Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool

BACKGROUND

Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need.

OBJECTIVE

This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory.

METHODS

The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool.

RESULTS

We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, "getting worse" or "getting better"; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code.

CONCLUSIONS

Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively.

Safety and efficacy of alternating treatment with EP2006, a filgrastim biosimilar, and reference filgrastim: a phase III, randomised, double-blind clinical study in the prevention of severe neutropenia in patients with breast cancer receiving myelosuppressive chemotherapy

Background

In 2015, the biosimilar filgrastim EP2006 became the first biosimilar approved by the US Food and Drug Administration for commercial use in the United States, marketed as Zarxio® (Sandoz). This phase III randomised, double-blind registration study in patients with breast cancer receiving (neo)adjuvant myelosuppressive chemotherapy (TAC; docetaxel + doxorubicin + cyclophosphamide) compares reference filgrastim, Neupogen® (Amgen), with two groups receiving alternating treatment with reference and biosimilar every other cycle.

Patients and methods

A total of 218 patients receiving 5 µg/kg/day filgrastim over six chemotherapy cycles were randomised 1: 1: 1: 1 into four arms. Two arms received only one product, biosimilar or reference (unswitched), and two arms (switched) received alternating treatments every other cycle (biosimilar then reference or vice versa over six cycles). Since the switch occurred from cycle 2 onwards, this analysis compared pooled switched groups to the unswitched reference group for efficacy during cycles 2-6. Safety was also assessed. Non-inferiority in febrile neutropenia (FN) rates between groups for cycles 2-6 was shown if 95% were within a pre-defined margin of - 15%.

Results

A total of 109 patients switched treatment, and 52 patients received reference in all cycles. Baseline characteristics were similar between groups. The incidence of FN was 0% (reference) versus 3.4% (n = 3, switched) across cycles 2-6, with a difference of - 3.4% (95% confidence interval: -9.65% to 4.96%), showing non-inferiority. Infections occurred in 9.3% (switched) versus 9.9% (reference). Hospitalisation due to FN was low (one patient in cycle 6; switched). Adverse events related to filgrastim were reported in 42.1% (switched) versus 39.2% (reference) (all cycles). Musculoskeletal/connective tissue disorders related to filgrastim occurred in 35.5% (switched) versus 39.2% (reference) (all cycles), including bone pain (30.8% versus 33.3%). No neutralising antibodies were detected.

Conclusions

There were no clinically meaningful results regarding efficacy, safety or immunogenicity when switching from reference to biosimilar filgrastim/EP2006, or vice versa.

Abstract P1-06-04: Small-molecule screening nominates diverse combination therapies that sensitize BRCA mutant and wild-type triple negative breast cancer to PARP inhibition

Background: Triple negative breast cancer (TNBC) remains a heterogeneous clinical phenotype with few, known therapeutic targets. PARP inhibitors (PARPi) are the first approved, targeted therapy in TNBC, limited to germline BRCA mutant (BRCAm) cancers that lack homologous recombination repair capacity. Even in this context, resistance quickly emerges via secondary mutations that restore DNA repair ability. While DNA damage repair is an intriguing target in BRCA wild type (BRCAwt) TNBC due to inherent, genomic instability, PARPi alone have been ineffective in unselected populations. Systematic approaches to define novel drugs that sensitize BRCAwt and BRCAm TNBC to PARPi would greatly improve therapeutic efficacy and durability.

Methods: BRCAwt (HCC1806) and BRCAm (SUM149PT) cell lines were screened in duplicate using a 2,100-compound small molecule library. Cell lines were plated in media containing DMSO or sub-lethal doses of the PARPi, olaparib, onto Selleck Bioactive drug plates. Cell viability was assessed after 72 hours, then normalized to vehicle control. Hit cut-offs were predefined as log2 drug/DMSO of ≤ -0.7 with a viability difference greater than 20% -where stringent scoring thresholds were chosen to exceed the full range of scores observed in 816 empty control wells. Hits were sorted by target and pathway to provide mechanistic insight into the synergy of combinations. Drug combinations with the highest potential for near term translation were validated using GI50 viability assays in 9 BRCAwt and BRCAm TNBC cell lines. The most promising combination was further validated via immunoblotting, colony formation, and apoptosis assays.

Results: Several drug classes affecting well-known oncogenic signaling pathways conferred sensitivity to PARPi, with more hits in the BRCAm cell line. Relevant druggable targets sensitizing cells to olaparib in BRCAm TNBC that met the predefined cut-point were inhibitors of PI3K (pan-PI3K, PI3Kα and PI3Kβ specific), VEGFR, MEK, EGFR, NF-kB, aurora kinase and several DNA damaging agents. Aurora kinase, EGFR, and NF-kB inhibition sensitized cells to olaparib, yet upon further validation, synergy was mild. The screen identified ATM inhibitors, KU-55933 and KU-60019, as sensitizers of BRCAm cells to olaparib. The potent ATM inhibitor, AZD0156, and olaparib were a highly synergistic combination validated in all 9 BRCAm and BRCAwt TNBC cell lines via cell viability, annexin V, and colony formation assays. Immunoblotting of relevant DNA damage repair proteins showed that olaparib caused upregulation of p-ATM in BRCAm and BRCAwt cells. p-ATM expression decreased in response to combination ATM and PARP inhibition. Attenuated levels of p-ATM resulted in increased levels of p- and T-γH2AX, indicating an accumulation of double stranded DNA breaks.

Conclusion: In vitro, inhibition of several relevant, oncogenic pathways yielded sensitivity to PARPi in TNBC. We identified the ATM inhibitor, AZD0156, and olaparib as a potent combination regardless of BRCA status, a finding currently being evaluated in patient-derived in vivo models. Combination ATM plus PARP inhibitor therapy is a promising and feasible approach for near term translation in metastatic TNBC.

Citation Format: Sammons S, Yip C, Anderson G, Force J, Marcom K, Westbrook K, Anders CK, Blackwell K, Wood K. Small-molecule screening nominates diverse combination therapies that sensitize BRCA mutant and wild-type triple negative breast cancer to PARP inhibition [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-06-04.

Pooled analysis of two randomized, double-blind trials comparing proposed biosimilar LA-EP2006 with reference pegfilgrastim in breast cancer

Background

Following the functional and physicochemical characterization of a proposed biosimilar, comparative clinical studies help to confirm biosimilarity by demonstrating similar safety and efficacy to the reference product in a sensitive patient population.

Patients and methods

LA-EP2006 is a proposed biosimilar that has been developed for pegfilgrastim, a long-acting form of granulocyte colony-stimulating factor for the prevention of neutropenia. The current analysis reports data pooled from two independent, multinational, prospective, randomized, controlled, double-blind phase III studies of similar design comparing the safety and efficacy of reference pegfilgrastim with LA-EP2006 in patients with breast cancer receiving myelotoxic (neo)adjuvant TAC (docetaxel, doxorubicin, and cyclophosphamide) chemotherapy and requiring granulocyte colony-stimulating factor.

Results

A total of 624 patients were randomized in the PROTECT-1 and PROTECT-2 studies (NCT01735175; NCT01516736) (LA-EP2006: n = 314; reference: n = 310). Baseline characteristics of patients were well balanced across treatment groups. The primary end point, mean duration of severe neutropenia in the first chemotherapy cycle was similar in both the LA-EP2006 and reference groups (1.05 ± 1.055 days versus 1.01 ± 0.958 days), with a treatment difference of - 0.04 days [95% confidence interval (CI): -0.19 to 0.11] that met the equivalence criteria (the 95% CI were within the defined margin of ±1 day). Secondary end points, such as the nadir of absolute neutrophil count and the incidence of febrile neutropenia, were also similar between LA-EP2006 and reference pegfilgrastim. The safety and tolerability profile of LA-EP2006 was similar to that observed with reference pegfilgrastim, and there were no reports of neutralizing antibodies.

Conclusions

This pooled analysis confirms, as a part of totality of evidence approach, that the proposed biosimilar pegfilgrastim LA-EP2006 has a comparable efficacy and safety profile to reference pegfilgrastim in patients with breast cancer receiving TAC chemotherapy.

Clinical trial numbers

NCT01735175 and NCT01516736.

Abstract P6-09-03: Gene expression patterns in younger versus older HR+ breast cancer patients: An age-related analysis of HoxB13/IL17BR (H/I), proliferation status, and quantitative hormone receptor expression

Background: HR+ breast cancer in younger vs older patients may have distinct biological features. The Breast Cancer Index (BCI) is a gene expression-based assay that includes two component biomarkers: the HoxB13/IL17BR (H/I ratio), an endocrine response biomarker; and the molecular grade index (MGI), a set of proliferation-related genes. The objective of this study was to assess age-related associations with endocrine sensitivity (H/I), proliferative status (MGI), and quantitative expression of ER and PR.

Methods: Data were extracted from the BCI Clinical Database for Correlative Studies, an IRB-approved de-identified database containing clinicopathologic and molecular variables from clinical cases submitted for BCI testing. Molecular results from H/I, MGI, and quantitative (qPCR–based) ER and PR were analyzed across age groups. Chi-squared tests and ANOVA were used to compare the results between age groups (<40y, 40-49y, 50-59y, 60-69y, and ≥70y).

Results: Analyses included 19,126 patients (median age at diagnosis 58.6y; 4.5% <40y, 20.6% 40-49y, 28.9% 50-59y, 32.5% 60-69y, and 13.6% ≥70y). Proliferation status (MGI) was significantly higher in patients <40y and 40-49y compared to older groups (P<.0001).H/I analysis indicated a similar distribution of high versus low endocrine responsiveness across all groups (P=.94), except the 40-49y group, in which fewer patients had high H/I (44.2% in <40y, 39.4% in 40-49y, 43.7% in 50-59y, 43.7% in 60-69y, and 43.1% in ≥70y; P=.0001). Median qER increased with age (P<0.0001), while qPR was similar across all age groups except for the 40-49y group (P=.57), in which expression was higher (P<.0001).

