacy and overcome a hostile tumor microenvironment in mouse ovarian peritoneal carcinomatosis

Chimeric antigen receptor T cell (CAR T) therapy for solid tumors has not replicated the success seen with hematologic malignancies such as CD19-expressing B cell acute lymphoblastic leukemia (B-ALL) and Myeloma. One hypothesis for this lack of efficacy is an immunosuppressive tumor microenvironment that renders adoptively transferred cells ineffective. Armored CAR T cells are CAR T cells that have been further engineered to express additional costimulatory ligands, soluble cytokines or secretable proteins in order to overcome a hostile tumor microenvironment. IL-12 is a proinflammatory cytokine that is only secreted by antigen presenting cells and has been shown to activate effector cells, suppress regulatory T cells and reprogram tumor associated macrophages. We hypothesize that CAR T cells that have been genetically engineered to secrete IL-12 will be more efficacious in the treatment of Muc16ecto positive ovarian cancer by overcoming an otherwise immunosuppressive ascitic tumor microenvironment. Herein we report the mechanisms of enhanced efficacy of an IL-12-armored CAR T cell (4H1128ζ-IL12) directed towards the retained portion of Muc16 (Muc16ecto). Using an immunocompetent syngeneic peritoneal carcinomatosis model of ovarian cancer (i.p ID8-muc16ecto), we show superior therapeutic efficacy of armored CAR T cells compared to second generation CARs (4H1128ζ). Tumor-bearing mice treated after 35 days with 4H1128ζ-IL12 were tumor-free for over 100 days compared to 4H1128ζ-treated mice (o.s: not reached vs 46 days, p= 0.008). Even when the tumor was allowed to establish for 42 days, mice treated with 4H1128ζ-IL12 survived longer than 4H1128ζ- treated mice (o.s: 97 vs 54 days, p= 0.0123). Investigations into the mechanism of improved survival in armored CAR T cell-treated mice showed increased in vivo expansion and modulation of the immunosuppressive ascites cytokine milieu via increased secretion of IL-12, IFN-γ, and TNF-α. Furthermore, 4H1128ζ-IL12 CAR T cells demonstrated enhanced in vitro proliferation and cytotoxic activity when cultured in ascites compared to control CAR T cells. Taken together, these results show that armored CAR T cells can be successfully engineered to overcome an otherwise immunosuppressive solid tumor microenvironment. These results represent the mechanistic companion of an ongoing phase I clinical trial of IL-12 armored CAR T cells in patients with relapsed/refractory ovarian cancer (NCT02498912).

This abstract is also being presented as Poster A32.

Citation Format: Oladapo Yeku, Terence Purdon, David Spriggs, Renier Brentjens. Armored CAR T cells genetically modified to secrete IL-12 show enhanced efficacy and overcome a hostile tumor microenvironment in mouse ovarian peritoneal carcinomatosis. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr PR08.

Medical service redesign shares the load saving 6000 bed days and improving morale

BACKGROUND AND AIMS

In 2010, demand on the Auckland City Hospital general medical service exceeded capacity. A review by the Royal Australasian College of Physicians was critical of training offered to registered medical officers, and low morale was a problem across the service. Management offered support for an improved model that would solve these problems.

METHODS

A project to redesign the general medical service was undertaken. Baseline analysis found uneven workload and insufficient capacity at peak times for patient presentations. Workshops involving the entire service led to a new model that splits workload and teams into patients likely to have a short stay from those requiring longer, ward-based care. Admissions are now distributed over 12 teams on weekdays and 4 on the weekends. There was an increase of approximately 2.5 in consultant full time equivalents but no change in registrar or house officer staffing.

RESULTS

Since the introduction of the new model, the average length of stay has fallen from 3.7 to 3.2 days (14%) and the median length of stay by 28%, resulting in a saving of 6000 bed days per year. Readmission, inpatient and 30-day mortality rates are unchanged. These results have been sustained over 18 months with signs of continuing improvement.

CONCLUSION

This project owes its success to the following factors - management support; iterative engagement of a range of staff; provision of timely data analysis; increases in senior medical officer staffing and reorganisation leading to more predictable and fair work practices. One challenge is discontinuity, whether between doctors and patients or within the medical team.

IL-12 secreting tumor-targeted chimeric antigen receptor T cells eradicate ovarian tumors in vivo

