Discontinuation rate and serious adverse events of chemoimmunotherapy as neoadjuvant treatment for triple-negative breast cancer: a systematic review and meta-analysis

BACKGROUND

The use of combination of chemotherapy with immune checkpoint inhibitors (ICIs) has shown efficacy in triple-negative breast cancer (TNBC), and chemoimmunotherapy has been introduced in clinical practice. However, limited data are available on the discontinuation rate and serious adverse events of these treatments, particularly in the neoadjuvant setting. Herein, we carried out a comprehensive systematic review and meta-analysis to assess discontinuation rate and serious adverse events of chemoimmunotherapy compared to chemotherapy alone in phase II and III neoadjuvant clinical trials in TNBC.

MATERIALS AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, EMBASE, Cochrane Library, and PubMed/Medline were searched for articles published from June 2008 to May 2023. The outcomes of interest were the discontinuation rate, serious adverse events, and grade 3-4 adverse events.

RESULTS

Four studies were included in the analysis. The pooled odds ratios (ORs) for discontinuation rate and serious adverse events were 1.26 [95% confidence interval (CI) 0.78-2.06] and 1.79 (95% CI 1.4-2.28), respectively, in patients receiving chemoimmunotherapy compared to chemotherapy alone as neoadjuvant treatment for TNBC. The chemoimmunotherapy group had a higher risk of grade 3-4 adverse events (OR 1.30, 95% CI 1.07-1.59). The analysis showed substantial heterogeneity, and the risk of discontinuation rate was heavily influenced by the KEYNOTE-522 trial.

CONCLUSIONS

Our findings highlight the need for clinical trials specifically focused on safety, quality of life, and treatment adherence in TNBC patients receiving neoadjuvant treatment. Close monitoring of tolerability remains crucial in this clinical setting.

Multimaterial and multiscale scaffold for engineering enthesis organ

Tendon and ligament injuries are relevant clinical problems in modern society, and the current medical approaches do not guarantee complete recovery of the physiological functionalities. Moreover, they present a non-negligible failure rate after surgery. Failures often occur at the enthesis, which is the area of tendons and ligaments insertion to bones. This area is highly anisotropic and composed of four distinct zones: tendon or ligament, non-mineralized fibrocartilage, mineralized fibrocartilage, and bone. The organization of these regions provides a gradient in mechanical properties, biochemical composition, cellular phenotype, and extracellular matrix organization. Tissue engineering represents an alternative to traditional medical approaches. This work presents a novel biofabrication approach for engineering the enthesis. Gradient-based scaffolds were fabricated by exploiting the combination of electrospinning and three-dimensional (3D) bioprinting technologies. Studies were conducted to evaluate scaffold biocompatibility by seeding bone marrow-derived mesenchymal stem cells (BM-MSCs). Then, the scaffold's ability to promote cellular adhesion, growth, proliferation, and differentiation in both tenogenic and osteogenic phenotypes was evaluated. Fabricated scaffolds were also morphologically and mechanically characterized, showing optimal properties comparable to literature data. The versatility and potentiality of this novel biofabrication approach were demonstrated by fabricating clinical-size 3D enthesis scaffolds. The mechanical characterization highlighted their behavior during a tensile test was comparable to tendons and ligaments in vivo.

Final results of the global and Asia cohorts of KAMILLA, a phase IIIB safety trial of trastuzumab emtansine in patients with HER2-positive advanced breast cancer

Background

KAMILLA is a single-arm safety study of trastuzumab emtansine (T-DM1) in patients with human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (BC; NCT01702571). We report the final analysis of cohort 2 (Asia) within the context of published cohort 1 (Global) findings.

Methods

Patients had HER2-positive, locally advanced, or metastatic BC progressing after chemotherapy and anti-HER2 therapy or ≤6 months after adjuvant therapy. The primary objective was to further evaluate T-DM1 (3.6 mg/kg, administered intravenously every 3 weeks) safety/tolerability, including the following adverse events of primary interest (AEPIs): grade ≥3 AEPIs (hepatic events, allergic reactions, thrombocytopenia, hemorrhage events), all grade ≥3 treatment-related AEs, and all-grade pneumonitis.

Results

KAMILLA enrolled 2185 patients (cohort 1, n = 2003; cohort 2, n = 182) as of 31 July 2019. Of these, 2002 and 181 per cohort were treated and included in the safety population. Approximately 70% of patients had two or more previous treatment lines in the metastatic setting. Median T-DM1 exposure was 5.6 and 5.0 months per cohort; median follow-up was 20.6 and 15.1 months. The overall AEPI rate was higher in cohort 2 (93/181; 51.4%) versus cohort 1 (462/2002; 23.1%), mostly driven by a higher grade ≥3 thrombocytopenia rate in cohort 2. In cohort 2, grade ≥3 thrombocytopenia was not associated with grade ≥3 hemorrhagic events and most (128/138) fully resolved. Grade ≥3 treatment-related AEPI rates were 18.4% (cohort 1) and 48.6% (cohort 2), the latter mainly due to thrombocytopenia. Any-grade pneumonitis rates were 1.0% and 2.2%. No new safety signals were identified. Median (95% confidence interval) progression-free survival was 6.8 months (5.8-7.6 months) and 5.7 months (5.5-7.0 months) in cohorts 1 and 2, respectively; median overall survival was 27.2 months (25.5-28.7 months) and 29.5 months (21.1 months to non-estimable). In both cohorts, median progression-free survival and overall survival decreased with increasing prior therapy lines.

Conclusions

Cohort 2 results aligned with previous findings in Asian patients, supporting the manageable safety profile and use of T-DM1 in advanced BC.

•

KAMILLA safety results for cohorts 1 (global; n = 2002) and 2 (Asia; n = 181) aligned with results from prior T-DM1 mBC trials.

•

The overall rate of adverse events of primary interest (AEPIs) was higher in cohort 2 (51.4%) versus cohort 1 (23.1%).

•

The higher AEPI rate was mostly due to a higher grade ≥3 thrombocytopenia event rate in cohort 2, most of which resolved.

•

Median PFS and OS were similar for both cohorts, and decreased with increasing prior therapy lines.

•

The manageable safety profile and efficacy of T-DM1 further support its favorable benefit/risk balance.

P11.26.A STAT3 expression in brain metastases from breast cancer: correlations with different molecular subtypes and clinical outcome

Background

STAT3 expression in peritumoral reactive astrocytes (RA) of brain metastases (BM) may favor a pro-metastatic environment. The aim of the study was to evaluate in a retrospective cohort of surgically resected BM from breast cancer (BC) the expression of pSTAT3 in RA of peritumoral tissue of BM, identify different patterns of expression according to molecular subtypes, and correlate with intracranial progression-free survival (i-PFS).

Material and Methods

Patients with histologically proven BM diagnosis from BC were identified from the biobank of Pathology Unit of University of Turin and Spanish national BrM network (RENACER). pSTAT3 expression was evaluated and scored in RA of peritumoral tissue using GFAP and STAT3 immunohistochemistry, according to Priego et al. (Nat Med 2018). Data on histological diagnosis, molecular subtypes, and i-PFS were retrieved by chart review. Intracranial progression was defined based on MRI reports.

