Abstract OT3-01-02: CNIO-BR-008 trial: Reversion of T-cell exhaustion caused by chronic treatment with hypoxia-inducing antiangiogenic treatment by durvalumab in HER2-negative breast cancer: A pilot proof-of-concept trial

Background: The role of immune checkpoints in tumor progression is less relevant in breast cancer than in other malignancies. However, in preclinical experimentation we found a niche for immune checkpoint inhibitors. In an immunocompetent model of HER2-negative breast cancer (MMTV-PyMT) we observed that antiangiogenic agents may induce either a tumor normoxic or hypoxic adaptation. Normoxic adaptation leads to a therapeutically exploitable dependence on mitochondrial metabolism (Cell Rep 2016; 15: 1-14). Hypoxic adaptation (usually caused by monoclonal antibody type antiangiogenics) induces an increase in PGE2 and PGA synthesis, followed by a switch of the tryptophan metabolism from 5HIAA to kinurenine that culminates in differentiation of naive T-cells to Tregs and expression of PD-L1 in the hypoxic areas. The exhausted T-cell response observed in this model can be restored with PD-L1 inhibitors. We sought to prove the relevance of T-cell exhaustion an its reversibility by the anti-PD-L1 antibody durvalumab in patients receiving chronic bevacizumab (Bev).

Trial design

Single-arm, prospective, multicentric, phase II open-label trial. Patients receiving Bev maintenance after a chemotherapy+Bev regimen administered in the first line of metastatic disease that experience disease progression (PD) during maintenance will be candidates. The treatment will start by adding durvalumab (10 mg/kg q2w) to the ongoing Bev (15 mg/kg q3 w). Patients will undergo serial tumor biopsies, tumor-cfDNA sequencing (baseline and progression), and immunophenotyping (baseline and q4w). RECIST/I-RECIST and NCI CTC AE V4.03 criteria will be used for assessing disease response and toxicity.

Elegibility criteria

Women >18 year old diagnosed of HER2-negative advanced breast cancer; 2) have received chemotherapy plus Bev for the first line treatment and experienced PR, CR or SD, 3) followed by maintenance with three-weekly Bev in monotherapy for at least 6 weeks before diagnosis of PD. 4) Concurrent hormonal therapy is allowed for ER+ patients, but reception of previous immunotherapy is precluded. 5) Adequate organ function defined according to standard parameters.

Specific aims

Primary:

1) To determine the relative percentages of innate and adaptive immune cell subpopulations and ascertain the status of T-cell function and polarization by multiparametric flow cytometry in patients with acquired resistance against Bev

2) To assess the reversibility of the abnormalities evidenced in (1) by durvalumab

3) To determine the disease control rate of the combination, and its relationship with (1) and (2)

Secondary:

4) To determine potential tumor neoantigens generated by chronic tumor hypoxia secondary to the antiangiogenic treatment.

Statistical methods

The sample size is calculated on the basis of the expected change in the Treg percentage in peripheral blood (10%), with an alpha and beta errors of 5% and 20% respectively. The minimum number of patients necessary to observe a 10% decrease is 25. Changes in lymphocytes will be compared with intra-subject measurements and Z-scores.

Accrual: 2 of 25 (target accrual) patients have been recruited.

Contact info: mquintela@cnio.es.

Citation Format: Quintela-Fandino M, Manso L, Mouron S, Lopez-Acosta JF, García-Saenz JA, Holgado E, Pascual-Martinez T, Medicna L, Guerra J, Gonzalez-Cortijo L, Mañes S. CNIO-BR-008 trial: Reversion of T-cell exhaustion caused by chronic treatment with hypoxia-inducing antiangiogenic treatment by durvalumab in HER2-negative breast cancer: A pilot proof-of-concept trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-01-02.