Conclusion: Results from >19,000 patients with early-stage HR+ breast cancer and BCI testing showed a broad distribution in all variables. Tumors from the youngest patients (<40y) had the highest expression of proliferative genes and the lowest quantitative ER expression. However, endocrine response, according to the H/I biomarker, does not appear to be strongly linked to age.

Citation Format: Melisko M, Chien AJ, Poage GM, Salganik M, Schnabel CA, Ruddy KJ, Blackwell K. Gene expression patterns in younger versus older HR+ breast cancer patients: An age-related analysis of HoxB13/IL17BR (H/I), proliferation status, and quantitative hormone receptor expression [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-03.

Abstract OT3-04-02: The DORA trial: A non-comparator randomised phase II multi-center maintenance study of olaparib alone or olaparib in combination with durvalumab in platinum treated advanced triple negative breast cancer (TNBC)

Background: Recent data from the OlympiaD study revealed an improvement in response rate and progression-free survival (PFS) with the PARP inhibitor (PARPi) olaparib vs. standard of care chemotherapy in patients with metastatic breast cancer who harbor germline BRCA (gBRCA) mutations. Maintenance PARPi has improved median PFS in relapsed ovarian cancer regardless of gBRCA mutation status or HRD status. The similarities between the molecular aberration profiles of high-grade serous ovarian cancer and TNBC invites exploration of maintenance PARPi in mTNBC. Furthermore, because durable responses have been reported in subsets of patients with metastatic TNBC (mTNBC) with checkpoint blockade and because high mutational load is associated with both gBRCA and TNBC, these patients may be particularly susceptible to immunotherapy with PARPi. Thus, we hypothesize that olaparib either alone or in combination with the PD-L1 inhibitor durvalumab will be active in TNBC subjects who have responded to platinum-based chemotherapy.

Trial design: DORA is a non-comparator randomized, international, multicenter phase II study designed to explore the efficacy of olaparib with or without durvalumab as maintenance therapy in platinum-treated mTNBC. Subjects will be enrolled following four cycles of treatment with a platinum-based (cisplatin or carboplatin) chemotherapy as single agent or combination therapy. Subjects deriving clinical benefit (CR / PR / SD) with platinum-based therapy as determined by the treating physician will be eligible and randomized in a 1:1 ratio. Patients in arm 1 will receive olaparib orally 300mg BID continuously and in arm 2 will receive olaparib orally 300mg BID continuously in combination with durvalumab 1500mg IV every 4 wks. Tumor responses will be assessed every 8 wks.

Eligibility criteria: Subjects with mTNBC who are receiving platinum-based chemotherapy and who have had no more than 2 lines of chemotherapy in the metastatic or advanced setting, with one of those being a platinum, will be included in this trial. Eligible patients must have been assessed by their treating physicians to have derived clinical benefit with platinum based therapy. Archival tissue or fresh biopsy samples are mandated for biomarker analyses.

Aims:The primary endpoint is PFS; the key secondary endpoint is overall survival.

Statistical methods: The sample size is calculated based upon data derived from contemporary trials of chemotherapy in mTNBC. In both arms of the study, it is proposed to test a null hypothesis of a median PFS of 2 months against an alternative hypothesis of a median PFS of 4 months; there is no intention to make a formal statistical comparison between the two treatment arms. To test this hypothesis, assuming an exponential PFS distribution, use of an exponential MLE test, a two-sided significance level of 5% and a power of 90%, 25 subjects are required per arm.

Target accrual: To allow for a drop-out rate of approximately 20%, the sample size per arm will be inflated to 30 subjects. We plan to enroll approximately 60 subjects with mTNBC from 6 centers.

ClinicalTrials.gov Identifier: NCT03167619

Citation Format: Dent R, Tan T, Kim S-B, Traina T, McArthur H, Im Y-H, Creel T, Blackwell K. The DORA trial: A non-comparator randomised phase II multi-center maintenance study of olaparib alone or olaparib in combination with durvalumab in platinum treated advanced triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-04-02.

Abstract P6-10-01: Incidence and mortality among breast cancer patients < 40 years old: U.S. trends from 1992-2014

Introduction:

Breast cancer (BC) is the most commonly diagnosed cancer among women in the United States, but less than 5% of women develop BC before age 40. We sought to determine the trend over time in incidence and survival rates, and pathologic features of Non-Hispanic White (W), Non-Hispanic Black (B) and Hispanic (HIS) women (<40 years) with invasive breast cancer.

Methods:

Women <40 years old diagnosed with invasive BC were identified from the SEER 13 registry. Patients were stratified by year of diagnosis (1992-2014), race/ethnicity (W, B, and HIS) and pathologic features (stage, grade, ER and PR status). Age-adjusted incidence rates and 5- and 10-year disease-specific survival (DSS) rates were calculated. Incidence rate ratios (IRRs) were estimated by race/ethnicity group and pathologic features to express relative risk of BC incidence. Temporal trends of incidence rates (1992-2014), 5- (1992-2009) and 10-year (1992-2004) DSS rates were assessed as average annual percentage change (AAPC) using a joinpoint model. Survival estimates were calculated using the Kaplan-Meier method and Log-rank tests were used to test for differences in DSS among the race/ethnicity groups.

Results:

A total of 28,686 patients were included in this analysis: 64.1% W, 16.6% B, and 19.3% HIS. Overall, young B women had a higher incidence and worse survival than W women. Tumors with poor prognostic features (stage IV, grade III, ER- and PR-) were more common than those with better prognosis (stage 1, grade 1, ER+ and PR+, respectively) among young B women compared to W and HIS women. Young B women had worse 5- and 10-year DSS compared to their W and HIS counterparts (all p<0.001).

Young W women experienced a 0.8% per year increase in the incidence of invasive BC; incidence rates were stable in B and HIS women. B women had a slightly higher AAPC than W women for 5- and 10-year DSS rates. The incidence of advanced stage tumors (stage 4) and PR- tumors has been rising slightly faster in B than W women.

Trends of incidence and mortality rates by race/ethnicity and pathologic features. WBHISIRR (95% CI)Overall vs HIS1.38 (1.34-1.42)1.74 (1.69-1.81)referenceStage 4 vs 10.13 (0.12-0.14)0.41 (0.36-0.46)0.26(0.23-0.30)Grade 3 vs 17.43 (7.02-7.89)13.82 (11.99-16.00)10.40 (9.22-11.76)ER- vs +0.55 (0.53-0.56)0.83 (0.78-0.88)0.64 (0.60-0.66)PR- vs +0.71 (0.69-0.73)1.13 (1.06-1.20)0.85 (0.80-0.91)DSS   5-yr86.7 (86.1-87.2)72.9 (71.5-74.3)80.6 (79.4-81.8)10-yr78.0 (77.3-78.7)63.2 (61.5-64.8)71.4 (69.9-72.9)AAPCOverall0.8*0.20.2Stage 44.3*4.4*3.0*Grade 31.4*1.11.0*ER--0.4-0.50.2PR-1.1*1.2*1.9*DSS   5-yr0.6*0.8*0.8*10-yr0.9*1.0*1.1**AAPC is statistically different from zero (p<0.05).

.

Conclusion:

The incidence of higher stage and PR- tumors is increasing at a faster rate in young black women when compared to whites. Although the incidence of BC is increasing over time for young white women and not young black women, disparities still exist in overall incidence. Similarly, although DSS is increasing at higher rates for black and Hispanic women compared to whites, large survival disparities still exist. Improvements have been made over time, but more work needs to be done to determine which factors are associated with these disparities and how to close the gap in survival.

Citation Format: Oyekunle TO, Thomas SM, Greenup RA, Hyslop T, Blackwell K. Incidence and mortality among breast cancer patients < 40 years old: U.S. trends from 1992-2014 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-10-01.

Abstract P2-04-19: Elucidating the tumor immune microenvironment phenotype in early stage untreated BRCA mutated breast cancer patients

Background: Increased stromal tumor infiltrating lymphocytes (TILs) are predictive and prognostic for improved outcomes from neoadjuvant or adjuvant chemotherapy in triple negative breast cancer. Increased tumor mutational burden may promote neoantigens causing immune system upregulation. Microsatellite instability in gastrointestinal cancer predicts for response to checkpoint inhibition and is associated with inherited cancer predisposition. The immune system response in BRCA mutated breast cancer has not been described. The purpose of this study is to assess tumor infiltrating immune cells in early stage breast cancer patients with and without BRCA gene mutations.

Methods: We retrospectively investigated 124 early stage breast cancer patients with BRCA mutations (n=62, BRCA+) and without BRCA mutations (n=62, BRCA WT). The %TILs was measured manually by H&E. Our control group consisted of age, stage, and receptor status matched early stage untreated breast cancer patients who were deemed BRCA WT by extended gene panel testing or were negative for BRCA 1/2 and had a posttest probability of harboring an autosomal dominant mutated gene of ≤ 1% using the Bayes-Mendel algorithm. We used a two-sample binomial arcsin approximation to detect a 20% difference in TILs between cohorts to attain 80% power with a one-side alpha of 0.05. Wilcoxon Rank-Sums test was used to compare differences in the central tendencies for continuous variables. We used the Nanostring PanCancer immune profiling panel to immunophenotype a portion of the BRCA+ and BRCA WT cohorts and used nSolver for quality control, normalization, and bioinformatics analyses.

