Immunotherapeutic Targeting and PET Imaging of DLL3 in Small-Cell Neuroendocrine Prostate Cancer

Effective treatments for de novo and treatment-emergent small-cell/neuroendocrine (t-SCNC) prostate cancer represent an unmet need for this disease. Using metastatic biopsies from patients with advanced cancer, we demonstrate that delta-like ligand 3 (DLL3) is expressed in de novo and t-SCNC and is associated with reduced survival. We develop a PET agent, [89Zr]-DFO-DLL3-scFv, that detects DLL3 levels in mouse SCNC models. In multiple patient-derived xenograft models, AMG 757 (tarlatamab), a half-life-extended bispecific T-cell engager (BiTE) immunotherapy that redirects CD3-positive T cells to kill DLL3-expressing cells, exhibited potent and durable antitumor activity. Late relapsing tumors after AMG 757 treatment exhibited lower DLL3 levels, suggesting antigen loss as a resistance mechanism, particularly in tumors with heterogeneous DLL3 expression. These findings have been translated into an ongoing clinical trial of AMG 757 in de novo and t-SCNC, with a confirmed objective partial response in a patient with histologically confirmed SCNC. Overall, these results identify DLL3 as a therapeutic target in SCNC and demonstrate that DLL3-targeted BiTE immunotherapy has significant antitumor activity in this aggressive prostate cancer subtype.

SIGNIFICANCE

The preclinical and clinical evaluation of DLL3-directed immunotherapy, AMG 757, and development of a PET radiotracer for noninvasive DLL3 detection demonstrate the potential of targeting DLL3 in SCNC prostate cancer.

A phase 1 study of AMG 509 in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC)

TPS5101

Background: Six-transmembrane epithelial antigen of prostate 1 (STEAP1) is overexpressed on the surface of prostate cancer cells with low or no expression on normal tissue. AMG 509 is a bispecific XmAb 2+1 T-cell engager that simultaneously binds to STEAP1 on tumor cells and the CD3 complex on T cells resulting in T-cell mediated lysis of STEAP1-expressing cells. AMG 509 demonstrated significant antitumor activity in preclinical prostate cancer models. Methods: This 4-part, first-in-human study will evaluate AMG 509 in pts with mCRPC previously treated with novel hormonal therapy (NHT) and will assess the safety, tolerability, pharmacokinetics (PK), and efficacy of AMG 509 to establish the maximum tolerated dose (MTD) and/or the recommended phase 2 dose (RP2D). Part 1 is currently enrolling pts previously treated with NHT and up to 2 prior taxanes. As of 31 January 2022, 60 of up to 110 pts have been enrolled for treatment with intravenous (IV) AMG 509 with initial inpatient dosing followed by outpatient treatment. Part 2 will evaluate subcutaneous dosing of AMG 509 in the same patient population as in Part 1. Part 3 will explore AMG 509 IV dosing in chemotherapy-naïve pts who have been treated previously with one NHT and will provide additional data on the safety, PK, efficacy, pharmacodynamics, and correlative biomarkers at the MTD or RP2D determined in Part 1. Part 4 will evaluate the combination of AMG 509 with abiraterone (Part 4A) or enzalutamide (Part 4B) in pts previously treated with one NHT and up to 1 prior taxane for castration-sensitive disease. Primary outcome measures include dose-limiting toxicities, treatment-emergent and treatment-related adverse events, and change in clinical and laboratory parameters. Key secondary outcome measures include PK, objective response per RECIST 1.1, prostate-specific antigen response, progression-free survival, and overall survival. Key inclusion criteria are men ≥18 years of age with pathologically confirmed mCRPC, refractoriness to NHT, evidence of progressive disease, and ECOG performance status of 0–1. Key exclusion criteria are pure small cell or neuroendocrine carcinoma of the prostate, untreated CNS metastases or leptomeningeal disease, recent anticancer therapy or immunotherapy within 4 weeks of start of first dose not including luteinizing hormone-releasing hormone/gonadotropin-releasing hormone analogue (agonist/antagonist) therapy, radiation therapy, and a history of or current autoimmune disease or any disease requiring chronic immunosuppressive therapy. The trial is being carried out in investigative sites in North America, Australia, Asia, and Europe. The study opened in January 2020 and is recruiting pts for the dose exploration phase of Part 1; parts 2 and 4 are open for enrollment. Part 3 will be initiated once the MTD and/or RP2D have been determined in Part 1. Clinical trial information: NCT04221542.

Phase 1b study of tarlatamab, a half-life extended bispecific T-cell engager (HLE BiTEimmune therapy) targeting DLL3, in de novo or treatment emergent neuroendocrine prostate cancer (NEPC)