Results

Eighty-five BM specimens from BC of 85 female patients with a median age of 54 years (range 30-81 years) were available for analysis. Immunohistochemistry for GFAP and pSTAT3 was feasible in 68/85 (80%). Fifteen out of 68 patients (21.1%) had BM from luminal BC, 27/68 (39.7%) from HER2-positive BC, and 26/68 (39.2%) from TNBC. Fifty-six out of 68 (82.4%) showed positive staining of pSTAT3 in peritumoral RA, of which 9/68 (13.3%) scored with 3, 26/68 (38.2%) with 2, and 21/68 (30.9%%) with 1, while pSTAT3 expression was negative (score 0) in 12/68 (17.6%). High pSTAT3 expression (score 2-3) was observed in 17/27 (62.9%) BM from HER2-positive BC and in 15/26 (57.7%) BM from TNBC, while most of BM from luminal BC (12/15 - 80%) had low or absent pSTAT3 (score 0-1) (p=0.021). Overall i-PFS was 16 months (range 7-41): low pSTAT3 BM (score 0-1) had a median i-PFS of 21 months versus 12 months for high pSTAT3 BM (score 2-3). A shorter median i-PFS was observed in high pSTAT3 BM from TNBC (4 months) as compared with low pSTAT3 BM (11 months). Conversely, i-PFS of high pSTAT3 BM (7 months) was similar to low pSTAT3 BM (6 months) in HER2-positive BC.

Conclusion

pSTAT3 expression in RA of peritumoral tissue of BM from TNBC and HER2-positive BC is higher than in BM from luminal BC. Of note, patients with high pSTAT3 BM from TNBC progressed earlier in comparison with those with low pSTAT3, suggesting that pSTAT3 expression has an influence on the outcome.

Study of the Adhesion of the Human Gut Microbiota on Electrospun Structures

Although the adhesion of bacteria on surfaces is a widely studied process, to date, most of the works focus on a single species of microorganisms and are aimed at evaluating the antimicrobial properties of biomaterials. Here, we describe how a complex microbial community, i.e., the human gut microbiota, adheres to a surface to form stable biofilms. Two electrospun structures made of natural, i.e., gelatin, and synthetic, i.e., polycaprolactone, polymers were used to study their ability to both promote the adhesion of the human gut microbiota and support microbial growth in vitro. Due to the different wettabilities of the two surfaces, a mucin coating was also added to the structures to decouple the effect of bulk and surface properties on microbial adhesion. The developed biofilm was quantified and monitored using live/dead imaging and scanning electron microscopy. The results indicated that the electrospun gelatin structure without the mucin coating was the optimal choice for developing a 3D in vitro model of the human gut microbiota.

Physicochemical Characterization of Pectin-Gelatin Biomaterial Formulations for 3D Bioprinting

Developing biomaterial formulations with specific biochemical characteristics and physical properties suitable for bioprinting of 3D scaffolds is a pivotal challenge in tissue engineering. Therefore, the design of novel bioprintable formulations is a continuously evolving research field. In this work, the authors aim at expanding the library of biomaterial inks by blending two natural biopolymers: pectin and gelatin. Cytocompatible formulations are obtained by combining pectin and gelatin at different ratios and using (3-glycidyloxypropyl)trimethoxysilane (GPTMS) as single crosslinking agent. It is shown that the developed formulations are all suitable for extrusion-based 3D bioprinting. Self-supporting scaffolds with a designed macroporosity and micropores in the bioprinted struts are successfully obtained by combining extrusion-based bioprinting and freeze-drying. The presence of gelatin in these formulations allows for the modulation of porosity, of water uptake and of scaffold stiffness in respect to pure pectin scaffolds. Results demonstrate that these new biomaterial formulations, processed with this specific approach, are promising candidates for the fabrication of tissue-like scaffolds for tissue regeneration.

Pectin as Rheology Modifier of a Gelatin-Based Biomaterial Ink

Gelatin is a natural biopolymer extensively used for tissue engineering applications due to its similarities to the native extracellular matrix. However, the rheological properties of gelatin formulations are not ideal for extrusion-based bioprinting. In this work, we present an approach to improve gelatin bioprinting performances by using pectin as a rheology modifier of gelatin and (3-glycidyloxypropyl)trimethoxysilane (GPTMS) as a gelatin-pectin crosslinking agent. The preparation of gelatin-pectin formulations is initially optimized to obtain homogenous gelatin-pectin gels. Since the use of GPTMS requires a drying step to induce the completion of the crosslinking reaction, microporous gelatin-pectin-GPTMS sponges are produced through freeze-drying, and the intrinsic properties of gelatin-pectin-GPTMS networks (e.g., porosity, pore size, degree of swelling, compressive modulus, and cell adhesion) are investigated. Subsequently, rheological investigations together with bioprinting assessments demonstrate the key role of pectin in increasing the viscosity and the yield stress of low viscous gelatin solutions. Water stable, three-dimensional, and self-supporting gelatin-pectin-GPTMS scaffolds with interconnected micro- and macroporosity are successfully obtained by combining extrusion-based bioprinting and freeze-drying. The proposed biofabrication approach does not require any additional temperature controller to further modulate the rheological properties of gelatin solutions and it could furthermore be extended to improve the bioprintability of other biopolymers.

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.

•

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

•

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

•

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

•

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

•

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

Phase II study of eribulin in combination with gemcitabine for the treatment of patients with locally advanced or metastatic triple negative breast cancer (ERIGE trial). Clinical and pharmacogenetic results on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC)

Background

The combination of a microtubule inhibitor (eribulin) with a nucleoside analog (gemcitabine) may synergistically induce tumor cell death, particularly in triple negative breast cancer (TNBC) characterized by high cell proliferation, aggressive behavior, and chemo-resistance.

Patients and methods

This is an open-label, multicenter phase II study evaluating the combination of eribulin (0.88 mg/m²) plus gemcitabine (1000 mg/m²) on days 1 and 8 of a 21-day cycle as either first- or second-line treatment of locally advanced or metastatic TNBC. The primary endpoint was the objective response for evaluable patients. A prospective, molecular correlative study was carried out to assess the role of germinal BRCA pathogenic variants and single nucleotide polymorphisms (SNPs) in predicting efficacy and toxicity of the combination regimen.

Results

From July 2013 to September 2016, 83 evaluable patients were enrolled. They received a median number of six cycles of treatment. An overall response rate (ORR) of 37.3% (31 patients) was observed, with a complete response rate of 2.4% and a partial response rate of 34.9%; the clinical benefit rate was 48.8%. With a median follow-up of 28.8 months, the median response duration was 6.6 months, the median progression-free survival (PFS) was 5.1 months, and the median overall survival (OS) was 14.5 months. The most common grade 3-4 adverse events were aminotransferase elevation (in 25% of the patients) and neutropenia (in 23.8%). Women with BRCA1/2 pathogenic variants were associated with worse ORR, PFS, and OS than BRCA1/2 wild-type carriers. CYP3A4 and FGD4 SNPs were associated with increased risk of liver toxicity. Three different SNPs in CDA∗2, RRM1, and CYP2C8 genes were significantly associated with poorer OS.

Conclusions

The combination of eribulin and gemcitabine showed promising activity and a moderate toxicity profile in metastatic TNBC. BRCA status and pharmacogenetics tests may help identify patients with high probability of response with negligible toxicity.

EudraCT number

2012-003505-10.

•

Eribulin plus gemcitabine showed a remarkable best ORR of 37.3% and a clinical benefit rate of 48.8%.

•

The most common grade 3/4 toxicities were liver toxicity and neutropenia without febrile neutropenia.

•

The study regimen partially lost its efficacy in patients harboring BRCA1/2 pathogenic variants.

•

SNPs in CYP3A4 and FGD4 genes were associated with increased risk of liver toxicity.

•

Three different SNPs in CDA∗2, RRM1, and CYP2C8 genes were significantly associated with poorer OS.