A novel approach for the treatment of ovarian cancer includes immunotherapy with genetically engineered T cells targeted to ovarian cancer cell antigens. Using retroviral transduction, T cells can be created that express an artificial T cell receptor (TCR) termed a chimeric antigen receptor (CAR). We have generated a CAR, 4H11-28z, specific to MUC-16^ecto antigen, which is the over-expressed on a majority of ovarian tumor cells and is the retained portion of MUC-16 after cleavage of CA-125. We previously demonstrated that T cells modified to express the 4H11-28z CAR eradicate orthotopic human ovarian cancer xenografts in SCID-Beige mice. However, despite the ability of CAR T cells to localize to tumors, their activation in the clinical setting can be inhibited by the tumor microenvironment, as is commonly seen for endogenous antitumor immune response. To potentially overcome this limitation, we have recently developed a construct that co-expresses both MUC16^ecto CAR and IL-12 (4H11-28z/IL-12). In vitro, 4H11-28z/IL-12 CAR T cells show enhanced proliferation and robust IFNγ secretion compared to 4H11-28z CAR T cells. In SCID-Beige mice with human ovarian cancer xenografts, IL-12 secreting CAR T cells exhibit enhanced antitumor efficacy as determined by increased survival, prolonged persistence of T cells, and higher systemic IFNγ. Furthermore, in anticipation of translating these results into a phase I clinical trial which will be the first to study IL-12 secreting CAR T cells in ovarian cancer, an elimination gene has been included to allow for deletion of CAR T cells in the context of unforeseen or off-tumor on-target toxicity.

Effect of Montanide and poly-ICLC adjuvant on human self/tumor antigen-specific CD4+ T cells in phase I overlapping long peptide vaccine trial

Vaccination of patients with ovarian cancer with overlapping long peptides (OLP) from cancer-testis antigen NY-ESO-1 and poly-ICLC in Montanide-ISA-51 (Montanide) was found to consistently induce integrated immune responses (antibody, CD4(+), and CD8(+) T cells). Using detailed methods, we investigated the respective effects of poly-ICLC and Montanide adjuvant on pre- and postvaccine NY-ESO-1-specific CD4(+) T cells, because of their central function for induction and maintenance of both antibody and CD8(+) T cells. Polyclonal NY-ESO-1-specific CD4(+) T-cell lines were generated from 12 patients using CD154-based selection of precursors before and after vaccination with (i) OLP alone, (ii) OLP in Montanide, or (iii) OLP and poly-ICLC in Montanide. Kinetics, quantification, fine specificity, avidity, and cytokine-producing pattern were analyzed in depth and compared between vaccine cohorts. Vaccination with OLP alone did not elicit CD4(+) T-cell responses; it suppressed high-avidity CD4(+) T-cell precursors that recognized naturally processed NY-ESO-1 protein before vaccination. Emulsification of OLP in Montanide was required for the expansion of high-avidity NY-ESO-1-specific CD4(+) T-cell precursors. Poly-ICLC significantly enhanced CD4(+) Th1 responses while suppressing the induction of interleukin (IL)-4-producing Th2 and IL-9-producing Th9 cells. In summary, Montanide and poly-ICLC had distinct and cooperative effects for the induction of NY-ESO-1-specific Th1 cells and integrated immune responses by OLP vaccination. These results support the use of admixing poly-ICLC in Montanide adjuvant to rapidly induce antitumor type I immune responses by OLP from self/tumor antigens in human cancer vaccines.

Lead poisoning from Ayurvedic medicines

A case of lead poisoning with established exposure to Ayurvedic medicines is presented. This patient migrated from India to New Zealand 8 years previously. He regularly visits India where he purchases "herbal remedies" for his wellbeing.

Simple prescribing errors and allergy documentation in medical hospital admissions in Australia and New Zealand

This study aimed to quantify and compare the prevalence of simple prescribing errors made by clinicians in the first 24 hours of a general medical patient's hospital admission. Four public or private acute care hospitals across Australia and New Zealand each audited 200 patients' drug charts. Patient demographics, pharmacist review and pre-defined prescribing errors were recorded. At least one simple error was present on the medication charts of 672/715 patients, with a linear relationship between the number of medications prescribed and the number of errors (r = 0.571, p < 0.001). The four sites differed significantly in the prevalence of different types of simple prescribing errors. Pharmacists were more likely to review patients aged > or = 75 years (39.9% vs 26.0%; p < 0.001) and those with more than 10 drug prescriptions (39.4% vs 25.7%; p < 0.001). Patients reviewed by a pharmacist were less likely to have inadequate documentation of allergies (13.5% vs 29.4%, p < 0.001). Simple prescribing errors are common, although their nature differs from site to site. Clinical pharmacists target patients with the most complex health situations, and their involvement leads to improved documentation.

Quality of resuscitation orders in general medical patients

BACKGROUND

Documentation of resuscitation status in hospitalized patients has relevance in the management of cardiopulmonary arrest. Its association with mortality, Length Of hospital Stay (LOS) and the patients' primary diagnosis has not been established in general medical inpatients in hospitals in Australia and New Zealand.

AIM

To investigate the association of resuscitation orders with in-hospital mortality and LOS in a range of diagnoses, adjusting for severity of illness and other covariates.

DESIGN

Retrospective study.

METHODS

The admission notes of 1681 medical admissions to four tertiary care teaching hospitals across Australia and New Zealand were reviewed retrospectively for frequency and nature of resuscitation documentation and its association with mortality, LOS and primary diagnosis.