TPS197

Background: NEPC is an aggressive cancer with no standard treatment approach and poor prognosis. It is usually treatment-emergent, occurring in 15%–20% of patients (pts) with metastatic castration-resistant prostate cancer following treatment with androgen signaling inhibitors (ASI) and is characterized by histological transformation from adenocarcinoma to a high-grade neuroendocrine tumor.1 The tumor associated antigen delta-like ligand 3 (DLL3) has been identified as a promising target in both NEPC and small cell lung cancer (SCLC), as it is highly expressed in these tumors and minimally expressed on normal tissue. Tarlatamab is a DLL3-targeting HLE BiTE® immune therapy designed to bind DLL3 on cancer cells and CD3 on T cells, resulting in T cell activation and expansion and T cell-dependent killing of tumor cells. In preclinical studies, tarlatamab induced T-cell dependent lysis of DLL3-expressing neuroendocrine tumor cell lines, including NEPC cells.2 Interim results of an ongoing first-in-human study in pts with SCLC (NCT03319940) show evidence for tarlatamab efficacy with an acceptable safety profile.3 Together, these findings support a clinical study of tarlatamab in NEPC. Methods: NCT04702737 is an open-label, phase 1b study evaluating tarlatamab infusion in pts with metastatic de novo or treatment-emergent NEPC, consisting of dose exploration and then dose expansion. Key eligibility criteria include adults (≥18 y) with metastatic NEPC whose disease progressed/recurred after ≥1 prior line of systemic therapy (platinum-based regimen for de novo NEPC or an ASI if treatment-emergent), measurable disease per RECIST 1.1 with Prostate Cancer Working Group 3 modifications, and ECOG performance status ≤2. Primary objectives are to evaluate safety and tolerability and determine the maximum tolerated dose or recommended phase 2 dose of tarlatamab. Secondary objectives are to evaluate antitumor activity (as assessed by objective response, duration of response, progression-free survival, overall survival, and disease control rate) and characterize pharmacokinetics. Four US and international study sites have been activated with two enrolled pts. References: Aggarwal R, et al. J Clin Oncol. 2018;36:2492-2503. Cooke K, et al. Abstract 627. Presented at: SITC Annual Meeting, Nov 9–14, 2020; Virtual. Owonikoko TK, et al. Abstract 8510. Presented at: ASCO Annual Meeting, June 4–8, 2021; Virtual. Clinical trial information: NCT04702737.

Safety and efficacy of AMG 160, a half-life extended BiTE immune therapy targeting prostate-specific membrane antigen (PSMA), and other therapies for metastatic castration-resistant prostate cancer (mCRPC)

TPS5088

Background: Lesions in mCRPC are typically immunologically cold. AMG 160 binds to PSMA on cancer cells and CD3 on T cells, leading to T-cell infiltration, activation, expansion, and tumor cell killing. In a first-in-human study, AMG 160 has demonstrated a manageable safety profile with preliminary efficacy in heavily pretreated patients. Enzalutamide and abiraterone are novel hormonal therapies (NHTs) that improve survival in mCRPC and may enhance T-cell responses, but resistance occurs. Combination therapy with AMG 160 may help overcome hormonal therapy resistance and broaden use for earlier line mCRPC. Preclinical data have demonstrated enhanced activity when AMG 404, an anti-PD-1 that can overcome T-cell exhaustion, and AMG 160 are combined. The safety and efficacy of AMG 160 combinations will be evaluated. Methods: NCT04631601 will enroll ∼100 men with histologically or cytologically confirmed adenocarcinoma of the prostate. The protocol consists of 3 subprotocols. Subprotocols A and B are phase 1b, multicenter, open-label studies; subprotocol C is a phase 1b/2 study. Therapeutic combinations include AMG 160 + enzalutamide (A), AMG 160 + abiraterone (B), and AMG 160 + AMG 404 vs AMG 404 monotherapy (C). Patients who received prior PSMA radionuclide therapy may be eligible. Patients must not have received prior PSMAxCD3 bispecific therapy, prior taxane treatment (unless approved by the sponsor) across subprotocols, and prior NHT specific to the subprotocol. In subprotocol C, patients must have progressive disease on an NHT to be eligible. Patients with CNS metastases, leptomeningeal disease, or active autoimmune disease will be excluded. AMG 160 will be administered intravenously (IV). Dexamethasone (or other corticosteroids) will be administered before AMG 160 administration in cycle 1 and possibly subsequent cycles. Enzalutamide or abiraterone will be administered per label. AMG 404 will be administered IV. Primary objectives are to evaluate safety and tolerability and determine the maximum tolerated dose (MTD) or recommended phase 2 dose (RP2D) of AMG 160 combinations. Subprotocol C will also evaluate the preliminary antitumor activity of AMG 404 monotherapy. Secondary objectives are to assess preliminary antitumor activity and characterize pharmacokinetics. MTD/RP2D will be established in the dose-escalation phase, and the safety and tolerability of the MTD/RP2D will be confirmed in the expansion phase. Evaluation of preliminary antitumor activity will be based on RECIST 1.1 with Prostate Cancer Working Group 3 modifications, prostate-specific antigen (PSA) response, circulating tumor cell response, progression-free survival (radiographic, PSA, clinical), overall survival, and 68Ga-PSMA-11 and 18F-FDG PET/CT imaging. The study is currently recruiting patients. Clinical trial information: NCT04631601.

Phase 1b study of AMG 757, a half-life extended bispecific T-cell engager (HLE BiTEimmune-oncology therapy) targeting DLL3, in de novo or treatment emergent neuroendocrine prostate cancer (NEPC)

TPS5100

Background: NEPC is an aggressive cancer with poor prognosis. No standard treatment approach for NEPC exists and it remains an unmet need. NEPC is usually treatment-emergent, characterized by histological transformation from adenocarcinoma to a high-grade neuroendocrine tumor (NET), and may develop in 15%–20% of patients (pts) treated with standard prostate adenocarcinoma therapies, including novel hormonal therapies. The inhibitory Notch ligand, Delta-like ligand 3 (DLL3), is highly expressed on the surface of cancer cells, including NEPC cells, making it an attractive and a promising therapeutic target. AMG 757 is an HLE BiTE immuno-oncology therapy designed to redirect cytotoxic T cells to tumor cells by binding DLL3 on cancer cells and CD3 on T cells, resulting in T cell activation and expansion and T cell-dependent killing of tumor cells. AMG 757 showed in vitro activity in DLL3-expressing NETs, including NEPC. Preliminary results of an on-going first-in-human study suggest AMG 757 is safe and effective in pts with small cell lung cancer (NCT03319940), which prompted its study in NEPC. Methods: NCT04702737 is an open-label, phase 1b study evaluating AMG 757 infusion in pts with metastatic de novo or treatment-emergent NEPC, consisting of dose exploration and then dose expansion. Key eligibility criteria include adults (≥18 y) with NEPC whose disease progressed/recurred after ≥1 treatment course including a platinum-based regimen for de novo NEPC or an androgen signaling inhibitor, measurable disease per modified RECIST 1.1 per Prostate Cancer Working Group 3 modifications, ECOG performance status ≤2, life expectancy > 3 mo, adequate organ function, and no untreated/symptomatic brain metastases. Primary objectives are to evaluate safety and tolerability and determine the maximum tolerated dose or recommended phase 2 dose of AMG 757. Secondary objectives are to evaluate antitumor activity (ie, objective response, duration of response, progression-free survival, overall response) and characterize pharmacokinetics. The starting dose for dose exploration will be based on the dose deemed safe and tolerable in the ongoing trial of AMG 757 in SCLC. The study is open to enrollment. Clinical trial information: NCT04702737.