A novel 3D in vitro model of the human gut microbiota

Clinical trials and animal studies on the gut microbiota are often limited by the difficult access to the gut, restricted possibility of in vivo monitoring, and ethical issues. An easily accessible and monitorable in vitro model of the gut microbiota represents a valid tool for a wider comprehension of the mechanisms by which microbes interact with the host and with each other. Herein, we present a novel and reliable system for culturing the human gut microbiota in vitro. An electrospun gelatin structure was biofabricated as scaffold for microbial growth. The efficiency of this structure in supporting microbial proliferation and biofilm formation was initially assessed for five microbes commonly inhabiting the human gut. The human fecal microbiota was then cultured on the scaffolds and microbial biofilms monitored by confocal laser and scanning electron microscopy and quantified over time. Metagenomic analyses and Real-Time qPCRs were performed to evaluate the stability of the cultured microbiota in terms of qualitative and quantitative composition. Our results reveal the three-dimensionality of the scaffold-adhered microbial consortia that maintain the bacterial biodiversity and richness found in the original sample. These findings demonstrate the validity of the developed electrospun gelatin-based system for in vitro culturing the human gut microbiota.

How do novel and conventional agri-food wastes, co-products and by-products improve soil functions and soil quality?

Agriculture is estimated to generate about 700 million tons of waste annually in the EU. Novel valorization technologies are developing continuously to recover and recycle valuable compounds and nutrients from waste materials. To close the nutrient loop, low-value agri-food wastes, co-products and by-products (AFWCBs) produced during the valorization process, need to be returned to the soil. However, knowledge on their reaction in soils that is needed to allow efficient and environmentally sound recycling is largely lacking. To this end, we set up a series of laboratory incubation experiments using 10 AFWCBs including insect frass residues made from three different feedstocks, anaerobic digestates from two feedstocks, potato-pulp, rice bran compost, duckweed and two reference crop residues (wheat straw and sugar beet) and measured net N release, C mineralization, dehydrogenase activity (DHA), microbial biomass C (MBC) and community structure. The suppressing potential of frasses and digestates against Rhizoctonia solani was determined using bean. The digestates released the highest net mineral N (50-70%) followed by rice bran compost (55%) and duckweed (30%), while frass made from general food waste and potato-pulp immobilized N like the reference straw for 91 days after incubation. All AFWCBs except digestates significantly increased MBC compared to the control while frasses, potato-pulp and duckweed increased DHA. Frasses and digestates significantly suppressed the development of Rhizoctonia solani in bean plants. AFWCBs from emerging valorizing technologies have the potential to improve microbial activities, C sequestration and may play a significant role in closing the nutrient loop.

Endothelial cells support osteogenesis in an in vitro vascularized bone model developed by 3D bioprinting

Bone is a highly vascularized tissue, in which vascularization and mineralization are concurrent processes during skeletal development. Indeed, both components should be included in any reliable and adherent in vitro model platform for the study of bone physiology and pathogenesis of skeletal disorders. To this end, we developed an in vitro vascularized bone model, using a gelatin-nanohydroxyapatite (gel-nHA) three-dimensional (3D) bioprinted scaffold. First, we seeded human mesenchymal stem cells (hMSCs) on the scaffold, which underwent osteogenic differentiation for 2 weeks. Then, we included lentiviral-GFP transfected human umbilical vein endothelial cells (HUVECs) within the 3D bioprinted scaffold macropores to form a capillary-like network during 2 more weeks of culture. We tested three experimental conditions: condition 1, bone constructs with HUVECs cultured in 1:1 osteogenic medium (OM): endothelial medium (EM); condition 2, bone constructs without HUVECs cultured in 1:1 OM:EM; condition 3: bone construct with HUVECs cultured in 1:1 growth medium:EM. All samples resulted in engineered bone matrix. In conditions 1 and 3, HUVECs formed tubular structures within the bone constructs, with the assembly of a complex capillary-like network visible by fluorescence microscopy in the live tissue and histology. CD31 immunostaining confirmed significant vascular lumen formation. Quantitative real-time PCR was used to quantify osteogenic differentiation and endothelial response. Alkaline phosphatase and runt-related transcription factor 2 upregulation confirmed early osteogenic commitment of hMSCs. Even when OM was removed under condition 3, we observed clear osteogenesis, which was notably accompanied by upregulation of osteopontin, vascular endothelial growth factor, and collagen type I. These findings indicate that we have successfully realized a bone model with robust vascularization in just 4 weeks of culture and we highlighted how the inclusion of endothelial cells more realistically supports osteogenesis. The approach reported here resulted in a biologically inspired in vitro model of bone vascularization, simulating de novo morphogenesis of capillary vessels occurring during tissue development.

Electrospun Structures Made of a Hydrolyzed Keratin-Based Biomaterial for Development of in vitro Tissue Models

The aim of this study is the analysis and characterization of a hydrolyzed keratin-based biomaterial and its processing using electrospinning technology to develop in vitro tissue models. This biomaterial, extracted from poultry feathers, was mixed with type A porcine gelatin and cross-linked with γ-glycidyloxy-propyl-trimethoxy-silane (GPTMS) to be casted initially in the form of film and characterized in terms of swelling, contact angle, mechanical properties, and surface charge density. After these chemical-physical characterizations, electrospun nanofibers structures were manufactured and their mechanical properties were evaluated. Finally, cell response was analyzed by testing the efficacy of keratin-based structures in sustaining cell vitality and proliferation over 4 days of human epithelial, rat neuronal and human primary skin fibroblast cells.

Cell-Free Demineralized Bone Matrix for Mesenchymal Stem Cells Survival and Colonization

Decellularized bone matrix is receiving much attention as biological scaffolds and implantable biomaterials for bone tissue regeneration. Here, we evaluated the efficacy of a cell-free demineralized bone matrix on mesenchymal stem cells (MSCs) survival and differentiation in vitro. The seeding of human umbilical cord-derived MSCs (hUC-SCs) on decellularized bone matrices up to 14 days was exploited, assessing their capability of scaffold colonization and evaluating gene expression of bone markers. Light and Scanning Electron Microscopies were used. The obtained cell-free decalcified structures showed elastic moduli attributable to both topology and biochemical composition. Morphological observation evidenced an almost complete colonization of the scaffolds after 14 days of culture. Moreover, in hUC-SCs cultured on decalcified scaffolds, without the addition of any osteoinductive media, there was an upregulation of Collagen Type I (COL1) and osteonectin (ON) gene expression, especially on day 14. Modifications in the expression of genes engaged in stemness were also detected. In conclusion, the proposed decellularized bone matrix can induce the in vitro hUC-SCs differentiation and has the potential to be tested for in in vivo tissue regeneration.

Abstract P2-08-34: The network metanalysis of data from PALOMA 2, MONALEESA 2, MONARCH 3, FALCON, SWOG and FACT trials: Progression free survival (PFS) benefit from first-line endocrine-based therapies in postmenopausal women with HR+ HER2- metastatic breast cancer (MBC) according to different prognostic subgroups

Background

The three classes of Cycline Dependend Kinase (CDK) 4/6 inhibitors, Palbociclib (P), Ribociclib (R) and Abemaciclib (A), in combination with non-Steroidal Aromatase Inhibitors (nSAIs) showed improvement on Progression Free Survival (PFS) in patients with HR+/HER2- MBC compared to AIs monotherapy.

Fulvestrant (F) also showed a PFS benefit over AIs in first-line setting of endocrine naive patients (pts) which was even greater in pts whithout visceral disease.

The absence of direct comparison between F and CDK 4/6 combination therapies and their less favorable toxicity profile generated great interest in the identification of a specific subgroup of pts based on clinical and pathological factors for decision-making in the use of endocrine monotherapy.

This analysis combines data from six randomized phase III trials investigating the role of endocrine-based therapies in the first-line setting of HR+/HER2- MBC to identify clinical factors in the choice among available drugs.

