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Finn RS, Yau T, Hsu CH, De Toni EN, Goyal L, Galle PR, Qin S, Rao S, Sun F, Wang C, Widau RC, Zhu AX. Ramucirumab for Patients with Advanced Hepatocellular Carcinoma and Elevated Alpha Fetoprotein Following Non-Sorafenib Systemic Therapy: An Expansion Cohort of REACH-2. Oncologist 2022; 27:e938-e948. [PMID: 36190331 DOI: 10.1093/oncolo/oyac183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/05/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ramucirumab is indicated for patients with advanced hepatocellular carcinoma (HCC) and α-fetoprotein (AFP) ≥400 ng/mL following sorafenib. Here, we prospectively studied ramucirumab following non-sorafenib systemic therapies. MATERIALS AND METHODS This open-label, non-comparative cohort of REACH-2 enrolled patients with advanced HCC, Child-Pugh class-A liver disease, and AFP ≥400 ng/mL who had received 1-2 lines of therapy, excluding sorafenib or chemotherapy. Ramucirumab was administered 8 mg/kg intravenously Q2W. The primary endpoint was safety. Secondary endpoints were overall survival, progression-free survival, objective response rate (RECIST v1.1), time to progression, pharmacokinetics, and patient-reported outcomes. Final analysis occurred after all enrolled patients completed ≥3 treatment cycles or discontinued treatment. RESULTS Between April 27, 2018, and March 29, 2021, 47 patients were treated at 21 investigative sites in Asia, Europe, and USA. The most frequently reported grade ≥3 adverse events, regardless of causality, were hypertension (11%), proteinuria (6%), hyponatremia (6%), and AST increased (6%). Two patients died from adverse events (myocardial infarction and upper gastrointestinal hemorrhage), deemed related to treatment. Median progression-free survival, time to progression, and overall survival were 1.7 months, 2.8 months, and 8.7 months, respectively. The objective response rate was 10.6% with a median duration response of 8.3 months. Median time to deterioration in FHSI-8 total score was 4.4 months. CONCLUSION Ramucirumab demonstrated consistent and meaningful clinical activity with no new safety signals following non-sorafenib therapies in patients with advanced HCC and AFP ≥400 ng/mL. This represents one of the first sequencing studies for patients with advanced HCC not treated with sorafenib.
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Affiliation(s)
| | - Thomas Yau
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Chih-Hung Hsu
- Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Lipika Goyal
- Department of Medicine, Mass General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Peter R Galle
- Department of Internal Medicine, University Medical Center Mainz, Mainz, Germany
| | - ShuKui Qin
- Department of Medical Oncology, People's Liberation Army Cancer Center, Nanjing Bayi Hospital, Nanjing, People's Republic of China
| | - Sujata Rao
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | | | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.,Jiahui International Cancer Center, Jiahui Health, Shanghai, People's Republic of China
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Shao G, Bai Y, Yuan X, Chen X, Gu S, Gu K, Hu C, Liang H, Guo Y, Wang J, Yen CJ, Lee VHF, Wang C, Widau RC, Zhang W, Liu J, Zhang Q, Qin S. Ramucirumab as second-line treatment in Chinese patients with advanced hepatocellular carcinoma and elevated alpha-fetoprotein after sorafenib (REACH-2 China): A randomised, multicentre, double-blind study. EClinicalMedicine 2022; 54:101679. [PMID: 36247923 PMCID: PMC9562926 DOI: 10.1016/j.eclinm.2022.101679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the global REACH-2 study, ramucirumab significantly improved overall survival (OS) compared with placebo in patients with advanced hepatocellular carcinoma (HCC) and elevated alpha-fetoprotein (AFP). REACH-2 China study aimed to evaluate the efficacy and safety of ramucirumab in Chinese patients with advanced HCC (NCT02435433). METHODS REACH-2 China was a randomised, double-blind, placebo-controlled, phase 3 study done at 31 centres in China between Sep 16, 2015, and March 15, 2021. Patients with advanced HCC and AFP ≥400 ng/mL after first-line sorafenib were randomly assigned (2:1) to receive ramucirumab 8 mg/kg intravenously or placebo Q2W, until disease progression or unacceptable toxicity. The primary endpoint was OS. Efficacy was assessed per intention-to-treat, and safety in patients who received any treatment. FINDINGS Of 104 Chinese patients enrolled (44 in the global study and 60 in the China extension study), 70 received ramucirumab and 34 received placebo. Median OS was 9·1 months in the ramucirumab group and 6·2 months in the placebo group (HR = 0·854 [95% CI: 0·536, 1·359]). The most common grade 3 or worse treatment-emergent adverse event were hypertension (5 [7·1%] of 70 patients in the ramucirumab group vs 1 [2.9%] of 34 in the placebo group), pneumonia (5 [7·1%] vs 1 [2·9%]), and hyponatraemia (4 [5·7%] vs 0 [0%]). INTERPRETATION Ramucirumab demonstrated clinically meaningful improvement in OS compared to placebo for Chinese patients with advanced HCC and elevated AFP, although lacking statistical superiority. Ramucirumab was well tolerated, with a manageable safety profile. The results are consistent with those of the global REACH-2 study, supporting a favourable risk-benefit profile for ramucirumab in this population. FUNDING Eli Lilly and Company, USA.
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Affiliation(s)
- Guoliang Shao
- Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yuxian Bai
- Department of Gastrointestinal Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xianglin Yuan
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaomin Chen
- Department of Intervention Therapy, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Shanzhi Gu
- Department of Interventional Radiology, Hunan Cancer Hospital, Changsha, China
| | - Kangsheng Gu
- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chunhong Hu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Houjie Liang
- Department of Oncology and Southwest Cancer Centre, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yabing Guo
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jufeng Wang
- Department of Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Chia-Jui Yen
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Victor Ho-Fun Lee
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | | | | | | | | | | | - Shukui Qin
- Cancer Centre of Jinling Hospital, Nanjing University of Chinese Medicine, Nanjing, China
- Corresponding author at: Cancer Centre of Jinling Hospital, Nanjing University of Chinese Medicine, Nanjing 210002, China.
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Zhu AX, Lin Y, Ferry D, Widau RC, Saha A. Surrogate end points for survival in patients with advanced hepatocellular carcinoma treated with immune checkpoint inhibitors. Immunotherapy 2022; 14:1341-1351. [DOI: 10.2217/imt-2022-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The authors investigated surrogacy of radiology-based end points for clinical trials investigating immune checkpoint inhibitors in advanced hepatocellular carcinoma. Methods: Data were collected from electronic databases reporting median overall survival (OS), median progression-free survival (PFS) and objective response rate (ORR). Weighted Pearson correlation coefficients and 95% confidence intervals (CIs) were calculated. Results: 26 clinical trials (41 treatment arms, 5144 patients) were included. ORR (coefficient: 0.71; 95% CI: 0.52–0.84) and PFS (coefficient: 0.63; 95% CI: 0.21–0.92) were positively correlated with OS. Sensitivity analyses suggested liver function, line of therapy and study phase did not greatly impact results. The COSMIC-312 study negatively impacted the overall weighted correlation. Conclusion: ORR and PFS are positively correlated with OS in patients with advanced hepatocellular carcinoma.
