Targeted therapy for multiple myeloma: an overview on CD138-based strategies

Multiple myeloma (MM) is an incurable hematological disease characterized by the uncontrolled growth of plasma cells primarily in the bone marrow. Although its treatment consists of the administration of combined therapy regimens mainly based on immunomodulators and proteosome inhibitors, MM remains incurable, and most patients suffer from relapsed/refractory disease with poor prognosis and survival. The robust results achieved by immunotherapy targeting MM-associated antigens CD38 and CD319 (also known as SLAMF7) have drawn attention to the development of new immune-based strategies and different innovative compounds in the treatment of MM, including new monoclonal antibodies, antibody-drug conjugates, recombinant proteins, synthetic peptides, and adaptive cellular therapies. In this context, Syndecan1 (CD138 or SDC1), a transmembrane heparan sulfate proteoglycan that is upregulated in malignant plasma cells, has gained increasing attention in the panorama of MM target antigens, since its key role in MM tumorigenesis, progression and aggressiveness has been largely reported. Here, our aim is to provide an overview of the most important aspects of MM disease and to investigate the molecular functions of CD138 in physiologic and malignant cell states. In addition, we will shed light on the CD138-based therapeutic approaches currently being tested in preclinical and/or clinical phases in MM and discuss their properties, mechanisms of action and clinical applications.

Su(var)3-9 mediates age-dependent increase in H3K9 methylation on TDP-43 promoter triggering neurodegeneration

Aging progressively modifies the physiological balance of the organism increasing susceptibility to both genetic and sporadic neurodegenerative diseases. These changes include epigenetic chromatin remodeling events that may modify the transcription levels of disease-causing genes affecting neuronal survival. However, how these events interconnect is not well understood. Here, we found that Su(var)3-9 causes increased methylation of histone H3K9 in the promoter region of TDP-43, the most frequently altered factor in amyotrophic lateral sclerosis (ALS), affecting the mRNA and protein expression levels of this gene through epigenetic modifications that appear to be conserved in aged Drosophila brains, mouse, and human cells. Remarkably, augmented Su(var)3-9 activity causes a decrease in TDP-43 expression followed by early defects in locomotor activities. In contrast, decreasing Su(var)3-9 action promotes higher levels of TDP-43 expression, improving motility parameters in old flies. The data uncover a novel role of this enzyme in regulating TDP-43 expression and locomotor senescence and indicate conserved epigenetic mechanisms that may play a role in the pathogenesis of ALS.

A comprehensive overview on antibody-drug conjugates: from the conceptualization to cancer therapy

Antibody-Drug Conjugates (ADCs) represent an innovative class of potent anti-cancer compounds that are widely used in the treatment of hematologic malignancies and solid tumors. Unlike conventional chemotherapeutic drug-based therapies, that are mainly associated with modest specificity and therapeutic benefit, the three key components that form an ADC (a monoclonal antibody bound to a cytotoxic drug via a chemical linker moiety) achieve remarkable improvement in terms of targeted killing of cancer cells and, while sparing healthy tissues, a reduction in systemic side effects caused by off-tumor toxicity. Based on their beneficial mechanism of action, 15 ADCs have been approved to date by the market approval by the Food and Drug Administration (FDA), the European Medicines Agency (EMA) and/or other international governmental agencies for use in clinical oncology, and hundreds are undergoing evaluation in the preclinical and clinical phases. Here, our aim is to provide a comprehensive overview of the key features revolving around ADC therapeutic strategy including their structural and targeting properties, mechanism of action, the role of the tumor microenvironment and review the approved ADCs in clinical oncology, providing discussion regarding their toxicity profile, clinical manifestations and use in novel combination therapies. Finally, we briefly review ADCs in other pathological contexts and provide key information regarding ADC manufacturing and analytical characterization.

Final results of the real-life observational VICTOR-6 study on metronomic chemotherapy in elderly metastatic breast cancer (MBC) patients

Nowadays, treatment of metastatic breast cancer (MBC) has been enriched with novel therapeutical strategies. Metronomic chemotherapy (mCHT) is a continuous and frequent administration of chemotherapy at a lower dose and so whit less toxicity. Thus, this strategy could be attractive for elderly MBC patients. Aim of this analysis is to provide insights into mCHT's activity in a real-life setting of elderly MBC patients. Data of patients ≥ 75 years old included in VICTOR-6 study were analyzed. VICTOR-6 is a multicentre, Italian, retrospective study, which collected data on mCHT in MBC patients treated between 2011 and 2016. A total of 112 patients were included. At the beginning of mCHT, median age was 81 years (75-98) and in 33% of the patients mCHT was the first line choice. Overall Response Rate (ORR) and Disease Control Rate (DCR) were 27.9% and 79.3%, respectively. Median PFS ranged between 7.6 and 9.1 months, OS between 14.1 and 18.5 months. The most relevant toxicity was the hematological one (24.1%); severe toxicity (grade 3-4) ranged from 0.9% for skin toxicity up to 8% for hematologic one. This is a large study about mCHT in elderly MBC patients, providing insights to be further investigated in this subgroup of frail patients.

