Immunogenicity of COVID-19 vaccines in lung cancer patients

OBJECTIVE

Patients with lung cancer are at increased risk of SARS-CoV-2 infection and severe complications from COVID-19, but information on the efficacy of anti-SARS-CoV-2 vaccine in these patients is scarce. We aimed at evaluating the safety and immunogenicity of COVID-19 vaccines in this population.

PATIENTS AND METHODS

The prospective, nationwide SOLID substudy, enrolled adults with lung cancer who were fully vaccinated against COVID-19. Serum anti-SARS-CoV-2 IgG antibody levels were quantitatively assessed two weeks and six months after receipt of the last dose using a chemiluminescent microparticle immunoassay. Multivariate odds ratios for the association between demographic and clinical factors and seronegativity after vaccination were estimated.

RESULTS

1973 lung cancer patients were enrolled. Most patients had stage IV disease (66%) and were receiving active cancer treatment (82.7%). No significant differences were found in the probability of being seronegative for anti-SARS-CoV-2 IgG antibodies after full vaccination between patients who were receiving active cancer treatment and those who were not (p = 0.396). The administration of immunotherapy or oral targeted therapy and immunization with mRNA-1273 COVID-19 vaccine were factors independently associated with increased odds of being seropositive after vaccination. From all patients, 1405 received the second dose of vaccine and high levels of antibody titers were observed in 93.6% of patients two weeks after second dose. At six months, multivariate logistic regression analysis showed that performance status ≥ 2 was independently associated with a higher probability of being seronegative after full vaccination with an OR 4.15. On the other hand, received chemotherapy or oral target therapy and vaccination with mRNA-1273 were a factor independently associated with lower odds of being seronegative after full vaccination with an OR 0.52, 0.37 and 0.34, respectively.

CONCLUSIONS

Lung cancer patients can safely achieve a strong immune response against SARS-CoV-2 after full vaccination, regardless of the cancer treatment received.

TRIAL REGISTRATION

NCT04407143.

Nurse-Supervised Exercise for People with Stage IV Cancer: The EFICANCER Randomized Clinical Trial

OBJECTIVES

To assess the effectiveness of the EFICANCER individualized and supervised exercise program for people with gastrointestinal, breast, or non-small cell lung stage IV cancer, in terms of quality of life and functional capacity.

DATA SOURCES

Randomized controlled clinical trial with two parallel groups: EFICANCER (n = 47) and control (n = 43). Both groups received standard oncological care. In addition, the EFICANCER group participated in a nurse-supervised exercise program. Primary outcome was cancer-specific (EORTC QLQ-C30 questionnaire) and general quality of life (SF-36) at baseline and after 2, 6, and 12 months. Secondary outcomes were functional capacity (6-minute walking test), strength, and fatigue. The evolution in both groups was compared over 12 months using mixed-effect longitudinal models; 74.47% of patients completed at least one session of the program. At 12 months, EFICANCER group had better scores in cancer-related quality of life, with a difference between groups of 15.7 points (95% confidence interval 4.4 to 25.9) and in functional capacity, with a difference of 4.5 points (95% confidence interval -0.5 to 9.5). No significant differences in any other secondary variables were observed.

CONCLUSION

The EFICANCER primary care nurse supervised exercise program is safe and feasible and improves cancer patient's outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Providing the best care and trying to improve the quality of life of cancer patients are essential parts of nursing practice. Eficancer adds a new dimension to nursing practice by providing greater attention and care to patients during treatment through the supervision of physical exercise, thereby contributing to improve the quality of life of this population.

Differences in Quality of Life and Emotional Well-being in Breast, Colon, and Lung Cancer Patients During Outpatient Adjuvant Chemotherapy: A Longitudinal Study

BACKGROUND

Adjuvant chemotherapy used at each cancer site may affect quality of life (QoL) and emotional well-being (affect) of cancer patients differently; however, these differences between groups have not been studied.

OBJECTIVES

The aim of this study was to assess differences in QoL and affect by cancer site at the start of outpatient adjuvant chemotherapy, whether QoL and affect change during this treatment, and whether adverse effects influence these variables.

METHODS

A multicenter longitudinal descriptive study was conducted with 247 participants with breast, colon, or lung cancer at the beginning (T1) and end of treatment (T2). We used the SF-12 Health Survey, Positive and Negative Affect Scale, and an "ad hoc" adverse effects questionnaire.

RESULTS

At the start of chemotherapy, the lung group had poorer Physical Component Summary and poorer positive and negative affect ( P < .05) scores. In the end-of-treatment comparisons, breast and colon cancer patients' status had worsened, whereas lung cancer patients had tended to stabilize, although they remained the most vulnerable. Adverse effect severity was significant for Physical Component Summary ( r = -0.13, P = .035), with decreases in positive affect ( r = -0.17, β = -.16) and increases in negative affect ( r = 0.15, β = .14).

CONCLUSIONS

Changes in QoL and emotional state differ between groups, implying a need for varying levels of follow-up and emotional support. Patients with lung cancer seem particularly vulnerable.

IMPLICATIONS FOR PRACTICE

Cancer nurses could strengthen the assessment of patients undergoing chemotherapy using more sensitive instruments such as the Positive and Negative Affect Scale and considering differences by cancer site, to provide care tailored to individual patient needs and preferences.

Just an Acute Pulmonary Edema? Paraneoplastic Thyroid Storm Due to Invasive Mole

Hydatidiform mole is a malignant entity included in the gestational trophoblastic diseases. It usually produces pregnancy hormones such as beta-human chorionic gonadotropin (β-hCG), which in turn stimulates endogenous thyroid hormone production. We report the case of a high-risk complete invasive hydatidiform mole with pulmonary metastasis and associated paraneoplastic syndrome. The patient is a 30-year-old woman who presented symptoms of pregnancy and metrorrhagia. A uterine mass was detected. Urine β-hCG was found negative. In serum, 2,662,000 mIU/mL (normal range: <5) was found, together with parameters of severe hyperthyroidism. The patient underwent uterine curettage with diagnostic and therapeutic means. At that precise moment, her pregnancy-like symptoms worsened and she developed restlessness, tachycardia, diaphoresis, dyspnea at rest, and peripheral edema. A scan showed bilateral pulmonary nodules suggestive of metastasis, acute pulmonary edema, and bilateral pleural effusion without signs of pulmonary thromboembolism. At that time, she presented a free T4 of 2.34 ng/dL (normal range: 0.8–1.8 ng/dL), causing a thyroid storm with secondary cardiac dysfunction. The patient was treated with corticosteroid therapy to decrease peripheral conversion of thyroid hormone T4 to active T3. Her symptoms remitted within 8 h. After 48 h, T4 level was 1.2 ng/dL while serum β-hCG was 80,000 mIU/mL, with a positive urine result. The change in the urine analysis is due to the “hook effect” of the reactive test. An effective chemotherapy treatment was started according to the EMA-CO scheme, remaining free of disease at present. Knowing paraneoplastic syndromes is necessary to achieve the best clinical management and to start treatment early.