Methods

A Bayesian network meta-analysis was carried out for PFS; Hazard Ratio (HR) and 95% CI were reported. Potential treatment effect modifying covariates were investigated using sub-group analysis, stratifying by age, ECOG, ethnicity, prior chemotherapy or endocrine therapy exposure, measurable disease at the time of metastasis occurrence, visceral or bone only disease, time from the initial diagnosis of breast cancer to the metastasis onset. Data analysis was performed using R Statistical Software version 3.5.0

Results

In the absence of direct comparison between CDK 4/6 inhibitors + nAIs and F endocrine-based therapies, all these therapeutic options resulted in significant PFS benefit compared to nAIs monotherapy (HR: 0.74; 95% CI 0.67-0.80). However, among the three classes of CDK 4/6 inhibitors and F a significant longer PFS was observed according to some clinical-pathological factors as followed reported: from P + nAIs in “bone only” disease (HR 0.47; CI 0.25-0.86); from A + nAis in “de novo” subgroup (HR 0.60; CI 0.37-0.97), in “Asian” population (HR 0.37; CI 0.16-0.85) and “non visceral” disease (HR 0.48 CI 0.25-0.89); from R + nAIs in “de novo” subgroup (HR 0.55; CI 0.32-0.95) and in “visceral” disease (HR 0.66 CI 0.45-0.96); from all the three combination strategies (A, P and R) in “prior endocrine” exposure subgroup (HR 0.47 CI 0.25-0.87; HR 0.60 CI 0.45-0.80; HR 0.64 CI 0.41-1.0, respectively). Even though no significant PFS benefit was observed in the remaining subgroups, combined CDK 4/6 strategies appeared more effective than F according to relative HR.

Conclusions

CDK 4/6 inhibitors endocrine-based therapies as first-line treatment for postmenopausal women with HR+/HER2- MBC showed PFS improvement, regardless of prognostic subgroup and additionally advantage was emerged by indirect comparison with F. Further direct comparative studies are needed to explore greater benefits from different therapeutic options.

Citation Format: Rossi V, Giannarelli D, Berchialla P, Montemurro F, Ferretti G, Nistico' C, Vigna L, Cognetti F, Fabi A. The network metanalysis of data from PALOMA 2, MONALEESA 2, MONARCH 3, FALCON, SWOG and FACT trials: Progression free survival (PFS) benefit from first-line endocrine-based therapies in postmenopausal women with HR+ HER2- metastatic breast cancer (MBC) according to different prognostic subgroups [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 P2-08-34.

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.

Abstract P1-14-05: Phase II study of eribulin in combination with gemcitabine for the treatment of patients with locally advanced or metastatic triple negative breast cancer (ERIGE Trial). Clinical and pharmacogenetic results on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC)

Background: There are no well-established chemotherapy regimens for metastatic triple negative breast cancer. The combination of a microtubule inhibitor (eribulin) with a nucleoside analog (gemcitabine) may synergistically induce tumor cell death, especially in tumors like triple negative breast cancers (TNBC) characterized by high cell proliferation, aggressive tumor behavior, and chemo-resistance.

Materials and Methods:This is an open-label, national multicenter phase II study evaluating the combination of eribulin (0.88 mg/m2) plus gemcitabine (1000 mg/m2) on day 1 and 8, q21 as either first- or second-line treatment of locally advanced or metastatic TNBC.The primary endpoint was the objective response rate (ORR) for evaluable patients (pts). The study was designed according to the Simon's two stage optimal design. We chose the lower activity (p0) of 0.20 and target activity level (p1) of 0.35. A prospective, molecular correlative study has been being carried out on germinal DNA of study population to assess the role of BRCA mutations and single nucleotide polymorphisms (SNPs) in predicting efficacy and toxicity of the combination regimen.

Results: From July 2013 to September 2016, 83 evaluable pts (37 in the first stage, 46 in the second one) were enrolled. They received a median number of 6 cycles of treatment (range 1-24). The ORR (CR+PR) was 37.35% (90% CI: 28.47-46.93) and the clinical benefit rate (CR+PR+SD ≥ 24wks) was 48.78% (90% CI: 39.24%-58.39%). The most common grade 3-4 adverse events (> 10% of patients) were neutropenia and liver toxicity. With a median follow-up of 28.8 months, the median progression-free survival (PFS) and overall survival (OS) were 5.1 months (95% CI: 4.2-7.0) and 14.7 months (95% CI: 10.2-20.0), respectively. BRCA1/2 deleterious mutations were observed in 15 (22%) out of 68 genotyped pts. Women with BRCA1/2 mutations were associated with worse ORR, PFS and OS than those with BRCA1/2 wild-type. A panel of SNPs in genes of study drug metabolism pathways was evaluated. Among these, CYP3A4 392A >G and FGD4 2044236G>A SNPs were associated with greater liver toxicity by logistic regression analysis. Furthermore, CDA*2 79A>C, RRM1 2455 A>G, and CYP2C8 416G>A SNPs were associated with poorer overall survival by Cox proportional hazards model.

Conclusions:The combination of eribulin and gemcitabine shows promising activity and a moderate toxicity profile in metastatic TNBC. BRCA status and pharmacogenetics tests may help identify pts with high probability of response with negligible toxicity.

Citation Format: Musolino A, Cavanna L, Boggiani D, Zamagni C, Frassoldati A, Caldara A, Rocca A, Gori S, Piacentini F, Berardi R, Brandes AA, Foglietta J, Villa F, Pellegrino B, Todeschini R, Tognetto M, Naldi N, Bortesi B, Boni L, Montemurro F, Ardizzoni A. Phase II study of eribulin in combination with gemcitabine for the treatment of patients with locally advanced or metastatic triple negative breast cancer (ERIGE Trial). Clinical and pharmacogenetic results on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC) [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 P1-14-05.

Abstract OT1-03-03: Phase II, open label, randomized, biomarker study of immune-mediated mechanism of action of neoadjuvant subcutaneous trastuzumab in patients with operable or locally advanced/Inflammatory HER2-positive breast cancer. ImmunHER trial on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC)

Background: Tumor-infiltrating lymphocytes (TILs) have been reported to be associated with increased therapeutic efficacy of trastuzumab in the (neo)adjuvant setting for HER2-positive breast cancer (BC). Subcutaneous (SC) trastuzumab has been observed to act at different immunologic levels than IV trastuzumab. Therefore, by modifying the modality of administration of trastuzumab, it could be possible to interfere with different pathways of the immune system and exert a favorable immunomodulation in HER2-positive BC.

Trial design: In this non-comparative, phase II, neoadjuvant, randomized study, patients will be treated with FEC chemotherapy (fluorouracil 500 mg/m2; epirubicin 75 mg/m2; cyclophosphamide 500 mg/m2) q21 for 3 cycles. Then, they will be randomly assigned in a 1:1 ratio to receive: docetaxel (75 mg/m2) plus pertuzumab (840 mg loading dose, then 420 mg) plus IV trastuzumab (8 mg/kg loading dose, then 6 mg/kg) q21 for 4 cycles (Group A) or, docetaxel plus pertuzumab plus SC trastuzumab (fixed dose of 600 mg) q21 for 4 cycles (Group B). After surgery, study patients will receive trastuzumab q21 x 14 cycles using the same formulation (SC or IV) of the preoperative phase.

Eligibility criteria: Patients must have previously untreated, T2-4d primary HER2-positive BC with no metastatic disease. Other inclusion criteria are: age 18 or older; ECOG performance status 0-1; availability of tumor tissue from diagnostic biopsy; normal left ventricular ejection fraction; normal organ and marrow function.

Specific aims: The main objective of this trial is to evaluate variations of host immune response parameters to either trastuzumab SC or trastuzumab IV given in combination with pertuzumab and chemotherapy as neoadjuvant treatment of patients with HER2-positive BC. Tumor samples obtained at diagnosis and at definitive surgery will be centrally analyzed for TILs. Blood samples will be also collected during study treatment for tumor-specific lymphocyte cell activity (TLA) analysis. Feasibility, efficacy, safety and health-related quality of life will be also evaluated.