Phase I study of AMG 509, a STEAP1 x CD3 T cell-recruiting XmAb 2+1 immune therapy, in patients with metastatic castration-resistant prostate cancer (mCRPC)

TPS5589

Background: Six transmembrane epithelial antigen of the prostate 1 (STEAP1) is a cell surface antigen that is highly expressed in prostate cancer. AMG 509 is a potent bispecific XmAb 2+1 immune therapy designed to direct T-effector cells to STEAP1-expressing cells. AMG 509 contains two identical humanized anti-STEAP1 Fab domains that bind STEAP1-expressing cells, an anti-CD3 scFv domain that binds T cells, and an Fc domain, engineered to lack effector function, that extends serum half-life. In preclinical studies, AMG 509 induced potent and specific T-cell-mediated lysis of STEAP1-expressing cancer models. Methods: This open-label, phase I, first-in-human study will evaluate the safety, tolerability, pharmacokinetics (PK), and efficacy of AMG 509 in patients with relapsed/refractory mCRPC. The dose exploration phase (n=40) will estimate the maximum tolerated dose (MTD) or recommended phase II dose (RP2D) using a Bayesian logistic regression model. The dose expansion phase (n=30) will confirm safety, PK, and pharmacodynamics at the MTD or RP2D and collect further safety, efficacy, and biomarker data. Efficacy will be assessed by prostate-specific antigen response, circulating tumor cell response, and objective tumor response per RECIST 1.1 with Prostate Cancer Working Group 3 modifications. Key inclusion criteria: men ≥18 years with histologically/cytologically confirmed mCRPC who are refractory to novel hormonal therapy (e.g., abiraterone and/or enzalutamide) and have failed 1–2 taxane regimens or are medically unsuitable for or have refused taxanes; ongoing castration with total serum testosterone ≤50 ng/dL; evidence of progressive disease; ECOG performance status 0–1; life expectancy ≥3 months; and adequate hematologic, renal, hepatic, and cardiac function. In the dose exploration phase, novel antiandrogen therapy must have been given in the metastatic setting. Key exclusion criteria: pure small-cell or neuroendocrine carcinoma of the prostate; untreated CNS metastases or leptomeningeal disease; any anticancer therapy or immunotherapy, radiation therapy, or major surgery <4 weeks from first dose; history of or current autoimmune disease or any disease requiring immunosuppressive therapy (≤10 mg/d prednisone permitted); prior STEAP1-targeted therapy; infection requiring IV antimicrobials <7 days from first dose. The study opened in January 2020 and is recruiting patients. Clinical trial information: NCT04221542 .

Phase I study of AMG 160, a half-life extended bispecific T-cell engager (HLE BiTE immune therapy) targeting prostate-specific membrane antigen, in patients with metastatic castration-resistant prostate cancer (mCRPC)

TPS5590

Background: Prostate-specific membrane antigen (PSMA) is a clinically validated therapeutic target for the imaging and treatment of mCRPC. AMG 160 is an HLE BiTE immune therapy designed to redirect T cells to cancer cells by binding to PSMA on cancer cells and CD3 on T cells. BiTE immune therapy leads to direct tumor cell killing, T-cell activation and expansion, and the creation of a pro-inflammatory tumor microenvironment. Combining AMG 160 with a PD-1 inhibitor may enhance antitumor activity by enabling sustained T-cell-dependent killing of tumor cells in the inflamed tumor microenvironment. Methods: NCT03792841 is a phase I study of AMG 160 as monotherapy (part 1) and in combination with pembrolizumab (part 2) in men with histologically/cytologically confirmed mCRPC who are refractory to a novel hormonal therapy (abiraterone, enzalutamide, and/or apalutamide) and have failed 1–2 taxane regimens (or are medically unsuitable or have refused taxanes), who have ongoing castration with total serum testosterone ≤ 50 ng/dL, and have evidence of progressive disease. Patients who received prior PSMA radionuclide therapy may be eligible. Patients with CNS metastases, leptomeningeal disease, spinal cord compression, or active autoimmune disease will be excluded. Primary objectives are to evaluate safety and tolerability and determine the maximum tolerated dose (MTD) or recommended phase II dose (RP2D) of AMG 160 given as monotherapy or in combination with pembrolizumab. Secondary objectives are to characterize pharmacokinetics and preliminary antitumor activity. Exploratory objectives include evaluation of potential pharmacodynamic and patient selection biomarkers, immunogenicity, and patient-reported pain and functional outcomes. The part 1 dose exploration will determine the MTD/RP2D of AMG 160. The part 1 dose expansion will confirm the safety and tolerability of the MTD/RP2D. The part 2 dose exploration will estimate the MTD/RP2D of AMG 160 in combination with pembrolizumab. Evaluation of preliminary antitumor activity will be based on RECIST 1.1 with Prostate Cancer Working Group 3 modifications, PSA response, CTC response, progression-free survival (radiographic and PSA), and overall survival. PSMA PET/CT and FDG PET/CT imaging will be used for evaluation of exploratory objectives. The study opened in February 2019 and is currently recruiting patients into both part 1 and part 2. Clinical trial information: NCT03792841 .