First-line osimertinib in patients with epidermal growth factor receptor-mutant non-small-cell lung cancer and with a coexisting low allelic fraction of Thr790Met

AIM OF THE STUDY

The AZENT (NCT02841579) study aimed to assess the efficacy and safety of first-line osimertinib in patients with epidermal growth factor receptor(EGFR)mutation-positive advanced non-small-cell lung cancer (NSCLC) and with a coexisting low allelic fraction of Thr790Met.

METHODS

In this multicentre, single-arm, open-label, phase IIa study, patients with locally advanced or metastatic NSCLC harbouring centrally confirmedEGFR Thr790Met mutation received 80 mg osimertinib daily. The primary end-point was objective response rate (ORR). The secondary end-points included disease control rate (DCR), progression-free survival (PFS), overall survival (OS) and safety. Efficacy was assessed as per Response Evaluation Criteria in Solid Tumours, version 1.1. Blood samples collected at baseline, end of week 2 and disease progression were analysed using next-generation sequencing. As osimertinib was approved as a first-line therapy during the trial, this led to early termination of phase II; thus, analysis is considered exploratory.

RESULTS

Twenty-two patients were enrolled and received osimertinib. All 22 patients were included in the efficacy and safety analysis. At the data cutoff, 10 (50%) patients remained on treatment. The median duration of follow-up was 24.4 months (interquartile range 12.9 to 26.0). The ORR was 77.3% (17/22 [95% confidence interval {CI} 54.6 to 89.3]). The DCR was 86.4% (19/22, [95% CI 65.1 to 97.1]). The median PFS was 23.1 months (95% CI 14.1 to NE). The median OS was 28·4 months (95% CI 25.6 to NE).

CONCLUSION

Despite early study termination, osimertinib first-line therapy yields an overall PFS of 23.1 months in EGFR-mutant patients harbouring a coexisting low allelic fraction of EGFR Thr790Met mutation.

Pretreatment Tissue TCR Repertoire Evenness Is Associated with Complete Pathologic Response in Patients with NSCLC Receiving Neoadjuvant Chemoimmunotherapy

PURPOSE

Characterization of the T-cell receptor (TCR) repertoire may be a promising source for predictive biomarkers of pathologic response to immunotherapy in locally advanced non-small cell lung cancer (NSCLC).

EXPERIMENTAL DESIGN

In this study, next-generation TCR sequencing was performed in peripheral blood and tissue samples of 40 patients with NSCLC, before and after neoadjuvant chemoimmunotherapy (NADIM clinical trial, NCT03081689), considering their complete pathologic response (CPR) or non-CPR. Beyond TCR metrics, tissue clones were ranked by their frequency and spatiotemporal evolution of top 1% clones was determined.

RESULTS

We have found a positive association between an uneven TCR repertoire in tissue samples at diagnosis and CPR at surgery. Moreover, TCR most frequently ranked clones (top 1%) present in diagnostic biopsies occupied greater frequency in the total clonal space of CPR patients, achieving an AUC ROC to identify CPR patients of 0.967 (95% confidence interval, 0.897-1.000; P = 0.001), and improving the results of PD-L1 tumor proportion score (TPS; AUC = 0.767; P = 0.026) or tumor mutational burden (TMB; AUC = 0.550; P = 0.687). Furthermore, tumors with high pretreatment top 1% clonal space showed similar immune cell populations but a higher immune reactive gene expression profile. Finally, the selective expansion of pretreatment tissue top 1% clones in peripheral blood of CPR patients suggests also a peripheral immunosurveillance, which could explain the high survival rate of these patients.

CONCLUSIONS

We have identified two parameters derived from TCR repertoire analysis that could outperform PD-L1 TPS and TMB as predictive biomarkers of CPR after neoadjuvant chemoimmunotherapy, and unraveled possible mechanisms of CPR involving enhanced tumor immunogenicity and peripheral immunosurveillance.

Long-term response to first-line bevacizumab-based therapy in patients with metastatic breast cancer: results of the observational "LORENA" study

Background

Randomized controlled trials of the first-line combination of bevacizumab and chemotherapy in patients with metastatic breast cancer (MBC) have shown improvements in tumor response and progression-free survival (PFS).

Objective

The aim of this ambispective, observational study (LORENA) was to describe the clinical characteristics of long-term responders to bevacizumab-based therapy.

Patients and methods

This study consisted of a retrospective and a prospective phase. During the retrospective phase, patients with HER2-negative MBC who were treated with bevacizumab-based first-line therapy were included. During the prospective phase, patients with PFS of ≥12 months were treated according to routine clinical practice procedures. Overall survival (OS) and PFS were estimated using the Kaplan–Meier method. Univariate and multivariate analyses of prognostic factors were performed.

Results

In total, 148 women were included (median age: 50 years; range: 29–81 years). The mean duration of exposure to bevacizumab was 18 months. The majority of patients experienced objective response (complete: 23%; partial: 57%). Median PFS was 22.7 months and median OS was 58.2 months. In multivariate analyses, patients receiving maintenance hormonal therapy (MHT) had longer PFS (P=0.002; hazard ratio [HR] =1.8) and OS (P=0.009; HR=2.0), while patients not previously treated with taxanes had longer OS (P<0.0001; HR =3.3). No unexpected adverse events were observed.

Conclusion

The results of this study suggest, that among long-term responders, first-line bevacizumab-based therapy is more effective in patients who had not been previously treated with taxanes, and that MHT provides additional therapeutic benefits by extending PFS and OS.