Statistical methods: The primary endpoint is post-surgery pathologic TIL rate on residual disease. The threshold for classifying subjects with high TILs, or not, is defined as equal to 15%, according to the median TIL rate observed in primary HER2-positive tumors. Because this is a phase II study with 2 non-comparative arms, Simon's optimal 2-stage design will be used for each of the 2 study groups. For each arm we assume: p1 = 0.4, expected rate of subjects with high TILs on residual disease, p0 = 0.1, lowest limit of the subject rate (alpha= 0.05; beta= 0.20).

Present accrual and target accrual: A total of 60 patients (first stage: 16 patients) will be enrolled from multiple institutions. From November 29, 2016 to June 11, 2017, 34 patients have been recruited.

Contact information:Dr. Antonino Musolino, MD, MSc, PhD; Medical Oncology Unit, University Hospital of Parma; Tel: +390521702316; Fax: +390521995448; e-mail: amusolino@ao.pr.it. Clinical Trials.gov: NCT03144947.

Citation Format: Musolino A, Gori S, Cavanna L, Graiff C, Frassoldati A, Bria E, Bisagni G, Zambelli A, Partesotti G, Brandes A, Bonetti A, Moscetti L, Zamagni C, Rocca A, Generali D, Montemurro F, Gianni L, Tognetto M, Maglietta G, Todeschini R. Phase II, open label, randomized, biomarker study of immune-mediated mechanism of action of neoadjuvant subcutaneous trastuzumab in patients with operable or locally advanced/Inflammatory HER2-positive breast cancer. ImmunHER trial on behalf of the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-03-03.

Abstract P1-13-06: Safety of trastuzumab in the subcutaneous formulation for the treatment of HER2 positive early breast cancer (eBC) patients: Primary results of SCHEARLY trial

Background:: This study in Italian breast cancer patients is part of a phase IIIB, open-label, multinational umbrella study (UmbHER1), assessing the safety and tolerability of the subcutaneous (SC) formulation of Trastuzumab as primary end point. Present analysis is relative to the safety during the treatment period, with a major focus to side effects associated with the Trastuzumab SC administration.

Methods: Patients with HER2-positive eBC and LABC were eligible and included in two sequential cohorts: 120 patients treated with Trastuzumab SC by handheld syringe (Cohort A), and 120 with Trastuzumab SC by single-use injection device (SID, Cohort B). All the patients received adjuvant or neo-adjuvant treatment (clinician choice) with Anthracycline-containing regimens (FEC/EC/AC) followed by Trastuzumab SC in combination with taxanes (weekly Paclitaxel or Docetaxel) and then in monotherapy for a total of 18 cycles. Safety clinical and instrumental evaluations were planned at definite time points.

Results: 240 patients were enrolled and 202 patients (82.6% in cohort A and 84.9% in cohort B) completed the treatment. Reasons for discontinuation were the following: 7.9% AE/intercurrent illness, 3.3% withdrew consent, 1.7% recurrence of disease, 1.7% refused treatment, 0.9% violation of inclusion criteria, 0.9% other reasons. In the safety population, 98.2% of patients experienced at least one adverse event from the start of the Anthracycline treatment until the Safety Follow-up visit. Patients experiencing a Treatment Emergent (from Trastuzumab start date) AEs defined as Grade ≥3 were 26.8%; of these, 3.9% were considered related to study drug; Treatment Emergent Serious Adverse Events appeared in 7.5% of the safety population, of which 0.9% were considered related to study drug: one pleuropericarditis and one anaphylactic shock, both resolved.

The frequency of systemic administration-related reactions, ARRs (pyrexia 25%, erythema 20,2%, rash 7,0%, chest pain 7,0%, pruritus 6,6%, chills 1,3%, anaphylactic shock 0,9%) and local injection site reactions, ISRs (pain 6,6%, injection site reactions 3,9%, subcutaneous abscess 0,9%, administration site oedema 0,4%) potentially related to the subcutaneous formulation is cumulatively reported below.

 % all / G≥3% related to IMP% related cohort A% related cohort B% during Tax+Trast all/ G≥3% during Trast only all/ G≥3Systemic ARRs68,0 / 2,28,85,33,916.7 / 0.425.0 / 0.4Local ISRs21,9 / 0,97,04,81,36.6 / 0.43.1 / 0.0

The mean reduction of Left Ventricular Ejection Fraction (LVEF) at the end of 1 year treatment from screening was 2.9%. 8.8% of patients experienced a decrease in LVEF, in most cases defined related to study drug (18 patients out of 20); no cases of CHF were reported.

Conclusion: Local and systemic tolerability of subcutaneous Trastuzumab administration is good in both groups and there is no evidence of increased incidence and severity of IMP-related systemic side effects in comparison with the standard intravenous route.

Citation Format: Zambetti M, Montemurro F, Morandi P, Zamagni C, Stell A, Rozzi A, Gianni L. Safety of trastuzumab in the subcutaneous formulation for the treatment of HER2 positive early breast cancer (eBC) patients: Primary results of SCHEARLY trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-13-06.

Abstract OT3-05-06: EarLEE-2: A phase 3 study of ribociclib + endocrine therapy (ET) for adjuvant treatment of patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–), intermediate-risk, early breast cancer (EBC)

Background: Adjuvant ET with or without chemotherapy reduces the risk for recurrence of HR+, HER2– EBC. However, recurrence is still common, especially in patients with adverse clinical and pathologic features. In the phase 3 MONALEESA-2 trial, the cyclin-dependent kinase 4/6 inhibitor ribociclib (LEE011), in combination with letrozole, prolonged progression-free survival versus letrozole plus placebo in postmenopausal women with HR+, HER2– advanced breast cancer and no prior therapy for advanced disease (HR = 0.56, 95% CI, 0.43-0.72; P = 3.29×10−6; Hortobagyi et al. N Engl J Med. 2016). EarLEE-2 is investigating the efficacy and safety of ribociclib with ET versus placebo with ET as adjuvant treatment in patients with intermediate-risk EBC.

Trial design: In this double-blind, placebo-controlled, phase 3 adjuvant trial, ˜4,000 women and men with fully resected, intermediate-risk, HR+, HER2– EBC (defined as AJCC 8th ed. Prognostic Stage Group II) are being randomized 1:1 to oral ribociclib (600 mg/day, 3 weeks on/1 week off for ˜24 months) plus ET or to placebo plus ET. Adjuvant ET may include tamoxifen, letrozole, anastrozole, or exemestane for ≥ 60 months with ovarian suppression for premenopausal women at the discretion of the investigator. Adjuvant ET in men will be tamoxifen only. Neoadjuvant therapy is not permitted. Randomization is stratified by menopausal status (men and premenopausal women vs postmenopausal women), prior adjuvant chemotherapy (yes vs no), Prognostic Stage Group (IIA vs IIB), and geographic region (North America/Europe/Australia vs rest of the world). Eligible patients must have tumor tissue from the surgical specimen, adequate bone marrow and organ functions, normal serum electrolytes, QTc interval < 450 msec, and completed and recovered from acute toxicities of adjuvant radiotherapy and/or chemotherapy. The primary endpoint is invasive disease-free survival (per STEEP system; Hudis et al. J Clin Oncol. 2007). Secondary endpoints include recurrence-free survival, distant disease-free survival, overall survival, quality of life, and safety. Global recruitment to EarLEE-2 is ongoing. NCT03081234

Citation Format: O'Shaughnessy J, Alba E, Bardia A, Dent S, Dieras V, Hortobagyi G, Im S-A, Montemurro F, Untch M, Yardley DA, Chakravartty A, Germa C, Miller M, Slamon D. EarLEE-2: A phase 3 study of ribociclib + endocrine therapy (ET) for adjuvant treatment of patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–), intermediate-risk, early breast cancer (EBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-05-06.