Abstract P4-22-22: Cobimetinib (C) combined with paclitaxel (P) as a first-line treatment in patients (pts) with advanced triple-negative breast cancer (COLET study): Updated clinical and biomarker results

Resistance to standard taxane-based chemotherapy is common in triple-negative breast cancer (TNBC). Mutations and gene amplifications in the MAPK pathway that upregulate MAPK signaling are present in many TNBC tumors. Upregulation of the MAPK signaling pathway can result in degradation of the pro-apoptotic protein BIM and upregulation of anti-apoptotic proteins, including BCL-2, BCL-XL, and MCL-1, thus promoting cell survival and desensitizing tumor cells to the pro-apoptotic effects of taxane chemotherapy. Updated data on clinical safety and efficacy are presented along with biomarker data evaluating the effects of treatment on induction of apoptosis.The COLET study (ClinicalTrials.gov ID, NCT02322814; EudraCT number, 2014-002230-32) consisted of a safety run-in (n∼12) followed by a blinded 1:1 randomized expansion stage (n∼90) to C + P or placebo (PBO) + P. The safety stage is complete and the randomized stage is enrolling pts. Two additional cohorts investigating the effect of adding atezolizumab will be recruiting and are out of scope of this submission. Pts in cohort I were treated with P 80 mg/m2 on days 1, 8, and 15 and C/PBO 60 mg/day on days 3–23 of each 28-day cycle until disease progression or unacceptable toxicity. Gene expression and apoptotic index were measured by RNA-Seq and TUNEL staining, respectively, to assess the biologic activity of C + P.Sixteen women (median age, 55.5 years) were enrolled in the safety run-in stage. At data snapshot (April 22, 2016), all 16 pts had received ≥1 dose of study treatment. Median time on treatment was 116 days (range, 7-336) for C and 84 days (range, 0-351) for P. Fifteen (94%) pts had ≥1 adverse event (AE); 5 (31%) pts had grade 1/2 AEs and 10 (63%) pts had grade 3 AEs (Table). No pts experienced grade 4–5 AEs. Among the 16 safety run-in patients, responses to date include partial response (PR; n = 8 [50.0%]), stable disease (SD, n = 4 [25.0%]), and progressive disease (n = 2 [12.5%]), as well as 2 pts with no post-baseline tumor assessment. Six pts maintained a PR at ∼20 weeks and three maintained a PR at ≥40 weeks. To date, matched pre- and on-treatment biopsies were evaluable for 2 pts, 1 with a PR and 1 with SD. In the patient who attained a PR, increased expression of pro-apoptosis genes, including BIM, was observed; but this was not seen in the patient experiencing SD. The PR patient also had an increase in apoptotic index. Updated biomarker data will be reported.This is the first study to evaluate C + P in TNBC. The safety profile of C + P is consistent with that of known safety profiles. Efficacy and safety will be further evaluated in the ongoing randomized stage.

Most common (any grade ≥20%) AEsTreatment-emergent AEs, n (%)C + P (safety run-in stage), N = 16 All gradesGrade 3Diarrhea10 (63)1 (6)Rash8 (50)0Nausea7 (44)0Alopecia5 (31)0Blood CPK level increase5 (31)1 (6)Stomatitis4 (25)2 (13)Asthenia4 (25)1 (6)Constipation4 (25)0Dyspnea4 (25)0Edema peripheral4 (25)0Pyrexia4 (25)0Vomiting4 (25)0AEs, adverse events; C, cobimetinib; CPK, creatinine phosphokinase; P, paclitaxel.

Citation Format: Brufsky A, Kim S-B, Velu T, García-Saenz JA, Tan-Chiu E, Sohn JH, Dirix L, Borms MV, Liu M-C, Moezi MM, Kozloff MF, Sparano JA, Xu N, Wongchenko M, Simmons B, McNally V, Miles D. Cobimetinib (C) combined with paclitaxel (P) as a first-line treatment in patients (pts) with advanced triple-negative breast cancer (COLET study): Updated clinical and biomarker results [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-22.

Abstract P3-15-02: A prospective, open label, non-comparative trial to determine the incidence of chemotherapy-induced nausea and vomiting associated with the docetaxel-cyclophosphamide regimen in early breast cancer patients. Results from the GEICAM 2009-02 study

Background: Docetaxel-Cyclophosphamide (TC) has become a common chemotherapy regimen for moderate-high risk Early Breast Cancer (EBC) patients. The incidence of chemotherapy induced nausea and vomiting (CINV) with TC together with an adequate standard anti-emetic therapy with 5-HT3 antagonist and corticosteroids are unknown. This study investigates the incidence of emesis control (complete response), defined as no vomiting (any grade of NCI CTCAE version 4.0) and no use of rescue treatment within 120 hours after the first cycle of TC. Secondary objective evaluates the efficacy of Aprepitant in non-responding patients.

