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Lynggaard LS, Vaitkeviciene G, Langenskiöld C, Lehmann AK, Lähteenmäki PM, Lepik K, El Hariry I, Schmiegelow K, Albertsen BK. Asparaginase encapsulated in erythrocytes as second-line treatment in hypersensitive patients with acute lymphoblastic leukaemia. Br J Haematol 2022; 197:745-754. [PMID: 35344210 DOI: 10.1111/bjh.18152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/06/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Abstract
Asparaginase is essential in treating acute lymphoblastic leukaemia (ALL). Asparaginase-related hypersensitivity causes treatment discontinuation, which is associated with decreased event-free survival. To continue asparaginase treatment after hypersensitivity, a formulation of asparaginase encapsulated in erythrocytes (eryaspase) was developed. In NOR-GRASPALL 2016 (NCT03267030) the safety and efficacy of eryaspase was evaluated in 55 patients (aged 1-45 years; median: 6.1 years) with non-high-risk ALL and hypersensitivity to asparaginase conjugated with polyethylene glycol (PEG-asparaginase). Eryaspase (150 u/kg) was scheduled to complete the intended course of asparaginase (1-7 doses) in two Nordic/Baltic treatment protocols. Forty-nine (96.1%) patients had asparaginase enzyme activity (AEA) ≥100 iu/l 14 ± 2 days after the first eryaspase infusion [median AEA 511 iu/l; interquartile range (IQR), 291-780], whereas six of nine (66.7%) patients had AEA ≥100 iu/l 14 ± 2 days after the fourth infusion (median AEA 932 iu/l; IQR, 496-163). The mean terminal half-life of eryaspase following the first infusion was 15.3 ± 15.5 days. Few asparaginase-related adverse events were reported; five patients (9.1%) developed clinical allergy associated with enzyme inactivation. Replacement therapy was successfully completed in 50 patients (90.9%). Eryaspase was well tolerated, and most patients had AEA levels above the therapeutic target after the first infusion. The half-life of eryaspase confirmed that a 2-week schedule is appropriate.
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Affiliation(s)
- Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Goda Vaitkeviciene
- Center of Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | | | | | - Päivi M Lähteenmäki
- Department of Pediatric and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Kristi Lepik
- Department of Hematology and Oncology, Tallinn Children's Hospital, Tallinn, Estonia
| | | | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Bachet JB, Blons H, Hammel P, Hariry IE, Portales F, Mineur L, Metges JP, Mulot C, Bourreau C, Cain J, Cros J, Laurent-Puig P. Circulating Tumor DNA is Prognostic and Potentially Predictive of Eryaspase Efficacy in Second-line in Patients with Advanced Pancreatic Adenocarcinoma. Clin Cancer Res 2020; 26:5208-5216. [PMID: 32605910 DOI: 10.1158/1078-0432.ccr-20-0950] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/13/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Eryaspase is composed of l-asparaginase encapsulated in erythrocytes and has demonstrated significant efficacy in a randomized phase II trial. We assessed the prognostic and predictive value of circulating tumor DNA (ctDNA) in patients, plasma included in this trial. EXPERIMENTAL DESIGN Samples prospectively collected pretreatment were centrally analyzed by next-generation sequencing. Prognostic values of baseline ctDNA and ctDNA early changes between day 0 and 28 were assessed in both arms combined on objective response rate (ORR), progression-free survival (PFS), and overall survival (OS); three groups were defined: negative ctDNA (Neg), ctDNA responders (Resp), and ctDNA nonresponders (NResp). Predictive value of ctDNA for eryaspase efficacy was investigated. RESULTS ctDNA was positive at baseline in 77 patients of the 113 tested patients (68%). Detectable ctDNA was an independent negative prognostic factor for OS (4.6 vs. 8.8 months; P = 0.0025) and PFS (1.6 vs. 3.3 months; P = 0.00043). Early change in ctDNA levels was correlated with ORR (20%, 26%, 0%; P < 0.04), PFS (3.7, 3.4, 1.6 months; P < 0.0001), and OS (11.7, 6.5, 4.3 months; P < 0.0001) according to the three defined groups (Neg, Res, NResp, respectively). In patients with ctDNA detectable at baseline, eryaspase was associated with better PFS [HR = 0.53; 95% confidence interval (CI): 0.3-0.94)] and OS (HR = 0.52; 95% CI: 0.29-0.91). CONCLUSIONS We confirm from a prospective randomized trial that: (i) the presence of ctDNA at baseline is a major prognostic factor, (ii) the early change of ctDNA correlates with treatment outcome, and (iii) the ctDNA could be a predictive biomarker of eryaspase efficacy.