Results: Here we report TILs from the first 21 patients of our study. Thirteen patients harbored BRCA mutations and eight patients did not. All patients were HER2 negative. Eight (61%) and four (50%) patients were hormone receptor positive (HR+) in the BRCA+ and BRCA WT cohorts, respectively. Median %TILs were not significantly different between the BRCA+ (15, range 0-70) and BRCA WT (17.5, range 5-60; p=0.7) groups. Median %TILs in the HR+/BRCA+ (12.5, range 0-50) and HR-/BRCA+ (15, range 5-70) cohorts were not statistically different when compared to HR+/BRCA WT (10, range 5-15; p=0.4) and HR-/BRCA WT (30, range 20-60; p=0.2) cohorts, respectively. There were 2 patients with lymphocyte predominant breast cancer (n=1, HR-/BRCA+; n=1, HR-/BRCA WT).

Conclusions: This is the first study to characterize TILs and a tumor immune microenvironment phenotype in early stage breast cancer patients with BRCA mutations. These results suggest harboring a BRCA mutation is not associated with increased TILs in early stage untreated breast cancer patients. This conclusion stayed true regardless of hormone receptor status. However, a trend of decreased TILs was seen in HR-/BRCA+ patients when compared to those with HR-/BRCA WT disease. Moreover, the median and range of TILs were higher in the HR+/BRCA+ group compared to the HR+/BRCA WT group. This suggests increased TILs may exist in some HR+ patients with a BRCA mutation. Further investigation of TILs and immune profiling of early stage untreated breast cancer patients with and without BRCA mutations is warranted.

Citation Format: Force J, Abbott S, Broadwater G, Kimmick G, Westbrook K, Hwang S, Kauff N, Stashko I, Weinhold K, Nair S, Hyslop T, Blackwell K, Castellar E, Marcom PK. Elucidating the tumor immune microenvironment phenotype in early stage untreated BRCA mutated breast cancer patients [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 P2-04-19.

Abstract OT2-01-17: A Phase II randomized trial of pembrolizumab with carboplatin and gemcitabine for treatment of patients with metastatic triple-negative breast cancer (mTNBC)

Background: Treatment for mTNBC is limited, and significant challenges persist in treating this disease, as outcomes remain largely dependent on chemotherapy without any effective targeted treatment. Pembrolizumab (MK-3475) is a highly selective, humanized monoclonal antibody against PD-1, blocking the negative immune regulatory signaling of the PD-1 receptor that is usually expressed by T-cells. Recent data showed that some patients with mTNBC may benefit from immune-based therapies (PD-1 or PD-L1 antibodies). Cumulative evidence suggest that stromal tumor infiltrating lymphocytes (sTILs) have a prognostic and predictive role in response to treatment in subsets of TNBC, particularly in response to carboplatin use. Preclinical data revealed that blocking PD-1/PD-L1 pathway in combination with platinum containing cytotoxic therapy improved response rates and survival. High levels of sTILs and an increased PD-L1 expression make mTNBC a candidate for PD-1–targeted therapy. As studies showed that the subset of TNBC with better response rates to carboplatin are heavily infiltrated with sTILs, pembrolizumab, becomes a very attractive drug to be tested in combination with carboplatin, with the goal of improving outcomes in mTNBC. A Phase II multicenter, randomized, trial has been initiated to evaluate the efficacy and safety of combining pembrolizumab with carboplatin and gemcitabine in patients with mTNBC.

Methods: A safety run-in will assess the safety and tolerability of combining pembrolizumab with carboplatin and gemcitabine in patients with mTNBC. Following the completion of the safety run-in, patients will be randomized 2:1 to receive pembrolizumab (200 mg IV) on day 1 along with carboplatin (AUC 2, day 1 and day 8, IV) plus gemcitabine (800 mg/m2, day 1 and day 8, IV) of a 21-day cycle, or carboplatin plus gemcitabine (same aforementioned dose) alone. Patients will have histologically documented unresectable mTNBC. Prior systemic therapy for mTNBC, for up to 2 lines is allowed, and patients will have ECOG PS 0–2 and measurable disease (RECIST v1.1). Prior carboplatin/gemcitabine or cisplatin therapy is allowed in the adjuvant or neoadjuvant setting, as long as it occurred more than 12 months from the beginning of their enrollment. Subjects whose tumors progressed while on treatment with carboplatin or cisplatin are excluded. Known CNS disease (except asymptomatic treated metastases), autoimmune disease or prior immune checkpoint blockade therapy is an exclusion to enrollment on this trial. Primary endpoint is assessing the objective response rate according to RECIST v1.1 . Other endpoints include clinical benefit rate (CBR), progression-free survival (PFS), overall survival (OS), duration of response (DOR), and safety. Tumor biopsies will be obtained at baseline and just prior to initiation of cycle 3 to assess biomarkers of response and immune escape. PD-L1 expression will be evaluated in exploratory analysis with a planned assessment of response based on PD-L1 status. This trial will enroll 6-12 patients in the safety run-in portion, and 75 patients in the randomized part, at 7 sites in the United States. Clinical trial information: NCT02755272 www.clinicaltrials.gov.

Citation Format: Obeid E, Miller KD, Sparano JA, Blackwell K, Goldstein LJ. A Phase II randomized trial of pembrolizumab with carboplatin and gemcitabine for treatment of patients with metastatic triple-negative breast cancer (mTNBC) [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 OT2-01-17.

Abstract P2-11-05: Safety, immunogenicity and efficacy of proposed biosimilar pegfilgrastim (LA-EP2006) compared with reference pegfilgrastim in breast cancer: Pooled analysis of two randomized, double-blind, phase III trials

Background: Biosimilars are highly similar to a biological reference product with no clinically meaningful differences in terms of efficacy and safety. Here we present the pooled analysis of two randomized trials (PROTECT1 and 2) comparing the efficacy, safety and immunogenicity of proposed biosimilar pegfilgrastim (LA-EP2006) with reference pegfilgrastim (Neulasta®*).

Methods: Two multinational, independent, prospective, double-blind, phase III studies (EudraCT: 2011-004532-58; 2012-002039-28) enrolled adult chemotherapy-naïve women with breast cancer scheduled to receive ≤6 cycles of (neo)-adjuvant chemotherapy with docetaxel 75 mg/m2, doxorubicin 50 mg/m2 and cyclophosphamide 500 mg/m2 (TAC). Patients were randomized to receive a single 6 mg injection of LA-EP2006 or reference on Day 2 of each cycle. Primary endpoint was duration of severe neutropenia (DSN) (number of consecutive days with ANC <0.5x109/L) in Cycle 1. Equivalence was confirmed if the 95% confidence intervals (CI) for the difference in mean DSN between groups were within a pre-defined margin of ±1 day. Secondary efficacy endpoints included incidences of febrile neutropenia (FN), fever and infections, and depth of ANC nadir and time to ANC recovery (≥2×109/L after the nadir) in Cycle 1. Safety was assessed at each visit with follow-up visits at 4 weeks and 6 months (PROTECT1 only) after last administration of pegfilgrastim. Immunogenicity was assessed before the first pegfilgrastim injection, on Day 15 of cycle 6, and 4 weeks and 6 months (PROTECT1 only).

Results: A total of 624 patients were randomized (LA-EP2006: n=314; reference: n=310). Baseline demographics were well balanced (mean age: LA-EP2006: 49.3 years, reference: 49.8; median duration (months) since initial diagnosis: LA-EP2006: 1.33 [0.1−76.0], reference: 1.35 [0.2−11.2]; ECOG status 0: LA-EP2006: 78%, reference: 75%). Mean DSN difference in Cycle 1 was -0.04 days (95% CI: -0.19, 0.11), showing statistical equivalence. FN was reported in 5.7% of patients with LA-EP2006 vs. 8.4% with reference in Cycle 1 (all cycles: 8.0% vs. 10.3%). Across all cycles, frequency of fever (LA-EP2006: 18.5%; reference: 19.7%) and infections (LA-EP2006: 15.6%; reference: 18.1%) were similar in both groups. Mean ANC time courses were almost superimposable in the two groups, with similar time and depth of ANC nadir and median time to ANC recovery was 2 days in both groups in Cycle 1. Treatment-emergent adverse events (TEAEs) were similar across groups (LA-EP2006: 92%; reference: 89%), and TEAEs with a suspected relationship to pegfilgrastim were reported in 22.6% of patients with LA-EP2006 and 21.3% with reference across all cycles, with the most frequent being musculoskeletal and connective tissue disorders (LA-EP2006: 10.2%; reference: 9.7%). Serious TEAEs were reported in 14.3% (LA-EP2006) vs. 17.1% (reference) across all cycles. No neutralizing or clinically relevant anti-pegfilgrastim antibodies were identified.

Conclusions: LA-EP2006 demonstrated similar clinical efficacy and safety to reference pegfilgrastim in patients with breast cancer receiving myelotoxic chemotherapy.

*Neulasta® is a registered trademark of Amgen Inc.

Citation Format: Blackwell K, Gascon P, Jones CM, Nixon A, Nakov R, Mo M, Krendyukov A, Nadia H. Safety, immunogenicity and efficacy of proposed biosimilar pegfilgrastim (LA-EP2006) compared with reference pegfilgrastim in breast cancer: Pooled analysis of two randomized, double-blind, phase III trials [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 P2-11-05.