RESULTS

Resuscitation orders were documented in 741 patients (44.7%). For the 232 patients with a Not For Resuscitation (NFR) order, the in-hospital mortality rate was higher than in control patients (14% vs. 1.2%, P<0.005). The mortality rate remained significantly higher in the NFR group after propensity matching of the controls for age and co-morbidity (14% vs. 5%, P<0.005). The death-adjusted LOS for the NFR group was also significantly higher compared to the control patients (9.7 days vs. 4.7 days, P<0.005) and this difference remained after propensity matching (9.7 days vs. 7.7 days, P<0.05). Those patients with a primary diagnosis of respiratory tract infection or cardiac failure were more likely to be documented NFR compared to those with cellulitis or urinary tract infection.

CONCLUSIONS

The documentation of NFR in a patient's admission notes is associated with increased in-hospital mortality and LOS. This is only partly explicable in terms of these patients' greater age and co-morbidity.

Topotecan in patients with BRCA-associated and sporadic platinum-resistant ovarian, fallopian tube, and primary peritoneal cancers

OBJECTIVE

To evaluate the efficacy of topoisomerase I inhibitor, topotecan, in patients with recurrent BRCA+ versus BRCA- ovarian, fallopian tube, and primary peritoneal carcinomas.

METHODS

A single-institution retrospective analysis of platinum-resistant patients characterized for the presence or absence of known deleterious BRCA mutations. Patients received topotecan at a dose and schedule determined by their treating physician (five day or weekly). Response rate and progression-free survival (PFS) were assessed.

RESULTS

A total of 50 patients (9 BRCA+, 41 BRCA-) were treated with topotecan. Both groups were well balanced in terms of age, stage, grade, and number of prior therapies. All patients had high-grade serous carcinoma. The clinical benefit rate in BRCA+ and BRCA- patients was 0% and 26.8% (6 PRs, 6 SDs), respectively (p=0.18). Median PFS in BRCA+ and BRCA- pts was 1.7 months (95% CI: 1.0-2.8 months) and 2.5 months (95%CI: 1.9-2.8 months), respectively (p=0.057). Median time to best response was 1.9 months, and median response duration 2.6 months.

CONCLUSIONS

This analysis in a heavily pretreated cohort of patients fails to support the superiority of topotecan in BRCA+ platinum-resistant ovarian, fallopian tube, and primary peritoneal cancers. Further study of this class of agents, specifically in less heavily-pretreated patients, may still be warranted.

The design of phase II clinical trials testing cancer therapeutics: consensus recommendations from the clinical trial design task force of the national cancer institute investigational drug steering committee

The optimal design of phase II studies continues to be the subject of vigorous debate, especially studies of newer molecularly targeted agents. The observations that many new therapeutics "fail" in definitive phase III studies, coupled with the numbers of new agents to be tested as well as the increasing costs and complexity of clinical trials, further emphasize the critical importance of robust and efficient phase II design. The Clinical Trial Design Task Force (CTD-TF) of the National Cancer Institute (NCI) Investigational Drug Steering Committee (IDSC) has published a series of discussion papers on phase II trial design in Clinical Cancer Research. The IDSC has developed formal recommendations about aspects of phase II trial design that are the subject of frequent debate, such as endpoints (response versus progression-free survival), randomization (single-arm designs versus randomization), inclusion of biomarkers, biomarker-based patient enrichment strategies, and statistical design (e.g., two-stage designs versus multiple-group adaptive designs). Although these recommendations in general encourage the use of progression-free survival as the primary endpoint, randomization, inclusion of biomarkers, and incorporation of newer designs, we acknowledge that objective response as an endpoint and single-arm designs remain relevant in certain situations. The design of any clinical trial should always be carefully evaluated and justified based on characteristic specific to the situation.

Consolidation strategies in ovarian cancer: observations for future clinical trials

PURPOSE.: To describe the characteristics of a series of study populations of ovarian cancer patients with identical eligibility criteria in second or subsequent clinical remission (cCR) and to propose endpoint benchmarks for future consolidation studies. PATIENTS AND METHODS.: The patient populations consisted of those (1) untreated (U; observed until progression; n=35, (2) receiving imatinib (G; n=32), (3) receiving goserelin and bicalutamide (A; n=32), and (4) receiving vaccine (V; n=68; total=167). The endpoint of the combined analysis was progression-free survival in second remission (PFS 2). Patient characteristics were compared by chi-square test, and factors predicting PFS 2 evaluated in multivariate Cox model. RESULTS.: Groups were comparable for age, stage, grade, and debulking. Multivariate model to predict PFS 2 duration included histology, stage, optimal debulking, PFS 1 duration, and the type of intervention. As a benchmark for future studies, the median PFS 2 of the combined population of G, A, and U (removing V which had the most impact in prolonging PFS 2, n=68) was 11.3 months (95% CI: 10.4-12.5 months). The percent of patients with PFS 2>PFS 1 was 14/90 (16%). At 12 months, 43% remain progression-free. CONCLUSION.: Preliminary benchmarks for efficacy endpoints are suggested for future consolidation trials of patients in cCR. However, the suggested strategies will require validation in randomized trials and larger data sets.