Phase I study of AMG 160, a half-life extended bispecific T-cell engager (HLE BiTE) immune therapy targeting prostate-specific membrane antigen (PSMA), in patients with metastatic castration-resistant prostate cancer (mCRPC)

TPS261

Background: AMG 160 is a novel HLE BiTE immune therapy that redirects T cells to kill tumor cells by binding to PSMA on tumor cells and CD3 on T cells. Methods: Primary objectives of this open-label, ascending, multiple-dose, phase 1 study (NCT03792841) are to evaluate safety and tolerability and determine the maximum tolerated dose (MTD) or recommended phase 2 dose (RP2D) of AMG 160 in men with mCRPC; secondary objectives are to characterize pharmacokinetics (PK) and evaluate preliminary efficacy. The dose exploration will estimate the MTD or RP2D by Bayesian logistic regression modeling. The dose expansion will assess safety, efficacy, PK, and pharmacodynamics (PD) of the selected dose and provide further safety and efficacy data. PD biomarkers and potential patient selection biomarkers will be explored. Preliminary antitumor activity will be assessed by objective response per RECIST 1.1 with PCWG3 modifications, PSA response, duration of response, time to progression, PFS (radiographic and PSA)/OS, and circulating tumor cell (CTC) response (CTC0 and CTC conversion). Imaging will include CT/MRI, bone scan, 68Ga-PSMA-11 PET/CT, and 18F-FDG PET/CT. In cycle 1, patients will be pretreated with dexamethasone before short-term IV infusion of AMG 160 and will be hospitalized for 72 h after each AMG 160 dose. Key inclusion criteria: age ≥18 y; histologically/cytologically confirmed mCRPC that progressed after novel hormone therapy; failure of 1–2 taxane-based regimens or have refused a taxane regimen; bilateral orchiectomy or continuous androgen-deprivation therapy; evidence of progressive disease; total serum testosterone ≤50 ng/dL. Key exclusion criteria: active autoimmune disease or diseases requiring immunosuppressive therapy (low-dose prednisone permitted); CNS metastases, leptomeningeal disease, or spinal cord compression; prior PSMA-targeted therapy (177Lu-PSMA-617 may be allowed). The study will enroll 30–50 patients in the dose exploration and 50 patients in the dose expansion globally. The study opened in January 2019; dose exploration is ongoing. Clinical trial information: NCT03792841.

Abstract 3813: Development of JNJ-64164711, a low fucose anti-GITR antibody for enhanced depletion of tumor regulatory T cells (Tregs)

Background: Checkpoint blockade of PD-1/PDL-1 or CTLA-4 has demonstrated clinical benefit in a subset of cancer patients (pts). To further improve the outcome, approaches to deplete immunosuppressive Tregs are being developed. Emerging evidence supports that the TNF receptor superfamily member 18 (TNFRSF18 or GITR) is highly expressed on intratumoral (i.t.) Tregs with limited expression on effector T cells or circulating immune cells (1,2). This differential expression allows for development of monoclonal antibody (mAb) therapies that eliminate this population while sparing other immune subsets. Herein we characterize JNJ-64164711 (JNJ-711), a fully human anti-GITR mAb being developed to selectively deplete GITR+ Tregs and expand the population of pts that may respond to immunotherapy.

Methods: Treg frequency and GITR expression on human cancer specimens was performed by IHC and multicolor flow cytometric analysis (FC). JNJ-711 was assessed for binding to GITR (human and cyno) and human Fcγ receptors, and inhibition of hGITRL binding to hGITR. The JNJ-711 binding epitope was mapped by hydrogen-deuterium exchange. JNJ-711 functional activity was determined by 1) an NF-kB reporter assay, 2) antibody dependent cellular cytotoxicity (ADCC) on GITR+ cell lines, and 3) JNJ-711 mediated Treg depletion in primary pts tumor samples.

Results: GITR expression prevalence was evaluated by IHC in multiple solid tumors. Immune cell GITR expression was observed in head and neck (HN), esophageal (ESO), non-small cell lung carcinoma (NSCLC), colorectal (CRC) and prostate cancers. GITR was moderately expressed on HN and ESO tumor cells. GITR expression (by FC) was higher on tumor Tregs versus other T cell populations in the tumor and periphery across NSCLC, CRC, ovarian and renal cell carcinoma samples. GITR was differentially higher on i.t. effector Tregs (eTreg) whereas CCR4 was highest on CD4+ T cells in circulation. JNJ-711 binds to hGITR on cells with high affinity [KD= 180 pM], has a log greater affinity to FcγRIIIa [KD= 37 nM on 158V; KD= 180 nM on 158F], a slower dissociation rate than most GITR agonist (Ag) mAb tested [Koff= 5.47 x 10-4 s-1 for Fab], and binds to the CRD1 of GITR. Unlike other GITR Ag mAbs tested, JNJ-711 does not block GITR interaction with GITRL. JNJ-711 demonstrates higher ADCC mediated cell depletion than other GITR Ag mAbs in clinical development on 1) GITR+ hematologic tumor cell lines (HuT102, KMS-12-BM, RPMI 8226, JJN-3), 2) primary activated GITR+ T cells, and 3) in vitro expanded Tregs. Using dissociated primary pts samples, JNJ-711 selectively depleted i.t. eTregs.

Conclusion: JNJ-64164711 selectively depletes hGITR+ cells including Tregs and has potential to enhance antitumor immune response. This antibody is being evaluated for clinical development.