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Affiliation(s)
- Andrew X Zhu
- Jiahui International Cancer Center, Jiahui Health, Shanghai, 200233, China
| | - Yong Lin
- Eli Lilly & Company, Indianapolis, IN 46225, USA
| | - David Ferry
- Eli Lilly & Company, Indianapolis, IN 46225, USA
| | - Ryan C Widau
- Eli Lilly & Company, Indianapolis, IN 46225, USA
| | - Abhijoy Saha
- Eli Lilly & Company, Indianapolis, IN 46225, USA
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Shao G, Bai Y, Chen X, Gu S, Gu K, Yuan X, Widau RC, Zhang W, Zhang Q, Qin S. Ramucirumab as second-line treatment in patients with advanced hepatocellular carcinoma (HCC) and elevated alpha-fetoprotein (AFP) following first line sorafenib: Pooled efficacy and safety in Chinese patients across two global randomized phase 3 studies (REACH-2 and REACH). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e16081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16081 Background: REACH-2 and REACH were two global, randomized, double-blind, placebo (PL)-controlled phase 3 studies of Ramucirumab (RAM) versus PL in patients with HCC after prior sorafenib. REACH-2 confirmed the RAM treatment benefit for patients with baseline AFP ≥ 400 ng/mL, consistent with results in a prespecified subgroup of patients in REACH with AFP ≥ 400 ng/mL. A pooled analysis was performed to evaluate the efficacy and safety of RAM in Chinese patients (including patients from mainland China, Hong Kong, and Taiwan) from REACH-2 and REACH with baseline AFP ≥400 ng/mL. Methods: Except for AFP level requirement, REACH-2 and REACH were similar in study design and included patients who had advanced HCC (BCLC stage C or B disease refractory or not amenable to locoregional therapy), Child-Pugh A, ECOG PS 0-1, and prior sorafenib. Patients were randomized to RAM (8 mg/kg) I.V. or PL Q2W, plus best supportive care, until disease progression or unacceptable toxicity. Individual patient data were pooled from REACH-2 and REACH (AFP ≥400 mg/mL). Overall survival (OS) and progression-free survival (PFS) were evaluated using Kaplan-Meier method and Cox proportional hazard model. Objective response rate (ORR), disease control rate (DCR), and safety were reported. Efficacy analyses were stratified by study to account for any potential difference in the two studies. Results: Data from 155 Chinese patients were pooled from REACH (51) and REACH-2 (104) (N = 98 RAM vs N = 57 PL). Baseline characteristics were generally balanced between arms in pooled data set; however, lower median level of AFP was noted in the RAM arm. In the pooled population, RAM treatment numerically improved OS over PL (median OS 7.1 months vs 4.7 months; HR = 0.735 [95% CI: 0.512, 1.055]). Improvements in PFS (median PFS 2.6 months vs 1.5 months; HR = 0.666 [95% CI: 0.459, 0.967]), ORR (3.1% vs 0%), and DCR (44.9% vs 29.8%) were also observed. Hypertension (6.1% vs 1.8%), pneumonia (5.1% vs 1.8%), and hyponatremia (5.1% vs 1.8%) were the Grade ≥3 treatment-emergent adverse events (TEAEs) among ≥ 5% patients that was more frequently observed in the RAM arm compared with the PL arm. Conclusions: Pooled analysis of two phase 3 trials of RAM as second-line treatment in patients with HCC following sorafenib demonstrated a clinically meaningful benefit with a manageable safety profile in Chinese HCC patients with baseline AFP ≥ 400 ng/mL. Treatment benefits in OS observed in the pooled Chinese population were consistent with the entire population from REACH/REACH-2 (AFP ≥ 400 ng/mL). Clinical trial information: NCT01140347, NCT02435433.
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Affiliation(s)
- Guoliang Shao
- Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yuxian Bai
- Department of Gastrointestinal Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xiaoming Chen
- Department of Intervention Therapy, Guangdong Provincial People’s Hospital, Guangzhou, China
| | - Shanzhi Gu
- Department of Interventional Radiology, Hunan Cancer Hospital, Changsha, China
| | - Kangsheng Gu
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xianglin Yuan
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | | | - Shukui Qin
- Jinling Hospital, Nanjing University of Chinese Medicine, Nanjing, China
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Llovet JM, Singal AG, Villanueva A, Finn RS, Kudo M, Galle PR, Ikeda M, Callies S, McGrath LM, Wang C, Abada P, Widau RC, Gonzalez-Gugel E, Zhu AX. Prognostic and Predictive Factors in Patients with Advanced HCC and Elevated Alpha-Fetoprotein Treated with Ramucirumab in Two Randomized Phase III Trials. Clin Cancer Res 2022; 28:2297-2305. [PMID: 35247922 PMCID: PMC9662930 DOI: 10.1158/1078-0432.ccr-21-4000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/19/2022] [Accepted: 03/02/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Ramucirumab is an effective treatment for patients with advanced hepatocellular carcinoma (aHCC) and baseline alpha-fetoprotein (AFP) ≥400 ng/mL. We aimed to identify prognostic and predictive factors of response to ramucirumab in patients with aHCC with AFP ≥400 ng/mL from the phase III REACH and REACH-2 randomized trials. PATIENTS AND METHODS Patients with aHCC, Child-Pugh class A with prior sorafenib treatment were randomized in REACH and REACH-2 (ramucirumab 8 mg/kg or placebo, biweekly). Meta-analysis of individual patient-level data (pooled population) from REACH (AFP ≥400 ng/mL) and REACH-2 was performed. A drug exposure analysis was conducted for those with evaluable pharmacokinetic data. To identify potential prognostic factors for overall survival (OS), multivariate analyses were performed using a Cox proportional hazards regression model. To define predictors of ramucirumab benefit, subgroup-by-treatment interaction terms were evaluated. RESULTS Of 542 patients (316 ramucirumab, 226 placebo) analyzed, eight variables had independent prognostic value associated with poor outcome (geographical region, Eastern Cooperative Oncology Group performance score ≥1, AFP >1,000 ng/mL, Child-Pugh >A5, extrahepatic spread, high neutrophil-to-lymphocyte ratio, high alkaline phosphatase and aspartate aminotransferase). Ramucirumab survival benefit was present across all subgroups, including patients with very aggressive HCC [above median AFP; HR: 0.64; 95% confidence interval (CI): 0.49-0.84] and nonviral aHCC (HR: 0.56; 95% CI: 0.40-0.79). While no baseline factor was predictive of a differential OS benefit with ramucirumab, analyses demonstrated an association between high drug exposure, treatment-emergent hypertension (grade ≥3), and increased ramucirumab benefit. CONCLUSIONS Ramucirumab provided a survival benefit irrespective of baseline prognostic covariates, and this benefit was greatest in patients with high ramucirumab drug exposure and/or those with treatment-related hypertension.