[Antenatal ear examination: When, how and why?]

Antenatal ear examination is an integral part of the thorough examination of the fetal face. The discovery of an anomaly, whether it is made by chance or during a complementary in-depth examination, leads the practitioner to determine its isolated or associated character, in order to characterise its possible belonging to a syndromic entity. In this context, the realization of genetic analysis more precise and wider allowing a return of the results in a time compatible with an evolutive pregnancy, gives to the geneticist a central role in the management of these couples. The main challenge lies in obtaining a set of concordant clinical and biological clues, enabling the genetic results identified to be interpreted correctly, the optimised functioning of the ultrasound practitioner - geneticist duo is therefore fundamental. This results in a complex information to deliver, in the fact that the clinical translation of an ear anomaly in antenatal can go from an isolated aesthetic anomaly to a genetic syndrome with neurodevelopmental disorder. The objective of this work is to describe, from a methodological analysis of antenatal ears, the accessible malformative entities, isolated or associated, and to discuss the problems in the need or not to propose their screening.

Metronomic chemotherapy (mCHT) in metastatic triple-negative breast cancer (TNBC) patients: results of the VICTOR-6 study

Purpose

Triple-negative breast cancer (TNBC) represents a subtype of breast cancer which lacks the expression of oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor-2 (HER2): TNBC accounts for approximately 20% of newly diagnosed breast cancers and is associated with younger age at diagnosis, greater recurrence risk and shorter survival time. Therapeutic options are very scarce. Aim of the present analysis is to provide further insights into the clinical activity of metronomic chemotherapy (mCHT), in a real-life setting.

Methods

We used data included in the VICTOR-6 study for the present analysis. VICTOR-6 is an Italian multicentre retrospective cohort study, which collected data of metastatic breast cancer (MBC) patients who have received mCHT between 2011 and 2016. Amongst the 584 patients included in the study, 97 were triple negative. In 40.2% of the TNBC patients, mCHT was the first chemotherapy treatment, whereas 32.9% had received 2 or more lines of treatment for the metastatic disease. 45.4% out of 97 TNBC patients received a vinorelbine (VRL)-based regimen, which resulted in the most used type of mCHT, followed by cyclophosphamide (CTX)-based regimens (30.9%) and capecitabine (CAPE)-based combinations (22.7%).

Results

Overall response rate (ORR) and disease control rate (DCR) were 17.5% and 64.9%, respectively. Median progression free survival (PFS) and overall survival (OS) were 6.0 months (95% CI: 4.9–7.2) and 12.1 months (95% CI: 9.6–16.7). Median PFS was 6.9 months for CAPE-based regimens (95% CI: 5.0–18.4), 6.1 months (95% CI: 4.0–8.9) for CTX-based and 5.3 months (95% CI: 4.1–9.5) for VRL-based ones. Median OS was 18.2 months (95% CI: 9.1-NE) for CAPE-based regimens and 11.8 months for VRL- (95% CI: 9.3–16.7 and CTX-based ones (95%CI: 8.7–52.8). Tumour response, PFS and OS decreased proportionally in later lines.

Conclusion

This analysis represents the largest series of TNBC patients treated with mCHT in a real-life setting and provides further insights into the advantages of using this strategy even in this poor prognosis subpopulation.

Assessing the Impact of A Community-Based Pro-Active Monitoring Program Addressing the need for Care of Community-Dwelling Citizens aged more than 80: Protocol for a Prospective Pragmatic Trial and Results of the Baseline Assessment

The aim of this paper is to describe the protocol of a study assessing the impact of a Community-based pro-Active Monitoring Program, by measuring the effect in counteracting the adverse outcomes related to frailty.

Methods

a prospective pragmatic trial will be carried out to describe the impact of an intervention on people aged>80, adjusted for relevant parameters: demographic variables, comorbidities, disability and bio-psycho-social frailty. They have been assessed with the Functional Geriatric Evaluation questionnaire that is a validated tool. Mortality, Acute Hospital Admission rates, Emergency Room Visit rates and Institutionalization rates are the main outcomes to be evaluated annually, over three years. Two groups of patients, made up by 578 cases (undergoing the intervention under study) and 607 controls have been enrolled and interviewed.

Results

at baseline the two groups are quite similar for age, living arrangement, comorbidity, disability and cognitive status. They differ in education, economic resources and physical status (that are better in the control group) and in social resources (that is better in the case group). The latter was expected since the intervention is focused on increasing social capital at individual and community level and aimed at improving survival among the cases as well as reducing the recourse to hospital and residential Long Term Care.

Conclusion

The proposed study addresses a crucial issue: assessing the impact of a bottom up care service consisting of social and health interventions aimed at reducing social isolation and improving access to health care services.

