Phase II Study of Docetaxel and Trametinib in Patients with KRAS Mutation Positive Recurrent Non-Small Cell Lung Cancer (NSCLC; SWOG S1507, NCT-02642042)

PURPOSE

Efficacy of MEK inhibitors in KRAS+ NSCLC may differ based on specific KRAS mutations and comutations. Our hypothesis was that docetaxel and trametinib would improve activity in KRAS+ NSCLC and specifically in KRAS G12C NSCLC.

PATIENTS AND METHODS

S1507 is a single-arm phase II study assessing the response rate (RR) with docetaxel plus trametinib in recurrent KRAS+ NSCLC and secondarily in the G12C subset. The accrual goal was 45 eligible patients, with at least 25 with G12C mutation. The design was two-stage design to rule out a 17% RR, within the overall population at the one-sided 3% level and within the G12C subset at the 5% level.

RESULTS

Between July 18, 2016, and March 15, 2018, 60 patients were enrolled with 53 eligible and 18 eligible in the G12C cohort. The RR was 34% [95% confidence interval (CI), 22-48] overall and 28% (95% CI, 10-53) in G12C. Median PFS and OS were 4.1 and 3.3 months and 10.9 and 8.8 months, overall and in the subset, respectively. Common toxicities were fatigue, diarrhea, nausea, rash, anemia, mucositis, and neutropenia. Among 26 patients with known status for TP53 (10+ve) and STK11 (5+ve), OS (HR, 2.85; 95% CI, 1.16-7.01), and RR (0% vs. 56%, P = 0.004) were worse in patients with TP53 mutated versus wild-type cancers.

CONCLUSIONS

RRs were significantly improved in the overall population. Contrary to preclinical studies, the combination showed no improvement in efficacy in G12C patients. Comutations may influence therapeutic efficacy of KRAS directed therapies and are worthy of further evaluation. See related commentary by Cantor and Aggarwal, p. 3563.

Abstract 1671: Evaluation of total PD-1 expression using multi-color flow cytometry in metastatic non-small Cell lung cancer patients treated with multi-neoantigen vector (ADXS-503) alone and in combination of pembrolizumab to assess T-cell & T-cell memory subsets

Precision for Medicine (Precision) developed and qualified two 17 color flow immunophenotyping assays to be used as pharmacodynamic biomarkers for Advaxis clinical studies in patients with Metastatic Non-Small Cell Lung Cancer treated with ADXS-503 alone and in combination with Pembrolizumab (Pembro). ADXS-503 (A503) is an off-the-shelf, attenuated Listeria monocytogenes (Lm)-based immunotherapy bioengineered to elicit potent T-cell responses against 22 tumor antigens commonly found in NSCLC. Pembrolizumab (Pembro) is a programmed death receptor-1 (PD-1)-blocking antibody approved for the treatment of advanced lung cancer. A503 and Pembro have complementary mechanisms of immune activation and reversal of immune tolerance. Here, we qualified two multi-color flow cytometry assays to quantify total PD-1 expression in cryopreserved peripheral blood mononuclear cells (PBMCs) from individuals that were treated either with A503 only or with A503 in combination with Pembro. The detection of free PD-1 and Pembro-bound PD-1 was achieved by co-staining a partially competing αPD-1 antibody (clone PD1.3.1.3) with a biotinylated αHu-IgG4 antibody. The robustness of the assay was demonstrated using a nine-point half-log serial dilution of Pembro, where the highest concentration was 10µg/mL and the lowest concentration was 0.001µg/mL, including a no drug control. The assay conditions were optimized for sensitivity, optimal signal:noise ratio, detection of free and drug bound receptor by titrating and testing various commercial αPD-1 antibody clones and tertiary reagents to detect biotinylated αHu-IgG4. The Pembro bound receptor was detected using a biotinylated αHu-IgG4 antibody, while the free receptors were quantified using a commercial αPD-1 antibody. The assay was able to quantify free and drug bound PD-1 in the intended immune cell types without compromising the staining of other cell surface and intra-nuclear markers. Majority of the evaluable patients, 6 out of 8, had increased counts of NK, CD4+ and CD8+ T-cells, including TCM, TEM and memory stem cells after the administration of ADXS-503 ± Pembro. PD1 expression on circulating CD4+, CD8+ and NK T-cells was also increased while PD-L1 expression was elevated in on-therapy tumor biopsies in some of these patients. Measuring total PD-1 in T-cells can be more challenging in patients on Pembrolizumab therapy as no known commercial non-competing αPD-1 antibody clones are available. This novel assay will facilitate the evaluation of total PD-1 expression as a pharmacodynamic biomarker in T-cells when PD-1 blockade is being used. These results also support that combination of ADXS-503 with PD-1 blockade could lead to enhancement of efficacy of anti-tumor immunotherapy.