MUC16/CA125 specific targeting of critical signaling kinases in ovarian cancer

e22112

Background: The serum marker CA125 is known to originate from the transmembrane protein, MUC16; however, the biological importance of MUC16 is not known. Our lab previously created fluorescent-labeled transfectants, containing truncated versions of the MUC16 molecule. MUC16 expression vectors were transfected into CA125-negative ovarian cancer cell lines. These cell lines have allowed for a unique means of studying MUC16 biology. In vivo data suggest that MUC16 drives a more aggressive phenotype in ovarian cancer, including increased growth, invasion and dissemination. MUC16 transfection is also associated with the upregulation of specific signaling kinases, including EGFR, Erk, Src and Akt. To validate these findings and explore the potential of MUC16 signal targeting through inhibition of downstream kinases, we are examining the effect of a kinase-directed siRNA library on the A2780 ovarian cancer cell line transfected with a carboxy-terminus MUC16-expression vector. With the identification of kinases important to the survival of CA125+ ovarian cancer tissue, we will identify molecular targets for novel, tumor-specific therapies. Methods: Pilot plates containing candidate kinase-directed, negative control and total kill siRNA (Qiagen) were applied to MUC16+ and MUC16- cells. Cells were grown in culture in parallel 96-well plates. Immunofluorescent readings and Alamar Blue viability staining were performed at 72 hours. Results: Transfection reagents and nonspecific siRNA did not substantially change the survival of fluorescent protein expression in MUC16± cells; while hrGFP and mCherry proteins were decreased by ∼75%. None of the final transfection conditions altered Alamar Blue survival. Preliminary studies suggest that siRNA against AKT2 and SRC had specific inhibition against MUC16+ cells compared to MUC16- controls. Studies of three additional AKT2 siRNAs and a full complement of 714 human kinases are now being tested. Kinases with MUC16-specifc effects will be confirmed with three additional siRNAs. Conclusions: Dual fluorescence isogenic cell lines can be used to explore the kinase profile of MUC16+ ovarian cancer cells. Identified target kinases will enhance our knowledge about MUC16/CA125 biology and provide future leads for the treatment of ovarian cancer.

No significant financial relationships to disclose.

Intraperitoneal chemotherapy (IPC) in older women with epithelial ovarian cancer (EOC)

5541

Background: Over half of patients (pts) diagnosed with EOC are ≥ 65 yrs of age. GOG 172 showed a significant survival advantage with post-operative IPC in all women with newly diagnosed stage III EOC, regardless of age. Toxicity can be significant and there is limited data for pts ≥ 65 yrs. Methods: A descriptive intention-to-treat analysis of pts ≥ 65yrs treated with IPC for EOC at our center from 1994–2008. Medical records were reviewed retrospectively to detail toxicity (CTCAEv3.0), compliance and outcome. Results: 118 pts with a median age of 70 yrs (range 65–83), KPS 90% (range 70–90), and co-morbidities 2 (range 0–6) were treated with IPC: 27 pts (23%) as primary postoperative IPC (IV paclitaxel 135mg/m2 D1, IP cisplatin 75mg/m2 D2 & IP paclitaxel 60mg/m2 D8) and 91 pts (77%) as consolidation (IP cisplatin regimen, alone or combined with IV paclitaxel or with IP gemcitabine). Median no. of cycles was 3 (range 0–7) with 55% pts completed total no. planned. 18% were switched to IV treatment. 14% had treatment delays. 32% required dose reductions, 22% at cycle 1. Toxicities included: 32% had IP port complications, 42% functional decline, 43% new ≥ Gr1 neuropathy (4% Gr3), 12% Gr2 hearing impairment, 60% ≥ Gr1 nausea/vomiting (4% Gr3), 57% ≥ Gr1 diarrhea/constipation (0% Gr3), 37% ≥ Gr1 abdominal pain (2% Gr3). For evaluable pts, 78% had ≥ Gr1 electrolyte disturbance (5% Gr3–4), 71% ≥ Gr1 nephrotoxicity (5% Gr2; 1% Gr3), 20% ≥ Gr2 neutropenia (6%Gr3; 3% Gr4). Ca125 normalized in 90% (pts with elevated baseline Ca125). Kaplan-Meier estimated median PFI was 1.2yrs (95% CI: 1–1.6yrs). Conclusions: Rate of completed full IPC cycles and toxicity is similar to published data. IPC can be safely administered in pts ≥ 65yrs with adequate support and dose modifications. Older patients must be adequately represented in future prospective trials.

No significant financial relationships to disclose.