Abstract P4-14-01: Trastuzumab emtansine improves overall survival versus capecitabine plus lapatinib in patients with previously treated HER2-positive advanced breast cancer: Final results from the phase 3 EMILIA study

Introduction

T-DM1 is indicated for the treatment of advanced HER2-positive MBC in patients who previously received trastuzumab and a taxane (separately or in combination) based on data from the phase 3 EMILIA study (BO21977/TDM4370g; NCT00829166). In the primary PFS and second interim OS analyses, respectively, T-DM1 significantly improved PFS (median 9.6 vs 6.4 months; HR=0.65; 95% CI, 0.55–0.77; p<0.0001) and OS (median 30.9 vs 25.1 months; HR=0.68; 95% CI, 0.55–0.85; p<0.0006) compared with capecitabine (X) plus lapatinib (L). T-DM1 treatment was associated with fewer grade ≥3 AEs (41% vs 57%) vs XL. Here we present the final OS analysis from EMILIA.

Methods

EMILIA was a randomized, open-label study of patients with centrally confirmed HER2-positive (IHC3+ and/or FISH amplification ratio ≥2.0), unresectable, locally advanced or MBC, previously treated with trastuzumab and a taxane. Patients were randomized 1:1 to T-DM1 (3.6 mg/kg IV every 3 weeks) or X (1000 mg/m2 PO twice daily, days 1–14 every 3 weeks) plus L (1250 mg PO daily). The final OS analysis was to be conducted following 632 events, and these results are descriptive only. Since the OS efficacy boundary (HR<0.71, p=0.0025) was crossed in the second interim analysis, a protocol amendment allowed crossover from XL to T-DM1.

Results

From Feb 2009 to Oct 2011, 991 patients were randomized to T-DM1 (n=495) or XL (n=496). Patient disposition by the data cutoff (31 Dec 2014) is shown in Table 1. OS was longer with T-DM1 vs XL (median OS 29.9 vs 25.9 months; HR=0.75; 95% CI, 0.64–0.88; p=0.0003). In a sensitivity analysis, which censored crossover patients at the time of switching from XL to T-DM1, the HR was 0.69 (95% CI, 0.59–0.82; p<0.0001). The overall safety profile was similar to previous analyses (Table 2). More grade ≥3 thrombocytopenia occurred with T-DM1 vs XL (14.3% vs 0.4%). Cardiac dysfunction occurred in 2.7% of T-DM1 patients vs 3.5% of XL patients.

Table 1. Patient disposition. T-DM1 (n=495)XL (n=496)Median treatment duration, months7.6X: 5.3  L: 5.5Median duration of follow-up, months47.841.9Discontinued study, n (%)364 (74)404 (82)Crossover, n (%)  Per protocolaNot applicable136 (27)Non-protocol therapybX: 252 (54)X: 53 (11) L: 224 (48)L: 74 (15)aMedian duration of follow-up among per-protocol crossover patients was 24.1 months.bBy investigator choice after study treatment discontinuation; X or L could be given in combination with each other or other agents after progression.

Table 2. Safety summary in patients who received ≥1 dose of study treatment.n (%)T-DM1 (n=490)XL (n=488)Grade ≥3 AEs233 (47.6)291 (59.6)Serious AEs91 (18.6)99 (20.3)AEs leading to dose reduction91 (18.6)X: 205 (42.0)  L: 98 (20.1)

Conclusions

This final analysis of EMILIA shows an OS benefit of T-DM1 compared with XL. While median drug exposure was longer with T-DM1 than XL, T-DM1 was associated with fewer grade ≥3 AEs and AEs leading to dose reduction compared with XL. These final OS results confirm that T-DM1 treatment improved survival, even in the presence of treatment crossover, and reaffirm T-DM1 as the standard of care in patients with previously treated HER2-positive MBC.

Citation Format: Diéras V, Miles D, Verma S, Pegram M, Welslau M, Baselga J, Krop I, Blackwell K, Kang B, Xu J, Green M, Gianni L. Trastuzumab emtansine improves overall survival versus capecitabine plus lapatinib in patients with previously treated HER2-positive advanced breast cancer: Final results from the phase 3 EMILIA study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-01.

Abstract OT1-03-15: The METRIC trial: A randomized international study of the antibody-drug conjugate glembatumumab vedotin (GV or CDX-011) in patients with metastatic gpNMB-overexpressing triple-negative breast cancer (TNBC)

Background

Glycoprotein NMB (gpNMB) is an internalizable transmembrane protein overexpressed in approximately 20% of breast cancer (BC), including approximately 40% of TNBC. gpNMB is a poor prognostic marker in BC (Rose CCR 2010) and preclinically has been implicated in tumor invasion, metastasis, and angiogenesis. GV is a novel antibody-drug conjugate targeting the potent cytotoxin monomethylauristatin E (MMAE) to gpNMB overexpressing cancer cells.

In a Phase I/II study and the Phase II "EMERGE" study, GV demonstrated promising activity with TNBC patients (pts) deriving the greatest benefit and exhibiting the highest degree of gpNMB overexpression. GV was well-tolerated with the most frequent treatment-related toxicities consisting of rash, neutropenia, and neuropathy. In subset analyses of the EMERGE trial, objective response rate (ORR) was 30% (7/23) for GV vs. 9% (1/11) for investigator's choice in tumors with gpNMB overexpression (>25% of tumor epithelium); 18% (5/28) vs. 0% (0/11) in TNBC; and 40% (4/10) vs. 0% (0/6) in gpNMB-overexpressing TNBC for GV and IC respectively, with apparent improvements in progression-free survival (PFS; hazard ratio (HR) = 0.11) and overall survival (OS; HR = 0.14).

Trial design

The METRIC Trial (NCT#01997333) is an international (USA, CA, Aus), two-arm phase II study. Pts are randomized 2:1 to GV (1.88 mg/kg IV q 21 days) or capecitabine, a current standard of care for this population (2,500 mg/m2 daily for d1-14, q21 days) until progression or intolerance. Crossover is not permitted.

Eligibility criteria

Key eligibility criteria include: >25% of tumor epithelium gpNMB+ by central immunohistochemistry (IHC) screening of archival tissue; estrogen receptor and progesterone receptor <10% and HER2 negative [0-1+ IHC, or ISH copy number <4.0/ratio <2.0] by local assessment; ECOG 0-1; taxane resistance; anthracycline exposure (if indicated); <2 chemotherapy regimens for advanced BC; measurable disease; no persistent Grade >2 toxicity.

Specific aims

The primary endpoint is PFS per independent, blinded central review committee according to RECIST 1.1. Secondary endpoints are ORR, duration of response, OS, safety, pharmacokinetics and pharmacodynamics. Exploratory endpoints are quality of life and/or cancer-related pain.

Statistical methods and target accrual

The trial has 85% power to detect a PFS HR of 0.64 with two sided α = 0.05. The hypothesized median PFS is 4.0 months for capecitabine and 6.25 months for GV. Target accrual is open for 300 pts.

Citation Format: Melisko M, Yardley DA, Blackwell K, Forero A, Ma C, Montero A, Daniel BR, Wright G, Fehrenbacher L, Chew H, Ferrario C, Nanda R, Seiler Jr M, Guthrie T, Vance K, Ouellette G, He Y, Bagley RG, Zhang J, Vahdat LT. The METRIC trial: A randomized international study of the antibody-drug conjugate glembatumumab vedotin (GV or CDX-011) in patients with metastatic gpNMB-overexpressing triple-negative breast cancer (TNBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-15.

Abstract P1-10-01: A randomized, double-blind trial to compare the efficacy and safety of proposed biosimilar pegfilgrastim (LA-EP2006) with reference pegfilgrastim in patients with breast cancer (PROTECT1)

Background: An abbreviated pathway for biological products shown to be biosimilar to the reference product exists in Europe and the US. The randomized PROTECT1 trial compared the efficacy and safety of the proposed biosimilar pegfilgrastim with reference pegfilgrastim.

Methods: In this multinational, prospective, double-blind trial, chemotherapy-naïve women aged ≥18 years with histologically proven breast cancer received up to 6 cycles of (neo)-adjuvant TAC chemotherapy (docetaxel 75 mg/m2, doxorubicin 50 mg/m2, cyclophosphamide 500 mg/m2). Patients were randomized to a single 6 mg SC injection of the proposed biosimilar pegfilgrastim (LA-EP2006) or the reference (Neulasta®) on day 2 of each cycle. Primary endpoint was duration of severe neutropenia (DSN) during Cycle 1, defined as number of consecutive days with an absolute neutrophil count (ANC) <0.5 x 109/L. The study was powered at 90% and had a hierarchical testing procedure utilizing a ±1 day margin to test for equivalence (2-sided 95% confidence interval [CI]) and a subsequent −0.6 day non-inferiority margin (1-sided 97.5% CI) for DSN during Cycle 1. DSN was analyzed with an ANCOVA model adjusted for treatment, chemotherapy, region and baseline ANC. Secondary efficacy assessments were: time to ANC recovery, ANC nadir, incidence of febrile neutropenia, number of days of fever, frequency of infections and mortality due to infection. Safety was assessed at 4 weeks and 6 months after the last pegfilgrastim administration. Immunogenicity was assessed by testing for neutralizing anti-pegfilgrastim antibodies.