Preradiation Chemotherapy with VM-26 and CCNU in Patients with Glioblastoma Multiforme

Aims and Background

The objective of the study was to evaluate the efficacy of combined chemoradiation in patients with newly diagnosed glioblastoma multiforme. The main end points were time to progression and overall survival.

Methods

Thirty-one patients with glioblastoma multiforme underwent surgery whenever possible and then received intravenous VM26 (120 mg/m2) and oral CCNU (120 mg/m2) for three cycles followed by radiotherapy (60 Gy).

Results

Surgery consisted of a complete resection in 39% of patients, partial resection in 35% and a biopsy in 26%. Sixteen patients had clinical or radiological evidence of progression during or after chemotherapy. Hematologic toxicity was mild. Forty-five percent of patients received the scheduled dose of radiation. The outcome was disappointing, with a median time to progression of 18 weeks and median survival of 37.17 weeks.

Conclusions

The survival of patients with glioblastoma multiforme remains disappointing. Multimodal therapy does not seem to modify the evolution of the tumor. Stratification according to prognostic factors might detect a potential benefit of other therapeutic approaches.

Fixed-Dose-Rate Gemcitabine Infusion in Patients with Advanced Pancreatic or Biliary Tree Adenocarcinoma

Aims and background

Gemcitabine is an effective agent in pancreatic adenocarcinoma. Fixed-dose-rate gemcitabine has an interesting biological and clinical rationale, with successful results in previous studies. We conducted a trial to confirm efficacy and toxicity of fixed-dose-rate gemcitabine in patients with pancreatic or biliary tree adenocarcinoma.

Methods

Eligible patients with locally advanced or metastatic pancreatic or biliary tree adenocarcinoma received fixed-dose-rate gemcitabine at a dose of 1500 mg/m2 at a rate of 10 mg/m2/min weekly for 3 weeks every 28 days. Efficacy measures were overall survival, response rate and progression-free survival.

Results

Sixty-two patients were enrolled, and 59 were assessable for response. Seven patients (11.3%) had a partial response, 26 stable disease (41.9%) and 26 progressive disease (41.9%). Median time to progression was 21 weeks and median overall survival, 37.71 weeks. Main toxicities were grade 3–4 neutropenia (45.2%) and grade 2–3 asthenia (54.8%). No toxic deaths were documented.

Conclusions

Fixed-dose-rate gemcitabine has a relevant antitumor activity but with significant toxicity. It represents an interesting schedule and could be combined with other biological or chemotherapeutic agents.

Nab-Paclitaxel in Metastatic Breast Cancer: Defining the Best Patient Profile

Around 40% of patients with breast cancer will present with a recurrence of the disease. Chemotherapy is recommended for patients with recurrent hormone-independent or hormone-refractory breast cancer and almost all patients with metastatic breast cancer (MBC) receive chemotherapy during their medical history. Nanoparticle albuminbound (nab)-paclitaxel is a solvent-free, 130-nanometer particle formulation of paclitaxel. Nab-paclitaxel can be administered to all patients for whom the treatment choice is a taxane. In this review, 6 patient profiles for which nabpaclitaxel may be particularly useful are described and analyzed: (i) as first-line treatment of MBC, (ii) as second-line treatment of MBC after oral chemotherapy, (iii) after a standard taxane, (iv) as third-line treatment after a standard taxane and oral chemotherapy, (v) for patients with HER2-positive MBC and (vi) for patients with intolerance to standard taxanes. Nab-paclitaxel is a rational treatment choice for patients with MBC in different settings, as well as for those with prior exposure to a standard taxane.

Abstract 265: Cotargeting EGFR, STAT3 and Src-Notch pathways: a promising approach to improve the efficacy of EGFR-TKIs in the treatment of NSCLC patients

Intrinsic or acquired resistance limits the clinical effectiveness of EGFR tyrosine kinase inhibitors (TKIs) for non-small cell lung cancer (NSCLC) patients (p) with EGFR mutations. One of the signaling mediators downstream of activated EGFR is signal transducer and activator of transcription 3 (STAT3). Not only does gefitinib not inhibit STAT3, but it also augments STAT3 tyrosine phosphorylation. EGFR blockade enriches lung cancer stem cells (CSCs) through NOTCH3-dependent signaling. A co-receptor of IL-6 (gp130) associates with Src and triggers activation of YAP and NOTCH. Our study is designed with three parallel objectives: firstly, to demonstrate that single EGFR TKI treatment cannot abrogate STAT3 and Src in EGFR mutant NSCLC cell lines; secondly, to examine whether the combination of gefitinib with compounds that target STAT3, (TPCA-1) and Src (saracatinib), suppresses the mechanisms of resistance; thirdly, to identify biomarkers in clinical tumor samples that may help us predict the outcome of EGFR TKIs and design effective combination therapies. Cell viability assay (MTT), western blotting, quantitative-real time PCR (qRT-PCR) and aldefluor assay-flow cytometry were used. We found that gefitinib increases pSTAT3 Y705 in PC-9 cells (that harbor the exon 19 deletion) in a time- and dose-dependent manner. Nine days after gefitinib treatment STAT3 mRNA level was significantly elevated. PC-9 cells showed dramatic increase in the fraction of ALDH+ cells upon treatment with gefitinib. TPCA-1 increased sensitivity to gefitinib in the PC-9 cells. Combination of gefitinib with TPCA-1 abrogated pSTAT3 Y705 but neither inhibited pPaxillin Y118 (Src induced) and pYAP S127 nor prevented the increment in the ALDH+ CSCs subpopulation. The triple combination of gefitinib, TPCA-1 and saracatinib was highly synergistic and abrogated pSTAT3 Y705, pPaxillin Y118 and pYAP S127. We performed qRT-PCR at baseline tumor samples of 64 EGFR mutant NSCLC p treated with first line EGFR TKIs and found that high expression of STAT3 and YAP were significantly correlated with shorter median progression-free survival (mPFS). mPFS was 9.6 months (m) (95% CI, 5.9 to 14.1) for p with low STAT3 and 18.4m (95% CI, 8.8 to 30.2) for p with high STAT3 mRNA expression (P&lt;0.001). mPFS was 9.6 months (95% CI, 7.7 to 15.2) for p with low YAP and 23.4 months (95% CI, 13.0 to 28.1) for p with high YAP mRNA expression (P = 0.005). A combined STAT3 and YAP risk group model was constructed since the mRNA expression of the 2 transcripts was weakly correlated (r = .0.15; P = 0.305). mPFS was 25.7 months for p with low STAT3 and YAP mRNA (95% CI, 8.5 to 60.9), 9.4 months for p with high STAT3 and YAP mRNA (95% CI, 2.8 to 15.2), and 14.1 months for others (95% CI, 8.2 to 23.4) (P = 0.004). Single EGFR TKI treatment can no longer be considered adequate for p with EGFR mutant lung cancer and a clinical trial co-targeting STAT3 and Src is warranted.