A phase II study of intravenous (IV) and intraperitoneal (IP) paclitaxel, IP cisplatin, and IV bevacizumab as first-line chemotherapy for optimal stage II or III ovarian, primary peritoneal, and fallopian tube cancer

5539

Background: IP cisplatin (Cis) plus IV/IP paclitaxel (Tax) is a standard therapy for optimally debulked ovarian cancer. Bevacizumab (Bev) is a recombinant humanized IgG1 monoclonal antibody directed against vascular endothelial growth factor. Activity of Bev in recurrent ovarian cancer has been reported in phase II trials. In this study IP Cis and IV/IP Tax are combined with IV Bev as front-line therapy. Methods: Patients with optimal (<1 cm residual), FIGO stage II or III, epithelial ovarian, fallopian tube, or peritoneal cancer, acceptable organ function, and KPS ≥ 70% are eligible. Patients receive 6 cycles of chemotherapy plus Bev: Tax 135 mg/m2 IV over 3 hours on Day 1, Cis 75 mg/m2 IP on Day 2, Tax 60 mg/m2 IP on Day 8, Bev 15 mg/kg IV on Day 1 (starting cycle 2). Bev is continued every 3 weeks for 17 treatments after chemotherapy is complete. This study will enroll 41 patients. The primary endpoint is safety and tolerability, determined by whether at least 60% of patients complete the prescribed 6 cycles of cytotoxic chemotherapy without unacceptable toxicity. Results: Thirty-nine women [median age 56 (40–69)] have been treated on study: 26 (67%) completed 6 IV/IP cycles; 5 (13%) are receiving ongoing IV/IP treatment; 4 (10%) experienced IP port malfunction (3 finished 5 IV/IP cycles, 1 came off study for port revision); 3 (8%) switched from IP Cis to IV carboplatin due to grade 3 nephrotoxicity in cycle 1 (n = 2) or grade 3 hypertension in cycle 6 (n = 1); and 1 (2.5%) patient died following rectosigmoid anastomotic dehiscence during cycle 4. Grade 3/4 treatment-related toxicities include hypertension (10%), vasovagal events (10%), neutropenia (26%), nausea/vomiting (10%), and hypomagnesemia (8%). There were 3 occurrences of grade 3 abdominal pain (8%); and 3 adhesion-related grade 3 small bowel obstructions (8%), during cycles 3, 9, and 15, respectively. Conclusions: The addition of Bev to this IV/IP regimen appears to be feasible. Bev may increase the risk of small bowel obstruction/perforation in these patients. Enrollment continues and updated results will be presented.

[Table: see text]

The prognostic value of pretreatment CA 125 in patients with advanced ovarian carcinoma: a Gynecologic Oncology Group study

BACKGROUND

The objective of the current study was to determine the prognostic significance of a pretreatment serum CA 125 level in patients with advanced epithelial ovarian carcinoma (EOC) who received treatment with a standard chemotherapy regimen.

METHODS

Patients with International Federation of Gynecology and Obstetrics stage III/IV ovarian carcinoma who were on 1 of 7 Gynecologic Oncology Group (GOG) phase 3 trials and received treatment with a standard regimen of intravenous cisplatin and paclitaxel were included. A Cox regression model was used to assess the impact of CA 125 levels drawn before the initiation of chemotherapy on progression-free survival (PFS) both overall and by subgroup, including surgical debulking status, disease stage, and histologic subtype.

RESULTS

In total, 1,299 patients who were on the cisplatin/paclitaxel arms of the GOG trials were eligible. The median CA 125 level was 246 U/mL. Only 7.6% of patients had a normal CA 125 level (<or=35 U/mL). The lowest median CA 125 level was observed in the group with mucinous tumors; however, 69% of women who had mucinous tumors had abnormal CA 125 levels. Shorter PFS was observed with increasing CA 125 and persisted in multivariate analysis. Overall and in the serous subgroup, a 1-fold increase in CA 125 level was associated with a 7% increase in the hazard of disease progression (P < .001). This association was even more pronounced in patients who had stage III disease that was debulked to microscopic disease (15%; P = .003) and in patients who had endometrioid tumors (17%; P = .001).

CONCLUSIONS

A normal CA 125 level in the setting of advanced EOC was rare even after surgical debulking. The pretreatment CA 125 level was an independent predictor of PFS in patients with advanced EOC who received a standard chemotherapy regimen, particularly in the setting of disease that was debulked to a microscopic residual and in the serous or endometrioid subtypes.

CA-125 change after chemotherapy in prediction of treatment outcome among advanced mucinous and clear cell epithelial ovarian cancers: a Gynecologic Oncology Group study

BACKGROUND

There are limited data regarding unique clinical or laboratory features associated with advanced clear cell (CC) and mucinous (MU) epithelial ovarian cancers (EOC), particularly the relationship between CA-125 antigen levels and prognosis.

METHODS

A retrospective review of 7 previously reported Gynecologic Oncology Group phase 3 trials in patients with stage III/IV EOC was conducted. A variety of clinical parameters were examined, including the impact of baseline and changes in the CA-125 level after treatment of CC and MU EOC on progression-free (PFS) and overall survival (OS).

RESULTS

Clinical outcomes among patients with advanced CC and MU EOC were significantly worse when compared with other cell types (median PFS, 9.7 vs 7.0 vs 16.7 months, respectively, P < .001; median OS, 19.4 vs 11.3 vs 40.5 months, respectively, P < .001). Suboptimal debulking was associated with significantly decreased PFS and OS among both. Although baseline CA-125 values were lower in CC (median, 154 micron/mL) and MU (100 micron/mL), compared with other cell types (275 micron/mL), this level did not appear to influence outcome among these 2 specific subtypes of EOC. However, an elevated level of CA-125 at the end of chemotherapy was significantly associated with decreased PFS and OS (P < .01 for all).