References:

1. Asma et al. Tumor Biol 2015;36:3727-34.

2. Pedroza-Gonzalez et al. OncoImmunology 2015;4:12, e1051297.

Citation Format: Cam V. Holland, John Kehoe, Judith Hailey, Rupesh Nanjunda, Eilyn Lacy, Robin Ernst, Di Zhang, Sam Wu, Alexey Teplyakov, Weimin Li, Michelle Kinder, Edward W. Thompson, Patrick Wilkinson, Jackson Wong, Gerald Chu, Linda Okonkwo, John D. Alvarez, Anhco Nguyen, Iqbal S. Grewal, Moitreyee Chatterjee-Kishore, Mark Salvati, Marco Gottardis. Development of JNJ-64164711, a low fucose anti-GITR antibody for enhanced depletion of tumor regulatory T cells (Tregs) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3813.

Radiation-Induced Schwannomas of the Neuraxis. Report of Three Cases

We report 3 cases of possible radiation-induced schwannomas observed in our Department. Their salient clinical and pathogenetic features are analyzed and the role of radiation therapy in the oncogenesis of these lesions is discussed. Several cases of radiation-induced tumors, including some of the nervous system, have been reported, but schwannomas have only occasionally been reported in connection with ionizing radiation. The possible adjuvant role of antineoplastic drugs is also discussed, and the literature on this topic is reviewed.

Prolonged Stabilization of Multiple and Single Brain Metastases from Breast Cancer with Tamoxifen. Report of Three Cases

Cancer frequently metastasizes to the brain, and such lesions, whether multiple or solitary, have a poor prognosis, despite all efforts to treat them. There have been recent sporadic reports of brain metastases from breast cancer responding for some years to antiestrogens (particularly tamoxifen) or bromocryptine. We report three cases of brain metastasis from cancer – two multiple and one a solitary lesion. The long survival of the patients – two for 5 years and one for 6 years, with more than an acceptable quality of life – should prompt therapeutic trials to test tamoxifen and designed to assess its effects on a sizable number of patients.

Single Brain Metastases from Kidney Tumors. Clinico-Pathologic Considerations on a Series of 29 Cases

Twenty-nine cases of single cerebral metastases from renal carcinoma were the object of a retrospective and prospective study covering a period of 15 years (1975–1988). The best diagnostic means were NMR imaging with paramagnetic contrast medium and CAT scans after intravenous injection of a double dose of contrast medium. All patients underwent total surgical removal of the cerebral lesion. Radiotherapy was useful but had less influence on further reproduction than in metastases from tumors of other sites. The median survival was 28.1 months in patients who received radiotherapy and 23 months in the others. No significant difference in survival was found between the group of patients with unknown primary tumors and the other group with diagnosed primary neoplastic disease.

Post-Radiation Gliomas

Aims and background

Radiotherapy is important in the treatment of neoplasm of the central nervous system, but various side effects, particularly neoplastic, have been described. Recently, post-radiation gliomas have been reported.

Methods

The authors review 88 cases of cerebral glioma following radiotherapy in patients operated for neoplasms of the nervous system, including 6 personal cases of post-radiation gliomas treated in the Neurosurgical Division of the Department of Neurological Sciences, “La Sapienza” University, Rome. The criteria used to define this unusual pathologic association are discussed.

Results

There was a male predominance. Post-radiation gliomas were particularly malignant, the average dose was 33 Gy, and average free latency was 9.6 years. The first disease was most frequently acute lymphatic leukemia.

Conclusions

Post-radiation gliomas have particular features but do not present a histologic or clinical behavior different from analogous spontaneous gliomas. The fact that 88 cases have been reported in recent years suggests that a thorough biological, clinical studies be carried out on this association.

Association of Breast Carcinoma and Meningioma: Report of Nine New Cases and Review of the Literature

Nine patients with diagnosed breast cancer who developed meningiomas are reported. Articles suggesting that an association of these two tumors is possible. Some authors have noted hormonal sensivity and the presence of hormonal receptors in some meningiomas. Since breast cancer is the most common tumor in women, an association between it and meningiomas might be fortuitous. However, it is important to fully investigate brain lesions in patients with breast cancer so that potentially curable meningiomas are not considered as metastases.

Single Brain Metastases from Breast Cancer: Remarks on Clinical Pattern and Treatment

Thirty-four breast cancer patients with single brain metastases were reviewed: 9 underwent surgical removal only and 25 surgical removal and radiotherapy. A longer survival was seen in patients who underwent surgical removal and radiotherapy, with a mean survival of 28 months. In the 9 patients who did not receive whole brain radiotherapy, the mean survival was 15 months and there was an higher frequency of brain relapse.

Solitary Brain Metastases from Thyroid Carcinoma: Study of 6 Cases

Aims and background

Although systemic metastases from thyroid cancer are relatively frequent, they rarely affect the nervous system and only exceptionally originate from well-differentiated carcinoma.

Methods

The authors describe 6 cases of solitary brain metastases from thyroid carcinoma, well-differentiated in 3 cases and anaplastic in the other 3 cases.

Results

Four patients were females and 2 males (M:F ratio, 1:2); average age was 51 yrs (range 48-56). On average, the interval between diagnosis of the thyroid tumor and appearance of the metastasis was 2.8 years (range 1-12 years) and was shorter in the anaplastic forms (1.2 versus 4.4 years). Average survival was 15 months (range 6-48 months); in particular, average survival was longer in patients with well-differentiated carcinoma (9 vs 21 months) as also in those who did not present other metastatic sites (6 vs 24 months). Death was due to systemic progression of the disease in 4 cases and to brain-relapse in the other 2 cases.

Conclusions

Surgery, radioactive iodine (where uptake is demonstrable), and radiotherapy are the main therapies available for metastases from thyroid carcinoma. However, survival of patients appears to be modified by the type of treatment performed.