Citation Format: Niki Karachaliou, Imane Chaib, Sara Pilotto, Jordi Codony, Xueting Cai, Xuefei Li, Ana Drozdowskyj, Carles Codony, Andrés Felipe Cardona, Guillermo López-Vivanco, Alain Vergnenègre, José Miguel Sánchez, Mariano Provencio, Filippo de Marinis, Enric Carcereny, Noemí Reguart, Rosario García-Campelo, Silvia Marin, Cristina Teixido, Isabella Sperduti, Sonia Rodríguez, Roger Estrada, Raimon Puig de la Bellacasa, José Luis Ramírez, Miguel Angel Molina-Vila, Caicun Zhou, Peng Cao, Patrick Ma, Trever Bivona, Rafael Rosell. Cotargeting EGFR, STAT3 and Src-Notch pathways: a promising approach to improve the efficacy of EGFR-TKIs in the treatment of NSCLC patients. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 265.

Treatment patterns of adjuvant interferon-α2b for high-risk melanoma: a retrospective study of the Grupo Español Multidisciplinar de Melanoma - Prima study

Adjuvant interferon-α2b (IFN-α2b) has been studied extensively in clinical trials, but there have been few studies of real-world use. The aim of this study is to describe the IFN-α2b real-world patterns in patients with high-risk melanoma in Spain. This was a retrospective and multicentre chart review study of an unselected cohort of patients with melanoma at high risk for relapse (stage IIB/IIC/III) treated with IFN-α2b. Patterns were assessed in terms of dose and compliance to planned treatment. A survival analysis was carried out for the full population and according to Kirkwood scheme compliance and the presence of ulceration. Of 327 patients treated with IFN-α2b, 318 received a high-dose regimen following the standard Kirkwood scheme; thus, patterns are described for this regimen. A total of 121 (38%) and 88 (28%) patients had at least one dose reduction during the induction and maintenance phases, respectively. Dose delay was required in fewer than 10% of patients. A total of 78, 40 and 38% of the patients completed the induction phase, maintenance phase and completed treatment, respectively. The median progression-free and overall survival for the full population were 3.2 and 10.5 years, respectively. There were no differences in progression-free survival and overall survival according to Kirkwood scheme compliance and the presence of ulceration. The most frequent adverse events were neutropenia (31%) and fatigue (30%). High-dose IFN-α2b is the most frequently used regimen in Spain as an adjuvant systemic treatment for high-risk melanoma. Despite poor compliance, in this retrospective study, IFN-α2b treatment provided a benefit consistent with that described previously.

[Cost of breast cancer treatment by clinical stage in the Basque Country, Spain]

BACKGROUND

The burden of breast cancer is important for the healthcare system. In the context of the evaluation of the breast cancer screening program in the Basque Country it is important to determine the unitary costs related to diagnosis as well as the treatment costs depending on the clinical stage at detection. The main objective was to calculate the total cost and the components of breast cancer (BC) treatment depending on the clinical stage by 2011.

METHODS

The estimated costs include BC diagnosis as so as to initial treatment and follow-up, based on resource consumption and unitary costs of the Basque Health Services. Micro-costing technique was applied based on the clinical guidelines.

RESULTS

Our model showed the estimated loss of productivity due to premature The initial cost was 9.838€ for the stage 0, 17.273€ for stage I, 22.145€ for stage II and 28.776€ for stage III. The follow up annual cost was 172€ for the stage 0, 908€ for stage I, 994€ for stage II and 1.166€ for stage III. The annual cost for stage IV was 17879€.

CONCLUSIONS

Chemotherapy determines the greatest percentage of BC costs. The two main drivers of the total cost of breast cancer are the initial treatment of stages I to III and the cost of stage IV, the latter reaching € 50,061 per patient.

Two biomarker-directed randomized trials in European and Chinese patients with nonsmall-cell lung cancer: the BRCA1-RAP80 Expression Customization (BREC) studies

BACKGROUND

In a Spanish Lung Cancer Group (SLCG) phase II trial, the combination of BRCA1 and receptor-associated protein 80 (RAP80) expression was significantly associated with outcome in Caucasian patients with nonsmall-cell lung cancer (NSCLC). The SLCG therefore undertook an industry-independent collaborative randomized phase III trial comparing nonselected cisplatin-based chemotherapy with therapy customized according to BRCA1/RAP80 expression. An analogous randomized phase II trial was carried out in China under the auspices of the SLCG to evaluate the effect of BRCA1/RAP80 expression in Asian patients.

PATIENTS AND METHODS

Eligibility criteria included stage IIIB-IV NSCLC and sufficient tumor specimen for molecular analysis. Randomization to the control or experimental arm was 1 : 1 in the SLCG trial and 1 : 3 in the Chinese trial. In both trials, patients in the control arm received docetaxel/cisplatin; in the experimental arm, patients with low RAP80 expression received gemcitabine/cisplatin, those with intermediate/high RAP80 expression and low/intermediate BRCA1 expression received docetaxel/cisplatin, and those with intermediate/high RAP80 expression and high BRCA1 expression received docetaxel alone. The primary end point was progression-free survival (PFS).

RESULTS

Two hundred and seventy-nine patients in the SLCG trial and 124 in the Chinese trial were assessable for PFS. PFS in the control and experimental arms in the SLCG trial was 5.49 and 4.38 months, respectively [log rank P = 0.07; hazard ratio (HR) 1.28; P = 0.03]. In the Chinese trial, PFS was 4.74 and 3.78 months, respectively (log rank P = 0.82; HR 0.95; P = 0.82).