CONCLUSIONS

Surgical debulking status is the most important variable at prechemotherapy predictive of prognosis among advanced CC and MU EOC patients. Changes in the CA-125 levels at the end treatment as compared with baseline can serve as valid indicators of PFS and OS, and likely the degree of inherent chemosensitivity.

Adjuvant gemcitabine plus docetaxel for completely resected stages I-IV high grade uterine leiomyosarcoma: Results of a prospective study

OBJECTIVE

Patients with completely resected stages I-IV high grade uterine leiomyosarcoma are at high risk for recurrence. No adjuvant treatment has been shown to improve survival, although prospective data are limited. We sought to determine whether adjuvant gemcitabine-docetaxel would yield a 2-year progression-free survival of at least 50% in this leiomyosarcoma population.

METHODS

Eligible patients were treated with gemcitabine 900 mg/m(2) over 90 min days 1 and 8 plus docetaxel 75 mg/m(2) day 8, every 3 weeks for 4 cycles. CT imaging was performed at baseline, after cycle 4, and every 3 months. Progression was defined as evidence of new disease on CT.

RESULTS

Twenty-five patients (median age 49; range, 37-73) enrolled; 23 were evaluable (1-never treated, 1-ineligible). With median follow-up of 49 months for all patients, 10 (45%) of the 23 evaluable patients remained progression free at 2 years, with a median progression-free survival of 13 months. The median overall survival is not yet reached. Among the 18 patients with stages I or II uterine leiomyosarcoma, 59% remain progression-free at 2 years, with a median progression-free survival of 39 months. Median overall survival for stages I and II patients is not yet reached with median follow-up duration of 49 months. Sites of first recurrence were: lung only - 3/23 (13%); pelvis only - 5/23 (22%); both - 5 (22%).

CONCLUSIONS

Post-resection gemcitabine-docetaxel for stages I-IV high-grade uterine leiomyosarcoma yields 2-year progression-free survival rates that appear superior to historical rates. Gemcitabine-docetaxel merits further study as part of an adjuvant strategy for patients with completely resected, early-stage uterine leiomyosarcoma.

A phase II evaluation of goserelin and bicalutamide in patients with ovarian cancer in second or higher complete clinical disease remission

BACKGROUND

The current study was conducted to determine the effect of goserelin and bicalutamide on progression-free survival (PFS) in patients with epithelial ovarian cancer who were in second or greater complete disease remission.

METHODS

Patients received bicalutamide at a dose of 50 mg orally daily and goserelin at a dose of 3.6 mg subcutaneously every 4 weeks. CA 125 was obtained monthly, with computed tomography performed every 3 months. Correlative studies included serum luteinizing hormone, follicle-stimulating hormone, vascular endothelial growth factor, free testosterone, and androstenedione and the germline polymorphisms CYP19A1 and androgen receptor.

RESULTS

Between October of 2000 and October of 2002, 35 patients were enrolled. Three patients (9%) received therapy at the time of first disease remission and were removed from the study, and 1 patient (3%) was removed for liver function test abnormalities. The most frequent toxicities were grade 1 alkaline phosphatase (54%), fatigue (57%), and hot flashes (42%) based on the National Cancer Institute common toxicity scale, version 2.0. The PFS for patients receiving protocol therapy in second disease remission (21 patients) was 11.4 months (95% confidence interval [95% CI], 10.2-12.6 months). The PFS for patients receiving protocol therapy in third or fourth disease remission (11 patients) was 11.9 months (95% CI, 10.8-14.1 months). The percentage of patients remaining in second disease remission at given times are: 100% at 3 months, 100% at 6 months, 72% at 9 months, 47% at 12 months, 28% at 15 months, 22% at 18 months, 19% at 21 months, and 13% at 24 months. There were no associations noted between androgen receptor repeat number, genotype, allelotype, or haplotypes and PFS.

CONCLUSIONS

The use of goserelin and bicalutamide did not appear to prolong PFS in patients with epithelial ovarian cancer in second or greater complete disease remission. The number of patients in disease remission at given time points may serve as a clinical trial endpoint for future studies of consolidation therapy.

Duration of second or greater complete clinical remission in ovarian cancer: exploring potential endpoints for clinical trials

OBJECTIVE

To explore benchmarks for future consolidation strategies, we evaluated a strictly defined (normal CA-125 and normal CT) second-complete-remission (CR) ovarian cancer population for 1) the median progression-free survival (PFS), 2) the frequency with which second remission exceeds first, and 3) the proportion of patients in remission at given time points.

METHODS

Retrospective sampling was carried out at Memorial Sloan-Kettering (10/1993-12/2000) and the Royal Marsden Hospital (1/1995-4/2003) for the following: histological confirmation and elevated CA-125 at diagnosis; primary surgery; first-and second-line platinum-based chemotherapy with CR; and no maintenance therapy.