T-DM1 versus pertuzumab, trastuzumab and a taxane as first-line therapy of early-relapsed HER2-positive metastatic breast cancer: an Italian multicenter observational study

Background

The current standard first-line treatment of human epidermal growth factor receptor 2 (HER2)-positive (+) metastatic breast cancer is the combination of pertuzumab, trastuzumab and a taxane (P + T + taxane), while standard second-line is ado-trastuzumab-emtansine (T-DM1). The registration trial of pertuzumab, however, did not include early-relapsing patients, defined as patients experiencing tumor relapse ≤12 months from the end of (neo)adjuvant anti-HER2 therapy. Conversely, the pivotal trial of T-DM1 included some patients relapsing ≤6 months after the end of (neo)adjuvant trastuzumab. Thus, a proportion of early-relapsing patients are currently eligible to receive T-DM1 as first-line treatment. Nevertheless, no direct comparison exists between the two regimens in this clinical setting.

Patients and methods

We retrospectively compared T-DM1 versus P + T + taxane as first-line treatment in two cohorts of early-relapsing patients in an Italian ‘real-world’ setting, involving 14 public health care institutions. The primary endpoint was progression-free survival. Secondary endpoints included patients' characterization, overall survival and post-progression survival. Univariate and multivariate analyses were carried out. All tests were two-sided and a P ≤ 0.05 was considered statistically significant.

Results

Among 1252 screened patients, 75 met the inclusion criteria. Forty-four (58.7%) received P + T + taxane and 31 (41.3%) received T-DM1. The two cohorts showed similar characteristics of aggressiveness and no significant differences in treatment history. T-DM1, compared with P + T + taxane was associated with worse progression-free survival (adjusted hazard ratio: 2.26, 95% confidence interval: 1.13-4.52, P = 0.021) and overall survival (adjusted hazard ratio: 3.95, 95% confidence interval: 1.38-11.32, P = 0.010), irrespective of previous (neo)adjuvant treatment, age, hormone receptors status, time-to-relapse (≤6 months or within 6-12 months) and presence of visceral/brain metastases. No differences were observed in post-progression survival (P = 0.095).

Conclusions

Our study suggests superiority for P + T + taxane over T-DM1 as up-front treatment of early-relapsing HER2+ metastatic breast cancer, which merits further assessment in larger and prospective trials.

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This is the first study comparing pertuzumab + trastuzumab + taxane (P + T + taxane) with T-DM1 in early-relapsing HER2+ MBC.

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The majority of early-relapsing HER2+ MBC have high-grade, node-positive, large primary tumors.

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First-line T-DM1 compared with P + T + taxane is associated with worse progression-free survival.

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First-line T-DM1 compared with P + T + taxane is associated with worse overall survival.

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Post-progression survival does not differ between the two treatments cohorts.

The effect of community nurse on mortality and hospi- talization in a group of over-75 older adults: a nested case-control study

Background

Bio-psycho-social frailty can negatively affect the health status of an ageing population. The integration between community nurses and social services can emphasize community care and prevent the onset of both health and social negative outcomes in the older population. The aim of the paper is to explore the causal association through the analysis of the hospitalization and mortality rate after a pro-active social service integrated by the community nurse.

Study Design

A nested case-control study comparing groups of older adults has been carried out. Methods. The paper compares data stem from a cohort followed up by the University of Rome "Tor Vergata" with data from the "Long Live the Elderly!" program (LLE) cohort.

Results

One-year standardized mortality rate was 6.5%, 4.7% and 7.5% in the control group, the LLE group and the LLE group integrated by the community nurse (LLE-CN), respectively. One-year hospitalization rate was 15.4%, 15.5% and 10.8% in the control group, the LLE group and the LLE-CN group, respectively.

Conclusions

According to our results a social service with a pro-active approach, integrated by the community nurse, appears to be able to reduce mortality and hospitalization in a group of older adults aged>75. The multidimensional assessment of frailty stands for the first step of a new organization of community services.

A Compensatory U1snRNA Partially Rescues FAH Splicing and Protein Expression in a Splicing-Defective Mouse Model of Tyrosinemia Type I

The elucidation of aberrant splicing mechanisms, frequently associated with disease has led to the development of RNA therapeutics based on the U1snRNA, which is involved in 5' splice site (5'ss) recognition. Studies in cellular models have demonstrated that engineered U1snRNAs can rescue different splicing mutation types. However, the assessment of their correction potential in vivo is limited by the scarcity of animal models with the targetable splicing defects. Here, we challenged the U1snRNA in the FAH5961SB mouse model of hepatic fumarylacetoacetate hydrolase (FAH) deficiency (Hereditary Tyrosinemia type I, HT1) due to the FAH c.706G>A splicing mutation. Through minigene expression studies we selected a compensatory U1snRNA (U1F) that was able to rescue this mutation. Intriguingly, adeno-associated virus-mediated delivery of U1F (AAV8-U1F), but not of U1wt, partially rescued FAH splicing in mouse hepatocytes. Consistently, FAH protein was detectable only in the liver of AAV8-U1F treated mice, which displayed a slightly prolonged survival. Moreover, RNA sequencing revealed the negligible impact of the U1F on the splicing profile and overall gene expression, thus pointing toward gene specificity. These data provide early in vivo proof-of-principle of the correction potential of compensatory U1snRNAs in HTI and encourage further optimization on a therapeutic perspective, and translation to other splicing-defective forms of metabolic diseases.