Ossifying Fibroma of the Skull: Clinical and Therapeutic Study

Aims and Backround

Ossifying fibroma is a tumor with benign course that rarely affects the cranial bones.

Methods

The authors report 5 cases of ossifying fibroma of the skull and analyze the clinical course and treatment of this lesione.

Results

3 patients were females and 2 males. The mean clinical history was 3.2 years. 4 patients underwent total removal and 1 partial. At mean follow-up of 19 years, all patients who underwent total removal showed improvement of neurological deficit, whereas the patient who underwent partial removal had clinical regrowth.

Conclusion

The authors conclude that total removal of fibroma should be extended to normal bone and in cases in which total removal is not possible the residue should be checked for regrowth by serial MRI.

Intramedullary Teratoma: Case Report and Review of the Literature

Aims and Background

Intramedullary teratoma is an extremely exceptional tumor (5 cases), although a careful review of international literature has shown it to be more frequent (32 cases) than believed.

Methods

The authors present a personal case with some unusual aspects.

Results

Our case is unusual not only because it was diagnosed by MRI (only one case has been reported in the literature) but also because surgical removal of the tumor was apparently total (only 4 other cases have been described), with a long follow-up period (4.5 years) and excellent results, in clinical and neuroradiologic terms.

Carcinoma of the Prostate: Brain Stem Metastasis as the Only Site of Spread

Aims and background

Metastasis to the brain from prostate carcinoma is a rare event; it is reported in less than 4% of postmortem examinations. The prevalence of cases detected antemortem is even smaller, and the prevalence of brain stem metastasis as the only site of metastasis has been reported in only two other cases.

Method

The authors present a third such case.

Results

A 55-year-old man, treated for an adenocarcinoma of the prostate (prostatectomy and radiotherapy), started to complain of facial expression disturbances and headaches 2 years later. Physicial examination showed a left VII cranial nerve palsy. MRI showed an enhancing mass in the pons. Total body CT was negative. The patient was treated with a course of whole-brain and brain stem radiotherapy following stereotactic biopsy. Four months after radiotherapy, the neurological symptoms had disappeared and the patient died of a myocardial infarct. The systemic disease was still clinically silent.

Conclusion

Our case involved only brain stem metastasis, probably implicating Batson's direct route of the paravertebral venous pathway.

Overall Survival and Long-Term Safety of Nivolumab (Anti-Programmed Death 1 Antibody, BMS-936558, ONO-4538) in Patients With Previously Treated Advanced Non-Small-Cell Lung Cancer

PURPOSE

Programmed death 1 is an immune checkpoint that suppresses antitumor immunity. Nivolumab, a fully human immunoglobulin G4 programmed death 1 immune checkpoint inhibitor antibody, was active and generally well tolerated in patients with advanced solid tumors treated in a phase I trial with expansion cohorts. We report overall survival (OS), response durability, and long-term safety in patients with non-small-cell lung cancer (NSCLC) receiving nivolumab in this trial.

PATIENTS AND METHODS

Patients (N = 129) with heavily pretreated advanced NSCLC received nivolumab 1, 3, or 10 mg/kg intravenously once every 2 weeks in 8-week cycles for up to 96 weeks. Tumor burden was assessed by RECIST (version 1.0) after each cycle.

RESULTS

Median OS across doses was 9.9 months; 1-, 2-, and 3-year OS rates were 42%, 24%, and 18%, respectively, across doses and 56%, 42%, and 27%, respectively, at the 3-mg/kg dose (n = 37) chosen for further clinical development. Among 22 patients (17%) with objective responses, estimated median response duration was 17.0 months. An additional six patients (5%) had unconventional immune-pattern responses. Response rates were similar in squamous and nonsquamous NSCLC. Eighteen responding patients discontinued nivolumab for reasons other than progressive disease; nine (50%) of those had responses lasting > 9 months after their last dose. Grade 3 to 4 treatment-related adverse events occurred in 14% of patients. Three treatment-related deaths (2% of patients) occurred, each associated with pneumonitis.

CONCLUSION

Nivolumab monotherapy produced durable responses and encouraging survival rates in patients with heavily pretreated NSCLC. Randomized clinical trials with nivolumab in advanced NSCLC are ongoing.

Single brain metastases from cervical carcinoma: report of two cases and critical review of the literature

Single brain metastases from cervical carcinomas are rare. We report two cases of solitary brain metastases, showing different histological types, which have been excised with microsurgical technique. Neuroendocrine differentiation does not seem to be connected to clinical behavior, indeed a poor prognosis depends on poorly differentiated histological types. In our cases, brain metastases were a late event and they have been successfully excised in microsurgery, thanks to their solitary and resectable nature, and a well-controlled primary disease.

Safety and feasibility of the adjunct of local chemotherapy with biodegradable carmustine (BCNU) wafers to the standard multimodal approach to high grade gliomas at first diagnosis

AIM

Among physicians there is still a reluctant attitude in the employment of combined treatment with surgery and intraoperative placement of carmustina 7.7 mg wafers (Gliadel®), followed by standard adjuvant treatment with radiotherapy and concomitant and subsequent chemiotherapy with temozolomide (TMZ), for supratentorial high grade gliomas at first diagnosis. To determine the safety and feasibility of this multimodality sequential adjuvant therapy, we reviewed our single-institution experience, in the light to provide more insights on this continuous multi-stage chemotherapy approach to such a challenging disease as glioblastoma multiforme.

METHODS

From February 2006 to January 2008, 32 patients were treated at our institution for cerebral supratentorial high grade glioma with surgery and intraoperative placement of carmustine wafers. No postsurgical complications could be observed. After a median time of 4,8 weeks all patients began adjuvant concomitant radiotherapy with a mean of 60 Gy and TMZ chemotherapy 75 mg/m2 during which weekly hematologic assessments were performed. After 3 to 6 weeks patients commenced adjuvant TMZ, administered 5 days every 28, 200 mg/m2 for not less than 12 cycles. A contrast-enhanced magnetic resonance imaging (MRI) was routinely performed. Median follow-up after surgery was of 6.5 months, ranging from 4 to 23 months.