CONCLUSION

Accrual was prematurely closed on the SLCG trial due to the absence of clinical benefit in the experimental over the control arm. However, the BREC studies provide proof of concept that an international, nonindustry, biomarker-directed trial is feasible. Thanks to the groundwork laid by these studies, we expect that ongoing further research on alternative biomarkers to elucidate DNA repair mechanisms will help define novel therapeutic approaches.

TRIAL REGISTRATION

NCT00617656/GECP-BREC and ChiCTR-TRC-12001860/BREC-CHINA.

Thymidylate synthase expression determines pemetrexed targets and resistance development in tumour cells

Although treatment options for cancer patients are increasing every year, the drug resistance problem remains very present. It is very difficult to find a drug that acts equally on tumours of the same histology as the individual's genetic characteristics often determine the response to treatment. Furthermore, tumours that initially respond to anti-tumour therapy are able to adapt and develop resistance to the drug, while others do not. In addition, this usually implies resistance development to agents to which the cells have not been exposed, a phenomenon called cross-resistance or multidrug resistance. Given this situation, it has been suggested that the most appropriate treatment would be able to act in parallel on multiple pathways constitutively altered in tumour cells. Pemetrexed is a multitargeted antifolate that exerts its activity against folate-dependent enzymes involved in de novo pyrimidine and purine synthesis. It is currently in use in combination with cisplatin against malignant pleural mesothelioma and non-squamous non-small cell lung cancer with favourable results. By real-time RT-PCR gene expression assays and restoration viability assays we demonstrated that Pemetrexed targets folate-dependent enzymes involved in de novo biosynthesis of purines differently depending on the intrinsic genetic characteristics of the tumour. These differences did not, however, interfere either with the initial response to the drug or with the activation of apoptotic pathways. In addition, these genetic fingerprints can differentiate two groups of tumours: those capable of developing resistance to antifolate, and not capable. These results may be useful to employ targets gene expression as resistance markers, a valuable tool for identifying patients likely to receive combination therapy to prevent the development of resistance.

Molecular mechanism implicated in Pemetrexed-induced apoptosis in human melanoma cells

Background

Metastatic melanoma is a lethal skin cancer and its incidence is rising every year. It represents a challenge for oncologist, as the current treatment options are non-curative in the majority of cases; therefore, the effort to find and/or develop novel compounds is mandatory. Pemetrexed (Alimta®, MTA) is a multitarget antifolate that inhibits folate-dependent enzymes: thymidylate synthase, dihydrofolate reductase and glycinamide ribonucleotide formyltransferase, required for de novo synthesis of nucleotides for DNA replication. It is currently used in the treatment of mesothelioma and non-small cell lung cancer (NSCLC), and has shown clinical activity in other tumors such as breast, colorectal, bladder, cervical, gastric and pancreatic cancer. However, its effect in human melanoma has not been studied yet.

Results

In the current work we studied the effect of MTA on four human melanoma cell lines A375, Hs294T, HT144 and MeWo and in two NSCLC cell lines H1299 and Calu-3. We have found that MTA induces DNA damage, S-phase cell cycle arrest, and caspase- dependent and –independent apoptosis. We show that an increment of the intracellular reactive oxygen species (ROS) and p53 is required for MTA-induced cytotoxicity by utilizing N-Acetyl-L-Cysteine (NAC) to blockage of ROS and p53-defective H1299 NSCLC cell line. Pretreatment of melanoma cells with NAC significantly decreased the DNA damage, p53 up-regulation and cytotoxic effect of MTA. MTA was able to induce p53 expression leading to up-regulation of p53-dependent genes Mcl-1 and PIDD, followed by a postranscriptional regulation of Mcl-1 improving apoptosis.

Conclusions

We found that MTA induced DNA damage and mitochondrial-mediated apoptosis in human melanoma cells in vitro and that the associated apoptosis was both caspase-dependent and –independent and p53-mediated. Our data suggest that MTA may be of therapeutic relevance for the future treatment of human malignant melanoma.

Identification of a biomarker panel for colorectal cancer diagnosis

BACKGROUND

Malignancies arising in the large bowel cause the second largest number of deaths from cancer in the Western World. Despite progresses made during the last decades, colorectal cancer remains one of the most frequent and deadly neoplasias in the western countries.

METHODS

A genomic study of human colorectal cancer has been carried out on a total of 31 tumoral samples, corresponding to different stages of the disease, and 33 non-tumoral samples. The study was carried out by hybridisation of the tumour samples against a reference pool of non-tumoral samples using Agilent Human 1A 60-mer oligo microarrays. The results obtained were validated by qRT-PCR. In the subsequent bioinformatics analysis, gene networks by means of Bayesian classifiers, variable selection and bootstrap resampling were built. The consensus among all the induced models produced a hierarchy of dependences and, thus, of variables.

RESULTS

After an exhaustive process of pre-processing to ensure data quality--lost values imputation, probes quality, data smoothing and intraclass variability filtering--the final dataset comprised a total of 8, 104 probes. Next, a supervised classification approach and data analysis was carried out to obtain the most relevant genes. Two of them are directly involved in cancer progression and in particular in colorectal cancer. Finally, a supervised classifier was induced to classify new unseen samples.

CONCLUSIONS

We have developed a tentative model for the diagnosis of colorectal cancer based on a biomarker panel. Our results indicate that the gene profile described herein can discriminate between non-cancerous and cancerous samples with 94.45% accuracy using different supervised classifiers (AUC values in the range of 0.997 and 0.955).

Potential diagnostic markers in bronchial fluid of small cell lung cancer (SCLC)

e22221

Background: Lung cancer is a major cause of mortality worldwide and overall survival rate has not improved significantly over the past 20 years. An early diagnosis could improve prognosis and survival among these patients. The aim of this study was to identify protein markers obtained from bronchial fluids of SCLC patients which may differ from non-pathological bronchoscopy samples. Methods: We have included 43 patients with SCLC diagnosed using bronchoscope and 49 consecutive patients with non pathological bronchoscopy. Bronquial fluid was obtained from each patient and potential protein markers were studied. After being centrifuged, supernatant proteins were analysed using bidimensional electrophoresis with poliacrilamid gel stained with silver nitrate. Gel was scanned and analysed with Progenesis PG6220 program, which measures intensity of each spot. Resultant intensities in each group of patients (SCLC/non pathological bronchoscopy) were compared using T-Student method. We selected as potential markers those spots with a p value of less than 0.05. We calculated “fold change” of each spot as the ratio between mean intensity in SCLC bronchoscopy samples and non pathological bronchoscopy samples. Results: Optimal bidimensional gels of each sample were obtained. Among 300 comparable spots, 10 of them were expressed with a different intensity in both groups of patients; 6 of these potential markers were over expressed in SCLC samples, whereas 4 of them were underexpressed. The “fold change” of these 10 spots ranges from 1.5 to 8.67. Conclusions: Different protein markers can be detected in bronchial fluid obtained from SCLC samples. Significant differences in expression of these biomarkers were detected between SCLC patients and non pathological bronchoscopy patients. The development of an early diagnostic test using these proteins must be validated in future studies.