Citation Format: Venkat Mohanram, Natalya Belkina, Angelina R. Bisconte, Jonathan W. Goldman, Gregory J. Gerstner, Missak Haigentz, Thomas Stinchcombe, Balazs Halmos, Surya Vangala, Victor Kabala, Dinesh Simkhada, Cristiane Metran, Darren Davis, Megan Parsi, Andres A. Gutierrez, Deborah Phippard, Suresh S. Ramalingam. Evaluation of total PD-1 expression using multi-color flow cytometry in metastatic non-small Cell lung cancer patients treated with multi-neoantigen vector (ADXS-503) alone and in combination of pembrolizumab to assess T-cell & T-cell memory subsets [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1671.

Effect of Erlotinib Plus Bevacizumab vs Erlotinib Alone on Progression-Free Survival in Patients With Advanced EGFR-Mutant Non-Small Cell Lung Cancer: A Phase 2 Randomized Clinical Trial

IMPORTANCE

Erlotinib is a standard first-line therapy for patients with epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC). Median progression-free survival (PFS) with erlotinib is approximately 10 months.

OBJECTIVE

To determine whether adding bevacizumab to erlotinib treatment results in superior progression-free survival compared with erlotinib alone.

DESIGN, SETTING, AND PARTICIPANTS

This phase 2 randomized clinical trial compared erlotinib plus bevacizumab with erlotinib alone in EGFR-mutant NSCLC. The trial was conducted in 17 US academic and community medical centers among 88 patients with EGFR exon 19 deletion or exon 21 L858R mutation based on local testing and stage 4 NSCLC who were eligible for bevacizumab. Patients were enrolled between November 2, 2012, and August 22, 2016, and followed up for a median (range) of 33 (0.7-62.5) months. Data were analyzed on August 28, 2018, and included data from November 2, 2012, to August 20, 2018.

INTERVENTIONS

Patients were randomized with equal allocation to 150 mg of oral erlotinib daily alone or with 15 mg/kg of intravenous bevacizumab every 3 weeks. Study therapy continued until disease progression, unacceptable adverse event, or withdrawal of consent.

MAIN OUTCOMES AND MEASURES

The primary outcome was PFS as assessed by the investigator; secondary outcomes were objective response rate (ORR), adverse events, and overall survival (OS). Analysis was designed to detect a hazard ratio (HR) of 0.667 for PFS (an improvement from a median PFS of 10 to 15 months).

RESULTS

Among 88 patients enrolled, the median (range) age was 63 (31-84) years; 62 patients (70%) were female; 75 (85%) were white, 8 (9%) were African American, 3 (3%) were Asian, and for 2 (2%), data on race were not available. Forty-eight patients (55%) were never smokers, 45 patients (51%) were of Eastern Cooperative Oncology Group performance status 1, and 59 patients (67%) had EGFR exon 19 deletion. Compared with erlotinib, the combination did not result in a significant difference in PFS (HR, 0.81; 95% CI, 0.50-1.31; P = .39; median PFS 17.9 [combination] and 13.5 months [erlotinib]), ORR (81% vs 83%; P = .81), and OS (HR, 1.41; 95% CI, 0.71-2.81; P = .33; median OS, 32.4 months [combination] and 50.6 months [erlotinib]). Adverse events of grade 3 or higher observed in 5 or more patients in the combination and erlotinib arms were skin eruption in 11 (26%) vs 7 (16%) patients, diarrhea in 4 (9%) vs 6 (13%) patients, hypertension in 17 (40%) vs 9 (20%) patients, and proteinuria in 5 (12%) vs 0 (0%) patients.