Rescue of spinal muscular atrophy mouse models with AAV9-Exon-specific U1 snRNA

Spinal Muscular Atrophy results from loss-of-function mutations in SMN1 but correcting aberrant splicing of SMN2 offers hope of a cure. However, current splice therapy requires repeated infusions and is expensive. We previously rescued SMA mice by promoting the inclusion of a defective exon in SMN2 with germline expression of Exon-Specific U1 snRNAs (ExspeU1). Here we tested viral delivery of SMN2 ExspeU1s encoded by adeno-associated virus AAV9. Strikingly the virus increased SMN2 exon 7 inclusion and SMN protein levels and rescued the phenotype of mild and severe SMA mice. In the severe mouse, the treatment improved the neuromuscular function and increased the life span from 10 to 219 days. ExspeU1 expression persisted for 1 month and was effective at around one five-hundredth of the concentration of the endogenous U1snRNA. RNA-seq analysis revealed our potential drug rescues aberrant SMA expression and splicing profiles, which are mostly related to DNA damage, cell-cycle control and acute phase response. Vastly overexpressing ExspeU1 more than 100-fold above the therapeutic level in human cells did not significantly alter global gene expression or splicing. These results indicate that AAV-mediated delivery of a modified U1snRNP particle may be a novel therapeutic option against SMA.

Real-world outcomes according to treatment strategies in ALK-rearranged non-small-cell lung cancer (NSCLC) patients: an Italian retrospective study

PURPOSE

Anaplastic lymphoma kinase (ALK) rearrangement confers sensitivity to ALK inhibitors (ALKis) in non-small-cell lung cancer (NSCLC). Although several drugs provided an impressive outcome benefit, the most effective sequential strategy is still unknown. We describe outcomes of real-life patients according to the treatment strategy received.

PATIENTS

We retrospectively collected 290 ALK rearranged advanced NSCLC diagnosed between 2011 and 2017 in 23 Italian institutions.

RESULTS

After a median follow-up of 26 months, PFS for crizotinib and a new generation ALKis were 9.4 [CI 95% 7.9-11.2] and 11.1 months [CI 95% 9.2-13.8], respectively, while TTF were 10.2 [CI 95% 8.5-12.6] and 11.9 months [CI 95% 9.7-17.4], respectively, being consistent across the different settings. The composed outcomes (the sum of PFS or TTF) in patients treated with crizotinib followed by a new generation ALKis were 27.8 months [CI 95% 24.3-33.7] in PFS and 30.4 months [CI 95% 24.7-34.9] in TTF. The median OS from the diagnosis of advanced disease was 39 months [CI 95% 31.8-54.5]. Patients receiving crizotinib followed by a new generation ALKis showed a higher median OS [57 months (CI 95% 42.0-73.8)] compared to those that did not receive crizotinib [38 months (CI 95% 18.6-NR)] and those who performed only crizotinib as target agent [15 months (CI 95% 11.3-34.0)] (P < 0.0001).

CONCLUSION

The sequential administration of crizotinib and a new generation ALKis provided a remarkable clinical benefit in this real-life population, being an interesting option to consider in selected patients.

Metronomic chemotherapy for advanced breast cancer patients in the real world practice: Final results of the VICTOR-6 study

Metronomic chemotherapy (mCHT) refers to the minimum biologically effective dose of a chemotherapy agent given as a continuous dosing regimen, with no prolonged drug-free breaks, that leads to antitumor activity. Aim of the present study is to describe the use of mCHT in a retrospective cohort of metastatic breast cancer (MBC) patients in order to collect data regarding the different types and regimens of drugs employed, their efficacy and safety. Between January 2011 and December 2016, data of 584 metastatic breast cancer patients treated with mCHT were collected. The use of VRL-based regimens increased during the time of observation (2011: 16.8% - 2016: 29.8%), as well as CTX-based ones (2011: 17.1% - 2016: 25.6%), whereas CAPE-based and MTX-based regimens remained stable. In the 1st-line setting, the highest ORR and DCR were observed for VRL-based regimens (single agent: 44% and 88%; combination: 36.7% and 82.4%, respectively). Assuming VRL-single agent as the referee treatment (median PFS: 7.2 months, 95% CI: 5.3-10.3), the longest median PFS were observed in VRL-combination regimens (9.5, 95%CI 88.8-11.3, HR = 0.72) and in CAPE-single agent (10.7, 95%CI 8.3-15.8, HR = 0.70). The VICTOR-6 study provides new data coming from the real-life setting, by adding new information regarding the use of mCHT as an option of treatment for MBC patients.