RESULTS

In 35 patients 1) the duration of first PFS was 17.8 months (95% CI, 13.2-24.5 months) and second PFS was 10.8 months (95% CI, 9.6-12.2 months); 2) the number of patients with second response longer than first was 3/35 (9%); 3) the proportion of patients remaining in second complete remission was 100% (3 months), 100% (6 months), 83% (9 months), 34% (12 months), 23% (15 months) and 8.6% (18 months), respectively.

CONCLUSION

1) The median PFS from second complete remission is short. 2) A second response is rarely longer than the first even in this second CR population. 3) The number of patients with a second response longer than the first, or the proportion of patients remaining in complete remission at given time points could be evaluated as an outcome measure in future studies.

A phase II study of intravenous (IV) and intraperitoneal (IP) paclitaxel (Tax), IP cisplatin (Cis), and IV bevacizumab (Bev) as first-line chemotherapy for optimal stage II or III ovarian, primary peritoneal, and fallopian tube cancer

5523

Background: IP Cis plus IV/IP Tax is a standard therapy for optimally debulked ovarian cancer. Bev is a recombinant humanized IgG1 monoclonal antibody directed against vascular endothelial growth factor (VEGF). Activity of Bev against recurrent ovarian cancer has been reported in phase II trials. In this study IP Cis and IV/IP Tax are combined with IV Bev as front-line therapy to assess safety and tolerability. Methods: Patients with optimal (<1 cm residual), FIGO stage II or III, epithelial ovarian, fallopian tube, or peritoneal cancer, acceptable organ function, and KPS = 70% are eligible. Patients receive 6 cycles of chemotherapy plus Bev (starting cycle 2): Tax 135 mg/m2 IV over 3 hours on Day 1, Cis 75 mg/m2 IP on Day 2, Tax 60 mg/m2 IP on Day 8, Bev 15 mg/kg IV on Day 1. Extended treatment with Bev is continued every 3 weeks for 17 treatments after chemotherapy is complete. The study will enroll 41 patients. The primary endpoint is safety and tolerability, determined by the proportion of patients who complete the prescribed 6 cycles of cytotoxic chemotherapy without discontinuation and without dose-limiting non-hematologic and non-electrolyte toxicity. A stopping rule will be applied if excessive toxicity is encountered. Results: To date, 8 women have been treated on the study. Median age: 53 (48–59). All 31 planned doses of chemotherapy have been administered in full. One dose of IP Tax was delayed for 2 days due to abdominal pain. One patient had her first dose of Bev delayed for 1 cycle due to surgical wound infection. There have been no toxicities > grade 3. Grade 1/2 toxicities include: fatigue (87.5%); nausea (50%); and hypomagnesemia (37.5%). Grade 3 toxicities per patient: fatigue (12.5%); hyponatremia (25%); hypokalemia (25%); hypertension (12.5%); abdominal pain (12.5%); and neutropenia (12.5%). Of the 5 patients with pretreatment CA125 >35 Units/mL, 4 normalized their value after 1 cycle of chemotherapy and 1 patient normalized after 2 cycles. Conclusions: Preliminary experience suggests that the combination of IV Bev with IP Cis plus IV/IP Tax may be well tolerated. Enrollment continues and updated results will be presented.

No significant financial relationships to disclose.

VEGF-Trap for patients (pts) with recurrent platinum-resistant epithelial ovarian cancer (EOC): Preliminary results of a randomized, multicenter phase II study

5508

Background: Vascular endothelial growth factor (VEGF) is over-expressed in EOC and associated with poor prognosis. VEGF Trap, a potent angiogenesis inhibitor fusion protein, is comprised of portions of human VEGF-receptor R1+R2 (Flt-1, KDR) extracellular domains and fused to the Fc portion of human IgG. VEGF Trap binds VEGF-A and neutralizes all VEGF-A isoforms plus placental growth factor. Methods: This is a randomized, double blind, multicenter, 2-stage, phase II trial of VEGF Trap (2 or 4 mg/kg) administered intravenously every 2 weeks, in pts with recurrent EOC. Eligible criteria included 2 or 3 prior chemo regimens for advanced disease; platinum- resistance, topotecan- and/or liposomal doxorubicin-resistance; no prior VEGF inhibitor treatment; ECOG performance status 0–2; normal organ function; no proteinuria (<500 mg/24hrs or UPCR =1); controlled blood pressure. This Simon 2 stage design, requires 3 responders out of 42 evaluable, in each arm to continue accrual into stage 2. Results: Across 62 centers in Europe, Canada and US, rapid accrual led to 162 pts randomized from 5/06 to 12/06. Median age: 58, PS (0,1,2): 56,40,4%. Of 45 pts currently in the database, across the two arms, adverse events included (any grade): headache (38%), fatigue (36%), dysphonia (33%), nausea (29%), asthenia (24%), diarrhea (18%), hypertension (16%), proteinuria (7%), renal dysfunction (4%). Grade 3–4, included: hypertension (9%), proteinuria (4%), encephalopathy (2%) and renal failure (2%). Of the 162 pts who had at minimum one cycle, study drug-related SAE include (N): thrombocytopenia (1), anemia (1), headache (1) asthenia (2),dyspnea (1), hypertension (4), bowel perforation (2), encephalopathy (1), renal failure (2), proteinuria (1), phlebitis (1) and pulmonary embolism (1). 5 partial responses (11%) have been reported. Conclusions: VEGF Trap has activity in this heavily-pretreated EOC population. The first stage of accrual is complete and updated results will be presented.