CONCLUSIONS AND RELEVANCE

Erlotinib plus bevacizumab compared with erlotinib did not result in a significant improvement in PFS in EGFR-mutant NSCLC.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01532089.

[Breast cancer: morbidity and mortality in Austria. Descriptive epidemiology 1983-1987]

The incidence and mortality rate from breast cancer in Austria from 1983 to 1987 were obtained from data of the Austrian Cancer Register. There were on average 3012 new cases per year (75.8 per 100,000 women). Age-standardized incidence (European standard population) as calculated by the WHO was 64.1 per 100,000. Distribution by stages ("US end-result group") showed stage I (localized) in 44.7%, stage II (spread to immediate neighbouring structures and regional lymph nodes) in 41.3% and stage III (generalized) in 14%. There was no significant difference between the various age groups regarding stage distribution. The number of deaths increased from 1,462 in 1983 to 1,675 in 1987, a raw mortality rate of 36.8 and 42.2, respectively. Age-standardized mortality increased from 29.0 to 31.2, respectively. These data point to a further increase in incidence and mortality rate from breast cancer in Austria.

Interstitial fluid concentrations of ceftriaxone (1 g.i.v.) in the subperitoneal space after hysterectomy

The ability of an antibiotic to penetrate into the extravascular site of infection is particularly important for a successful perioperative antibiotic prophylaxis and postoperative therapy of bacterial infection. We, therefore, measured interstitial fluid concentrations of ceftriaxone in the subperitoneal space following hysterectomy using Rubinstein's disc method after intravenous administration of 1 g of ceftriaxone preoperatively. After removal of the uterus, two disc units were implanted intraoperatively in the right and left subperitoneal space of 16 patients and were drawn out through the open vaginal cuff after given periods of time. Five disc and blood specimens were obtained after 90 min and 2, 6, 12, 24, and 48 h, respectively. Ceftriaxone concentrations were determined by bioassay. After administration of 1 g of ceftriaxone, interstitial fluid concentrations following hysterectomy were above the MIC90 of most pathogens encountered in gynecologic infections over a period of 24 h.

Comparison of ceftriaxone (1 x 1 g/day) versus cefotaxime (3 x 1 g/day) for gynecologic and obstetric infections. A randomized clinical trial

A prospective, randomized clinical trial was conducted to compare the efficacy and tolerance of a single dose of 1 g ceftriaxone i.v. daily with 3 doses of 1 g cefotaxime i.v. daily for obstetric and gynecologic infections. Both agents are characterized by a wide spectrum and potent activity. Furthermore, ceftriaxone has an outstanding serum half-life of 8 h. 41 patients with pelvic inflammatory disease, pelvic or wound infections after vaginal or abdominal hysterectomy, endomyometritis and urinary-tract infection were included. Patients were monitored clinically by routine laboratory methods (erythrocyte sedimentation rate, white blood cell count and cross-reacting protein) and bacteriologically. Clinical parameters of infection were fever, local pain and/or tenderness, a sactosalpinx or pyosalpinx at palpation and cervical secretion. Clinical cure was achieved in 77.3% in the ceftriaxone and in 78.9% in the cefotaxime group, improvement in 3 (13.6%) and 4 patients (21.0%), respectively. 2 clinical failures were seen in the ceftriaxone group. One was a severe pelvic infection following vaginal hysterectomy, which responded to the addition of metronidazole, the other was due to a chlamydial salpingitis, which was cured with a 10-day course of doxycycline. Both antibiotics were well tolerated. Our results suggest that for obstetric and gynecologic infections a single 1-gram dose of ceftriaxone is equally effective as three 1-gram doses of cefotaxime.