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Affiliation(s)
- Jean-Baptiste Bachet
- Sorbonne Université, UPMC Université, IUC, Paris, France
- Assistance Publique-Hôpitaux de Paris, Department of Hepato-gastroenterology, Groupe Hospitalier Pitié Salpêtrière, Paris, France
- Centre de Recherche des Cordeliers, INSERM, CNRS, Sorbonne Université, USPC, Université de Paris, Equipe labellisée Ligue Nationale contre le cancer, Paris, France
| | - Hélène Blons
- Centre de Recherche des Cordeliers, INSERM, CNRS, Sorbonne Université, USPC, Université de Paris, Equipe labellisée Ligue Nationale contre le cancer, Paris, France
- Assistance Publique-Hôpitaux de Paris, Department of Biochemistry, Hôpital Européen Georges Pompidou, Paris, France
| | - Pascal Hammel
- Assistance Publique-Hôpitaux de Paris, Université de Paris, Medical Oncology Unit, Hôpital Beaujon, Clichy, France
| | | | | | - Laurent Mineur
- Institut Sainte Catherine, Gastrointestinal and Liver Cancer Unit, Chemin de baigne pieds, Avignon, France
| | | | - Claire Mulot
- Centre de Recherche des Cordeliers, INSERM, CNRS, Sorbonne Université, USPC, Université de Paris, Equipe labellisée Ligue Nationale contre le cancer, Paris, France
- Biological Ressources Center Epigenetec (BB-0033-00055), INSERM, Université de Paris, Paris, France
| | - Camille Bourreau
- Centre de Recherche des Cordeliers, INSERM, CNRS, Sorbonne Université, USPC, Université de Paris, Equipe labellisée Ligue Nationale contre le cancer, Paris, France
- Biological Ressources Center Epigenetec (BB-0033-00055), INSERM, Université de Paris, Paris, France
| | | | - Jérôme Cros
- Assistance Publique-Hôpitaux de Paris, INSERM, Paris University, Department of Pathology Hôpital Beaujon, Clichy, France
| | - Pierre Laurent-Puig
- Centre de Recherche des Cordeliers, INSERM, CNRS, Sorbonne Université, USPC, Université de Paris, Equipe labellisée Ligue Nationale contre le cancer, Paris, France.
- Assistance Publique-Hôpitaux de Paris, Department of Biochemistry, Hôpital Européen Georges Pompidou, Paris, France
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Bachet JB, Blons H, Hammel P, El Hariry I, Portales F, Mineur L, Metges JP, Mulot C, Bourreau C, Cain J, Cros J, Laurent-Puig P. Circulating tumor DNA is prognostic and potentially predictive of eryaspase efficacy in patients with advanced pancreatic adenocarcinoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.4617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4617 Background: Eryaspase is composed of L-asparaginase encapsulated in erythrocytes. It has demonstrated significant efficacy in combination with chemotherapy in a randomized phase 2 trial in second-line in patients with advanced pancreatic adenocarcinoma. We assessed, in this study, the prognostic and predictive value of circulating tumor DNA (ctDNA) in plasma samples of patients included in the eryaspase phase 2 trial. Methods: Samples prospectively collected pre-treatment at each 28-day cycle were centrally analyzed by next-generation sequencing (BPER method). Prognostic values of baseline ctDNA and ctDNA early changes between day 0 and 28 were assessed in both arms combined on objective response rate (ORR), progression free survival (PFS) and overall survival (OS). We conducted interaction test between ctDNA positivity and treatment arm, and the predictive value of ctDNA for eryaspase efficacy was investigated. Results: Patients with at least one available plasma sample have been included (n = 122/141). The presence of ctDNA at baseline was identified in 68% (77/113) of patients and was an independent negative prognostic factor for OS (4.6 vs 8.8 months; p = 0.0025) and PFS (1.6 vs 3.3 months; p = 0.00043). Early change in ctDNA levels was assessed by separating patients into three categories (one without detectable ctDNA, and two according to radio median value between day 0 and day 28) that were significantly correlated with ORR, PFS and OS. A significant interaction was observed between the presence of ctDNA and eryaspase efficacy. In patients with ctDNA detectable at baseline, eryaspase was associated with better PFS (HR = 0.53; 95% CI: 0.3-0.94) and OS (HR = 0.52; 95% CI: 0.29-0.91). Conclusions: We confirm from a prospective randomized trial that 1/ the presence of ctDNA at baseline is a major prognostic factor, 2/ the early change of ctDNA correlates with treatment outcome and 3/ the ctDNA could be a predictive biomarker of eryaspase efficacy. Clinical trial information: NCT02195180 .