Genetics of neonatal onset epilepsies: An overview

The weight of monogenic abnormalities in the possible causes of epilepsy has grown significantly in recent years, due to the emergence of next-generation sequencing (NGS) techniques. Especially notable in early neonatal and infantile epilepsies, which seem to be explained by monogenic abnormalities. This short review focuses on the major genes associated with very early-onset epilepsies, where NGS techniques are most cost-effective: early infantile epileptic encephalopathy, early myoclonic encephalopathy, and other neonatal epilepsies. The discovery of the genetic mutation often follows several weeks or months of management, and rarely modifies it. However, clinical studies can sometimes better define medical treatment. The genetic causes of these epilepsies are very numerous and the pathophysiological knowledge very minimal. The big challenge for the coming years is to develop more targeted treatments based on research on animal models.

Abstract P4-13-04: Not presented

This abstract was not presented at the conference.

Citation Format: Cazzaniga ME, Blasi L, Pronzato P, Giordano M, Garrone O, Donadio M, Del Mastro L, Livi L, Natoli C, Michelotti A, Turletti A, Riccardi F, De Laurentiis M, Marchetti P, Montemurro F, Romagnoli E, De Placido S, Biganzoli L, Bologna A, Bria E, Mustacchi G. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-04.

A Phase II Study of Paclitaxel/Cisplatin Combination in Patients with Metastatic Breast Cancer Refractory to Anthracycline-Based Chemotherapy

AIMS AND BACKGROUND

To investigate the safety and efficacy of a paclitaxel and cisplatin regimen in a selected group of metastatic breast cancer patients with primary or acquired chemo-resistance to anthracycline-based chemotherapy.

PATIENTS AND METHODS

Thirty-eight consecutive women with metastatic breast cancer (PS < or =2) were entered in this phase II trial; all patients had been previously treated for metastatic disease with chemotherapy containing anthracyclines and had shown a progression of the disease during drug administration or after a clinical response lasting less than 6 months. Fifteen patients had received 2 or more chemotherapeutic regimens for advanced disease; 31 patients had > or =2 sites of metastatic disease. Paclitaxel (135 mg/m2) was administered iv by a 3-hr infusion followed by iv infusion of cisplatin (75 mg/m2) on day 1, every 3 weeks for 6 cycles. After the completion of the planned chemotherapy administration, 9 responsive patients continued to receive paclitaxel alone (175 mg/m2) iv, on day 1, every 3 weeks, until disease progression or unacceptable toxicity.

RESULTS

A partial clinical response was recorded in 17 cases (45%; 95% CI, 30-64%). The median duration of overall response was 8 months; for the 9 responsive patients who continued treatment with paclitaxel alone, 4 had maintained the partial clinical response at the median follow-up of 24 months from the onset of therapy. The median time to progression was 6 months and median overall survival 8 months. Neurotoxicity was the most frequent adverse effect and caused treatment discontinuation in 5 cases for grade 3-4 paresthesia and/or an arthralgia/myalgia syndrome. Grade 3-4 neutropenia occurred in 16 patients (44%).

CONCLUSIONS

Paclitaxel/cisplatin is an active regimen for the treatment of patients with metastatic breast cancer refractory to anthracycline-based chemotherapy. However, the cumulative neurotoxicity should limit the efficacy of prolonged paclitaxel monotherapy in responsive patients.

The entity of thermal-crush-avulsion hand injury (hot-press roller burns) treated with fast acting debriding enzymes (nexobrid): literature review and report of first case

Hand burns are present in >60% of all burn cases and in fire mass casualty incidents even up to 100%. Most trauma and especially burns may be detrimental to the complex and delicate structures of the hand by direct injury, indirect BICS (Burn Induced Compartment Syndrome and interstitial high pressure) or by delayed or faulty treatment. BICS represents a special threat as the increasing swelling and oedema of the small diameter hand and forearm will exert pressure on the capillary/venous system, eventually ending in irreversible damage to the skin, nerves, muscle and vascular bed. Immediate release of constricting skin by incisional escharotomy and sometimes fasciotomy may arrest this vicious cycle: escharotomy is simple for experienced hand or burn surgeons, but they are not always present at the primary treatment site. The diagnosis of BICS is not simple either, as the direct measurement of interstitial/compartment pressure is rarely done. Burns caused by hot rollers such as industrial linen ironing machines are especially traumatic as besides the "simple" thermal burn, the hot rollers exert immense crushing pressure to the hand caught between the rollers. Over the last few years, several publications have described the role of a newly approved Bromelain derived enzymatic debriding agent (NexoBrid) for burns in general and hand burns in particular, and its ability to resolve or prevent BICS. We present a rare severe thermal/crush hand injury case where we were able to successfully treat the patient with NexoBrid enzymatic debridement-escharotomy.