Influence of brachytherapy (192Ir afterloading) on cell-mediated immune reactions in patients with stage I endometrial cancer

The influence of radiation therapy on cell-mediated immune reactions in cancer patients seems to depend on source, dose, and area of irradiation, as well as on the variables reflected by the patient population investigated. In the present study we demonstrated that brachytherapy (192Ir afterloading), applied to patients with inoperable stage I endometrial cancer, has no immediate or sustained effect on lymphocyte function. Both lymphocyte mitogen response and natural killer cell (NK) activity are not significantly changed in terms of baseline values compared with test results during and after therapy. Brachytherapy, as used in this study, has no influence on cell-mediated immunity in patients with endometrial cancer stage I.

Amoxicillin in the treatment of asymptomatic bacteriuria in pregnancy: a single dose of 3 g amoxicillin versus a 4-day course of 3 doses 750 mg amoxicillin

A prospective, randomized, controlled comparative clinical trial was carried out with the aim of investigating the efficacy and tolerance of two different dosage regimens of amoxicillin in the treatment of asymptomatic bacteriuria during pregnancy. Patients in group A received a single dose of 3 g amoxicillin, which was compared to a 4-day course of 3 X 750 mg amoxicillin tablets taken every 8 h (group B). Significant bacteriuria (CFU greater than or equal to 10(5)/ml clean catch midstream urine and CFU greater than or equal to 10(4)/ml urine obtained by bladder catheterization) was diagnosed using the dip-slide method (Uricult). 91 pregnant women with a mean gestational age of 25 weeks (14-38) were randomly allocated to the two treatment groups. 53 patients were assigned to group A and 38 patients to group B. The treatment groups were comparable in terms of age and duration of pregnancy. Urine culture tests were performed 1 and 4 weeks after completion of therapy. The predominant species was Escherichia coli, which was isolated in 60-65% of the cases. Bacteriological cure rates at 1 and 4 weeks, respectively, were 77 and 74% in group A, and 62 and 62% in group B. These differences were statistically not significant. The incidence of side effects was 4% in group A and 13% in group B. The results obtained in the present study suggest that in the treatment of asymptomatic bacteriuria in pregnancy, a single dose of 3 g amoxicillin is as effective and acceptable as a 4-day course. In addition, the single-dose regimen offers the advantage of a reduction in total dose, lower costs and better patient compliance.

Single and multiple dose pharmacokinetics of ciprofloxacin in gynecological tissues

In a prospective pharmacokinetic study the serum and tissue concentrations of ciprofloxacin (Bay O9867), a new carboxyquinolone antimicrobial agent were studied. 22 patients were given 300 mg ciprofloxacin i. v. before the operation (group A), and 19 patients were premedicated with 500 mg ciprofloxacin orally twice daily for three days followed by 300 mg i. v. preoperatively. Tissue samples weighing approximately 2 g were taken from the fallopian tubes, the ovaries, the fundus myometrium and the cervix. Ciprofloxacin concentrations were measured biologically by the cup plate agar diffusion method. Ciprofloxacin concentrations in serum and gynecological tissues were within the same range in both groups. Maximal serum concentrations of 6 and 4 mg/l, respectively, were recorded immediately after infusion. After 2 h serum concentrations ranged from 0.6 to 1.3 mg/l in both groups. At the same time, the tissue concentrations ranged from 0.62 to 3.3 mg/kg, indicating that tissue levels exceed corresponding serum concentrations. On average ciprofloxacin is concentrated in the extravascular space two-fold, as compared to the corresponding serum concentrations. There is no drug accumulation. The tissue concentrations obtained provide a full antibacterial coverage for gynecological infections, since the MIC for the most pathogenic bacteria is less than 1 mg/l.

[Burkitt's lymphoma of the ovary. Case report]

Bilateral adnexal masses in an 18-year old turkish girl were diagnosed as Burkitt's lymphoma. Aetiology, diagnosis and therapy (surgery and chemotherapy) of this by gynecologists rarely seen disease are presented.