Abstract P1-17-02: Ado-trastuzumab emtansine (TDM-1) treatment and brain metastases in HER2 positive metastatic breast cancer patients: Final analysis of an italian multicenter study

Background: Ado-trastuzumab emtansine (T-DM1) is a drug-antibody conjugate whose activity has been confirmed in HER2+ advanced breast cancer (BC) patients by the phase 3 EMILIA trial (Verma et al, NEJM 2012). Within the 991 patients enrolled in this trial, about 10% were affected with brain metastases (BM); in this subgroup, safety and efficacy of T-DM1 were confirmed although without any PFS improvement.

Patients and methods: In an Italian, multicenter, retrospective analysis involving 303 patients with advanced BC treated with T-DM1 (Fabi et al, Oncotarget 2017), we analyzed 87 patients with BM (BM-group). The study wanted to evaluate the efficacy of T-DM1 on BM; furthermore we compared BM-group with the remaining 216 patients without BM (nBM-group) in order to study outcome of disease. MRI was used as assessment imaging.

The number of extracranial metastatic sites in the BM-group and in the nBM-group was 1 for 10 (11.5%) and for 74 patients (34.3%), 2 for 23 (26.4%) and 93 (43%) patients, 3 for 25 (28.7% and 38 (17.6%) and 4 or more for 29 (33%) and 11 (5%), respectively.

In the BM-group, 5 patients (5.7%) had received surgery alone as local treatment for brain metastases, 13 (14.9%) surgery plus stereotactic radio-surgery (SRS), 4 (4.7%) surgery plus whole-brain radiotherapy (WBRT), 23 (26.5%) SRS alone, 40 (45.9%)WBRT alone and 2 (2.3%) WBRT followed by SRS. Twenty-eight patients (32.9%) and 89 (42.4%) in the BM-group and nBM-group, respectively, received T-DM1 as second line, 24 (28.2%) and 49 (23.3%) as third line and 33 (38.8%) and 72 (34.3%) as fourth line. Mean number of cycles was 6 in both groups.

Results:Among BM-group, 53 patients (60.9%) were evaluable for response. Two (3.8%) obtained brain complete response, 14 (26.4%) partial response and 13 (24.5%) stable disease [brain disease control rate: 54.7%); 24 (45.3%) progressed during T-DM1.

Regarding extracranial metastases, overall response rate was 35.1% in the BM-group and 38.3% in the nBM-group; 6 months-clinical benefit was 50.6% and 52.3%, respectively. Median PFS was 7 months in the BM-group and 8 months in the nBM-group; when T-DM1 was given as second line, median PFS was 5 months in the BM-group and 11 months in nBM-group (p=0.01) while as third, line in which 76% of patients received lapatinib/capacitabine before TDM1, median PFS was 12 and 13 months (p=NS), respectively.

Conclusions: T-DM1 showed a good activity on BM in BC patients. A better outcome was shown in patients previously treated with lapatinib. The identification of clinical and biological prognostic factors could be needed to better select more responder patients with BM to T-DM1.

Citation Format: Fabi A, Alesini D, Valle E, Carbognin L, Arpino G, Montemurro F, Ciccarese M, Cannita K, Paris I, Cursano MC, Moscetti L, Ferretti G, De Laurentiis M, Zambelli A, La Verde N, Nisticò C, Gasparro S, Giannarelli D, Cognetti F. Ado-trastuzumab emtansine (TDM-1) treatment and brain metastases in HER2 positive metastatic breast cancer patients: Final analysis of an italian multicenter study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-17-02.

Cardiac tissue regeneration: A preliminary study on carbon-based nanotubes gelatin scaffold

The aim of this study was set-up and test of gelatin and carbon nanotubes scaffolds. Gelatin-based (5%) genipin cross-linked (0.2%) scaffolds embedding single-walled carbon nanotubes (SWCNTs, 0.3, 0.5, 0.7, 0.9, and 1.3% w/w) were prepared and mechanically/electrically characterized. For biological evaluation, H9c2 cell line was cultured for 10 days. Cytotoxicity, cell growth and differentiation, immunohistochemistry, and real-time PCR analysis were performed. Myoblast and cardiac differentiation were obtained by serum reduction to 1% (C_1% ) and stimulation with 50 nM all trans-retinoic acid (C_RA ), respectively. Immunohistochemistry showed elongated myotubes in C_1% while round and multinucleated cells in C_RA with also a significantly increased expression of natriuretic peptides (NP) and ET-1 receptors in parallel with a decreased ET-1. On scaffolds, cell viability was similar for Gel-SWCNT_0.3%/0.9% ; NP and ET systems expression decreased in both concentrations with respect to control and CX-43, mainly due to a lacking of complete differentiation in cardiac phenotype during that time. Although further analyses on novel biomaterials are necessary, these results represent a useful starting point to develop new biomaterial-based scaffolds. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2750-2762, 2018.

The control of stem cell morphology and differentiation using three-dimensional printed scaffold architecture

In this work, we investigated the interactions of human mesenchymal stem cells (hMSCs) with three-dimensional (3D) printed scaffolds displaying different scaffold architectures. Pressure-assisted microsyringe system was used to fabricate scaffolds with square (SQR), hexagonal (HEX), and octagonal (OCT) architectures defined by various degrees of curvatures. OCT represents the highest degree of curvature followed by HEX, and SQR is composed of linear struts without curvature. Scaffolds were fabricated from poly(L-lactic acid) and poly(tyrosol carbonate). We found that hMSCs attached and spread by taking the shape of the individual struts, exhibiting high aspect ratios (ARs) and mean cell area when cultured on OCT scaffolds as compared with those cultured on HEX and SQR scaffolds. In contrast, cells appeared bulkier with low AR on SQR scaffolds. These significant changes in cell morphology directly correlate with the stem cell lineage commitment, such that 80 ± 1% of the hMSCs grown on OCT scaffolds differentiated into osteogenic lineage, compared with 70 ± 4% and 62 ± 2% of those grown on HEX and SQR scaffolds, respectively. Cells on OCT scaffolds also showed 2.5 times more alkaline phosphatase activity compared with cells on SQR scaffolds. This study demonstrates the importance of scaffold design to direct stem cell differentiation, and aids in the development of novel 3D scaffolds for bone regeneration.

Abstract P1-12-10: Safety and efficacy of trastuzumab emtansine (T-DM1) in 399 patients with central nervous system metastases: Exploratory subgroup analysis from the KAMILLA study

Introduction T-DM1 treatment significantly improved overall survival and had a lower incidence of grade ≥3 adverse events (AEs) vs capecitabine plus lapatinib in patients (pts) with HER2-positive advanced breast cancer (BC) in the EMILIA study, including pts with treated, asymptomatic CNS metastases (mets). KAMILLA is an ongoing, single-arm, open-label, phase 3b global safety study of T-DM1 in pts with HER2-positive locally-advanced or metastatic BC (target n=2220). In this interim analysis we describe clinical characteristics, safety, and efficacy in pts with stable CNS mets at baseline (BL).

Methods Eligible pts received prior HER2-directed therapy and chemotherapy and progressed on or after most recent treatment for advanced BC, or within 6 months of completing adjuvant therapy. Pts with asymptomatic CNS mets were eligible, including pts with stable CNS disease with prior radiation therapy. Pts received T-DM1 3.6 mg/kg every 3 weeks until unacceptable toxicity, withdrawal of consent, or disease progression. This exploratory analysis describes pts with BL CNS mets. Median progression-free survival (PFS) was estimated using the Kaplan-Meier method.

Results As of April 4, 2016, data were available for 2017 treated pts, of whom 399 (20%) had BL CNS mets, with a median follow-up of 33 months. Table 1 presents demographic and BL characteristics.