Methods: EBC patients with no prior moderate-high risk CINV were included. Patients received Docetaxel 75 mg/m2 plus Cyclophosphamide 600 mg/m2 IV every three weeks. Antiemetic treatment consisted of oral Dexamethasone (D) 8 mg (at night) on day 0; oral D 8 mg x 3 (in the morning, 1 hour before chemotherapy and at night) plus 5-HT3 antagonists on day 1; and oral D 8 mg x 2 (in the morning and at night) on days 2 and 3. Non-responding patients (vomiting or need of rescue therapy in the first cycle) were offered participation in the efficacy phase (Aprepitant 125mg day 1 and 80 mg days 2 and 3 added to the standard antiemetic therapy in cycle 2). In addition to the standard NCI-CTCAE adverse event collection, a patient´s diary (from day 1 to 6) and the FLIE (Functional Living Index-Emesis questionnaire) were used. Assuming a 25% (+/- 6%) of patients resistant to standard antiemetic therapy, 212 patients were estimated.

Results: From May-11 to March-13, 212 EBC patients were included. Median age was 57 years (range 34-82), 29.3% were premenopausal. Twenty-seven patients were excluded from the main analysis because of major protocol violations (25) or consent withdrawal (2). Twenty-four patients (13%; IC95%: 8.2 – 17.8) did not respond to standard antiemetics and entered the efficacy phase with Aprepitant. From these 24 patients, 14 (56%; IC95%: 36.5 – 75.5) achieved a complete response on cycle 2. No adverse events related to Aprepitant were observed.

Conclusions: Proper use of standard antiemetic therapy for early breast cancer patients treated with TC provides a high control rate (87%). Among no responding patients, about half of them were rescued with Aprepitant. Identification of the non-responding patients could lead to a better antiemetic control with Aprepitant from the first cycle.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-15-02.

Prospective transGEICAM study of the impact of the 21-gene Recurrence Score assay and traditional clinicopathological factors on adjuvant clinical decision making in women with estrogen receptor-positive (ER+) node-negative breast cancer

BACKGROUND

This study examined the impact of the Recurrence Score (RS) in Spanish breast cancer patients and explored the associations between clinicopathological markers and likelihood of change in treatment recommendations.

PATIENTS AND METHODS

Enrollment was offered consecutively to eligible women with estrogen receptor-positive; human epidermal growth factor receptor 2-negative, node-negative breast cancer. Oncologists recorded treatment recommendation and confidence in it before and after knowing the patient's RS.

RESULTS

Treatment recommendation changed in 32% of 107 patients enrolled: in 21% from chemohormonal (CHT) to hormonal therapy (HT) and in 11% from HT to CHT. RS was associated with the likelihood of change from HT to CHT (P < 0.001) and from CHT to HT (P < 0.001). Confidence of oncologists in treatment recommendations increased for 60% of cases. Higher tumor grade (P = 0.007) and a high proliferative index (Ki-67) (P = 0.023) were significantly associated with a greater chance of changing from HT to CHT, while positive progesterone receptor status (P = 0.002) with a greater probability of changing from CHT to HT.

CONCLUSIONS

Results from the first prospective European study are consistent with published experience and use of the RS as proposed in European clinical practice guidelines and provide evidence on how Oncotype DX and clinicopathological factors are complementary and patient selection may be improved.

Erlotinib and chemoradiation in patients with surgically resected locally advanced squamous cell carcinoma of the head and neck: a GICOR phase I trial

BACKGROUND

Standard treatment of advanced squamous cell carcinoma of the head and neck (SCCHN) is concurrent chemoradiation. Erlotinib is an oral tyrosine kinase inhibitor of epidermal growth factor receptor, which has shown activity in SCCHN. Phase I study aims to determine the maximum tolerated dose and dose-limiting toxicity (DLT) of adding erlotinib to chemoradiation therapy in patients with surgically resected locally advanced SCCHN.