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Affiliation(s)
- Josep M. Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- Translational Research in Hepatic Oncology, Liver Unit, IDIBAPS, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana d'Estudis Avançats (ICREA), Barcelona, Catalonia, Spain
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Augusto Villanueva
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Richard S. Finn
- Division of Hematology/Oncology, University of California, Los Angeles, California
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Peter R. Galle
- Department of Internal Medicine, Mainz University Medical Center, Mainz, Germany
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | | | | | | | - Paolo Abada
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | - Andrew X. Zhu
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
- Jiahui International Cancer Center, Jiahui Health, Shanghai, P.R. China
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Zhu AX, Lin Y, Ferry DR, Widau RC, Saha A. Meta-analysis of surrogate endpoints for survival in patients with unresectable hepatocellular carcinoma treated with immune checkpoint inhibitor-based regimens. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
483 Background: Overall survival (OS) remains the gold standard for demonstrating clinical benefit in advanced hepatocellular carcinoma (HCC). While surrogate radiology-based endpoints for OS, such as progression-free survival (PFS) and objective response rate (ORR) are commonly used in the field of oncology, they remain controversial in the setting of HCC where antiangiogenic agents were the mainstay of treatment until recently. Immune checkpoint inhibitors (CPIs) as monotherapy or in combination have shifted the treatment paradigm in HCC. We investigated the surrogacy of radiology-based endpoints from CPI clinical trials in advanced HCC. Methods: Study level data were collected for disclosures published in EMBASE, PubMed, Clinicaltrials.gov and conference abstracts. Keywords used included (abbreviated here): immune CPIs, advanced or metastatic HCC and ORR, PFS and OS. Key inclusion criteria included: Phase I, II and III trial data, and patients with advanced or metastatic HCC who received CPI monotherapy or in a combination regimen. The endpoints investigated were median OS (mOS), median PFS (mPFS) and ORR (RECIST v1.1). A weighted Pearson correlation coefficient, with weights corresponding to the number of patients in the different treatment arms of the trials, was calculated between ORR/mOS, ORR/mPFS and mPFS/mOS in all arms, arms that included only patients with Child-Pugh A liver function, and arms in the first-line therapy setting. 95% confidence intervals (CIs) based on the empirical bootstrap re-sampling method are also reported. Results: Eighteen clinical trials (8 randomized trials and 10 multi-cohort trials) published between 2017 and 2021, including 3,246 patients across 32 treatment arms, were selected for inclusion in this meta-analysis. Ten trials included CPI monotherapy arms, 5 trials included CPI + TKI arms, 4 trials included CPI + anti-angiogenic monoclonal antibody arms, and 2 trials included CPI + CPI arms. There was 1 CPI + chemotherapy arm and 1 CPI + CPI + TKI arm in separate trials. Weighted Pearson correlation coefficients and corresponding 95% CIs are presented in the table. Conclusions: Our analysis suggests ORR/mOS, ORR/mPFS, and mPFS/mOS are positively correlated, with ORR/mPFS more strongly correlated compared to the other pairs, in patients with advanced HCC who were treated with CPI-based regimens. [Table: see text]
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Affiliation(s)
- Andrew X. Zhu
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA & Jiahui International Cancer Center, Jiahui Health, Shanghai, China
| | - Yong Lin
- Eli Lilly and Company, Indianapolis, IN
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Finn RS, Yau T, Hsu CH, De Toni EN, Goyal L, Galle PR, Qin S, Rao S, Sun F, Wang C, Widau RC, Zhu AX. Ramucirumab for patients with advanced hepatocellular carcinoma and elevated α-fetoprotein following a non-sorafenib based first-line therapy: Final results from an expansion cohort of REACH-2. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
423 Background: Patients (pts) with advanced hepatocellular carcinoma (HCC) and elevated α-fetoprotein (AFP) have poor prognosis, and need effective, well-tolerated treatment options. Ramucirumab has been shown to improve survival and is currently approved as second-line therapy for pts with a baseline elevated AFP that have progressed on prior sorafenib. However, new options now exist in the front-line setting. This global open-label expansion cohort of REACH-2 (NCT02435433) was initiated to study ramucirumab in pts with advanced HCC and baseline AFP ≥400 ng/mL following a non-sorafenib based systemic therapy, representing one of the first sequencing studies in HCC. Methods: This single-arm study investigated ramucirumab in pts with advanced HCC (BCLC stage C or B disease), Child-Pugh A, ECOG PS 0/1, and baseline AFP ≥400 ng/mL who received 1-2 prior systemic regimens for advanced HCC, excluding prior sorafenib or chemotherapy. Enrolled pts received ramucirumab 8 mg/kg IV once every 14 days. The primary endpoint was safety. Secondary endpoints included overall survival (OS), progression-free survival (PFS) objective response rate (RECIST 1.1) and time to progression (TTP). Final analysis occurred after all enrolled pts completed ≥ 3 treatment cycles or discontinued treatment. Results: 47 pts were treated at 21 investigative sites in the USA (n = 12), Taiwan (n = 10), mainland China (n = 8), Hong Kong (n = 8), Germany (n = 8), and Switzerland (n = 1). At baseline, these pts with 2nd to 3rd+ line advanced HCC had ECOG PS 1 (51%), with vascular invasion or extrahepatic spread (85%), viral hepatitis B (55%), BCLC stage C disease (92%), and a median AFP of 3236 ng/mL (IQR: 1332, 18210). Prior systemic regimens included lenvatinib (n = 20), checkpoint inhibitor (CPI) monotherapy (n = 11), CPI + antiangiogenic (n = 15), and CPI + CPI (n = 4). Grade ≥ 3 treatment-emergent adverse events (AEs) were reported in 27 (57%) pts and were deemed to be treatment-related in 11 (23%) pts. Grade ≥ 3 AEs occurring in ≥ 5% pts were hypertension (n = 5; 11%), proteinuria (n = 3; 6%), hyponatremia (6%) and AST increased (6%). Two deaths occurred due to treatment-related AEs on therapy or within 30 days of treatment discontinuation (myocardial infarction and upper GI hemorrhage). Median OS was 8.7 months (95% CI 4.6-12.2), median PFS was 1.7 months (95% CI 1.5-4.1), and median TTP was 2.8 months (95% CI 1.5-4.2). The number of pts achieving an objective response was 5 (10.6%, 95% CI 1.8-19.5), with a median duration of response of 8.3 months (95% CI 2.4-NR). Conclusions: This expansion cohort of REACH-2 represents a non-sorafenib sequencing study in pts with advanced HCC. The safety/efficacy profile of ramucirumab following a non-sorafenib based systemic therapy was consistent with that observed in pts who received prior sorafenib in the Ph3 REACH-2 study. Clinical trial information: NCT02435433.
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Affiliation(s)
| | - Thomas Yau
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chih-Hung Hsu
- Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Lipika Goyal
- Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Peter R. Galle
- Department of Internal Medicine, University Medical Center Mainz, Mainz, Germany
| | - Shukui Qin
- Department of Medical Oncology, People’s Liberation Army Cancer Center, Nanjing Bayi Hospital, Nanjing, China
| | | | | | | | | | - Andrew X. Zhu
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA & Jiahui International Cancer Center, Jiahui Health, Shanghai, China
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Galle PR, Kudo M, Llovet JM, Finn RS, Karwal M, Pezet D, Kim TY, Yang TS, Lonardi S, Tomasek J, Phelip JM, Touchefeu Y, Koh SJ, Stirnimann G, Liang K, Ogburn KD, Wang C, Abada P, Widau RC, Zhu AX. Ramucirumab in patients with previously treated advanced hepatocellular carcinoma: Impact of liver disease aetiology. Liver Int 2021; 41:2759-2767. [PMID: 34173317 DOI: 10.1111/liv.14994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) is a common complication of chronic liver disease with diverse underlying aetiologies. REACH/REACH-2 were global phase III studies investigating ramucirumab in advanced HCC (aHCC) following sorafenib treatment. We performed an exploratory analysis of outcomes by liver disease aetiology and baseline serum viral load. METHODS Meta-analysis was conducted in patients with aHCC and alpha-fetoprotein (AFP) ≥400 ng/mL (N = 542) from REACH/REACH-2 trials. Individual patient-level data were pooled with results reported by aetiology subgroup (hepatitis B [HBV] or C [HCV] and Other). Pre-treatment serum HBV DNA and HCV RNA were quantified using Roche COBAS AmpliPrep/COBAS TaqMan. Overall survival (OS) and progression-free survival (PFS) were evaluated using the Kaplan-Meier method and Cox proportional hazard model (stratified by study). RESULTS Baseline characteristics were generally balanced between arms in each subgroup (HBV: N = 225, HCV: N = 127, Other: N = 190). No significant difference in treatment effect by aetiology subgroup was detected (OS interaction P-value = .23). Median OS (ramucirumab vs placebo) in months was 7.7 versus 4.5 (HR 0.74, 95% CI 0.55-0.99) for HBV, 8.2 versus 5.5 (HR 0.82, 95% CI 0.55-1.23) for HCV and 8.5 versus 5.4 (HR 0.56, 95% CI 0.40-0.79) for Other. Ramucirumab showed similar overall safety profiles across subgroups. Worst outcomes were noted in patients with a detectable HBV load. Use of HBV antiviral therapy, irrespective of viral load, was beneficial for survival, liver function and liver-specific adverse events. CONCLUSIONS Ramucirumab improved survival across aetiology subgroups with a tolerable safety profile, supporting its use in patients with aHCC and elevated AFP.