Results: A total of 316 patients were randomized and included in the full analysis set (LA-EP2006: n=159; reference: n=157). Baseline demographics were similar in both groups (mean±SD age: LA-EP2006 49.9±9.53, reference 50.5±10.87 years; breast cancer stage II-III: LA-EP2006 n=155 [97.5%], reference n=151 [96.2%]). Mean±SD DSN in Cycle 1 was 0.75±0.88 days with LA-EP2006 and 0.83±0.90 days with reference, with a treatment difference of 0.07 days (95% CI: −0.12, 0.26); LA-EP2006 was both equivalent and non-inferior to the reference. There were no clinically meaningful differences between LA-EP2006 and reference in incidence of febrile neutropenia (3.8% vs 7.0% in Cycle 1, 5.7% vs 7.6% across all cycles), days with fever, depth of ANC nadir in Cycle 1, time to ANC recovery in Cycle 1, or frequency of infections in Cycle 1 and across all cycles. Treatment-emergent adverse events (TEAEs) were similar across groups and consistent with the known safety profile of pegfilgrastim. Most frequently reported TEAEs related to treatment were musculoskeletal and connective tissue disorders (LA-EP2006 4.4%, reference 5.7%). Serious TEAEs were reported in 10.1% of LA-EP2006 and 13.4% of reference patients. No neutralizing anti-pegfilgrastim antibodies were detected.

Conclusions: Proposed biosimilar pegfilgrastim (LA-EP2006) met the primary endpoint demonstrating both equivalence and non-inferiority to the reference. LA-EP2006 and the reference are similar with no clinically meaningful differences regarding efficacy and safety in breast cancer patients receiving (neo)-adjuvant myelosuppressive chemotherapy.

Citation Format: Harbeck N, Zbarskaya I, Lipatov O, Frolova M, Udovitsa D, Topuzov E, Ganea-Motan DE, Nakov R, Singh P, Rudy A, Blackwell K. A randomized, double-blind trial to compare the efficacy and safety of proposed biosimilar pegfilgrastim (LA-EP2006) with reference pegfilgrastim in patients with breast cancer (PROTECT1). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-01.

Comparison of EP2006, a filgrastim biosimilar, to the reference: a phase III, randomized, double-blind clinical study in the prevention of severe neutropenia in patients with breast cancer receiving myelosuppressive chemotherapy

This randomized, double-blind comparison demonstrates that biosimilar filgrastim (EP2006) and the US-licensed reference filgrastim are similar with no clinically meaningful differences regarding efficacy and safety in prevention of severe neutropenia. Biosimilar filgrastim could represent an important alternative to the reference product, potentially increasing access to filgrastim treatment.

Background

Biosimilars of filgrastim are in widespread clinical use in Europe. This phase III study compares biosimilar filgrastim (EP2006), with the US-licensed reference product, Neupogen^®, in breast cancer patients receiving (neo)adjuvant myelosuppressive chemotherapy (TAC).

Patients and methods

A total of 218 patients receiving 5 µg/kg/day filgrastim over six chemotherapy cycles were randomized 1:1:1:1 into four arms. Two arms received only one product (nonalternating), biosimilar or reference, and two arms (alternating) received alternating treatments during each cycle (biosimilar then reference or vice versa). The primary end point was duration of severe neutropenia (DSN) during cycle 1.

Results

The baseline characteristics were balanced between the four treatment arms. Noninferiority of biosimilar versus the reference was demonstrated: DSN (days) in cycle 1 was 1.17 ± 1.11 (biosimilar, N = 101) and 1.20 ± 1.02 (reference, N = 103), 97.5% confidence interval lower boundary for the difference was −0.26 days (above the predefined limit of −1 day). No clinically meaningful differences were observed regarding any other efficacy parameter: incidence of febrile neutropenia (FN); hospitalization due to FN; incidence of infections; depth and time of absolute neutrophil count (ANC) nadir and time to ANC recovery during cycle 1 and across all cycles. The pattern and frequency of adverse events were similar across all treatments.

Conclusion

This study demonstrates that biosimilar and the reference filgrastim are similar with no clinically meaningful differences regarding efficacy and safety in prevention of severe neutropenia. Biosimilar filgrastim could represent an important alternative to the reference product, potentially benefiting public health by increasing access to filgrastim treatment.

Study number

NCT01519700.

Trastuzumab emtansine (T-DM1) versus lapatinib plus capecitabine in patients with HER2-positive metastatic breast cancer and central nervous system metastases: a retrospective, exploratory analysis in EMILIA

BACKGROUND

We characterized the incidence of central nervous system (CNS) metastases after treatment with trastuzumab emtansine (T-DM1) versus capecitabine-lapatinib (XL), and treatment efficacy among patients with pre-existing CNS metastases in the phase III EMILIA study.

PATIENTS AND METHODS

In EMILIA, patients with human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer previously treated with trastuzumab and a taxane were randomized to T-DM1 or XL until disease progression. Patients with treated, asymptomatic CNS metastases at baseline and patients developing postbaseline CNS metastases were identified retrospectively by independent review; exploratory analyses were carried out.

RESULTS

Among 991 randomized patients (T-DM1 = 495; XL = 496), 95 (T-DM1 = 45; XL = 50) had CNS metastases at baseline. CNS progression occurred in 9 of 450 (2.0%) and 3 of 446 (0.7%) patients without CNS metastases at baseline in the T-DM1 and XL arms, respectively, and in 10 of 45 (22.2%) and 8 of 50 (16.0%) patients with CNS metastases at baseline. Among patients with CNS metastases at baseline, a significant improvement in overall survival (OS) was observed in the T-DM1 arm compared with the XL arm [hazard ratio (HR) = 0.38; P = 0.008; median, 26.8 versus 12.9 months]. Progression-free survival by independent review was similar in the two treatment arms (HR = 1.00; P = 1.000; median, 5.9 versus 5.7 months). Multivariate analyses demonstrated similar results. Grade ≥3 adverse events were reported in 48.8% and 63.3% of patients with CNS metastases at baseline administered T-DM1 and XL, respectively; no new safety signals were observed.

CONCLUSION

In this retrospective, exploratory analysis, the rate of CNS progression in patients with HER2-positive advanced breast cancer was similar for T-DM1 and for XL, and higher overall in patients with CNS metastases at baseline compared with those without CNS metastases at baseline. In patients with treated, asymptomatic CNS metastases at baseline, T-DM1 was associated with significantly improved OS compared with XL.

Adverse event management in patients with advanced cancer receiving oral everolimus: focus on breast cancer

BACKGROUND

Everolimus, an orally administered rapamycin analogue, inhibits the mammalian target of rapamycin (mTOR), a highly conserved intracellular serine-threonine kinase that is a central node in a network of signaling pathways controlling cellular metabolism, growth, survival, proliferation, angiogenesis, and immune function. Everolimus has demonstrated substantial clinical benefit in randomized, controlled, phase III studies leading to approval for the treatment of advanced renal cell carcinoma, advanced neuroendocrine tumors of pancreatic origin, renal angiomyolipoma and subependymal giant-cell astrocytoma associated with tuberous sclerosis complex, as well as advanced hormone-receptor-positive (HR(+)) and human epidermal growth factor receptor-2-negative advanced breast cancer.

MATERIALS AND METHODS

We discuss clinically relevant everolimus-related adverse events from the phase III studies, including stomatitis, noninfectious pneumonitis, rash, selected metabolic abnormalities, and infections, with focus on appropriate clinical management of these events and specific considerations in patients with breast cancer.

RESULTS

The majority of adverse events experienced during everolimus therapy are of mild to moderate severity. The safety profile and protocols for toxicity management are well established. The class-effect adverse event profile observed with everolimus plus endocrine therapy in breast cancer is (as expected) distinct from that of endocrine therapy alone, but is similar to that observed with everolimus in other solid tumors. Information gained from the experience in other carcinomas on prompt diagnosis and treatments to optimize drug exposure, treatment outcomes, and patients' quality of life also applies to the patient population with advanced breast cancer.

CONCLUSIONS

As with all orally administered agents, education of both physicians and patients in the management of adverse events for patients receiving everolimus is critical to achieving optimal exposure and clinical benefit. Active monitoring for early identification of everolimus-related adverse events combined with aggressive and appropriate intervention should lead to a reduction in the severity and duration of the event.

Abstract P4-12-27: Efficacy and safety of trastuzumab emtansine (T-DM1) vs lapatinib plus capecitabine (XL) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) and central nervous system (CNS) metastases: Results from a retrospective exploratory analysis of EMILIA

Introduction

T-DM1 is an antibody–drug conjugate that was recently approved by the FDA for patients with HER2-positive MBC who have received prior treatment with trastuzumab and a taxane. In the phase 3 EMILIA trial, T-DM1 significantly prolonged progression-free survival (PFS) and overall survival (OS) compared with XL in patients with previously treated HER2-positive MBC (Verma 2012). Because the CNS is a common site of progression in HER2-positive MBC, it is of interest to characterize the incidence of CNS metastases in patients treated with TDM1 vs XL and the efficacy of T-DM1 in patients with pre-existing CNS metastases.

Methods

EMILIA is a multicenter, randomized, open-label trial in which patients with HER2-positive, unresectable, locally advanced or MBC previously treated with trastuzumab and a taxane were randomized (1:1) to T-DM1 (3.6 mg/kg every 21 days) or XL (X: 1000 mg/m2 bid on days 1–14 of each 21-day cycle; L: 1250 mg/day on days 1–21). Treatment continued until disease progression or unacceptable toxicity. All patients underwent brain magnetic resonance imaging or computed tomography at screening, and follow-up scans were performed as clinically indicated. Those with untreated or symptomatic brain metastases and those who required therapy for symptom control ≤2 months before randomization were excluded from the trial. Patients with CNS metastases at baseline or who developed CNS metastases on study were retrospectively identified using independent review committee data, and exploratory analyses were performed on data from these patients.