No significant financial relationships to disclose.

Increased expression levels of human telomerase reverse transcriptase (hTERT) mRNA correlates with poor prognosis in resected non-small cell lung cancer (NSCLC) patients

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Background: Telomerase adds hexameric TTAGGG nucleotide repeats onto the ends of chromosomal DNAs to compensate for losses of each cell replication. In several tumors, telomerase is expressed in a way that tumoral cell proliferates indefinitely. Correlation between telomerase level expression, clinico-pathological characteristics and survival of lung cancer is not well established in NSCLC. Methods: We studied 149 consecutive patients (140 men/9 women) with resected NSCLC: 37.6% adenocarcinoma, 59 % squamous cell, and 3.4% large cell carcinoma. Pathological stage: I (36.9%), II (32.3%) and III (30.8%). Reverse transcription-polymerase chain reaction (RT-PCR) analysis was used for the detection hTERT expression in lung cancer tissues immediately snap-frozen in liquid nitrogen at -80 °C. Results: Median and mean values of hTERT mRNA were 18.27 and 475.29 (SE 309.76). There were no significant differences on expression according to sex, histology, smoking history and pathological stage (ANOVA). Patients with highest values of hTERT mRNA expression (percentile 95, cut-off value >353) had worse median progression free survival (PFS) (p=0.024) and overall survival (OS) (p=0.020), using Kaplan-Meier method. Multivariate analysis by Cox regression yielded that hTERT level > 353 independently predicted a worse PFS (HR=0.39; 95% CI 0.17–0.93, p=0.034) and OS (HR=0.32; 95% CI 0.12–0.82, p=0.017). Conclusions: A high level of telomerase expression in tumoral tissue is strongly associated with increased risk of recurrence and mortality in resected NSCLC. The level of hTERT mRNA would predict the prognosis of lung cancer patients.

No significant financial relationships to disclose.

Improvement in symptoms and quality of life (QoL) for patients (p) with non-small cell lung cancer (NSCLC) treated with erloninib: TargeT study

18140

Background: Erlotinib is an EGFR TKI that is effective in the treatment of advanced NSCLC, in terms of longer survival, better quality of life and delayed symptom progression.We present here the outcome of a group of p from the TargeT study, whose QoL was assessed by the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire and the Lung Cancer Subscale (LCS). Methods: TargeT study was a multicenter, single-arm phase II study evaluating efficacy, safety, and tolerability of erlotinib (150 m/day) in p with stage IIIB or IV NSCLC, in 1st, 2nd and 3rd line treatment. Primary end-point was time to progression. QoL was a secondary end point as assessed monthly by the Functional Assessment of Cancer Therapy-Lung questionnaire (FACT- L) and its Lung Cancer Subscale. Physical and functional aspects of the QoL were measured by the Trial Outcome Index (TOI), which is the sum of the physical well being, functional well-being and LCS scores from the FACT-L questionnaire. Results: Data from 91 pts were available. QoL analysis showed that 53% of the p (95% IC 37–58%) had improvement in FACT-L or TOI. Similarly, 45% (95% IC35–56%) of improved their symptoms from baseline. Improvement was observed for each individual LCS item and specifically in the pulmonary items. In symptomatic p, shortened of breath was 17,6% at baseline vs 2.2% after treatment (p<0.001) and cough was 24.7% vs 8.8 % (p<0.001) after treatment. Those improvements in symptoms were rapid and, 73% of the patients who improved showed that recovery in the first cycle of treatment. In terms of association between efficacy of erlotinib and QoL, there is a statistically significative relationship between objective response and improvement in TOI or FACT-L (p<0.02). Conclusions: This QoL analysis confirms that erlotinib improves both symptoms and functional aspect of patients with NSCLC. The improvement in QoL is related with objective response.

No significant financial relationships to disclose.

Metastatic non-small-cell lung carcinoma successfully treated with pre-operative chemotherapy and bilateral adrenalectomy

Metastatic non-small-cell lung cancer is a common condition with a dismal prognosis. Although palliative chemotherapy improves survival and quality of life, nearly all patients die of progressive disease. Metastatic involvement of adrenal glands is not rare, but usually reflects widespread dissemination. Selected patients with single adrenal metastasis may be cured with surgery, although the level of evidence comes from single cases reports and short retrospective series. Here we report a patient with bilateral adrenal metastases from previously resected non-small-cell lung cancer, who remains free of disease four years after pre-operative chemotherapy and bilateral adrenalectomy.

A prospective phase II trial of erlotinib in advanced non-small cell lung cancer (NSCLC) patients (p) with mutations in the tyrosine kinase (TK) domain of the epidermal growth factor receptor (EGFR)

7020

Background: The EGFR TK inhibitor erlotinib is a standard treatment in previously treated NSCLC p. Recently, EGFR gene mutations have been reported to be a predictor of efficacy of this and related compounds. This phase II trial evaluated the efficacy and safety of erlotinib in untreated p with advanced NSCLC and mutated EGFR. Methods: Eligibility criteria included stage IIIB-IV chemotherapy-naive p with confirmed NSCLC and mutated EGFR, PS 0–2, age ≥ 18 years, adequate organ functions, measurable disease and written informed consent. DNA was extracted by laser capture microdissection. Exon 19 deletions were examined by Genscan and the L858R and T790M mutations with a TaqMan assay. Mutations were confirmed by sequencing. Erlotinib was given orally at 150 mg per day. Results: From March to December 2005, 37 (12.5%) of 297 tumors screened were found to have mutations in the TK domain of the EGFR gene (25 deletions; 11 L858R; no T790M). Median age: 68 years; 12 males, 25 females; histology: 28 adenocarcinoma, 4 BAC, 4 large cell carcinoma; 9 smokers. Response has been evaluated in 21 p so far: complete response, 6 p; partial response, 13 p; progressive disease, 2 p; overall response rate, 90% (95% CI:70%-90%). Responses occurred in 100% of tumors with exon 19 deletions and in 75% of those with L858R. All responses are ongoing (up to ≥8 months) and all but one p are still alive. Toxicity profile was predictable (mild to moderate rash, diarrhea, asthenia and emesis). No drug related severe adverse events occurred. Conclusions: Single-agent erlotinib produces a high response rate in previously untreated p with advanced NSCLC and mutated EGFR. In-frame deletions in exon 19 seem particularly predictive for response in this setting.