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Affiliation(s)
- Peter R Galle
- Department of Internal Medicine, Mainz University Medical Center, Mainz, Germany
| | - Masatoshi Kudo
- Departments of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Josep M Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Translational Research in Hepatic Oncology, Liver Unit, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institució Catalana d'Estudis Avançats (ICREA), Barcelona, Spain
| | | | - Mark Karwal
- University of Iowa Hospitals and Clinics, University of Iowa Health Care, Iowa City, IA, USA
| | - Denis Pezet
- Estaing Hospital, Aubrac, Clermont-Ferrand, France
| | - Tae-You Kim
- Seoul National University Hospital, Seoul, Korea
| | | | - Sara Lonardi
- Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Jiri Tomasek
- Masaryk Memorial Cancer Institute, Masaryk University, Brno, Czech Republic
| | | | | | - Su-Jin Koh
- Division of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Guido Stirnimann
- University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Kun Liang
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | - Paolo Abada
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Jiahui International Cancer Center, Jiahui Health, Shanghai, China
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Kudo M, Finn RS, Morimoto M, Rau KM, Ikeda M, Yen CJ, Galle PR, Llovet JM, Daniele B, Lim HY, McIlwain DW, Yoshikawa R, Nakamura K, Liang K, Wang C, Abada P, Widau RC, Zhu AX. Ramucirumab for Patients with Intermediate-Stage Hepatocellular Carcinoma and Elevated Alpha-Fetoprotein: Pooled Results from Two Phase 3 Studies (REACH and REACH-2). Liver Cancer 2021; 10:451-460. [PMID: 34721507 PMCID: PMC8527922 DOI: 10.1159/000516605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Intermediate-stage hepatocellular carcinoma (HCC), as defined by Barcelona Clinic Liver Cancer (BCLC) stage B, is heterogeneous in terms of liver function and tumor burden. REACH and REACH-2 investigated ramucirumab in patients with HCC after prior sorafenib, with REACH-2 enrolling only patients with baseline α-fetoprotein (AFP) ≥400 ng/mL. An exploratory analysis of outcomes by BCLC stage was performed. METHODS A pooled meta-analysis of independent patient data (stratified by study) from REACH (AFP ≥ 400 ng/mL) and REACH-2 was performed. All patients had Child-Pugh A, Eastern Cooperative Oncology Group performance status 0-1, prior sorafenib treatment, and either HCC BCLC stage B (refractory/not amenable to locoregional therapy) or BCLC stage C. Patients were randomized to ramucirumab 8 mg/kg or placebo every 2 weeks. Median overall survival (OS) and progression-free survival were estimated by the Kaplan-Meier method. Treatment effects in BCLC stage B and C were evaluated by Cox proportional-hazards model; prognosis of BCLC staging for OS was evaluated by multivariate Cox proportional-hazards model. Tumor responses were evaluated according to Response Evaluation in Solid Tumors v1.1. Liver function was assessed with albumin-bilirubin score. RESULTS Baseline characteristics were generally balanced between treatment arms in each BCLC stage. BCLC staging trended as an independent prognostic factor for OS (B vs. C; hazard ratio [HR] 0.756 [95% CI 0.546-1.046]). Consistent treatment benefit was observed for ramucirumab versus placebo across BCLC stages. Median OS for ramucirumab versus placebo was 13.7 versus 8.2 months; HR (95%): 0.43 (0.23-0.83) and 7.7 versus 4.8 months; HR (95%): 0.72 (0.59-0.89) for BCLC stage B and C, respectively. Adverse events (AEs) were consistent with observations from both studies; hypertension was the most frequent grade ≥3 AE. Liver function was preserved throughout the study and similar between treatment arms in both BCLC stages. CONCLUSIONS Ramucirumab provided a better survival benefit irrespective of BCLC stage and was well tolerated without compromising liver function during treatment.
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Affiliation(s)
- Masatoshi Kudo
- Departments of Gastroenterology and Hepatology, Kindai University, Osaka, Japan
| | - Richard S. Finn
- Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Kun-Ming Rau
- Chang Gung Memorial Hospital − Kaohsiung Branch, Kaohsiung City, Taiwan
- Hematology-Oncology Department, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Chia-Jui Yen
- Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Peter R. Galle
- Department of Internal Medicine, Mainz University Medical Center, Mainz, Germany
| | - Josep M. Llovet
- Mount Sinai Liver Cancer Program, Department of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Liver Cancer Translational Research Laboratory, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | | | - Ho Yeong Lim
- Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | | | | | | | - Kun Liang
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | - Paolo Abada
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | - Andrew X. Zhu
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
- Jiahui International Cancer Center, Jiahui Health, Shanghai, China
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10
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Kudo M, Ikeda M, Galle PR, Yamashita T, Finn RS, Liang K, Wang C, Sakaguchi S, Abada P, Widau RC, Zhu AX. Ramucirumab in patients with advanced hepatocellular carcinoma and elevated α-fetoprotein: Outcomes by treatment-emergent ascites. Hepatol Res 2021; 51:715-721. [PMID: 33743189 DOI: 10.1111/hepr.13638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/17/2021] [Accepted: 03/12/2021] [Indexed: 12/30/2022]
Abstract
AIM The REACH and REACH-2 trials investigated ramucirumab versus placebo in patients with advanced hepatocellular carcinoma (HCC). Ascites is common in HCC and is associated with poorer outcomes. This exploratory, pooled meta-analysis of patients with baseline α-fetoprotein (AFP) ≥400 ng/ml investigated outcomes by treatment-emergent (TE) ascites in REACH and REACH-2. METHODS A pooled meta-analysis of independent patient data for participants (N = 542) with baseline AFP ≥400 ng/ml (stratified by study) from REACH and REACH-2 was carried out. Overall survival (OS) and progression-free survival (PFS) were evaluated by Kaplan-Meier estimator, and OS further assessed by Cox models. The effect of TE ascites on OS was evaluated by multivariate Cox models. RESULTS Treatment-emergent ascites developed in 66 patients (20.9%) in the ramucirumab group and 33 patients (14.8%) in the placebo group. When adjusted for treatment duration, the incidence rates per 100 patient-years of any grade TE ascites were 59.1 and 71.9 for the ramucirumab and placebo groups, respectively, and the incidence of grade ≥3 TE ascites were 13.4 and 19.6, respectively. Treatment-emergent ascites was associated with TE hypoalbuminemia (odds ratio 4.9; 95% confidence interval 2.5-9.3), but not TE proteinuria or hypertension. One patient discontinued ramucirumab treatment due to TE ascites. Ramucirumab treatment improved OS and PFS compared with placebo, irrespective of TE ascites. CONCLUSIONS When adjusted for treatment duration, the incidence of TE ascites was no higher in patients who received ramucirumab than in those who received placebo. Ramucirumab was well tolerated and provided a survival benefit irrespective of the development of TE ascites.