The incidence of AEs was similar between pts with and without BL CNS mets. Serious AEs (SAEs) occurred in 112 pts with BL CNS mets (28%) vs 311 of 1618 pts without BL CNS mets (19%), and the frequency of SAEs was comparable to that observed in EMILIA. However, nervous system disorder SAEs, such as seizure, epilepsy, and brain edema, occurred more frequently in pts with BL CNS mets (30 pts [8%]) vs 18 pts [1%] with no BL CNS mets.

Mean T-DM1 treatment duration was 8.0 months (median 8 cycles; range 1–55) in pts with BL CNS mets and 9.4 months (median 9 cycles; range 1–57) in pts with no BL CNS mets. Median PFS was 5.5 months in pts with BL CNS mets vs 7.9 months in pts with no BL CNS mets. A decrease in the size of brain target lesions was observed during T-DM1 treatment in 84 of 126 pts with measurable CNS lesions.

Table 1. BL characteristics CNS mets at BL (n=399)No BL CNS mets (n=1618)Median age, yrs (range)52 (28–83)55 (26–88)ECOG performance status, n (%)  0193 (48)929 (57)1174 (44)605 (37)232 (8)83 (5)Hormone receptor status, n (%)  ER and/or PR positive246 (62)992 (61)ER and PR negative149 (37)593 (37)Median time since initial BC diagnosis, yrs (range)4.8 (0–28)5.0 (0–53)Median time since first metastasis, yrs (range)2.4 (0–25)2.6 (0–35)Median number of prior therapies for metastatic BC (range)3 (0–>10)2 (0–>10)

Conclusions This subgroup analysis of KAMILLA is the largest reported cohort of pts with CNS mets treated with T-DM1. The overall safety profile of T-DM1 in pts with BL CNS mets was comparable to that of pts without CNS mets. As might be expected in pts with CNS disease, serious neurological AEs occurred more frequently in pts with BL CNS mets vs those without. Response to T-DM1 was seen in the CNS in pts with BL CNS mets, however, median PFS was lower in pts with BL CNS mets vs those without BL CNS mets.

Citation Format: Montemurro F, Ellis P, Delaloge S, Wuerstlein R, Anton A, Button P, Lindegger N, Barrios C. Safety and efficacy of trastuzumab emtansine (T-DM1) in 399 patients with central nervous system metastases: Exploratory subgroup analysis from the KAMILLA 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 P1-12-10.

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.

Abstract P1-09-21: Clinical evaluation of miR-100 as a predictor of endocrine-responsiveness in hormone-receptor positive breast cancer

Background: Micro RNAs (miRNAs) are short, non-coding RNA molecules that act as negative regulators of gene-expression, mainly at the post-transcriptional level. Alterations in miRNA functions have been implicated in a variety of human diseases, including cancer

We demonstrated that the ectopic expression of miR-100 in cancer stem cells (CSCs) derived from aggressive, basal-like BC (HRs and HER2 negative) caused loss of stemness and the acquisition of a hormone receptor positive and endocrine treatment sensitive phenotype (Petrelli et al, Oncotarget 6;2315-30, 2015). We therefore sought to study whether miR-100 is a determinant of the endocrine-responsive phenotype in HR-positive BC patients (pts).

Methods: Women with newly diagnosed, estrogen-receptor and/or progesterone-receptor positive, HER2 negative BC were eligible for this study. Treatment consisting of tamoxifen for pre-menopausal and letrozole for post-menopausal pts was administered daily for 21 days (+/- 3 days) before breast surgery. MiR-100 levels in pre-treatment tumor biopsies, measured as fold-change with respect to a reference RNA and transformed to the natural logarithms to normalize the data, were correlated with proliferative response to endocrine therapy, as measured by Ki67 expression in the final surgical specimen. The primary end-point was a complete proliferative response (CPR), defined as a post-treatment Ki67≤1%. Additionally, we considered a “post-hoc” composite endpoint where response was defined as a post treatment Ki67 <10% together with a Ki67 reduction ≥80% compared to pre-treatment values. The target accrual is 88 patients (pts). Here we report the results of the first interim analysis focusing on post-menopausal pts receiving letrozole.

Results: A total of 42 pts were evaluable for miR-100 levels and response to endocrine therapy. Median ER and PgR expression was 99% (58%-99%) and 96% (0-99%) respectively. Median pre-treatment Ki67 was 18% (5-76%). Thirty-one tumors were ductal carcinomas, 9 were lobular and 2 were “other” histotypes. The median (range) miR-100 values in pre-treatment specimens was 2.253 (0.460-3.750). After treatment, median Ki67 was 4% (1%-46%) and the median percentage variation with respect to baseline values was -74% (0% to -94%). A CPR was observed in 5/42 pts (12%, 95% C.I. 5%-25%). The median miR-100 levels in responders and non-responders were 3.058 and 2.198, respectively (p = 0.03). Logistic regression analysis showed that each unit increase in miR-100 was associated with a 7-fold increase in the likelihood of a CPR (OR 7.056, 95% C.I. 1.103-45.141, p = 0.04).

Considering the composite end-point, 17/42 pts (40%, 95% C.I. 27%-56%) were considered responders. Median miR-100 levels in responders and non-responders were 2.427 and 1.956, respectively (p = 0.05).

Conclusions: preliminary results of this prospective clinical trial suggest that miR-100 can be a modulator of the endocrine-responsive phenotype in post-m pts with HR-positive breast cancer. The study is completing its target accrual and an investigation of miR-100 targets is being conducted.

GZ and AP contributed equally to this work.

Supported by Associazione Italiana per la Ricerca Sul Cancro (Investigator Grant IG-2013 Ref. 14451).

Citation Format: Zucchini G, Petrelli A, Kubatzki F, Cargnelutti M, Di Virgilio MR, Sarotto I, Martincich L, Ponzone R, Martinello R, Sapino A, Nuzzo A, Giordano S, Montemurro F. Clinical evaluation of miR-100 as a predictor of endocrine-responsiveness in hormone-receptor positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-21.

Abstract P5-14-09: Luminal A breast cancer: Is it really a “good prognosis” disease? Prelimary results of the GIM-13 - AMBRA study

This abstract was not presented at the symposium.

Abstract P1-09-12: Dose dense adjuvant chemotherapy in patients with early breast cancer: Differential treatment effects according to composite index of benefit

Background In patients with node-positive early breast cancer (EBC), dose-dense adjuvant chemotherapy improves disease-free survival (DFS) compared with standard interval chemotherapy. The GIM2 trial supports the value of dose-dense chemotherapy and suggests that the benefit is present in patients with hormone receptor-negative or hormone receptor-positive tumours (Del Mastro et al. Lancet 2015). In order to individualize decision making, there is a need to examine the absolute treatment effects of dose dense chemotherapy according to patient and tumor characteristics.

Patients and Methods The randomized phase III GIM2 trial enrolled 2091 patients. The primary endpoint was DFS. A continuous, composite measure of treatment benefit for each patient was determined from a Cox model incorporating potential predictive factors (age: 25-40/41-55/56-71; histological grade: 1+2/3; hormonal receptor status: positive/negative). Subpopulation treatment effect pattern plot methodology was used to reveal differential treatment effects on DFS according to composite index. The study focused on patients with HER2–negative disease (N=1287).

Results On average, the magnitude of benefit with dose dense chemotherapy versus standard chemotherapy ranged widely across different subpopulations, as quantified by the composite measure of relevant variables. The highest benefit was observed in patients with high grade, hormone receptor-negative disease (hazard ratio for DFS 0.44, 95% CI 0.23-0.83). Of note, a relevant benefit was observed also in patients with high grade, hormone receptor-positive disease (hazard ratio for DFS 0.74, 95% CI 0.50-1.09).