[Amoxicillin in the treatment of asymptomatic bacteriuria in pregnancy--3g single dose versus 3 times 750mg 4-day therapy]

A prospective, randomized, controlled comparative clinical trial was conducted to assess the efficacy and tolerability of 2 regimens of amoxicillin. In group A a single dose of 3 g amoxicillin and in group B a 4-day course of 3 doses of 750 mg amoxicillin tablets were administered 8-hourly. Significant bacteriuria (greater than or equal to 10(5) cfu/ml midstream urine) and of urine samples obtained by bladder catheterization (greater than or equal to 10(4) cfu/ml) was diagnosed with the dip-slide method (Uricult). 91 pregnant women with a mean gestational age of 25 weeks (14-38) were randomly allocated to both treatment groups. Group A consisted of 53 patients, group B of 38. The treatment groups were comparable in terms of age, duration of pregnancy and additional therapy. Control examinations of urine cultures were taken after 1 and 4 weeks following therapy. The predominant bacterial species was E. coli isolated in 60 to 65 percent. Bacteriological cure rates at 1 and 4 weeks were in group A 77% and 74% and in group B 62% each respectively. The differences in cure rates were not significant. Side effects occurred in group A in 4% and in group B in 13%. Our results suggest that for the treatment of asymptomatic bacteriuria in pregnancy a single dose of 3 g of amoxicillin is equally effective and acceptable as a 4-day course with the advantage of a lower total-dose, lower costs and a better compliance.

[Value of breast palpation in gynecologic practice]

A representative inquiry was carried out among 100 Austrian gynecologists and obstetricians. Aim of the study was to determine the percentage of gynecologists, who carry out routinely the palpation of the breast in their office: 73% of all gynecologists are performing breast-palpation routinely in every patient, 27% only in case of complaints. The highest percentage of routine-breast-palpation performing gynecologists was found among doctors, who are in private-practice only (97%). Particularly low percentages, however, were found e. g. among doctors, who have contracts with all social insurances (58%), who have a high frequency of social-insured patients (55%) or have many patients per day (61%). Since the routine-breast-palpation is of particular importance for the reduction of breast cancer mortality, this examination should be also performed routinely by all general practitioners, internists and surgeons. Therefore, from the point of view of preventive medicine and public health the routine examination of the female breast should be refunded by social insurance in Austria.

[Facts on the topic "gentle birth": a representative survey of Austrian gynecologists]

With regard to discussions in the public being held in this country throughout the past months, a representative inquiry was carried out among Austrian gynaecologists and obstetricians. Aim of the study was to determine the percentage of obstetricians performing the so-called "birth without violence" according to Leboyer as well as their opinion to this alternative obstetrical thinking: Approximately one half of Austrian gynaecologists is carrying out so-called "births without violence." However, the vast majority of them (78%) prefers for their own wives and their own children "electronic fetal monitoring" during labour and delivery. Analysis of our data according to the age of the doctor, the geographic region of his office, and the number of treated patients shows a considerable discrepancy between performance and personal preference of "alternative" obstetrical methods. These results should be taken into account for further discussions in the public about "births without violence", as obstetricians are among all professions those experts who can estimate the risks of pregnancy and delivery best.

Radiation therapy for primary carcinoma of the female urethra: a survey over 25 years

Sixty-two patients with primary carcinoma of the female urethra were treated with a combined radiation therapy (high-dose intracavitary vaginal radium and external beam). Treatment was strictly individualized, but an administered tumor dose of 5500-7000 rad (55-70 Gy) was always attempted. Forty-two patients (67.7%) had tumors of the anterior urethra, and in 20 women (32.3%) the posterior urethra was involved. In 19 patients (30.6%) the clinical diagnosis of lymph node involvement was made. The overall 5-year-survival rate was 64.5%. Patients with anterior urethral carcinoma had a higher 5-year-survival rate (71.4%) than patients with posterior carcinoma (50.0%). The favorable results underline the substantial role of radiation therapy for this malignancy.