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Affiliation(s)
| | | | - Peter R Galle
- Medizinische Klinik und Poliklinik, Universitätsmedizin, Mainz, Germany
| | | | - Richard S Finn
- University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Kun Liang
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Paolo Abada
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Ryan C Widau
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA.,Jiahui International Cancer Center, Jiahui Health, Shanghai, China
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11
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Llovet JM, Singal AG, Villanueva A, Finn RS, Kudo M, Galle PR, Wang C, Widau RC, Gonzalez Gugel E, Zhu AX. Prognostic and predictive factors in patients treated with ramucirumab (RAM) with advanced hepatocellular carcinoma (aHCC) and elevated alpha-fetoprotein (AFP): Results from two phase III trials. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.4146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4146 Background: Elevated AFP in patients with aHCC is a poor prognostic factor with distinct molecular features, including high vascular endothelial growth factor (VEGF) signalling and increased angiogenesis. RAM, a human IgG1 monoclonal antibody, VEGF receptor 2 (VEGFR2) inhibitor, demonstrated improved survival vs placebo among patients with elevated AFP in the REACH-2 trial and is accepted as a standard of care for management of aHCC. We analyzed prognostic factors in patients with AFP ≥400 ng/mL and predictors of clinical benefit to RAM in an individual participant data (IPD) meta-analysis of the REACH and REACH-2 Phase III trials. Methods: Patients with aHCC, Child-Pugh A, ECOG performance status (PS) ≤1, and prior sorafenib were randomized (REACH 1:1; REACH-2 2:1) to RAM 8 mg/kg or Placebo Q2W. Meta-analysis was conducted in patients with AFP ≥400 ng/mL (n = 542). Univariate (UV) and multivariate (MV) analyses were performed using a Cox proportional hazard regression model. MV used the cut-off p-value < 0.1 from UV, irrespective of treatment arm. Overall survival (OS) was evaluated by Kaplan-Meier estimator and Cox models. To define predictors of RAM benefit, treatment-by-covariate interactions terms were evaluated. Results: In terms of prognosis assessed by MV analysis in patients with AFP ≥400 ng/mL, 6 variables among demographic and baseline disease characteristics were associated with poor OS in the RAM cohort (ECOG PS 1, AFP > 1000 ng/mL, Child-Pugh > A5, Extrahepatic site > 1, neutrophil-to-lymphocyte ratio > 3.2 and aspartate aminotransferase > 57 U/L) with an additional 3 factors identified within the whole cohort (macrovascular invasion presence, etiology HCV vs. Other and alkaline phosphatase ≥146). RAM benefit was present across all subgroups, including patients with very aggressive HCCs (AFP > 4000 ng/mL; HR: 0.64; 95% CI: 0.49-0.84) and those with nonalcoholic steatohepatitis /alcohol related aHCC (HR: 0.56; 95% CI: 0.40-0.79). Of note, two treatment-emergent (TE) events were the only factors that were significantly associated with improved RAM-related survival: TE-hypertension (p interaction = 0.0392) and TE-ascites (p interaction = 0.0001). However, these results should be interpreted with caution given that TE events are factors only observed after randomization. Conclusions: Several poor prognostic factors for OS were identified in patients with aHCC and elevated AFP. RAM provided an OS benefit irrespective of baseline prognostic covariates, with greater benefit observed in patients with aggressive HCC and those who experienced TE-hypertension or TE-ascites. Clinical trial information: NCT01140347; NCT02435433.
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Affiliation(s)
- Josep M. Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amit G. Singal
- Department of Internal Medicine at UT Southwestern Medical Center, Dallas, TX
| | - Augusto Villanueva
- Villanueva Lab, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sina, Mt. Sinai, NY
| | - Richard S. Finn
- Division of Hematology/Oncology, University of California, Los Angeles, Los Angeles, CA
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Peter R. Galle
- Department of Internal Medicine, Mainz University Medical Center, Mainz, Germany
| | | | | | | | - Andrew X. Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
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12
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Zhu AX, Finn RS, Kang YK, Yen CJ, Galle PR, Llovet JM, Assenat E, Brandi G, Motomura K, Ohno I, Daniele B, Vogel A, Yamashita T, Hsu CH, Gerken G, Bilbruck J, Hsu Y, Liang K, Widau RC, Wang C, Abada P, Kudo M. Serum alpha-fetoprotein and clinical outcomes in patients with advanced hepatocellular carcinoma treated with ramucirumab. Br J Cancer 2021; 124:1388-1397. [PMID: 33531690 PMCID: PMC8039038 DOI: 10.1038/s41416-021-01260-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/11/2020] [Accepted: 01/07/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Post hoc analyses assessed the prognostic and predictive value of baseline alpha-fetoprotein (AFP), as well as clinical outcomes by AFP response or progression, during treatment in two placebo-controlled trials (REACH, REACH-2). METHODS Serum AFP was measured at baseline and every three cycles. The prognostic and predictive value of baseline AFP was assessed by Cox regression models and Subpopulation Treatment Effect Pattern Plot method. Associations between AFP (≥ 20% increase) and radiographic progression and efficacy were assessed. RESULTS Baseline AFP was confirmed as a continuous (REACH, REACH-2; p < 0.0001) and dichotomous (≥400 vs. <400 ng/ml; REACH, p < 0.01) prognostic factor, and was predictive for ramucirumab survival benefit in REACH (p = 0.0042 continuous; p < 0.0001 dichotomous). Time to AFP (hazard ratio [HR] 0.513; p < 0.0001) and radiographic (HR 0.549; p < 0.0001) progression favoured ramucirumab. Association between AFP and radiographic progression was shown for up to 6 (odds ratio [OR] 5.1; p < 0.0001) and 6-12 weeks (OR 1.8; p = 0.0065). AFP response was higher with ramucirumab vs. placebo (p < 0.0001). Survival was longer in patients with an AFP response than patients without (13.6 vs. 5.6 months, HR 0.451; 95% confidence interval, 0.354-0.574; p < 0.0001). CONCLUSIONS AFP is an important prognostic factor and a predictive biomarker for ramucirumab survival benefit. AFP ≥ 400 ng/ml is an appropriate selection criterion for ramucirumab. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, REACH (NCT01140347) and REACH-2 (NCT02435433).
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Affiliation(s)
- Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Boston, MA, USA.
- Jiahui International Cancer Center, Jiahui Health, Shanghai, China.
| | - Richard S Finn
- Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yoon-Koo Kang
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Chia-Jui Yen
- National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Josep M Llovet
- Liver Cancer Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institut d'Investigations Biomèdiques August Pi i Sunyer, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Eric Assenat
- Department of Medical Oncology, CHU de Montpellier, Montpellier, France
| | | | | | - Izumi Ohno
- National Cancer Center Hospital East-Hepatobiliary and Pancreatic Oncology, Kashiwa, Japan
| | - Bruno Daniele
- Azienda Ospedaliera Gaetano Rummo, Benevento, Italy
- Ospedale del Mare, Napoli, Italy
| | - Arndt Vogel
- Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Chih-Hung Hsu
- National Taiwan University Hospital, Taipei, Taiwan, ROC
| | | | | | - Yanzhi Hsu
- Eli Lilly and Company, New York, NY, USA
| | - Kun Liang
- Eli Lilly and Company, Branchburg, NJ, USA
| | | | | | - Paolo Abada
- Eli Lilly and Company, Indianapolis, IN, USA
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13
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Reig M, Galle PR, Kudo M, Finn R, Llovet JM, Metti AL, Schelman WR, Liang K, Wang C, Widau RC, Abada P, Zhu AX. Pattern of progression in advanced hepatocellular carcinoma treated with ramucirumab. Liver Int 2021; 41:598-607. [PMID: 33188713 PMCID: PMC7898500 DOI: 10.1111/liv.14731] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/23/2020] [Accepted: 11/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Radiological progression patterns to first-line sorafenib have been associated with post-progression and overall survival in advanced hepatocellular carcinoma, but these associations remain unknown for therapies in second- and later-line settings. This post hoc analysis of REACH and REACH-2 examined outcomes by radiological progression patterns in the second-line setting of patients with advanced hepatocellular carcinoma treated with ramucirumab or placebo. METHODS Patients with advanced hepatocellular carcinoma, Child-Pugh A and Eastern Cooperative Oncology Group Performance Status 0 or 1 with prior sorafenib were randomized to receive ramucirumab 8mg/kg or placebo every 2 weeks. Among 625 patients with ≥1 progression pattern (new extrahepatic lesion [including new macrovascular invasion], new intrahepatic lesion, extrahepatic growth or intrahepatic growth), data were analysed by trial and for pooled individual patient data for REACH-2 and REACH (alpha-fetoprotein ≥400 ng/mL). Cox models evaluated prognostic implications of progression patterns on overall and post-progression survival. RESULTS Post-progression survival was worse among those with new extrahepatic lesions in REACH (HR 2.33, 95% CI 1.51-3.60), REACH-2 (HR 1.49, 95% CI 0.72-3.08) and the pooled population (HR 1.75, 95% CI 1.12-2.74) compared to other progression patterns. Overall survival was also significantly reduced in those with new extrahepatic lesions across studies. Ramucirumab provided an overall survival benefit across progression patterns, including patients with new extrahepatic lesions (HR 0.56, 95% CI 0.39-0.80) in the pooled population. CONCLUSIONS The emergence of new extrahepatic lesions in the second-line setting is a poor prognostic factor for post-progression survival. The benefit of ramucirumab for overall survival was consistent across progression patterns.