Use of Tumor Markers in the Management of Head and Neck Cancer

Serologic tumor markers have been evaluated in the diagnosis, management and follow-up of patients with head and neck cancer. However, to the authors’ knowledge no tumor marker has yet been shown to be useful for monitoring the response to chemotherapy in this type of disease, in particular for undifferentiated tumors. The pretreatment levels of CEA, TPA, SCC and ferritin were evaluated in 98 patients with advanced head and neck cancer. Of this group 64 patients were studied sequentially every month during planned chemotherapy and three weeks after treatment using standard commercial kits. The results showed the following sensitivity values: TPA 50%, CEA 36%, SCC 34% and ferritin 19%. The incidence and magnitude of the marker elevations were correlated with the extent of disease. In patients with squamous cell cancer SCC and CEA were elevated (by 68% and 54%, respectively) in tumors with good differentiation (G1), but only by 13% (both markers) in tumors classified as poorly differentiated (G3). CEA, SCC and ferritin serum levels were not correlated with response to chemotherapy, while TPA values correlated with the clinical response to treatment in 100% of patients with undifferentiated cancer and in 75% of those with squamous cell cancer. Our data indicate that in patients with head and neck cancer TPA appears to be a sensitive marker, followed in decreasing order of sensitivity by CEA, SCC and ferritin. However, SCC and CEA seem to be the most suitable markers for squamous cell cancer and in particular for more differentiated tumors (G1). Finally, TPA has proved to be a useful marker for monitoring the response to chemotherapy in patients with head and neck cancer, in particular for undifferentiated tumors.

Abstract P5-15-07: First and further line choices of treatment for HER2-VE metastatic breast cancer (MBC) according to adjuvant treatment and biological subtype. Preliminary results of the observational “GIM-13 – AMBRA” Italian study

Frequency of CHT regimens according to biological subtypes and Setting of treatmentLuminal TumoursSettingRegimenAdj (%)1st-line (%)2nd-line (%)3rd-line (%)anthra-based (w/o Taxanes)44.27.15.19.9Anthra-Taxanes30.52.60.50CMF-like17.50.61.02.1Taxane mono/combo*6.319.314.521.5Pacliataxel + Bevacizumab020.24.33.7Platinum-based03.61.70.8Capecitabine +/- Vinorelbine019.122.217.4Eribuline002.312.4 TNBCSettingRegimenAdj (%)1st-line (%)2nd-line (%)3rd-line (%)Anthra-based (w/o Taxanes)25.73.15.116.2Anthra-Taxanes36.11.100CMF-like8.22.15.10Taxane mono/combo*6.318.417.810.8Paclitaxel + Bevacizumab024.71.70Platinum-based020.622.42.7Capecitabine +/- Vinorelbine025.720.610.8Eribuline003.429.7**Irrespectively of biological subtype, nab-paclitaxel was used in 3.6%, 15.3% and 16.4% of cases in 1st, 2nd and 3rd line, respectively

BACKGROUND

Breast Cancer prognosis improved in the last years due both to early diagnosis and Adj treatments. The choice of CHT regimens should consider previous Adj treatments, pattern of relapse and biological subtype. There are few information on the treatment of MBC in the clinical practice outside controlled trials, last study has been published 15 yrs ago in Italy.

PATIENTS AND METHODS

The GIM13-AMBRA Study is a multicenter longitudinal cohort study, describing the choice of first and subsequent lines of treatment for MBC in HER2-ve pts. We are collecting data of 30 consecutive pts from 42 Italian Centres who developed the first relapse in the years 2012-2015 and were treated with CHT, (+/- previous endocrine treatments (HT)) for MBC. One of the secondary aims is to evaluate the Time to Treatment Change (TTC) (time between treatment start and its change for any reason) as surrogate endpoint for Time To Progression outside clinical trials. The present report is focused on the choice of treatments in any line and TTC, according to biological subtypes. .

RESULTS

For the present analysis, 683 pts are evaluable. Pts with Luminal A and B tumours received CHT and HT in 65.3% (Adjuvant), 21.7% (1st line), 7.1% (2nd line) and 7% (3rd line) of the cases. The most used regimens according to tumour subtype and line of treatment are shown in Table 1.

Median TTC from 1st to 2nd line was 8.1 and 17.9 months in TNBC and Luminal tumours, respectively, whereas TTC from 2nd to 3rd line was 3.1 and 12.9 months, respectively.

CONCLUSION

Preliminary results of the AMBRA-GIM13 Italian observational study confirm that in most cases treatment for MBC is strongly related to the type of the Adj regimen, being the use of anthracyclines marginal in MBC, whereas taxanes are widely used in any line. In 1st line the most used regimens are Taxane and Bevacizumab or Capecitabine/Vinorelbine combinations. The last one remains the most used CHT in 2nd and 3rd lines. No difference have been observed according to biological subtype, except for Platinum-based regimens in TNBC. HT alone remains the preferred choice in 1st and 2nd line in Luminal cases. TTC seems to be a reliable surrogate for PFS in the “real world” practice . CHT still plays a crucial role in the treatment of MBC HER2-ve pts.