[Table: see text]

Elderly patients with advanced non-small cell lung cancer (nsclc). Results of chemotherapy and comparison with younger patients

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Background: Lung cancer is increasingly diagnosed in elderly patients and is the first cause of cancer death. Treatment of this subset represents a challenge to medical oncologists. Methods: We retrospectively reviewed clinical characteristics, co-morbidity (Charlson Index), toxicity and results of all patients ≥ 65 years (y) old, diagnosed of advanced NSCLC. We compared these results with younger patients’. Results: From January-95 to June-02, we treated 477 patients (pt), 176 ≥ 65 years, 301 < 65 y. Treatment: 177 pt, MIC (mitomycine + ifosfamide + cisplatin), 60 ≥ 65 y and 117 < 65 y; 156, CG (Cisplatin + Gemcitabine), 52 > 65 y and 104 < 65 y; 144, CP (Cisplatin + Paclitaxel), 64 ≥ 65 y and 120 < 65 y. Characteristics: median age 60 (31–78); 428 male, 49 female; ECOG 0/1/2/3: 83/312/71/5, Stage IIIA, IIIB and IV: 72/199/206, Histology: squamous carcinoma 215, adenocarcinoma 190, large cell 19, bronchioloalveolar 7, undifferentiated 45 pt. No significant differences between the two groups. Overall response rate: 39% (CR, 32.9%, PR, 6.1%), Stable disease 26.4% and Progressive disease, 26.4%. Patients ≥ 65 y: CR 5.7%, PR 45.5%, SD 23.3% and PD 18.2%. Patients < 65 y: CR 6.3% PR 25.6%, SD 28.2% and PD 31.2%. Predictive factors for response: ECOG and stage. Response rate was superior in patients ≥ 65 y and in patients ≥ 70 y. Overall survival: 38.29 weeks (w): < 65 y, 38.57 w; 65–70 y, 37.71 w and ≥ 70 y, 37 w. Multivariate analysis: ECOG, stage and sex were prognostic factors; age, histology, Charlson index and schedule treatment were not significant. Grade 3/4 episodes of toxicity: ≥ 65 y, 184/17, and < 65 y, 232/8. Treatment delays: ≥ 65 y, 115 and < 65 y, 100. Hospitalization due to toxicity: >≥ 65 y, 34 and < 65 y, 23. Treatment was stopped in 13 pt >≥ 65 y and in 7 pt < 65 y. Conclusions: Age is not a predictive factor for response to chemotherapy, neither a prognostic factor for survival. Charlson index does not seem to be useful for these patients. Although toxicity is superior, cisplatin-based schedules are safe and active.

No significant financial relationships to disclose.

Erlotinib in patients with advanced squamous cell carcinoma of the lung

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Background: Erlotinib is a potent HER1/EGFR TKI that is approved for the treatment as a single agent in 2nd and 3rd line NSCLC. Several phase II studies have shown that adenocarcinoma histology together with female gender, Asian origin, and never having smoked are associated with responsiveness of NSCLC to erlotinib. The purpose of the analyisis we present here was to describe the outcome in a group of patients with squamous carcinoma of the lung treated with erlotinib. Methods: Eligilibility criteria included stage IIIB-IV chemotherapy-naive patients with confirmed NSCLC, PS 0–2, age ≥ 18 years, adequate organ functions, measurable disease and written informed consent. Patients with diagnosis of squamous cell lung cancer that received erlotinib 150 mgr/day p.o until disease progression or withdrawal were the subject of this analysis. Results: From June 2004 to March 2005, 121 patients with histological diagnosis of squamous cell lung cacer from more than 100 different Spanish hospitals were included in the TARGET study. Median age was 66 yrs. All patients in our analysis were Caucasian. 111 patients were male (92%) and 113 (93%) were current smokers or have smoke sometime in their life. 88% of them have stage IV carcinoma and 74% have received previous treatment for metastatic disease. PS 0/1/≥2 18 (15%)/68 (56%)/32 (29%). In the evaluable population for response (69 pts) 5 PR and 0 CR were observed for an overall RR of 7.25%. Clinical benefit defined as CR+PR+SD was 54%. In the ITT populations median TTP was 3.6 months [95% CI 2.7–5.3]. Median OS was 5,7 m [95% CI 4.0–6.7]. Erlotinib was well tolerated.No unexpected toxicities were observed. Conclusions: This subgroup analysis confirms that erlotinib is active and well tolerated in patients with advanced or metastatic squamous cell carcinoma of the lung. Responses were seen in both genders and in patients with or without smoking history. At this moment histology should not be used as the only selection criteria for treatment of patients with NSCLC after failure to chemotherapy.