PATIENTS AND METHODS

Inclusion criteria--SCCHN patients with T3 or T4 primary lesion (except T3N0 with negative resection margins); pathologic N2-N3 disease; poor prognostic findings; age 18-70 years; Eastern Cooperative Oncology Group performance status of zero to one; no evidence of metastasis; adequate organic function and written informed consent. Study design--dose-escalating phase I study with three cohorts of three to six patients each that received increasing doses of erlotinib (100-150 mg/day p.o.) and cisplatin (30-40 mg/m(2) i.v., day 1) for 7 weeks. Radiotherapy--standard regimen of 1.8 Gy daily (5 fractions/week) to a maximum total dose of 63 Gy in 7 weeks.

RESULTS

Thirteen male (median age: 57 years) were enrolled. Overall, the regimen was well tolerated. Two of three patients treated at dose level III (erlotinib: 150 mg/day; cisplatin: 40 mg/m(2)) developed DLT consisting of grade 3 infection and grade 3 mucositis. Other toxic effects included diarrhea, asthenia, and rash. Recommended dose for additional studies: erlotinib 150 mg/day p.o.; cisplatin 30 mg/m(2)/week i.v.

CONCLUSION

Erlotinib can be safely combined with chemoradiation without requiring dose reduction of chemo- or radiotherapy in this postsurgical population.

Genomic predictors of response to doxorubicin versus docetaxel in primary breast cancer

Taxanes and anthracyclines improve the outcome of early breast cancer, although the benefit is limited to a small proportion of patients and are toxic. We prospectively looked for predictors of response to these drugs.

EXPERIMENTAL DESIGN

Four cycles of doxorubicin (75 mg/m²) or docetaxel (100 mg/m²) were compared as presurgical chemotherapy for breast cancer. Biomarkers were determined by immunohistochemistry and fluorescent in situ hybridization using prechemotherapy core biopsies. Tumors were also classified into one of the molecular intrinsic subtypes using an immunohistochemical panel of five biomarkers and genomic profiles. Single genes and intrinsic subtypes were correlated with response to doxorubicin versus docetaxel. Among the 204 evaluable patients, significant predictors of sensitivity in multivariate analysis were low topo2a expression and ER-negative status for doxorubicin and small tumor size and ER-negative status for docetaxel. Predictors of resistance in multivariate analysis were triple-negative status (ER/PgR/HER2 negative by IHC/FISH) for doxorubicin, and high TNM stage for docetaxel. Triple-negative tumors were associated with topo2a overexpression more than the other subtypes. In 94 patients with gene expression profiles, docetaxel was superior to doxorubicin in the basal-like subtype (good pathological response rate - PCR + class I of 56 vs. 0%; P = 0.034); no significant differences were observed in the other subtypes when comparing these two drugs. Low topo2a expression and ER-negative status were predictors of response to doxorubicin, while small tumor size and ER-negative status predicted response to docetaxel. Docetaxel was superior to doxorubicin in triple-negative/basal-like tumors, while no significant differences were seen in the remaining intrinsic subtypes.

Pegylated liposomal doxorubicin in combination with cyclophosphamide and trastuzumab in HER2-positive metastatic breast cancer patients: efficacy and cardiac safety from the GEICAM/2004-05 study

BACKGROUND

In order to determine the feasibility of substituting pegylated liposomal doxorubicin (PLD) for doxorubicin in combination with cyclophosphamide and trastuzumab as adjuvant therapy, we conducted a phase II study of the combination as first-line therapy in human epidermal growth factor receptor 2 (HER2) overexpressing metastatic breast cancer (MBC).

METHODS

PLD 50 mg/m(2) and cyclophosphamide 600 mg/m(2) were administered every 4 weeks for six cycles; trastuzumab (4 mg/kg loading dose, then 2 mg/kg) was administered weekly for 24 weeks. The primary end point was objective response rate (ORR), and the secondary end points included time to progression (TTP), overall survival (OS), and safety.