RESULTS

The mean presurgical KPS was of 80 (range: from 60 to 100), and it remained unmodified after adjuvant therapies even at suspension of steroids. In 4 cases there was a radiologic evidence of progression of the disease and the necessity of steroids, with a progression-free survival (PFS) of 6, 8, 9,5 and 13,6 months. One case died 14 months after first operation. All other patients are still alive.

CONCLUSION

The integration of local chemiotherapy with carmustine wafers and the standard adjuvant regimen with radiotherapy and concomitant chemiotherapy appears to be safe and feasible, without any adjunctive complication. Promising results on the efficacy require more follow up to be quantified.

Stereotactic radiosurgery plus whole-brain radiotherapy for treatment of multiple metastases from non-small cell lung cancer

BACKGROUND

The aim of this study was to evaluate local control and survival rates after stereotactic radiosurgery (SRS) plus whole-brain radiotherapy (WBRT) for the treatment of multiple brain metastases from non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Between June 2004 and September 2008, sixty-six patients with multiple brain metastases from NSCLC were enrolled in this prospective study. All patients were required to have 2-3 brain metastases and Karnofsky performance status (KPS) > or = 70. WBRT treatment dose was 30 Gy in 10 fractions followed by SRS. A matched control population treated with WBRT alone to a dose of 30 Gy in 10 fractions was used for comparison.

RESULTS

The median survival was 10.3 months in the WBRT plus SRS group and 7.2 months in the WBRT group (p=0.005). The 6-month and 12-month survival rates were 90% and 38% in the SRS plus WBRT group and 84% and 19% in the WBRT group (p=0.01). Stable extracranial disease and KPS were significant predictive factors of survival in both groups (p=0.001). Death due to neurological causes occurred in 18% and 35% of patients treated with WBRT plus SRS and WBRT (p=0.02), respectively. Disease control in the brain was 10 months in the SRS plus WBRT group and 7 months in the WBRT group (p=0.001); the 6-month and 12-month control rates were 82% and 42% for WBRT plus SRS, and 75% and 18% for WBRT (p=0.001), respectively. The 6-month and 12-month control rates of treated lesions (local control) were 90% and 47% in the WBRT group, and 100% and 93% in the WBRT plus SRS group (p=0.001).

CONCLUSION

WBRT plus SRS is a safe, minimally invasive and well-tolerated treatment for patients with up to three brain metastases from NSCLC. The treatment is associated with longer survival and better disease control in comparison with WBRT alone. Survival benefits need to be confirmed by large randomized studies.

Sarcoma metastatic to the brain: a series of 35 cases and considerations from 27 years of experience

The authors report their 27-year experience regarding 35 cases of supratentorial brain metastasis from sarcoma treated in a single institution: these included ten osteosarcomas, seven leiomyosarcomas, five Ewing sarcomas, four malignant fibrous histiocytomas, three alveolar soft-part sarcomas (ASPS), two rhabdomyosarcomas, one liposarcoma, and three unclassified sarcomas. The first 15 cases of the series have already been described in a previous publication. Median survival after craniotomy was 9.8 months (range: 4-24). In patients with preoperative Karnofsky performance score (KPS) > 60 it was 12.8 months (range: 6.5-24 months) versus 5.4 months for those patients with a KPS < or = 60 (P = 0.01). Eight patients had more than one lesion, six of which were treated in the last ten years. Of the three patients with ASPS, the first two were alive at 15 and 20 months (before being lost to follow-up) whereas the third patient is alive at 24 month follow-up. The authors conclude that surgery is more effective in treating selected patients with sarcoma metastatic to the brain, and that patients with metastasis from ASPS have good prognosis when submitted to surgical treatment. The complete removal of all brain metastases "en bloc" and a KPS > 60 are associated with the best prognosis. Finally, it seems that surgical indications for multiple brain metastases from sarcoma have increased during the last ten years.

Treatment of gliomatosis cerebri with temozolomide: A retrospective study of the AINO (Italian Association for Neuro- Oncology)

2033

Background: The optimal management for patients with primary gliomatosis cerebri is unknown, and some recent studies suggest that temozolomide could be useful as an upfront treatment. Methods: Between 1999 and 2005, 46 patients with biopsy proven gliomatosis cerebri were treated with temozolomide either upfront or at progression after prior radiotherapy/chemotherapy. Histological diagnoses were as follows: glioblastoma in 3 patients, malignant glioma in 8, anaplastic astrocytoma in 8, gemistocytic astrocytoma in 2, astrocytoma in 13, anaplastic oligodendroglioma in 1, anaplastic oligoastrocytoma in 1, oligoastrocytoma in 1, oligodendroglioma in 4, glial proliferation consistent with GC in 5. Median age was 49 years (range 14–70), with 20 males and 26 females and a median KPS at diagnosis of 80 (range 50–90). Twenty-three out of 46 (50%) pre-treatment MRI demonstrated some degree of contrast enhancement. Twenty-three of 46 patients were treated upfront, while 23 had received prior radiation therapy or nitrosourea-based chemotherapy. All patients received temozolomide 200 mg/m2 die for 5 days every 4 weeks until progression or unacceptable toxicity. Response was evaluated, according to Macdonald criteria, on T1-weighted with Gadolinium and FLAIR images. Results: Two patients (4%) showed a CR of the contrast enhancing area, 2 patients (4%) a PR, 5 (11%) a minor response, 18 (39%) a SD and 19 (42%) a PD. Overall response rate (CR + PR + “minor response”) was 19%, while a clinical benefit was observed in 13/46 patients (28%). Median TTP was 9 months (range 1–27), and median survival 14 months (range 3–123). PFS at 6 months was 57%, at 12 months 35%. Oligodendroglial tumours showed a 38% response rate and a TTP of 11 months. Response rate was higher among patients treated at progression compared to those treated upfront (13% versus 26%). Grade III-IV haematological toxicity was mild. Conclusions: Temozolomide has some activity in primary GC (19% response rate), and is well tolerated. A significant neurological improvement can be observed in patients with either response or stable disease on MRI. To improve the efficacy of temozolomide in the upfront setting (in order to delay a large field RT), a phase II study with a dose-dense regimen is ongoing.