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Affiliation(s)
| | | | - Pascal Hammel
- Hôpital Beaujon (AP-HP), Clichy, and University Paris VII, Paris, France
| | | | - Fabienne Portales
- Institut du Cancer de Montpellier (ICM), Univ Montpellier, Montpellier, France
| | | | - Jean-Philippe Metges
- Centre Hospitalier Regional Universitaire (CHRU) de Brest–Hopital Morvan, Brest, France
| | | | - Camille Bourreau
- Centre De Recherche Des Cordeliers, Inserm, Cnrs, Sorbonne Université, Uspc, Université De Paris, Equipe Labellisée Ligue Nationale Contre Le Cancer, Paris, France
| | | | - Jerome Cros
- APHP-INSERM U1149 Universite Paris Diderot, Clichy, France
| | - Pierre Laurent-Puig
- Paris Descartes University, Université Sorbonne Paris Cité, INSERM UMR-S1147 MEPPOT, CNRS SNC5014, Centre Universitaire des Saints-Pères, Equipe Labellisée Ligue Nationale Contre le Cancer, Paris, France
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Hammel P, Portales F, Mineur L, Metges JP, Andre T, De La Fouchardiere C, Louvet C, El Hajbi F, Faroux R, Guimbaud R, Tougeron D, Bouche O, Lecomte T, Rebischung C, Tournigand C, Cros J, Kay R, Hamm A, Gupta A, Bachet JB, El Hariry I. Erratum to 'Erythrocyte-encapsulated asparaginase (eryaspase) combined with chemotherapy in second-line treatment of advanced pancreatic cancer: An open-label, randomized Phase IIb trial' [European Journal of Cancer, Volume 124 (January 2020) Pages 91-101]. Eur J Cancer 2020; 130:275-276. [PMID: 32151460 DOI: 10.1016/j.ejca.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Pascal Hammel
- Digestive and Medical Oncology Unit, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, University Denis Diderot Paris VII, 92110 Clichy, France.
| | - Fabienne Portales
- Parc Euromedecine, 208 Rue Des Apothicaires, 34070 Montpellier, France
| | - Laurent Mineur
- Institut Sainte Catherine, Gastrointestinal and Liver Cancer Unit, Chemin de Baigne Pieds, 84000 Avignon, France
| | | | - Thierry Andre
- Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012 Paris, and Sorbonne Universités, France
| | | | - Christophe Louvet
- Department of Medical Oncology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France
| | - Farid El Hajbi
- Centre Oscar Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France
| | - Roger Faroux
- Les Oudairies, Hospital La Roche-Sur-Yon, Boulevard Stephane Moreau, 85000 La Roche Sur Yon, France
| | - Rosine Guimbaud
- Institut Universitaire du Cancer, Avenue Hubert Curien, 31100 Toulouse, France
| | - David Tougeron
- Gastroenterology Department and Medical Oncology Department, Poitiers University Hospital, Faculty of Medicine of Poitiers, 86000 Poitiers, France
| | - Olivier Bouche
- Service Oncologie Digestive, CHU Reims, Avenue Général Koenig, 51092 Reims Cede, France
| | - Thierry Lecomte
- Department of Hepatogastroenterology and Digestive Oncology, CHU de Tours, 37044 Tours Cedex, France
| | - Christine Rebischung
- Groupe Hospitalier Mutualiste de Grenoble, 8 Rue Docteur Calmette, 38100 Grenoble, France
| | - Christophe Tournigand
- Service d'Oncologie médicale, Hôpital Henri Mondor, AP-HP, Université Paris-Est, 94010 Créteil, France
| | - Jerome Cros
- Beaujon University Hospital, Department of Pathology-INSERM U1149, 100 Bvd Gal Lerclerc, 92110 Clichy, France