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Affiliation(s)
- Maria Reig
- Barcelona Clinic Liver Cancer Group, Liver UnitHospital Clínic of Barcelona. IDIBAPS. CIBERehd. University of BarcelonaBarcelonaSpain
| | - Peter R. Galle
- Department of Internal MedicineMainz University Medical CenterMainzGermany
| | - Masatoshi Kudo
- Departments of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Richard Finn
- Division of Hematology/OncologyUniversity of CaliforniaLos AngelesCAUSA
| | - Josep M. Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer InstituteIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- Translational Research in Hepatic Oncology, Liver UnitIDIBAPS, Hospital Clinic Barcelona, University of BarcelonaBarcelonaSpain
- Institució Catalana d’Estudis Avançats (ICREA)BarcelonaSpain
| | | | | | - Kun Liang
- Eli Lilly and CompanyBranchburgNJUSA
| | | | | | | | - Andrew X. Zhu
- Massachusetts General Hospital Cancer CenterHarvard Medical SchoolBostonMAUSA
- Jiahui International Cancer CenterJiahui HealthShanghaiChina
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14
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Kudo M, Galle PR, Brandi G, Kang YK, Yen CJ, Finn RS, Llovet JM, Assenat E, Merle P, Chan SL, Palmer DH, Ikeda M, Yamashita T, Vogel A, Huang YH, Abada PB, Yoshikawa R, Shinozaki K, Wang C, Widau RC, Zhu AX. Effect of ramucirumab on ALBI grade in patients with advanced HCC: Results from REACH and REACH-2. JHEP Rep 2020; 3:100215. [PMID: 33392490 PMCID: PMC7772786 DOI: 10.1016/j.jhepr.2020.100215] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023] Open
Abstract
Background & Aims The albumin–bilirubin (ALBI) grade/score is derived from a validated nomogram to objectively assess prognosis and liver function in patients with hepatocellular carcinoma (HCC). In this post hoc analysis, we assessed prognosis in terms of survival by baseline ALBI grade and monitored liver function during treatment with ramucirumab or placebo using the ALBI score in patients with advanced HCC. Methods Patients with advanced HCC, Child-Pugh class A with prior sorafenib treatment were randomised in REACH trials to receive ramucirumab 8 mg/kg or placebo every 2 weeks. Data were analysed by trial and as a meta-analysis of individual patient-level data (pooled population) from REACH (alpha-fetoprotein ≥400 ng/ml) and REACH-2. Patients from REACH with Child-Pugh class B were analysed as a separate cohort. The ALBI grades and scores were calculated at baseline and before each treatment cycle. Results Baseline characteristics by ALBI grade were balanced between treatment arms among patients in the pooled population (ALBI-1, n = 231; ALBI-2, n = 296; ALBI-3, n = 7). Baseline ALBI grade was prognostic for overall survival (OS; ALBI grade 2 vs. 1; hazard ratio [HR]: 1.38 [1.13–1.69]), after adjusting for other significant prognostic factors. Mean ALBI scores remained stable in both treatment arms compared with baseline and were unaffected by baseline ALBI grade, macrovascular invasion, tumour response, geographical region, or prior locoregional therapy. Baseline ALBI grades 2 and 3 were associated with increased incidence of liver-specific adverse events and discontinuation rates in both treatments. Ramucirumab improved OS in patients with baseline ALBI grade 1 (HR 0.605 [0.445–0.824]) and ALBI grade 2 (HR 0.814 [0.630–1.051]). Conclusions Compared with placebo, ramucirumab did not negatively impact liver function and improved survival irrespective of baseline ALBI grade. Lay summary Hepatocellular carcinoma is the third leading cause of cancer-related death worldwide. Prognosis is affected by many clinical factors including liver function both before and during anticancer treatment. Here we have used a validated approach to assess liver function using 2 laboratory parameters, serum albumin and bilirubin (ALBI), both before and during treatment with ramucirumab in 2 phase III placebo-controlled studies. We confirm the practicality of using this more simplistic approach in assessing liver function prior to and during anticancer therapy, and demonstrate ramucirumab did not impair liver function when compared with placebo. In patients with HCC, the severity of coexisting liver dysfunction is usually categorised using the Child-Pugh system. We demonstrate that the simpler albumin–bilirubin (ALBI) nomogram can be used for pre-treatment prognostication and on-treatment assessment. Ramucirumab did not negatively impact on liver function compared to placebo in patients with advanced HCC and elevated AFP. Liver-specific adverse events were reported more frequently in patients with more severe liver disfunction at baseline. Ramucirumab provided a survival benefit irrespective of baseline liver function in patients with advanced HCC and elevated AFP.
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Key Words
- AE, adverse event
- AESI, adverse event of special interest
- AFP, alpha-fetoprotein
- ALBI
- ALBI, albumin–bilirubin
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BCLC, Barcelona Clinic Liver Cancer
- BOR, best overall response
- BSC, best supportive care
- CP, Child-Pugh
- CR, complete response
- ECOG PS, Eastern Cooperative Oncology Group performance status
- EoT, end of treatment
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- IQR, inter-quartile range
- ITT, intent-to-treat
- Liver function
- MVI, macrovascular invasion
- OS, overall survival
- PD, progressive disease
- PR, partial response
- Prognosis
- Ram, ramucirumab
- SD, stable disease
- Safety
- Survival
- TACE, transarterial chemoembolisation
- Tumour response
- VEGF, vascular endothelial growth factor
- VEGFRs, vascular endothelial growth factor receptors
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Affiliation(s)
- Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University, Osaka-Sayama, Japan
| | - Peter R Galle
- Medizinische Klinik und Poliklinik, University Medical Center, Mainz, Germany
| | - Giovanni Brandi
- Department of Experimental, Diagnostic and Specialty Medicine, Saint Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Yoon-Koo Kang
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Chia-Jui Yen
- Division of Hematology and Oncology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Richard S Finn
- Division of Hematology/Oncology, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Josep M Llovet
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Institut d´Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Eric Assenat
- Département d'oncologie médicale, CHU de Montpellier, Montpellier, France
| | - Philippe Merle
- Hepatology and Gastroenterology Unit, Hôpital de la Croix Rousse, Lyon, France
| | - Stephen L Chan
- State Key Laboratory of Translational Oncology, Chinese University of Hong Kong, Hong Kong, People's Republic of China.,Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong, People's Republic of China
| | - Daniel H Palmer
- Molecular and Clinical Cancer Medicine, Clatterbridge Cancer Centre, University of Liverpool, Bebington, Wirral, UK
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Tatsuya Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Ishikawa, Japan
| | - Arndt Vogel
- Klinik für Gastroenterologie, Hepatologie and Endokrinologie, Hannover Medical School, Hannover, Germany
| | - Yi-Hsiang Huang
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | - Ryan C Widau
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical Center, Boston, MA, USA
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15
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Kudo M, Galle PR, Llovet JM, Finn RS, Vogel A, Motomura K, Assenat E, Merle P, Brandi G, Daniele B, Okusaka T, Tomášek J, Borg C, Dadduzio V, Morimoto M, Pracht M, Jen MH, Drove Ubreva N, Widau RC, Shinozaki K, Yoshikawa R, Zhu AX. Ramucirumab in elderly patients with hepatocellular carcinoma and elevated alpha-fetoprotein after sorafenib in REACH and REACH-2. Liver Int 2020; 40:2008-2020. [PMID: 32279446 DOI: 10.1111/liv.14462] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Limited data on treatment of elderly patients with hepatocellular carcinoma (HCC) increase the unmet need. REACH and REACH-2 were global phase III studies of ramucirumab in patients with HCC after prior sorafenib, where patients with alpha-fetoprotein (AFP) ≥400 ng/mL showed an overall ssurvival (OS) benefit for ramucirumab. These post-hoc analyses examined efficacy and safety of ramucirumab in patients with HCC and baseline AFP ≥ 400 ng/mL by three prespecified age subgroups (<65, ≥65 to <75 and ≥75 years). METHODS Individual patient data were pooled from REACH (baseline AFP ≥400 ng/mL) and REACH-2. Kaplan-Meier and Cox proportional hazards regression methods (stratified by study) assessed OS, progression-free survival (PFS), time to progression (TTP) and patient-reported outcomes (Functional Hepatobiliary System Index-8 [FHSI-8] score). RESULTS A total of 542 patients (<65 years: n = 302; ≥65 to <75 years: n = 160; ≥75 years: n = 80) showed similar baseline characteristics between ramucirumab and placebo. Older subgroups had higher hepatitis C and steatohepatitis incidences, and lower AFP levels, than the <65 years subgroup. Ramucirumab prolonged OS in patients <65 years (hazard ratio [HR], 0.753; 95% CI 0.581-0.975), ≥65 to <75 years (0.602; 0.419-0.866) and ≥75 years (0.709; 0.420-1.199), PFS and TTP irrespective of age. Ramucirumab showed similar overall safety profiles across subgroups, with a consistent median relative dose intensity ≥97.8%. A trend towards a delay in symptom deterioration in FHSI-8 with ramucirumab was observed in all subgroups. CONCLUSIONS In this post-hoc analysis, ramucirumab showed a survival benefit across age subgroups with a tolerable safety profile, supporting its use in advanced HCC with elevated AFP, irrespective of age, including ≥75 years.