No significant financial relationships to disclose.

Elderly and poor prognosis patients with high grade glioma: hypofractionated radiotherapy

AIM

To evaluate efficacy of short-course radiotherapy in elderly and/or poor performance status patients with high grade glioma.

MATERIALS AND METHODS

Twenty-one patients with high grade astrocytoma were selected in our Institute to receive hypofractionated radiotherapy. We considered two radiotherapy treatment arms: in arm I there were 22 patients treated with 60 Gy in 30 fractions at 5 fractions per week; in arm 2 there were 21 patients who received hypofractionated radiotherapy course of 30 Gy in 10 fractions at 5 fractions per week.

RESULTS

In arm1 the median survival time was 8.2 months and the 1 year overall survival was 36%; in arm 2 the estimated median survival was 6.2 months and the 1 year overall survival was 23%. Treatment was without acute toxicity.

CONCLUSIONS

In our experience, hypofractionated radiotherapy seems to be a reasonable treatment option for poor prognosis patients with high grade astrocytoma. It is well tolerated and can reduce the overall treatment time without negative effects on survival compared with conventional fractionation.

Gliomatosis cerebri treatment in 11 elderly patients

The Authors report their experience in the treatment of eleven patients over 70 years old (range from 70 to 83, average age 74.8, 7 males and 4 females), with histologically proven diagnosis of glioblastoma multiforme. The GC golden standard treatment is still debated, particularly in elderly patients. All the patients underwent a first line treament with chemotherapy (Temozolomide), followed by Whole Brain Radiotherapy (WBRT) and PCV schedule without Vincristine in case of progression of the disease. The median survival was 16.3 months, ranging from 13 to 22 months. According to our experience, elderly patients should undergo the same treatment of younger patients, provided they are in good health conditions.

Paragangliomas of the cauda equina. Report of one case and review of the literature

The authors report one case of cauda equina paraganglioma and review the neurosurgical, radiological and pathological literatureon this rare tumour. Although it is difficult to distinguish preoperatively the paraganglioma from other tumours of the cauda equina, like neurinoma or ependymoma, this neuroendocrine tumour should be included in differential diagnosis.

Sylvian subarachnoid and extra-pial cavernous angioma

Cavernous angiomas are one of the four types of vascular malformations of the central nervous system. Lesions situated subarachnoidally are rare although some cases with an infratentorial localization have been reported. Our case represents an unusual localization of a subarachnoid cavernous angioma. A 35- year-old patient was admitted to our department with signs of subarachnoid hemorrhage. A 1 cm hyperdense lesion placed at the right Sylvian fissure was distinguished by CT-scan examination and no arterial supply was revealed on cerebral angiography. Surgical intervention showed a lesion placed extra-pial and totally encased in the subarachnoid space in the superficial part of the Sylvian cistern. This case represents a radiologically visible supratentorial extra-pial subarachnoidal cavernous angioma. This case provides confirmation of one of the supposed causes of subarachnoid hemorrahage ''sine materia''.

Spinal glioblastoma with brain relapse in a child: clinical considerations

STUDY DESIGN

Case report.

OBJECTIVES

To describe a child with intramedullary glioblastoma at T9-T10-T11, and to discuss the clinical features of this rare pathology.

SETTING

Department of Neurological Sciences, Italy.

CASE REPORT

Spinal cord glioblastoma in children has only rarely been reported. It most frequently involves the thoracic region with a predilection for the second and third decades of life. This report describes one case of thoracic glioblastoma multiforme in a 6-year-old child and reviews other cases reported in the literature.

RESULTS

Laminectomy and excision of the tumour were performed. Postoperative radiotherapy and chemotherapy were given, but 4 months later the patient presented with a brain relapse of the tumour. At 9 months after diagnosis the patient died from cerebral tumour regrowth.

CONCLUSIONS

Full neuraxis MRI is always recommended in order to detect possible metastases. The prognosis after multimodality therapy (surgery, radiotherapy, chemotherapy) remains poor. From the literature, only four cases of paediatric patients with long-term survival have been reported.

Brain metastasis from prostate cancer. Report of 13 cases and critical analysis of the literature

Brain metastasis from prostate carcinoma occurs very rarely. We describe 13 patients with single brain metastasis from prostatic cancer. Total removal of the lesions was performed in ten patients. Three patients underwent stereotactic biopsy. All patients were treated with postoperative whole brain radiotherapy (WBRT). Eight patients died for systemic disease after a mean time of 9.2 months with a diagnosis of metastasis. Five patients are still alive at 20, 14, 11, 7 and 6 months, respectively. Even if brain metastasis from prostate cancer is often a terminal event with death occurring within few months from diagnosis, we suggest the same protocol (surgery and/or radiosurgery plus postoperative WBRT) usually adopted to treat brain metastasis from other primitive tumours. A non specific neurological symptomatology and a possible normal dosage of serum specific antigen may contribute to a delay in diagnosis. However, considering the rarity of brain metastasis from prostate carcinoma, standard brain MRI follow-up in men with prostatic cancer does not seem to be necessary yet.