Results

Of the 896 patients without CNS metastases at baseline (T-DM1 = 450; XL = 446), 9 (1.8%) and 3 (0.6%), respectively, developed CNS progression on study. Of the 95 patients with CNS metastases at baseline (T-DM1 = 45; XL = 50), 10 (2.0%) and 8 (1.6%), respectively, developed CNS progression on study. Median PFS in patients with CNS metastases at baseline was 5.9 months in the T-DM1 arm and 5.7 months in the XL arm (HR = 1.000; 95% CI: 0.542–1.844; P = 0.9998). Median OS was 26.8 months and 12.9 months in the T-DM1 and XL arms, respectively (HR = 0.382; CI: 0.184–0.795; P = 0.0081). Multivariate analysis adjusting for baseline risk factors produced similar results. Safety profiles of T-DM1 and XL in patients with CNS metastases at baseline (T-DM1 = 43; XL = 49) were consistent with those for the overall study population. Grade ≥3 adverse events (AEs) were reported in 17 (39.5%) patients in the T-DM1 arm and 29 (59.2%) patients in the XL arm. Serious AEs were reported in 5 (11.6%) and 11 (22.4%) patients in the T-DM1 and XL arms, respectively. No new safety signals were identified.

Conclusions

In this retrospective exploratory analysis of data from EMILIA, the rate of CNS progression in patients with or without baseline CNS metastases was low in both treatment arms. In the subset of patients with brain metastases at baseline, similar to the intent-to-treat population, T-DM1 was associated with significantly improved OS compared with XL. Prospective phase 3 trials are necessary to confirm these results.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-27.

Abstract P2-16-13: Phase I dose escalation clinical trial of the PI3K inhibitor BKM120 and capecitabine (C) in metastatic breast cancer (MBC)

Background: PIK3CA is one of the most frequently mutated genes in human breast cancer, and the high expression of a PIK3CA-pathway signature is associated with the poor prognosis Luminal B and Basal-like expression subtypes. BKM120 is an oral pan-class I phosphatidylinositol-3-kinase (PI3K) inhibitor, which has shown activity in preclinical and early clinical testing, and synergy with both endocrine and chemotherapy. In this trial we sought to evaluate the safety and estimate the maximum tolerated dose (MTD) of the combination of BKM120 and C in patients (pts) with MBC.

Methods: In a 3+3 dose escalation design, we evaluated four cohorts of BKM 120 daily plus C BID x 14 days in 21 day cycles. Standard definitions for DLT and MTD were used and evaluated on the first cycle. Toxicity was graded by CTCAE version 4. Response was evaluated after 2 cycles by RECIST criteria. Pts with MBC appropriate for treatment with C who had <4 prior chemotherapy regimens and normal organ, bone marrow and cardiac parameters were eligible.

Results: 21 pts (11 hormone receptor (HR)+, 3 HER2+, 9 HR/HER2-negative) were enrolled and treated. All were evaluable for toxicity and 14 for response to date. Median age was 54 (range 35-65). Median prior chemotherapy regimens for MBC was 2 (range 1-4). The following dose levels (DL) were evaluated: BKM120 50 mg/d + C 1000 mg/m2/BID x 14(DL 1-4 pts), BKM120 80 mg/d + C 1000 mg/m2/BID x 14 (DL2-3 pts), BKM120 100 mg/d + C 1000 mg/m2/BID x 14 (DL3-9 pts), BKM120 100 mg/d + C 1250 mg/m2/BID x 14 (DL4-5 pts). Most frequent adverse events (all grades) included: Nausea (12), mood disorders (11), PPE (9), diarrhea (8), fatigue (7), vomiting (5) mucositis (4), rash (4), photosensitivity (3), hyperglycemia (3). Grade 3 or higher AEs in any cycle were transaminitis (3) diarrhea (2) mood disorder (2), hyperglycemia, fatigue, photosensitivity, PPE (1 pt each). DLTs: grade 3 hyperglycemia (1/6 pts at DL3), and grade 3 mood disorder in 1/5 pts DL 4. Additionally 4 of 5 patients at DL 4 required dose reduction or delay prior to C3D1. Thus DL 4 exceeded the MTD and DL 3 was expanded for further safety evaluation. Antitumor activity was seen with best responses of 1 CR (at DL 3), 3 PR (DL1 and 4) and 7 SD.

PK analysis, assessment of tumor PIK3CA mutation status and intrinsic subtype by PAM50 is ongoing.

Conclusions: The combination of BKM120 100 mg po q day and C 1000 mg/m2 / BID x 14 d in 21 day cycles is tolerable and appears active. PK and biomarker analysis are ongoing. A phase II trial is planned.

Acknowledgements: This study was funded by Novartis Pharmaceuticals and by a grant from Susan G. Komen for the Cure (SAC 110044).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-13.

Abstract OT2-2-03: Dovitinib (TKI258) or placebo in combination with fulvestrant in postmenopausal, endocrine-resistant HER2–/HR+ breast cancer: a phase II study

Background: Overcoming endocrine resistance is a critical goal in the treatment of hormone receptor-positive (HR+) breast cancer. Molecular mechanisms associated with endocrine resistance include adaptive cross-talk between the estrogen receptor and the fibroblast growth factor receptor (FGFR). Up to 8% of HR+/ human epidermal growth factor receptor 2 negative (HER2–) breast cancer patients have amplification of the FGFR1 gene, which is associated with resistance to endocrine therapy. In preclinical models, resistance to endocrine therapy can be overcome via FGFR1 inhibition. Dovitinib is a potent oral inhibitor of receptor tyrosine kinases, including FGFR, vascular endothelial growth factor receptor (VEGFR), and platelet derived growth factor receptor (PDGFR), that demonstrated antitumor activity in heavily pretreated breast cancer patients with FGF-pathway amplification (FGFR1, FGFR2, or ligand FGF3; Andre et al, ASCO 2011). Dovitinib may reverse resistance to endocrine therapy related to FGF-pathway amplification and may also inhibit angiogenesis, which plays an essential role in breast cancer development. Dovitinib is studied here in combination with fulvestrant to determine if it can improve outcomes in postmenopausal patients with endocrine resistant HER2−/HR+ breast cancer.

Methods: This is a multicenter, randomized, double-blind, placebo-controlled, phase II trial that will enroll postmenopausal HER2–/HR+ locally advanced or metastatic breast cancer patients (N ≈ 150) progressing within 12 months of completion of adjuvant endocrine therapy or after ≤ 1 prior endocrine therapy in the advanced setting. Patients prospectively undergo molecular screening to enrich for FGF amplification (FGFR1, FGFR2, or FGF3 amplification by qualitative polymerase chain reaction (qPCR); 45 amplified and 30 nonamplified patients per arm). Patients are randomized 1:1 (stratified by FGF-amplification and presence of visceral disease) to receive fulvestrant intramuscularly (500 mg q4w [with an additional dose 2 weeks after the initial dose]) in combination with oral dovitinib (500 mg, 5 days on/2 days off) or placebo until disease progression, unacceptable toxicity, death or discontinuation due to any reason (eg, withdrawal). Crossover is not permitted. The primary endpoint is progression-free survival, with tumor assessments performed q8w. Secondary endpoints include overall response rate per RECIST v1.1, duration of response, overall survival, Eastern Cooperative Oncology Group performance status and patient-reported outcome scores over time, and safety. Additionally, the pharmacodynamic effect of dovitinib on FGFR-associated angiogenic pathways in tumor specimens and potential predictive biomarkers of response to dovitinib will be explored.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT2-2-03.

Neratinib in combination with trastuzumab for the treatment of advanced breast cancer: A phase I/II study

1004

Background: Neratinib (HKI-272) is an orally administered irreversible pan-ErbB receptor tyrosine kinase inhibitor. In an ongoing phase II study, the preliminary objective response rate was 26% in patients with ErbB2+ advanced breast cancer with prior trastuzumab therapy. This study assessed the safety and preliminary efficacy of the combination of neratinib plus trastuzumab. Methods: Patients with advanced ErbB2+ breast cancer that progressed following trastuzumab therapy were enrolled. The primary endpoint was 16-week progression free survival rate (PFS). In part 1 (dose escalation), patients received neratinib 160 mg or 240 mg daily plus trastuzumab 4 mg/kg IV loading dose then 2 mg/kg weekly. In part 2, patients received weekly trastuzumab with neratinib 240 mg daily. Timed blood samples were collected for PK analyses. PK analysis is ongoing. Results: 45 patients (part 1 n = 8; part 2 n = 37) were enrolled (mean age 52 yr); 9 are active. In part 1, cohorts 1 and 2 were fully enrolled with 4 patients each. No dose limiting toxicities were observed. Most common AEs, any grade, were diarrhea (91%), nausea (51%), anorexia (40%), vomiting (38%), and asthenia (27%). Grade 3/4 AEs were diarrhea (13%), nausea (4%), vomiting (4%). Two patients receiving neratinib 240 mg reported AEs leading to withdrawal. No AEs of congestive heart failure and no significant drops of left ventricular ejection fraction were reported. Among 33 patients evaluable for efficacy, objective response rate was 27% (95% CI, 13% - 46%); 16-week PFS rate (for part 2) 47% (95% CI, 29% - 63%); median PFS was 19 weeks (95% CI 15 - 32 weeks). Conclusions: Neratinib plus trastuzumab was well tolerated with no significant or unexpected toxicities, and demonstrated clinical activity.