| | - Richard Kay
- RK Statistics Ltd, St Giles View, Main Street, Great Longstone, Bakewell DE45 1TZ, UK
| | - Adam Hamm
- Cytel Inc., 675 Massachusetts Ave, Cambridge, MA 02139, USA
| | - Anu Gupta
- ERYTECH, One Main Street, Suite 1150, Cambridge, MA 02142, USA
| | - Jean-Baptiste Bachet
- Sorbonne Universités, UPMC Université, Gastroenterology and Digestive Oncology Department, Pitié Salpêtrière Hospital, 75013 Paris, France; Service Oncologie Digestive, CHU Reims, Avenue Général Koenig, 51092 Reims Cede, France
| | - Iman El Hariry
- ERYTECH, One Main Street, Suite 1150, Cambridge, MA 02142, USA; Service Oncologie Digestive, CHU Reims, Avenue Général Koenig, 51092 Reims Cede, France
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Hammel P, Fabienne P, Mineur L, Metges JP, Andre T, De La Fouchardiere C, Louvet C, El Hajbi F, Faroux R, Guimbaud R, Tougeron D, Bouche O, Lecomte T, Rebischung C, Tournigand C, Cros J, Kay R, Hamm A, Gupta A, Bachet JB, El Hariry I. Erythrocyte-encapsulated asparaginase (eryaspase) combined with chemotherapy in second-line treatment of advanced pancreatic cancer: An open-label, randomized Phase IIb trial. Eur J Cancer 2019; 124:91-101. [PMID: 31760314 DOI: 10.1016/j.ejca.2019.10.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/09/2019] [Accepted: 10/13/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE This Phase IIb (NCT02195180) open-label study evaluated erythrocyte-encapsulated asparaginase (eryaspase) in combination with chemotherapy in second-line advanced pancreatic adenocarcinoma. METHODS Eligible patients were randomized 2:1 to either eryaspase in combination with gemcitabine or mFOLFOX6 (eryaspase arm), or to gemcitabine or mFOLFOX6 alone (control arm). Co-primary endpoints were overall survival (OS) and progression-free survival (PFS) in patients with low asparagine synthetase (ASNS) expression. Secondary endpoints included OS and PFS in the entire population. RESULTS 141 patients were randomized (eryaspase arm, n = 95; control arm, n = 46). Median OS and PFS in patients with low ASNS expression were 6.2 months (95% CI, 5.1-8.8) in the eryaspase arm versus 4.9 months (3.1-7.1) in the control arm (HR, 0.63; 95% CI, 0.39-1.01; P = 0.056) and 2.0 months (95% CI, 1.8-3.4) in the eryaspase arm versus 1.8 months (1.4-3.8) in the control arm (HR, 0.67; 95% CI, 0.40-1.12; P = 0.127), respectively. In the entire population, median OS and PFS for the eryaspase arm versus control were 6.0 months versus 4.4 months (HR, 0.60; P = 0.008) and 2.0 months versus 1.6 months (HR, 0.56; 95% CI, 0.37-0.84; P = 0.005), respectively. The combination of eryaspase and chemotherapy was well tolerated. The most frequent Grade 3/4 adverse events in the eryaspase arm (n = 93) were gamma-glutamyltransferase increase (16 [17.2%]), neutropenia (12 [12.9%]), and physical health deterioration (12 [12.9%]). CONCLUSION Eryaspase in combination with chemotherapy is associated with improvements in OS and PFS, irrespective of ASNS expression in second-line advanced pancreatic adenocarcinoma. A Phase III trial is underway.
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Affiliation(s)
- Pascal Hammel
- Digestive and Medical Oncology Unit, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, University Denis Diderot Paris VII, 92110 Clichy, France.