RESULTS

Among the 48 evaluable patients, ORR was 68.8% [95% confidence interval (CI) 55.69% to 81.91%], with 6 patients (12.5%) achieving a complete response and 27 (56.2%) a partial response. The median TTP was 12 months (95% CI 9-15.1 months), and the median OS was 34.2 months (95% CI 27.2-41.2 months). Febrile neutropenia was seen in three patients, grade 3 hand-foot syndrome in 29.2% of patients, and grade 3-4 mucositis in 22.9% of patients. Symptomatic congestive heart failure was not observed, and 16.7% of patients experienced grade 2 asymptomatic left ventricular systolic dysfunction.

CONCLUSION

The combination of PLD-cyclophosphamide-concurrent trastuzumab is a feasible, safe, and effective first-line regimen for HER2-overexpressing MBC.

Randomized, phase II trial comparing continuous versus intermittent capecitabine monotherapy for metastatic breast cancer (MBC)

1086

Background: The approved capecitabine (X) regimen in MBC is 1,250 mg/m2 bid, d1–14 q21d (Xint). However, dose modifications are often required primarily for hand-foot syndrome and diarrhea. Therefore we designed an alternative regimen aimed to reduce the severity of these side effects while maintaining the total cumulative dose and efficacy of X. Methods: The primary objective was to show non-inferiority of X 800 mg/m2 bid, d1–21 q21d (Xcont) to Xint in terms of 1-year PFS rate. Secondary endpoints included response rate (RECIST), PFS, duration of response, OS, and safety (NCI CTCAE v2.0). Assuming median PFS of 5 months and 2-sided α=0.05, 176 evaluable patients (pts) will be needed to give 80% power. Pts are ineligible if they have received >2 chemotherapy regimens for MBC or prior X, or if they have HER2-positive MBC or symptomatic CNS metastases. Treatment is continued until progression, unacceptable toxicity, or refusal. Dose interruption/reduction is implemented if pts experience grade 2–4 clinically relevant adverse events. Results: The current interim analysis includes the first 60 pts, with median age 55 years (range 33–79) in the Xcont arm and 67 years (range 34–88) in the Xint arm. 26% and 14%, respectively, were hormone receptor negative. Prior chemotherapy included a taxane in 48% vs 52% and an anthracycline in 65% vs 76%, respectively. X was given as first-line chemotherapy in 48% and 38% of pts, respectively. Median duration of treatment was 7 cycles for Xcont vs 6 cycles for Xint. Dose reduction was required in 10% of cycles in each arm. Toxicity led to treatment discontinuation in 1 vs 8 pts, respectively. Activity and safety results at interim analysis are summarized below (Table). Conclusions: Xcont and Xint seem similarly active in MBC in this interim analysis. Xcont appeared slightly better tolerated. The study will continue recruiting additional pts.

[Table: see text]

No significant financial relationships to disclose.

Circulating tumor cells in colorectal cancer: correlation with clinical and pathological variables

BACKGROUND

The CellSearch System is a technique to detect circulating tumor cells (CTCs) in patients with cancer. Few data have been published concerning the role of CTCs detection by this method in colorectal cancer. The aim of this study was to correlate the presence of CTCs with the commonest clinical and morphological variables.

PATIENTS AND METHODS

Blood samples were collected from 97 patients and 30 healthy volunteers. Quantification of CTCs in 7.5 ml of blood was carried out with the CellSearch System. The results were expressed as number of CTCs/7.5 ml and the cut-off of >or=2 CTCs/7.5 ml was chosen to define the test as positive.

RESULTS

Positive CTCs were detected in 34 of 94 patients (36.2%). Correlation was not found among positive CTCs and location of primary tumor, increased carcinoembryonic antigen level, increased lactate dehydrogenase level or grade of differentiation. Only stage correlated with positive CTCs (20.7% in stage II, 24.1% in stage III and 60.7% in stage IV, P = 0.005).

CONCLUSIONS

CTCs detection by CellSearch is a highly reproducible method that correlates with stage but not with other clinical and morphological variables in patients with colorectal cancer. Colon cancer tumor cells are detectable in all stages. Further studies are warranted.