[Table: see text]

EGF103009, a phase II trial of lapatinib monotherapy in patients with relapsed/refractory inflammatory breast cancer (IBC): Clinical activity and biologic predictors of response

502

Background: Data from preclinical studies and small numbers of IBC patients inPhase I clinical trials suggest that IBC may be particularly sensitive to the anti-tumor effects of lapatinib, an inhibitor of ErbB1/ErbB2 tyrosine kinases. EGF103009 was initiated to confirm and expand these initial observations and identify a tumor profile predicting for the sensitivity of IBC to lapatinib. Methods: Patients with relapsed/refractory IBC based on clinical criteria, were assigned to Cohort A (ErbB2 overexpressors: 2/3+ IHC/FISH+) or B (ErbB1 +/ErbB2 non-overexpressors) after analysis of a fresh tumor biopsy in a central reference lab. Patients received lapatinib daily (1500mg/d). Clinical response was documented at day 56 and in the case of CR/PR, confirmed on day 84 and every 8 weeks thereafter. Target lesions were assessed according to RECIST criteria and response in skin disease documented by digital photography. Tumor expression of ErbB2, p-ErbB2, ErbB1, p-ErbB3, IGF-IR, PTEN, ER/PR, E-cadherin, β-catenin, and Rho B/C was analyzed by quantitative IHC from a fresh, pre-treatment biopsy. Results: Of 34 patients enrolled, clinical response data is available from 22 patients of which 17 had biopsies analyzed at a reference lab and assigned to Cohorts A (N=11) and B (N=6). Eight of 11 patients (72%) in Cohort A had a clinical response (CR/PR) to lapatinib documented by RECIST, skin disease, or both. There were no responders in Cohort B. All responders (i) overexpressed ErbB2 (2/3+ IHC or FISH+), (ii) increased p-ErbB2 (2/3+), (iii) co-expressed IGF-IR, and (iv) expressed activated, p-ErbB3. PTEN status did not affect response to lapatinib. Toxicity was generally grade I/II skin and G.I. with one grade III cardiotoxicity necessitating withdrawal from study. Conclusions: ErbB2 overexpression but not ErbB1 expression alone, predicts for sensitivity to lapatinib in IBC. High ErbB2, p-ErbB2 and IGF-IR co-expression predict for clinical response to lapatinib monotherapy in patients with relapsed/refractory IBC, illustrating the importance of selecting patients based on biology rather than histology alone, to maximize the clinical efficacy of ErbB kinase inhibitors in breast carcinomas.

[Table: see text]

The prevalence of stress urinary incontinence in patients with cystic fibrosis: an under-recognized problem

OBJECTIVE

To identify the prevalence of stress urinary and fecal incontinence in patients with cystic fibrosis (CF) and investigate any correlation between CF severity and the incidence and degree of incontinence.

PATIENTS AND METHODS

An initial postal questionnaire was used to identify patients with an incontinence problem, followed by a detailed interview-administered questionnaire assessing the type of incontinence and the impact of the incontinence on patients and the management of their CF. The correlation between CF severity and the incidence and severity of incontinence was also analysed. All patients aged 5-18 years attending the CF service at The Respiratory and Urology departments of a University Teaching Hospital were invited to participate. There was no therapeutic intervention.

RESULTS

Stress urinary incontinence was present in 31% of girls and 2.2% of boys, with fecal incontinence in four girls. The youngest patient with incontinence was 9 years old. Of the patients, 78% found their incontinence a problem and 44% had hidden the problem from parents and carers. There was no correlation between incontinence and the severity of CF as measured by the forced expiratory volume in 1s.

CONCLUSIONS

Urinary incontinence is common in girls with CF and in many cases it is a hidden problem. These patients need to be identified so they can receive appropriate management, instead of suffering in silence.

Regulation of insulin-like growth factor-1 by the renin-angiotensin system during regression of cardiac eccentric hypertrophy through angiotensin-converting enzyme inhibitor and AT1 antagonist

Angiotensin II (Ang II) mediates its effects through its non-tyrosine-kinase G protein coupled Ang-II type 1 receptor (AT1). Growing evidence indicates that a functional insulin-like growth factor-1 (IGF-1) tyrosine kinase receptor is required for Ang-II-induced mitogenesis. Along with Ang II, we have previously shown that changes in IGF-1 receptor binding at myofibers are causative agents for cardiac eccentric hypertrophy. This study investigated the interaction of the renin-angiotensin system with the IGF-1 receptor during the development and regression of cardiac hypertrophy. Alterations in IGF-1 binding were evaluated in the CHAPS-pretreated perfused heart. Four weeks of aortocaval shunt increased relative heart mass by 76% without a major change in body mass or systolic blood pressure. Binding studies showed that IGF-1 has a higher affinity for the cardiac myofibers of shunt than sham rats. Two weeks of treatment with the angiotensin-converting enzyme (ACE) inhibitor captopril (0.5 g/L in drinking water) or the AT1-antagonist losartan (10 mg/(kg x day)) reduced cardiac hypertrophy by 54 and 42%, respectively. However, while both ACE inhibition and AT1-antagonist treatments produced equivalent regression in ventricular hypertrophy, captopril was more efficacious than losartan in the regression of atrial hypertrophy. Regression of cardiac hypertrophy in the shunt by either captopril or losartan was accompanied with a reduction or normalization of the elevated IGF-1 affinity. Thus, the induction and regression of cardiac eccentric hypertrophy seems to be largely dependent on cross talk between the renin-angiotensin system and the IGF-1 axis at the receptor level.

Publication rate of abstracts presented at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery

BACKGROUND

Research projects are frequently presented at national meetings not only to make the data available, but also to further critically evaluate the project. The ultimate goal remains publication of the research. We assessed the publication rate of presentations at 1993-95 annual meetings.

METHODS

All presentations at the scientific sessions were searched in the computerized database Melvyl MEDLINE and PubMed. The papers were categorized in 6 broad groups.

RESULTS

The overall proportion of presentations that were published was 32%. Clinical papers in pediatrics had the highest publication rate, followed by basic science research in laryngology and plastics.

CONCLUSION

The publication rate of 32% is lower than the rate at meetings in other fields, reflecting variability in selection criteria for the presentations and quality of abstracts presented. Basic science presentations did not have a greater publication rate as compared to clinical presentations.

Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy

PURPOSE

Weight gain is a common problem among breast cancer patients who receive adjuvant chemotherapy (CT). We undertook a study to determine the causes of this energy imbalance.

PATIENTS AND METHODS

Factors related to energy balance were assessed at baseline (within 3 weeks of diagnosis) and throughout 1 year postdiagnosis among 53 premenopausal women with operable breast carcinoma. Thirty-six patients received CT and 17 received only localized treatment (LT). Measures included body composition (dual energy x-ray absorptiometry), resting energy expenditure (REE; indirect calorimetry), dietary intake (2-day dietary recalls and food frequency questionnaires) and physical activity (physical activity records).

RESULTS

Mean weight gain in the LT patients was 1.0 kg versus 2.1 kg in the CT group (P =.02). No significant differences between groups in trend over time were observed for REE and energy intake; however, a significant difference was noted for physical activity (P =.01). Several differences between groups in 1-year change scores were detected. The mean change (+/- SE) in LT versus CT groups and P values for uncontrolled/controlled (age, race, radiation therapy, baseline body mass index, and end point under consideration) analysis are as follows: percentage of body fat (-0.1 +/- 0.4 v +2.2 +/- 0.6%; P =.001/0.04); fat mass (+0.1 +/- 0.3 v +2.3 +/- 0.7 kg; P =.002/0.04); lean body mass (+0.8 +/- 0.2 v -0.4 +/- 0.3 kg; P =.02/0.30); and leg lean mass (+0.5 +/- 0.1 v -0.2 +/- 0.1 kg; P =.01/0.11).

CONCLUSION

These data do not support overeating as a cause of weight gain among breast cancer patients who receive CT. The data suggest, however, that CT-induced weight gain is distinctive and indicative of sarcopenic obesity (weight gain in the presence of lean tissue loss or absence of lean tissue gain). The development of sarcopenic obesity with evidence of reduced physical activity supports the need for interventions focused on exercise, especially resistance training in the lower body, to prevent weight gain.

The role of hyperplasia in multiple parathyroid adenomas

BACKGROUND

Parathyroid adenoma is the most common cause of primary hyperparathyroidism (pHPT). Adenomas usually involve only a single gland, and the remaining glands are normal or suppressed. Multiple parathyroid adenomas have been reported to occur in as high as 11% of patients with pHPT. The significant incidence of multiple adenomas with histologic similarities to hyperplasia has raised the possibility that adenoma is a continuation of the hyperplasia state. To test this theory, we used molecular genetics to compare clonality and proliferative activity of parathyroid adenoma with its corresponding normal glandular tissue. Furthermore, we devised a scheme to definitively distinguish between the different parathyroid states on a molecular level, because histologic distinction is unreliable.

METHODS

The study included three patients with a diagnosis of singular parathyroid adenoma and three with double parathyroid adenomas. Paraffin-embedded surgical specimens of both adenomas and normal glands were retrieved from each patient. Clonal analysis of the phosphoglycerolkinase (PGK) gene has suggested that parathyroid adenomas are monoclonal. Clonality of parathyroid adenomas and normal parathyroid glands was studied by polymerase chain reaction-based restriction fragment length polymorphic analysis for the PGK gene. Proliferative activity of the specimens was also analyzed using the immunohistochemical markers PCNA and Ki-67.

RESULTS

All adenomas were monoclonal and all normal parathyroid glands were polyclonal for the PGK gene in both the single and double adenoma specimens. All adenomas stained positive for proliferative activity. In the three patients with singular adenoma, proliferative activity was not detected in the normal parathyroid tissue. However, in the double adenoma group, two of the three patients showed hyperproliferative activity in the normal glands.

CONCLUSION

Proliferative activity consistent with hyperplasia was present in some normal glands of multiple adenoma patients. Our observation supports the theory that multiple adenomas may be a continuation of the hyperplasia state.