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Affiliation(s)
- Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Peter R Galle
- Department of Internal Medicine, Mainz University Medical Center, Mainz, Germany
| | - Josep M Llovet
- Translational Research in Hepatic Oncology Group, Liver Unit, IDIBAPS, Hospital Clinic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard S Finn
- Department of Medicine, Division of Hematology/Oncology, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arndt Vogel
- Department of Hepatology, Gastroenterology and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Kenta Motomura
- Department of Hepatology, Aso Iizuka Hospital, Fukuoka, Japan
| | - Eric Assenat
- Department of Medical Oncology, CHU de Montpellier, Montpellier, France
| | - Philippe Merle
- Hepatology and Gastroenterology Unit, Croix-Rousse Hospital, Northern Lyon Hospital Group, Lyon, France
| | - Giovanni Brandi
- Department of Experimental, Diagnostic and Speciality Medicicne, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Bruno Daniele
- Department of Oncology, Azienda Ospedaliera Gaetano Rummo, Benevento, Italy
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jiří Tomášek
- Department of Complex Oncology Care, Masaryk Memorial Cancer Institute, Masaryk University, Brno, Czech Republic
| | - Christophe Borg
- Department of Medical Oncology, University Hospital of Besançon, Besançon, France
| | - Vincenzo Dadduzio
- Department of Clinical and Experimental Oncology, Medical Oncology Unit-1, Veneto Institute of Oncology (IOV) - IRCCS, Padua, Italy
| | - Manabu Morimoto
- Department of Hepatobiliary and Pancreatic Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Marc Pracht
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Min-Hua Jen
- Global Statistical Sciences, Eli Lilly and Company, Surrey, UK
| | | | - Ryan C Widau
- Oncology, Eli Lilly and Company, Indianapolis, IN, USA
| | - Kenta Shinozaki
- Medicines Development Unit Japan, Eli Lilly Japan K.K, Kobe, Japan
| | | | - Andrew X Zhu
- Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
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16
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Nishio M, Nishio K, Reck M, Garon EB, Imamura F, Kawaguchi T, Yamaguchi H, Ikeda S, Hirano K, Visseren-Grul CM, Widau RC, Zimmermann AH, Homma G, Enatsu S, Nakagawa K. RELAY+: Exploratory study of ramucirumab plus gefitinib in untreated patients (pts) with epidermal growth factor receptor ( EGFR)-mutated metastatic non-small cell lung cancer (NSCLC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.9564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9564 Background: The phase III randomized part of the RELAY study (Part B; RELAY; NCT02411448) showed a significant improvement in progression-free survival (PFS) for ramucirumab (RAM) plus erlotinib (ERL) vs placebo plus ERL in 449 untreated pts with EGFR-mutated metastatic NSCLC (median PFS: 19.4 vs 12.4 months; stratified hazard ratio: 0.59, 95% CI: 0.46–0.76, p<0.0001; 1-year PFS rate: 71.9% vs 50.7%). Here we report initial results from RELAY+ (additional cohort of RELAY; Part C), an open-label, single-arm, exploratory study evaluating RAM plus gefitinib (GEF) in East Asian pts. Methods: Previously untreated East Asian pts with metastatic NSCLC and EGFR exon 19 deletions (Ex19del) or exon 21 substitution mutation (Ex21.L858R) received RAM (10 mg/kg Q2W) plus GEF (250 mg/day) until disease progression or unacceptable toxicity. The 1-year PFS rate (primary endpoint, assuming a 1-year PFS rate of 55% for RAM+GEF), tumor response, biomarkers, and safety were assessed. EGFR T790M status (baseline/30-day follow-up) was assessed in liquid biopsy samples by Guardant360 NGS. Results: In total, 82 pts were enrolled (Japan: 68; Taiwan: 8; Korea: 6); 65.9% were female, 65.9% were never-smokers, and 43.9% had Ex19del. With median follow-up of 13.8 months (range: 2.6–20.2; censoring rate: 58.5%), the overall 1-year PFS rate (95% CI) was 65.0% (52.4–75.1), 67.2% (48.6–80.3) in pts with Ex19del (n=36), and 63.4% (45.0–77.1) in pts with Ex21.L858R (n=46). The objective response rate was 70.7% (95% CI: 59.6–80.3), disease control rate was 98.8% (95% CI: 93.4–100.0), and duration of response was immature at this point in time with a censoring rate of 56.9% where the median point estimate was 13.6 months (95% CI: 11.1–18.2). Post-progression EGFR T790M was seen in 7 of 9 (78%; 95% CI: 45.3–93.7) pts with 30-day follow-up NGS results in which EGFR activating mutation was detected. Grade ≥3 treatment-emergent adverse events reported in >5% of pts were ALT increased (23.2%), hypertension (22.0%), and AST increased (12.2%). Conclusions: With a 1-year PFS rate of 65.0%, the primary endpoint of RELAY+ was met. The efficacy of RAM+GEF in RELAY+ was similar to that of RAM+ERL in RELAY, and the safety profile of the combination was similar to that of the individual drugs. Clinical trial information: NCT02411448 .