No significant financial relationships to disclose.

Phase I trial of PTK787/ZK222584 (PTK/ZK) in combination with carboplatin (C) and paclitaxel (T) in platinum-sensitive recurrent epithelial ovarian (EOC), fallopian tube (FT), or primary peritoneal (PPC) cancers

5564

Background: Targeting vascular endothelial growth factor (VEGF) in patients (pts) with ovarian cancer achieves objective responses. PTK/ZK is an orally active angiogenesis inhibitor which blocks all known VEGF receptor and platelet-derived growth factor receptor tyrosine kinases. A previous study administered PTK/ZK only on days 3–21 of C and T cycle based on pre-clinical data suggesting PTK/ZK increases T levels (PROC ASCO # 5042, 2005), and recent data supports bid dosing (JCO 18:1–10, 2005). Methods: In this open label, single institution phase I study, pts with platinum sensitive recurrent EOC, FT, or PPC were treated with C and T every 21 days with increasing continuous daily doses of PTK/ZK (250 mg to 1,250mg with bid dosing). Primary endpoints were safety and maximum tolerated dose (MTD). Pharmacokinetic (PK) analysis is planned to describe C and T pharmacokinetics when combined with PTK/ZK. Results: To date, 14 pts with median age 61 (range 45–73) have been enrolled on the first 3 dose levels, including 13 EOC and 1 PPC. All patients were evaluable for toxicity and 8 were evaluable for investigator assessed response. MTD has not been reached. Febrile neutropenia was dose limiting toxicity requiring expansion at levels II and III. PK analysis is ongoing. To date, best responses are: 4 (PR), 3 (SD) and 1 (POD). Other G III toxicity included: C hypersensitivity reaction (1, gr 3), hyperglycemia (4, gr 3), hypertension (1, gr 3), diarrhea (1, gr 3), and elevated liver function tests (1, gr 3). Conclusion: PTK/ZK can be administered continuously in combination with standard doses of C and T using bid dosing. MTD is not yet reached and accrual is ongoing. PK data and MTD will be presented. Supported by Novartis and Bayer Schering Pharma.

[Table: see text]

No significant financial relationships to disclose.

Phase II study of adjuvant gemcitabine plus docetaxel (GD) for completely resected stage I-IV high grade uterine leiomyosarcoma (HGuLMS)

5591

Background: Patients (pts) with completely resected stage I-IV HGuLMS are at high risk for recurrence, with reported 2-year progression-free survival ranging from 19–30% (Dinh, Gyn Onc 2004; Major, Cancer 1993). No adjuvant treatment has been shown to improve survival, although prospective data are limited. GD achieves objective responses in metastatic uLMS. We sought to determine whether 4 cycles GD given after complete resection of stage I-IV HGuLMS would yield a 2-year PFS of at least 40%, in order to determine whether GD was worth pursuing as an adjuvant strategy in a randomized trial. Methods: Eligible pts with completely resected HGuLMS within 8 weeks of surgery, no prior GD, no evidence of disease on post-resection CT, KPS = 80, and adequate organ function were treated with G 900 mg/m2 over 90 minutes days 1 and 8 + D 75 mg/m2 d8, with GCSF or pegfilgrastim, every 3 weeks for 4 cycles. CT was performed at baseline, after cycle 4, and every 3 months. Progression defined as new evidence of disease on CT. Results: 25 pts (median age 49, range 37–73) enrolled; 23 evaluable (1-never treated, 1-ineligible). Grade 3 related toxicities were: neutropenia (2/23) 8.7%, febrile neutropenia (2/23) 8.7%, anemia (2/23) 8.7%, thrombocytopenia (1/23) 4.3%, diarrhea (1/23) 4.3%, hyperglycemia (2/23) 8.7%, pulmonary (2/23) 8.7%; there were no ≥ grade 4 toxicities. With median follow-up of 29 months (range 0.5 to 45 months) for all pts, PFS at 2 y and 3 y is 45%, and median OS is not yet reached. For the 18 pts with stage I or II uLMS 2-y and 3-y PFS is 58%, and median PFS is 38 months (95%C.I. 6 months to not yet reached). Sites of first recurrence were: lung only-3/23 (13%); pelvis only-5/23 (22%); both-5 (22%). Treatment of recurrence was at physician discretion and included resection, resection plus pelvic radiation, and/or chemotherapy. Conclusions: Pts treated with post-resection GD for stage I-IV HGuLMS had 2-y and 3-y PFS that appears superior to historical rates of PFS. Incorporation of GD into a randomized trial of adjuvant chemotherapy vs adjuvant pelvic radiation for resected stage I and II uLMS is planned.

No significant financial relationships to disclose.