Citation Format: Mustacchi G, Cazzaniga ME, Biganzoli L, De Laurentiis M, Del Mastro L, De Placido S, Donadio M, Garrone O, Giordano M, Latini L, Livi L, Marchetti P, Michelotti A, Montemurro F, Natoli C, Pronzato P, Riccardi F, Turletti A. First and further line choices of treatment for HER2-VE metastatic breast cancer (MBC) according to adjuvant treatment and biological subtype. Preliminary results of the observational “GIM-13 – AMBRA” Italian study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-15-07.

Non-pegylated liposome-encapsulated doxorubicin citrate plus cyclophosphamide or vinorelbine in metastatic breast cancer not previously treated with chemotherapy:a multicenter phase III study

We conducted a phase III multicenter randomized trial to compare the efficacy of the combination of liposome encapsulated doxorubicin (Myocet(©)) plus either cyclophosphamide (MC) or vinorelbine (MV). Since July 2006, 233 patients affected with metastatic breast cancer were randomized to receive the combination of Myocet (M) 60 mg/m(2) i.v. plus cyclophosphamide (C) 600 mg/m2 on Day 1 of a 21‑day cycle (Arm A) or Myocet (M) at 50 mg/m2 plus vinorelbine (V) 25 mg/m2 i.v. on Day 1 and V 60 mg/m2 orally on Day 8 on a 21‑day cycle (Arm B). The primary endpoints of the study was time to progression (TTP); secondary endpoints were RR, toxicity and OS. Response was observed in 53/116 (45.7%) evaluable patients of Arm A vs. 51/112 (45.5%) of Arm B, respectively (P=NS). Median TTP was 41 weeks (95% CI, 32‑51) and 34 weeks (95% CI, 26‑39), for M/C and M/V, respectively (P=0.0234). The difference in median OS was not statistically significant (131 vs. 122 weeks; P=0.107). With regard to toxicity, patients treated with MV showed a slight increase of neutropenia and constipation, as compared to those treated with MC. No clinical signs of cardiotoxicity were observed. The MC combination remains as an unbeaten 'standard' in first line treatment of MBC.

First-line chemotherapy with liposomal doxorubicin plus cyclofosfamide in metastatic breast cancer: a case report of early and prolonged response

The treatment choice for metastatic breast cancer should consider the appropriate balance between efficacy and toxicity of the therapy. We discuss a clinical case with an early response and prolonged to liposomal anthracyclines-based chemotherapy, without cardiotoxicity, enhancing the evidence of safety of liposomal formulation to prevent heart damage. Moreover, the case seems to be of interest for the role of 18F-FDG-PET in clinical response assessment: an early decrease of the standardized uptake value value, even before conventional imaging evaluation, is highly predictive for prolonged clinical response.

The spectrum of factor XI deficiency in Italy

Factor XI (FXI) deficiency is a rare inherited bleeding disorder invariably caused by mutations in the FXI gene. The disorder is rather frequent in Ashkenazi Jews, in whom around 98% of the abnormal alleles is represented by Glu117X and Phe283Leu mutations. A wide heterogeneity of causative mutations has been previously reported in a few FXI deficient patients from Italy. In this article, we enlarge the knowledge on the genetic background of FXI deficiency in Italy. Over 4 years, 22 index cases, eight with severe deficiency and 14 with partial deficiency, have been evaluated. A total of 21 different mutations in 30 disease-associated alleles were identified, 10 of which were novel. Among them, a novel Asp556Gly dysfunctional mutation was also identified. Glu117X was also detected, as previously reported from other patients in Italy, while again Phe283Leu was not identified. A total of 34 heterozygous relatives were also identified. Bleeding tendency was present in very few cases, being inconsistently related to the severity of FXI deficiency in plasma. In conclusion, at variance with other populations, no single major founder effect is present in Italian patients with FXI deficiency.

Effect of adjuvant trastuzumab treatment in conventional clinical setting: an observational retrospective multicenter Italian study

Clinical trials have shown the efficacy of trastuzumab-based adjuvant therapy in HER2-positive breast cancers, but routine clinical use awaits evaluation of compliance, safety, and effectiveness. Adjuvant trastuzumab-based therapy in routine clinical use was evaluated in the retrospective study GHEA, recording 1,002 patients treated according to the HERA protocol between March 2005 and December 2009 in 42 Italian oncology departments; 874 (87.23 %) patients completed 1-year trastuzumab treatment. In 128 patients (12.77 %), trastuzumab was withdrawn due to cardiac or non-cardiac toxicity (28 and 29 patients, respectively), disease progression (5 patients) or the clinician's decision (66 patients). In addition, 156 patients experienced minor non-cardiac toxicities; 10 and 44 patients showed CHF and decreased LVEF, respectively, at the end of treatment. Compliance and safety of adjuvant trastuzumab-based therapy in Italian hospitals were high and close to those reported in the HERA trial. With a median follow-up of 32 months, 107 breast cancer relapses were recorded (overall frequency, 10.67 %), and lymph node involvement, estrogen receptor negativity, lymphoid infiltration, and vascular invasion were identified as independent prognostic factors for tumor recurrence, indicating that relapses were associated with advanced tumor stage. Analysis of site and frequency of distant metastases showed that bone metastases were significantly more frequent during or immediately after trastuzumab (<18 months from the start of treatment) compared to recurrences in bone after the end of treatment and wash-out of the drug (>18 months from the start of treatment) (35.89 vs. 14.28 %, p = 0.0240); no significant differences were observed in recurrences in the other recorded body sites, raising the possibility that the protection exerted by trastuzumab is lower in bone metastases.