[Infections in patients with gynecologic malignancies]

Infections in patients with gynecologic malignancies occur frequently and are the cause of death in 50 to 60% of the cases. The patient with cancer is a compromised host with an increased susceptibility to infection due to the malignancy itself on the one hand and due to therapeutic-modalities, like extensive surgical procedures, radiation- and cytotoxic chemotherapy on the other hand. Aetiologically these infections are mostly due to a disruption of anatomic structures which normally prevent the invasion of exogenous or endogenous microorganisms, or to obstructive processes or to tumour necrosis. Septicaemia can result from propagation of such a localized infection beyond the site of the tumour. The causative pathogens infecting the compromised host are mostly members of the indigenous microbial flora of the genital tract, which is influenced by surgery, irradiation and chemotherapy. Postoperatively in the vaginal vault the number of most potentially pathogenic aerobic and anaerobic bacterial species is higher, polymicrobial mixed infections are frequent. Neither the intracavitary radiation-therapy with Radium or Iridium-192 (afterloading) nor the external high-voltage therapy decrease the number of pathogenic bacterial species in the uterus and in the vagina of patients with cervical or endometrial cancer. The symptoms of infection in cancer patients can be "masked". Fever in patients with genital malignancies is mostly due to local infections and influences the prognosis negatively. The 5-year survival rate of irradiated patients with fever is significantly lower. Infections following radical hysterectomy, irradiation and/or cytotoxic chemotherapy like pelvic abscesses, peritonitis, pneumonia and septicaemia can be fatal. Urinary-tract-, wound- and vaginal vault-infections occur frequently, but are rarely severe. Therapeutically in severe infections a combination antibiotic therapy, which is effective against most pathogenic members of the genital flora, is required. Short courses of perioperative prophylactic antibiotics are useful both in radical hysterectomy and with intracavitary irradiation.

Endometrial bacteriology in patients with endometrial cancer before and after primary intracavitary irradiation using IR-192 and an afterloading technique

In a prospective clinical and bacteriological study the endocervical and endometrial flora of 38 patients with biopsy proven cancer of the endometrium was studied before and after intrauterine irradiation with 10 Gy (Ir-192, afterloading device, Buchler, Braunschweig). Bacteriological swabs were taken transcervically. Anaerobic transport media were used and cultures were done aerobically and anaerobically. The mean number of aerobic organisms per patient increased from 2.13 to 2.49 (not significant (n.s.)), and of anerobic organisms from 1.42 to 2.00 (n.s). Neither the recovery rate of aerobic and anaerobic bacteria nor the composition of endometrial flora was altered significantly by intracavitary irradiation. Only aerobic sporeformers increased from 5.3% to 21% (2 p less than 0.05). The most prevalent aerobic species were S. epidermidis, streptococci and E. coli, the predominant anaerobic species Pepto- and Peptostreptococcus and Bacteroides. Our results clearly show that the intrauterine administration of 10 Gy by a Ir-192-afterloading device does not sterilize the endocervix or endometrium and infections may occur after intracavitary radiotherapy.

Vaginal organisms in prepubertal children with and without vulvovaginitis. A vaginoscopic study

In a prospective clinical and microbiological study covering 67 prepubertal children the vaginal flora of 31 asymptomatic children was compared to 36 children suffering from abnormal vaginal discharge and/or vulvovaginitis. Vaginoscopy was employed to obtain bacteriological specimens without contamination. Swabs were inoculated into prereduced transportmedia (PORT A CUL, BBL) and cultured aerobically and anaerobically. The most prevalent aerobic organisms were Staphylococcus epidermidis. Enterococci and Escherichia coli; the predominant anaerobic bacteria were Peptococcus and Peptostreptococcus, Veillonella parvula, Eubacteria, Propionibacterium and Bacteroides species. A similar microbiological pattern was found in both groups, although anaerobes, like Peptococci and Peptostreptococci and Bacteroides species, as well as yeasts, like Candida albicans were significantly more frequent in the group with signs and symptoms. Lactobacilli were less common in this group.