| | - Portales Fabienne
- Parc Euromedecine, 208 Rue Des Apothicaires, 34070 Montpellier, France
| | - Laurent Mineur
- Institut Sainte Catherine, Gastrointestinal and Liver Cancer Unit, Chemin de Baigne Pieds, 84000 Avignon, France
| | | | - Thierry Andre
- Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012 Paris, and Sorbonne Universités, France
| | | | - Christophe Louvet
- Department of Medical Oncology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France
| | - Farid El Hajbi
- Centre Oscar Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France
| | - Roger Faroux
- Les Oudairies, Hospital La Roche-Sur-Yon, Boulevard Stephane Moreau, 85000 La Roche Sur Yon, France
| | - Rosine Guimbaud
- Institut Universitaire du Cancer, Avenue Hubert Curien, 31100 Toulouse, France
| | - David Tougeron
- Gastroenterology Department and Medical Oncology Department, Poitiers University Hospital, Faculty of Medicine of Poitiers, 86000 Poitiers, France
| | - Olivier Bouche
- Service Oncologie Digestive, CHU Reims, Avenue Général Koenig, 51092 Reims Cede, France
| | - Thierry Lecomte
- Department of Hepatogastroenterology and Digestive Oncology, CHU de Tours, 37044 Tours Cedex, France
| | - Christine Rebischung
- Groupe Hospitalier Mutualiste de Grenoble, 8 Rue Docteur Calmette, 38100 Grenoble, France
| | - Christophe Tournigand
- Service d'Oncologie médicale, Hôpital Henri Mondor, AP-HP, Université Paris-Est, 94010 Créteil, France
| | - Jerome Cros
- Beaujon University Hospital, Department of Pathology-INSERM U1149, 100 Bvd Gal Lerclerc, 92110 Clichy, France
| | - Richard Kay
- RK Statistics Ltd, St Giles View, Main Street, Great Longstone, Bakewell, DE45 1TZ, UK
| | - Adam Hamm
- Cytel Inc., 675 Massachusetts Ave Cambridge, MA 02139, USA
| | - Anu Gupta
- ERYTECH, One Main Street, Suite 1150, Cambridge, MA 02142, USA
| | - Jean-Baptiste Bachet
- Sorbonne Universités, UPMC Université, Gastroenterology and Digestive Oncology Department, Pitié Salpêtrière Hospital, 75013 Paris, France
| | - Iman El Hariry
- ERYTECH, One Main Street, Suite 1150, Cambridge, MA 02142, USA
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Awada A, Rodriguez AA, Kong A, Erban JK, Cortes J, Mano MS, Perez EA, El Hariry I, Vukovic VM, Teofilovici F, Yalcin I, Bradley R, Cameron DA. The ENCHANT-1 trial (NCT01677455): An open label multicenter phase II proof of concept study evaluating first-line ganetespib monotherapy in women with metastatic HER2-positive or triple-negative breast cancer (TNBC). J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.tps1136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS1136 Background: Hsp90 is a molecular chaperone protein required for the stabilization and activation of many proteins, referred to as Hsp90 ‘clients’, including those commonly implicated in breast tumorigenesis such as HER2, EGFR, ER, PI3K, AKT, P53 and VEGFR. Ganetespib is a novel triazolone inhibitor of Hsp90 being studied in over 20 clinical trials, with over 700 patients treated to date. Ganetespib is ~50x more potent than 1st-generation Hsp90 inhibitors, and has been well tolerated in clinical trials with a favorable safety profile. Mild to moderate, transient diarrhea is the most common adverse event associated with ganetespib infusion and is manageable with appropriate supportive care. Ganetespib has shown activity in preclinical models of HER2+, ER+/PR+ and triple negative breast cancer (TNBC). In a phase I trial, ganetespib demonstrated single-agent clinical activity in HER2+ disease with an objective response rate (ORR) of 15% and a disease stabilization rate of 46% in heavily pretreated patients. This efficacy-screening study is designed to provide further evidence of ganetespib activity and identify potentially predictive biomarkers in metastatic breast cancer. Methods: The ENCHANT-1 trial is an international, first-line Phase II study in two cohorts of breast cancer patients: Cohort A, HER2 amplified (n=35), and Cohort B, TNBC (n=35). HER2+ patients must have received prior anti-HER2 therapy in the adjuvant setting. Patients are treated with ganetespib at 150 mg/m2 twice weekly on a three out of four-week regimen. Primary endpoint: ORR assessed using RECIST1.1 criteria. Key secondary endpoints include metabolic effects as assessed by PET/CT at week 3. Tumor genetic signature and proteomic profiling are performed on patient’s tumors in an effort to develop biomarkers of response. At the time of submission 6 patients have been enrolled into this study. Clinical trial information: NCT01677455.
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Affiliation(s)
- Ahmad Awada
- Medical Oncology Clinic, Jules Bordet Institute, Brussels, Belgium
| | | | - Anthony Kong
- Churchill Hospital, Oxford University Hospitals NHS Trust and University of Oxford, Oxford, United Kingdom
| | - John Kalil Erban
- Division of Hematology Oncology, Tufts Medical Center, Boston, MA
| | | | - Max S. Mano
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
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