LRP1/CD91 is up-regulated in monocytes from patients with haemophilia A: a single-centre analysis

The low-density lipoprotein receptor-related protein 1 (LRP1) is an ubiquitously expressed endocytic receptor that, among its several functions, is involved in the catabolism of coagulation factor VIII (FVIII) and in the regulation of its plasma concentrations. Although LRP1/CD91 polymorphisms have been associated with increased FVIII levels and a consequent thrombotic risk, no data are available on LRP1/CD91 expression in patients with inherited FVIII deficiency. With the aim of elucidating this issue, 45 consecutive patients with haemophilia A (HA) (18 severe, 5 moderate and 22 mild HA) were enrolled in this cross-sectional, single-centre survey. The LRP1/CD91 mean fluorescence intensity (MFI) in monocytes from HA patients was significantly higher than that detected in 90 healthy blood donors (105 vs. 67, P < 0.001). This over-expression was independent of hepatitis C virus infection status and varied according to the severity of the haemophilia, being higher in patients with more severe FVIII deficiency. In conclusion, our study documents for the first time that LRP1/CD91 is over-expressed on monocytes from HA patients, with the intensity of expression varying according to the severity of the FVIII deficiency. Further studies are needed to assess the clinical implications of these findings.

P2-19-04: Changes in Adjuvant Treatment of Early Breast Cancer in Italy between 2000 and 2008. The NEMESI Study Versus the NORA Study

Background: In the early 2000s, we identified treatment patterns of early breast cancer (EBC) in Italy (NORA study). To ascertain whether attitudes have changed, we conducted a similar study in 2008. Patients and methods: In this retrospective study (NEMESI), we recorded the clinical, tumour and treatment characteristics of 1.894 EBC patients in 63 Italian oncological centres in 2008, and compared the results with those of NORA, on 3.515 patients in 70 same/similar Italian institutions, in 2000–2003. Tumor stage, surgery and endocrine-responsiveness are not comparable because of different recruitment protocols, patients charactheristics and adjuvant treatment strategies are perfectly comparable as a reliable picture of adjuvant strategies in Italy.

Results: There was no difference in age class distribution, menopausal status, ECOG performance status, tumor grade, ki67 and estrogen receptors content. HER2 status was simila but determined in 98% of cases in NEMESI vs 46.2% in NORA. The overall use of endocrine treatment (HT) increased from 80.3% in NORA to 83.5% in NEMESI (p = 0.005); the overall use of chemotherapy (CHT) decreased from 68.4% to 57.8% (p = 0.00001). HT alone increased from 31.6% to 42.2% (P = 0.00001) and CHT alone decreased from 18.8% to 16.2% (p = 0.017). The use of both treatments decreased from 49.2% to 41.6% (p = 0.00001). Trastuzumab was never given in NORA and in 15% of cases in NEMESI (85% of all HER2 positive cases).

The choice for HT was tamoxifen for 5 years in 32.5% of cases in NEMESI and 86.6% in NORA (p = 0.000001), and aromatase inhibitors for 5 years in 55.2% vs 13.3% of cases, respectively (P = 0.000001). The “switch” from tamoxifen 2–3 years to aromatase inhibitors 2–3 years was planned in 10.1% of cases in NEMESI and actually done in 12.9% of cases in NORA (p = 0.001). The overall use of LHRH analogues was significantly higher in NEMESI vs NORA (26.7% vs 3.0%, p = 0.00001). CMF-like regimens decreased from 37.0% in NORA to 9.1% (p = 0.000001). Anthracycline-containing regimens decreased from 52.1% in NORA to 48.8% in NEMESI; p = 0.0001) in favour of of regimens containing anthracyclines and taxanes, either in combination or sequential (0.9% in NORA vs 38.4% in NEMESIS, p = 0.000001). The use of taxanes alone regimens remained low (3.5% vs 3.7%, ns). The overall use of anthracyclines and taxanes increased from 53.0% to 87.5% and from 4.3% to 42.1%, respectively (both p =0.00001).

Conclusions: EBC treatment has changed significantly in 6 years. Adjuvant strategies are significantly different, with a great increase of aromatase inhibitors and LHRH analogues associated with tamoxifen; anthra-taxane combinations have also significantly increased.

Financial Support by Sanofi Aventis Italy

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-19-04.