Histamine alters endothelial barrier function at cell-cell and cell-matrix sites

To determine how histamine regulates endothelial barrier function through an integrative cytoskeletal network, we mathematically modeled the resistance across an endothelial cell-covered electrode as a function of cell-cell, cell-matrix, and transcellular resistances. Based on this approach, histamine initiated a rapid decrease in transendothelial resistance predominantly through decreases in cell-cell resistance in confluent cultured human umbilical vein endothelial cells (HUVECs). Restoration of resistance was characterized by initially increasing cell-matrix resistance, with later increases in cell-cell resistance. Thus histamine disrupts barrier function by specifically disrupting cell-cell adhesion and restores barrier function in part through direct effects on cell-matrix adhesion. To validate the precision of our technique, histamine increased the resistance in subconfluent HUVECs in which there was no cell-cell contact. Exposure of confluent monolayers to an antibody against cadherin-5 caused a predominant decrease in cell-cell resistance, whereas the resistance was unaffected by the antibody to cadherin-5 in subconfluent cells. Furthermore, we observed an increase predominantly in cell-cell resistance in ECV304 cells that were transfected with a plasmid containing a glucocorticoid-inducible promoter controlling expression of E-cadherin. Transmission electron microscopy confirmed tens of nanometer displacements between adjacent cells at a time point in which histamine maximally decreased cell-cell resistance.

Plasma D-dimer levels in operable breast cancer patients correlate with clinical stage and axillary lymph node status

PURPOSE

To investigate the relationship between preoperative plasma D-dimer levels and extent of tumor involvement in operable breast cancer patients.

PATIENTS AND METHODS

A total of 140 preoperative plasma specimens were obtained from women scheduled to undergo diagnostic breast biopsies. Ninety-five patients in the initial group went on to undergo axillary lymph node dissection. Of the 140 patients from whom plasma samples were obtained, 102 were subsequently diagnosed with invasive breast carcinoma, nine were subsequently diagnosed with ductal carcinoma-in-situ, and 20 were subsequently diagnosed with benign breast disease. Plasma D-dimer levels were quantitated using a commercially available immunoassay kit (DIMERTEST; American Diagnostica, Greenwich, CT). The relationships between plasma D-dimer and other prognostic variables (tumor size, estrogen receptor, progesterone receptor, nuclear grade, histologic grade, lymphovascular invasion, and clinical stage grouping) were then examined using univariate and multivariate linear and logistic regression analyses.

RESULTS

Median plasma D-dimer levels were significantly higher in patients with invasive carcinoma than those patients with either benign breast disease or carcinoma-in-situ (P =.0001). A significant relationship existed between the presence of elevated D-dimer (> 100 ng/mL) and involved axillary lymph nodes (chi(2) test; P =.001). Elevated D-dimer levels predicted positive lymph node involvement in both univariate regression (P =.0035) and multivariate linear regression (P =.012) models. In addition, elevated D-dimer levels predicted the presence of lymphovascular invasion in univariate logistic regression (P =. 0025) and multivariate logistic regression analysis (P =.0053). Quantitative D-dimer levels were highly correlated with clinical stage grouping (analysis of variance test; P =.002).

CONCLUSION

Plasma D-dimer levels were markers of lymphovascular invasion, clinical stage, and lymph node involvement in operable breast cancer. This correlation suggests that detectable fibrin degradation, as measured by plasma D-dimer, is a clinically important marker for lymphovascular invasion and early tumor metastasis in operable breast cancer.

cAMP protects endothelial barrier function independent of inhibiting MLC20-dependent tension development

Exposure of cultured human umbilical vein endothelial cells to the cAMP agonists theophylline and forskolin decreased constitutive isometric tension of a confluent monolayer inoculated on a collagen membrane, but it did not prevent increased tension in cells exposed to thrombin. The inability of cAMP agonists to prevent tension development correlated with an inability of cAMP stimulation to prevent increased 20-kDa myosin light chain (MLC20) phosphorylation in response to thrombin. Although cAMP did not prevent tension development or increased MLC20 phosphorylation, cAMP attenuated the effect of thrombin on transendothelial electrical resistance across a confluent monolayer inoculated on a gold microelectrode. Activation of cAMP-dependent signal transduction did not prevent a decline in resistance in thrombin-treated cells, but it more promptly restored transendothelial resistance to initial basal levels (10 min) compared with thrombin only (60 min). ML-7, an MLC kinase antagonist, at doses that attenuate increased MLC20 phosphorylation and tension development, did not prevent a decline in resistance in thrombin-treated cells. Yet, ML-7 also restored transendothelial resistance more rapidly than thrombin alone (20 min) but at a slower rate than cAMP. These data demonstrate that activation of cAMP-dependent signal transduction protects barrier function independent of inhibition of MLC20-dependent tension development.

Reconstruction of the laryngopharynx after hemicricoid/hemithyroid cartilage resection. Preliminary functional results

OBJECTIVE

To evaluate the use of a sensate radial forearm free flap and free cartilage graft for reconstruction of the laryngopharyngeal defect that results from resection of pyriform sinus carcinoma that extends to the apex of the pyriform sinus and includes the hemithyroid and hemicricoid cartilages.

DESIGN

Case series review of 6 patients treated during a 2 1/2-year period with an average follow-up of 23 months. Factors evaluated included oncologic outcome, as well as functional outcome with regard to the onset and quality of the airway, speech, and deglutition.

SETTING

Mount Sinai School of Medicine, New York, NY, an academic, tertiary referral center.

PATIENTS

Six men ranging in age from 51 to 73 years underwent a partial laryngopharyngectomy that included the hemicricoid and hemithyroid cartilages as well as the ipsilateral thyroid lobe and either unilateral or bilateral lymph node dissections for squamous cell cancer that involved the apex of the pyriform sinus.

INTERVENTION

These extensive laryngopharyngeal defects were reconstructed with a sensate radial forearm flap that resurfaced the endolarynx, restored the depth of the pyriform sinus, and reconstructed the remainder of the hypopharynx. In the final 4 patients, a free costal cartilage graft was used to restore the infrastructure of the larynx.

OUTCOME MEASURES

The status of the margins, the incidence and site of recurrent cancer, the quality of speech, and the times to decannulation and removal of the gastrostomy tube.

RESULTS

Three recurrences developed, with 1 each at the primary site, in the neck, and systemically. All but 1 patient who had completed radiotherapy by the last follow-up had been decannulated, and all but 1 patient regained the ability to maintain nutrition by mouth. Complications were limited to pharyngocutaneous fistulae requiring surgical closure in 3 patients early in the series.

CONCLUSIONS

Functional reconstruction of extensive laryngopharyngeal defects can be achieved with a sensate radial forearm flap and a cartilage graft, with favorable functional results and acceptable morbidity, thus expanding the limits of conservation laryngopharyngeal surgery.

Isometric tension of cultured endothelial cells: new technical aspects

In this paper new technical aspects are discussed in the measurement of the low amount of force typically expressed in cultured endothelial cells. We illustrate how potential background noises interfere with signal acquisition. We present a new generation prototype that measures isometric tension in vitro in multiple samples and in more than on isometric vector. We report that thrombin increases isometric tension in at least two separate vectors that are directed in opposite directions. We also report that phorbol ester dibutyrate can randomly mediate a false relaxation (anisotropic contraction) in cultured PPAEC, when the force vector is directed opposite to the referenced isometric vector of the transducer. In contrast, stimulation of cultured HUVEC with the cAMP agonists, theophylline and forskolin, decreased isometric force in both vectors. Thus direction of the force vector needs to be considered when interpreting isometric tension in cultured endothelial cells.

Control of recombination events during lymphocyte differentiation. Heavy chain variable region gene assembly and heavy chain class switching

Our recent studies have focused on the organization of immunoglobulin genes in mice and humans and the mechanism and control of the recombination events that are involved in their assembly and expression. This report describes our progress in this area with particular focus on elucidating factors that influence the generation of the antibody repertoire in normal and diseased states. We present a detailed analysis of the organization of the human VH locus, studies that help to elucidate the nature of the recombination defect in mice with severe combined immunodeficiency, and studies of transgenic mice that focus on the mechanism that regulates tissue-specific variable region gene assembly. In addition, we also characterize mechanisms that control the heavy chain class-switch process. Although the latter process apparently involve a recombination system distinct from that involved in variable region assembly, we find that the two recombination events appear to be controlled by similar mechanisms.

Synthesis of purines in human lymphoblast cells deficient in methylthioadenosine phosphorylase activity

Two human lymphoblastic cell lines, deficient in methylthioadenosine phosphorylase (MTAP) activity, were found to have increased rates of de novo purine synthesis. These MTAP- cell lines were K562, an undifferentiated leukemic line and CCRF-CEM, a leukemic line of T-cell origin. Another T-cell line, CCRF-HSB-2 was found to be deficient in activity. However, this line did not demonstrate elevated rates of purine synthesis. Purine metabolism in the above cell cultures was compared with MTAP+ human B-cell lines and two human T-cell lines (MOLT-3 and MOLT-4). In all the MTAP+ cell lines, the rate of de novo purine synthesis was inhibited by the presence of methylthioadenosine in the assay medium (10 microM concentration produced more than 90% inhibition). However, purine synthesis in the MTAP- cells was resistant to inhibition by methylthioadenosine. Adenine in the assay medium inhibited de novo purine synthesis in MTAP+ and MTAP- cells to a similar degree. This inhibition was dose dependent and was elicited by concentrations similar to those of methylthioadenosine. Growth of the cell lines in culture was not affected by either methylthioadenosine or adenine at the concentrations which produced inhibition of purine synthesis. These results suggest that purine synthesis in MTAP+ cells is inhibited by adenine formed from the phosphorolytic cleavage of methylthioadenosine by methylthioadenosine phosphorylase.