[Table: see text]

Biweekly schedule of cisplatin with prolonged infusion of gemcitabine in advanced non small cell lung cancer (NSCLC)

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Background: Firstly, we conducted a phase I of a biweekly schedule of cisplatin with prolonged infusion of gemcitabine (10 mg/m2/min) and stablished the dose to perform a phase II. We present final results of a phase II with this combination. Methods: Patients with cytologically or histologically confirmed NSCLC stage IIIB and IV were included. Treatment consisted of Cisplatin 50 mg/m2 days 1 and 15 with Gemcitabine 1600 mg/m2 in 160 minutes (10 mg/m2/min), days 1 and 15 every 28 days. Chemotherapy was administered to a maximum of 6 cycles; if radiotherapy was planned, patients received 4 cycles. Results: From March-04 to January-05, 55 patients were included. Patient characteristics: Median age 59 years (35–75). Gender: 51 male 4 female. ECOG performance status 0/1/2: 8/43/4. Histology: Squamous cell carcinoma 26 (47.3%), adenocarcinoma 22 (40%), large cell carcinoma 2 (3.6%), undifferentiated 5 (9%). Stage: IIIA 2 (3.6%), IIIB 27 (49.1%) and IV 26 (47.3%). Treatment compliance: Administrations: Mean 6.7 and median 8 (1–12). Dose intensity: Cisplatin 20.35 mg/m2/week (81%) Gemcitabine 632.61 mg/m2/week (79%). Toxicity: Extrahematological toxicity grade 3/4 per patient: nausea 10/0, emesis 6/0, asthenia 31/1, anorexia 14/0, mucositis 1/0, diarrhoea 1/1, infection 4/0, hepatic 2/0, vascular 0/1 (pulmonary thromboembolism). Neurotoxicity grade 1, 13 pt and grade 2, 1 pt. Hematological toxicity grade 3/4: anemia 1/0, thrombocytopenia 5/1, neutropenia 21/9 and neutropenic fever 4/0. Nine patients were hospitalised due to toxicity. There was one toxic death. Response rate: Response was evaluated in 52 pt (3 pt died after first cycle). Overall response rate was 38.1% (95% CI 50.93–25.26%). Complete response 2 (3.6%), Partial response 19 (34.5%), Stable disease 23 (41.8%), Progressive disease 8 (14.5%). Survival: Overall median survival was 9.6 months (95% CI 7.76–11.43): stage III 10.46 and stage IV 8.8. Overall progression-free survival was 8.06 months (95% CI 5.95–10.18): stage III 8.9 and stage IV 6.3. Conclusions: Biweekly cisplatin with prolonged infusion of gemcitabine is an active regimen for advanced NSCLC with a good toxicity profile. This better rational way of gemcitabine infusion should be more profoundly explored.

No significant financial relationships to disclose.

Chemotherapy-induced neutropenia and treatment efficacy in advanced non-small cell lung cancer: An analysis of the Spanish Lung Cancer Group pharmacogenomic study of cisplatin and docetaxel combination (PLATAX)

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Background: Chemotherapy is the standard treatment for advanced non-small-cell lung cancer, and myelosuppression is a common side-effect. We aimed to assess whether haematological toxic effects could be a biological measure of drug activity and a marker of efficacy. Methods: We analysed data of 493 patients who received chemotherapy (cisplatin and docetaxel) within the pharmacogenomic, open-label, single-arm, multicentric PLATAX trial. Three subgroups of patients were considered: global population, patients who received at least three cycles of chemotherapy, and those who received at least six cycles. Neutropenia was categorised on the basis of worst WHO grade during chemotherapy: absent (grade 0), mild (grade 1–2), or severe (grade 3–4). Relative dose intensity was analysed for both drugs. The primary endpoint was overall survival. Results: Median overall survival was 9 months (8.2–9.7). Median relative dose intensity was 0.97 for cisplatin and docetaxel. 403 patients received at least three cycles of chemotherapy, and 255 received six or more. Neutropenia appeared in 172 patients (30.8%), 72 of them G3–4 (18.6%). Dose intensity was lower in patients who presented any grade of neutropenia versus those without neutropenia in the three analyzed subgroups, for both drugs (p < 0.05). Factors associated with higher risk of death were ECOG 1–2 (HR 1.8, p = 0.00) and female (HR 1.5, p = 0.02). There were no differences in overall survival between patients with G0 vs G1–2 vs G3–4 neutropenia (8.7 vs 11.6 vs 9.6 m, p = 0.41), however the risk of death was lower in patients with ECOG 0, that presented neutropenia (HR: 0.545, IC 95%: 0.31, 0.96; p = 0.034). Conclusions: Neutropenia during chemotherapy may be associated with increased survival of patients with advanced non-small cell lung cancer and ECOG 0. Its absence is not a result of underdosing. Prospective trials are needed to assess whether neutropenia could be a biological measure of drug activity and a marker of efficacy.

No significant financial relationships to disclose.

Concurrent chemoradiotherapy (crt) with weekly docetaxel (d) for advanced head and neck cancer

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Background: Concomitant CRT has become a standard treatment for advanced head and neck cancer. The aim of this study was to evaluate the efficacy and toxicity of concurrent CRT with D in patients (pts) with advanced squamous cell carcinoma of head and neck (SCCHN). Methods: Patients with untreated and unresectable stage III or IV (M0) squamous cell carcinoma of head and neck were included. Treatment consisted of D 20 mg/m2 weekly with concomitant radiotherapy 70 Gy (2 Gy per day, 7 weeks). Results: From September 03 to October 05, sixty-four pts with advanced SCCHN, were recruited. Gender: 61 male, 3 female. Mean age: 56.5 years old (range 42–77). ECOG PS 0/1/2: 0/57/7. Primary sites of disease: oral cavity 8, oropharynx 26, hypopharynx 15 and larynx 15. Stage III 16 pts and stage IV 48 pts. Compliance: 393 administrations of D were given, median 6, mean 6 (range 1–8). Fifty-five pts (86%) completed the radiotherapy dose planned (mean dose of RT was 66 Gy). One refused more treatment with D after first administration. Nineteen pts required supportive percutaneous gastrostomy or nasogastric tubes previously or during therapy. Grade 2/3/4 toxicity per patient: anemia 4/2/0, mucositis 21/24/0, dermatitis 21/20/0. Neither thrombopenia nor neutropenia were observed. Four pts died of aspiration pneumonia during treatment, one of gastric perforation and two of unknown causes. Fifty-six pts were evaluable for response: CR 28 (44%), PR 23 (36%), SD 2 (3%), PD 3 (5%), with an overall response rate of 80%. Median overall survival was 74.86 weeks (95% CI: 40.40–109.32) and median progression free survival was 48 weeks (95% CI: 18.80–77.20). With a median follow up of 40 weeks 34 pts (53%) were alive and 21 of them (33%) remained free of disease. Conclusions: Concurrent weekly D with conventional radiotherapy showed a high response rate. Toxicity was manageable and allowed maintaining radiotherapy administration. Taking into account poor prognostic factors of our series, survival results seem promising.

No significant financial relationships to disclose.