Conclusion The absolute improvement in DFS with dose dense adjuvant chemotherapy is substantial in some patients with node-positive HER2-negative breast cancer, particularly those regarded as having high index risk (hormone receptor-negative, high grade disease). Interestingly, a significant effect of dose dense chemotherapy was observed also in patients with hormone receptor-positive, high grade disease.

Citation Format: Puglisi F, Ceppi M, Cognetti F, De Placido S, Bruzzi P, De Laurentiis M, Bisagni G, Cavazzini G, Durando A, Turletti A, Valle E, Montemurro F, Barni S, Ardizzoni A, Gamucci T, Colantuoni G, Del Mastro L. Dose dense adjuvant chemotherapy in patients with early breast cancer: Differential treatment effects according to composite index of benefit [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-12.

Abstract P4-21-11: T-DM1 in HER2 positive advanced breast cancer patients: Real world practice from a multicenter observational study

Background: T-DM1 showed remarkable activity in metastatic HER-2 positive breast cancer (mBC) and it was recently approved for clinical use in patients (pts) who previously failed Trastuzumab- and Taxanes-based therapies. Currently, little is known on the performance of T-DM1 in a “real life” scenario. Therefore, we investigated effectiveness and safety of T-DM1 in Italian daily practice.

Methods: Pts baseline characteristics and clinical outcome of pts with HER-2 positive mBC treated with T-DM1 between 2013 and 2015 at 20 Italian Institutions were retrospectively collected and analyzed.

Results: 300 pts were included in our analysis. Median age was 51 years (27-78); visceral metastases were present in 204 (68%) pts and brain metastases in 86 (29%). It is noteworthy that 111 (37%) pts received T-DM1 as pure second line, 83 (28%) as third line and 96 (32%) as further lines. Moreover 10 (3%) pts had T-DM1 as first line because disease recurrence occurred during or adjuvant trastuzumab of within 6 months of its completion. The overall response rate (ORR) was 40%, global disease control rate (gDCR) 64%, median progression-free survival (PFS) 7.0 months (C.I.95%: 5.6-8.4) and overall survival (OS) at 2 years 63%. Pts with 1, 2 and 3 or more metastatic site had OS at 2 years of 87%, 67% and 46%, respectively (p<0.0001). When T-DM1 was given as second line the PFS was 8.0 months and beyond second-line was 6.8 months. Interestingly, for 38 (13%) pts who progressed after Pertuzumab-plus trastuzumab and taxanes as first line treatment, ORR and gDCR were similar to pertuzumab-naïve patients (38% and 62%, respectively) However PFS was 5.0 months (C.I.95%: 4.3-5.7) compared to 9.0 (95% C.I. 5.5-12.4) achieved in pts not receiving a previous pertuzumab-based treatment. Most frequent grade ≥3 toxicities were thrombocytopenia (2.6%), alopecia (2.1%), hypertransaminasemia (2.2%), neutropenia (1.3%), asthenia (1.3%) and diarrhea (0.4%).

Conclusions: To our knowledge, this is the first real life, multicenter retrospective analysis evaluating efficacy and safety of T-DM1 in pretreated HER-2 positive mBC pts. We observed remarkable results in terms of PFS and OS, especially when T-DM1 was given early in the course of metastatic disease. Shortened PFS in patients progressing after pertuzumab suggest further analyses to better define possible molecular mechanisms of cross-resistences between two molecules. As a whole there was no evidence of significant or unexpected toxicities. Although these findings should be taken with caution due to the retrospective analysis and the different lines of previous treatment considered, we confirmed the potential therapeutic role of T-DM1 across a heterogeneous population of HER-2 positive mBC patients. The final analysis will be presented to the meeting.

Citation Format: Fabi A, De Laurentiis M, Caruso M, Valle E, Moscetti L, Santini D, Cannita K, Carbognin L, Ciccarese M, Rossello R, Arpino G, Leonardi V, Montemurro F, La Verde N, Generali DG, Zambelli A, Scandurra G, Russillo M, Paris I, D'Ottavio AM, Filippelli G, Giampaglia M, Stani S, Fabbri A, Alesini D, Giannarelli D, Cognetti F. T-DM1 in HER2 positive advanced breast cancer patients: Real world practice from a multicenter observational 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 P4-21-11.

Abstract P5-11-01: Self-evaluation of duration of adjuvant chemotherapy side effects in breast cancer patients: A prospective study

Background: Collection and analysis of chemotherapy-related side-effects (CSE) is critical in the management of cancer patients (pts) both in experimental trials and in the clinical practice. Usually, most of the available conventional systems like the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) capture CSE severity but not their duration. Recently we observed that self-evaluation of CSE incidence and severity by a CTCAE v4.0-based questionnaire was feasible and potentially more informative than doctor reports in pts undergoing standard adjuvant chemotherapy (ACT) for operable breast cancer (Montemurro et al., JAMA Oncol 2; 445-452, 2016). Our questionnaire had also a section for reporting, for each of the considered CSE, day of onset, duration and whether it was still present at the time of the visit. Here we report the analysis of patient self-evaluation of CSE duration.

Methods: The study prospectively enrolled 604 pts receiving ACT for operable breast cancer between January 2011 and October 2013 at 11 sites in Italy. CTCAE v4.0 definitions of grade of severity for nausea, vomiting, constipation, anorexia, dysgeusia, diarrhea, fatigue, pain, paresthesia, and dyspnea were translated into Italian and rephrased. Questionnaires were administered after the first and third cycle of chemotherapy. At each time-point, information on CSE was extracted from the medical charts and compared to patient questionnaires.

Results: Overall 1177 questionnaires were collected, 596 after cycle 1 and 581 after cycle 3 of ACT. A median of 82% of the fields was completely filled-in. 594 and 573 pts-questionnaires had a corresponding MD-questionnaire. Comparison of CSE duration after cycle 1 of chemotherapy as self-assessed by pts versus that reported by doctors is summarized in the table. For all CSE, patient reported longer duration than doctors did. Comparisons of reports after cycle 3 were similar.

 PatientsDoctors Item (available paried data)Incidence (%)Mean duration* (SD)Incidence 8%)Mean Duration* (SD)P**Nausea (538)673.7 (3.6)401.6 (2.6)<0.01Vomiting (571)221.8 (1.7)111.2 (1.8)<0.01Constipation (546)492.7 (3.4)121.0 (2.9)<0.01Anorexia (563)533.8 (4.2)71.0 (1.9)<0.01Dysgeusia (556)505.0 (5.7)81.0 (4.1)<0.01Diarrhea (568)152.4 (2.8)40.9 (1.8)<0.01Fatigue (533)756.7 (5.2)250.9 (2.5)<0.01Pain (518)323.6 (4.4)100.5 (2.4)<0.01Paresthesia (582)232.9 (5.2)35.2 (0.8)<0.01Dyspnea (574)256.2 (5.6)25.0 (1.8)<0.01 *5% trimmed mean, ** Student T test for paired samples

Conclusions: self-reporting of CSE duration is feasible in patients receiving ACT after breast cancer surgery by using a CTCAE-derived questionnaire. Because doctors tend to underestimate both incidence and duration of CSE, patient-reported outcomes should be incorporated into the clinical practice because of the potential to provide a better estimate of the total burden of CSE.

Supporte by a grant of the Rete Oncologica Del Piemonte e della Valle d'Aosta.

Citation Format: Galizia D, Martinello R, Cagnazzo C, Foresto M, Gallizioli S, Longo V, Berchialla P, Solinas G, Calori A, Volpone C, Parola G, Tealdi G, Ballari A, Montemurro F. Self-evaluation of duration of adjuvant chemotherapy side effects in breast cancer patients: A prospective 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 P5-11-01.