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Affiliation(s)
- Makoto Nishio
- Thoracic Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kazuto Nishio
- Department of Genome Biology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Martin Reck
- LungenClinic, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Edward B. Garon
- David Geffen School of Medicine, University of California/TRIO-US Network, Los Angeles, CA
| | - Fumio Imamura
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomoya Kawaguchi
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hiroyuki Yamaguchi
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Satoshi Ikeda
- Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Katsuya Hirano
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
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17
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Zhu AX, Ikeda M, Galle PR, Yamashita T, Llovet J, Liang K, Wang C, Sakaguchi S, Abada P, Widau RC, Kudo M. Ramucirumab in patients with advanced HCC and elevated alpha-fetoprotein (AFP): Outcomes by treatment-emergent ascites. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.4644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4644 Background: REACH and REACH-2 investigated ramucirumab (RAM) vs placebo (PL) in patients (pts) with advanced HCC following sorafenib, with REACH-2 enrolling only pts with baseline AFP ≥400 ng/mL. Ascites is common in HCC and associated with poorer outcomes. An exploratory analysis of outcomes by treatment-emergent (TE)-ascites was done. Methods: Pts with HCC, Child-Pugh A, ECOG PS ≤1, prior sorafenib, and no clinically meaningful ascites were randomized (REACH 1:1; REACH-2 2:1) to RAM 8 mg/kg or PL Q2W. A pooled meta-analysis of independent pt data (stratified by study) from REACH-2 and REACH (AFP ≥400 mg/mL) was done. OS and PFS were evaluated by Kaplan-Meier estimator and Cox models. Prognosis of TE-ascites in OS was evaluated by multivariate Cox models (adjusted for baseline ECOG PS, AFP, macrovascular invasion (MVI), and treatment [trt]). Results: Baseline characteristics were generally balanced between TE-ascites and non-ascites pts; however, more pts with ascites had MVI at baseline. Any-grade ascites was reported at a higher rate in RAM than PL (66 [21%] vs 33 [15%] pts, respectively), with most being low grade. Rate of Gr ≥3 ascites was similar between arms (15 [5%] vs 9 [4%] pts). Median time to onset (43 vs 47 days) and median duration of ascites (13 vs 18 days) were similar in RAM vs PL, with furosemide (22%) and spironolactone (19%) as most common trt and paracentesis (18%) as most common procedure for ascites in both arms. Ascites trended as a prognostic factor for OS after adjustment (with vs without; HR=1.3, 95% CI: 0.99, 1.62). Ascites was more commonly linked with hypoalbuminemia (odds ratio 4.9, 95% CI: 2.5, 9.3), but was not associated with proteinuria or hypertension. TEAEs occurred more frequently in pts with ascites in both arms. The most frequent Gr ≥3 TEAE in pts with ascites was hypertension. One RAM pt discontinued trt due to ascites. RAM trt was beneficial irrespective of presence of ascites (Table), and pts with ascites received more post-discontinuation therapy on RAM than PL (18% vs 6%). Conclusions: Acknowledging limitations of sample size, RAM provided a survival benefit in pts who did or did not experience TE-ascites. RAM was well tolerated and no new safety findings were observed. Clinical trial information: NCT011400347; NCT02435433 . [Table: see text]
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Affiliation(s)
- Andrew X. Zhu
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | | | | | - Tatsuya Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | | | - Kun Liang
- Eli Lilly and Company, Indianapolis, IN
| | | | | | | | | | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
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18
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Kudo M, Finn RS, Morimoto M, Rau KM, Ikeda M, Yen CJ, Galle PR, Llovet JM, Daniele B, Lim HY, Liang K, Shinozaki K, Wang C, Yoshikawa R, Abada P, Widau RC, Zhu AX. Ramucirumab for patients with intermediate-stage hepatocellular carcinoma (HCC) and elevated alpha fetoprotein (AFP): Pooled results from two phase III studies (REACH and REACH-2). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
549 Background: Intermediate-stage HCC, as defined as Barcelona Clinic Liver Cancer (BCLC) Stage B, is a heterogeneous disease in terms of liver function and tumor load. REACH (NCT01140347) and REACH-2 (NCT02435433) investigated ramucirumab (RAM) in patients (pts) with HCC after prior sorafenib (SOR), with REACH-2 enrolling only pts with baseline AFP ≥400 ng/mL. An exploratory analysis of outcomes by BCLC stage was performed. Methods: All pts had HCC (BCLC stage C or B disease refractory/not amenable to locoregional therapy), Child-Pugh A, ECOG PS 0-1, and prior SOR. Pts were randomized to RAM 8 mg/kg or Placebo (P) Q2W. A pooled meta-analysis of independent pt data (stratified by study) from REACH-2 and REACH (AFP ≥400 mg/mL) was performed. Prognosis of BCLC staging in overall survival (OS) was evaluated by multivariate Cox PH model (adjusted for baseline AFP and treatment (trt) arm); Trt effects in BCLC stage B and C by Cox PH model; median OS/PFS were estimated by Kaplan-Meier method. Objective response rate (ORR) per RECIST v1.1, disease control rate (DCR), and adverse events (AEs) were also reported by BCLC. Liver function was assessed at baseline and prior to each trt with the Albumin-Bilirubin (ALBI) linear predictor. Results: Baseline characteristics were generally balanced between trt arms in each BCLC stage. BCLC staging trended as an independent prognosis factor for OS [B v C; HR = 0.756 (0.546, 1.046)]. A consistent trt benefit for RAM v P was observed across staging (Table). Grade ≥3 AEs were consistent with observations from both individual studies; hypertension was the most frequent grade ≥3 AE. No difference in liver function, as measured by ALBI, was observed between trt arms in either BCLC stage. Conclusions: Acknowledging limitations of sample size, RAM provided a survival benefit irrespective of BCLC stage. RAM was well tolerated and did not alter liver function compared to P. Clinical trial information: NCT01140347, NCT02435433. [Table: see text]
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Affiliation(s)
- Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University School of Medicine, Osaka, Japan
| | | | | | - Kun-Ming Rau
- Division of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Chia-Jui Yen
- Division of Hematology and Oncology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | | | | | - Ho Yeong Lim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Seoul, South Korea
| | - Kun Liang
- Eli Lilly and Company, Indianapolis, IN
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Galle PR, Kudo M, Llovet JM, Finn RS, Karwal M, Pezet D, Kim TY, Yang TS, Zagonel V, Tomasek J, Phelip JM, Touchefeu Y, Koh SJ, Stirnimann G, Wang C, Ogburn K, Abada P, Widau RC, Zhu AX. Impact of baseline hepatitis B viremia and management on outcomes in patients (Pts) with advanced hepatocellular carcinoma (HCC) and elevated alpha-fetoprotein (AFP): Outcomes from REACH-2. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
569 Background: REACH (NCT01140347) and REACH-2 (NCT02435433) were global, randomized, blinded, placebo (PL)-controlled phase 3 trials of ramucirumab (RAM) in pts with advanced HCC following sorafenib. REACH-2 limited enrollment to pts with AFP ≥400 ng/mL, and met its primary OS endpoint, consistent with the prespecified REACH subgroup with baseline AFP ≥400 ng/mL. Analysis of pooled individual pt data from REACH (AFP ≥400 ng/mL) and REACH-2 showed improved OS with RAM vs PL for pts with hepatitis B virus (HBV) etiology (7.7 vs 4.5 mos; HR 0.74, 95% CI 0.55, 0.99). Here we investigate survival and liver function in REACH-2 pts with HBV etiology tested for serum HBV DNA. Methods: Pts had advanced HCC, Child-Pugh A, ECOG PS 0/1, AFP ≥400 ng/mL, prior sorafenib treatment, and were randomized (2:1) to receive RAM 8 mg/kg or PL Q2W. Pretreatment serum HBV DNA was quantified by HBV-specific PCR (Roche) by a central lab. HBV DNA > 15 IU/mL were detectable (HBV DNA+), < 15 IU/mL were undetectable (HBV DNA-). OS in pooled treatment arms was evaluated using Kaplan-Meier method and Cox proportional hazards model. Liver function was assessed at baseline and before each cycle with the ALBI linear predictor. Outcomes were assessed by concomitant antiviral therapy. Adverse events (AEs) were graded by NCI-CTCAE v4.0. Results: Of 107 REACH-2 pts with HBV etiology, 106 had available PCR samples and were included in a pooled analysis (70 RAM and 36 PL pts). 48 pts were HBV DNA+ and 58 pts were HBV DNA-. HBV DNA+ pts had poorer median OS vs HBV DNA- pts (5.3 vs 10.1 mos, unstratified HR 1.45 95% CI 0.93, 2.28). HBV DNA+ pts taking concomitant antiviral therapy (n = 36) had numerically improved OS compared with those without (n = 12) (5.8 vs 4.0 mos). No difference in OS was noted for HBV DNA- pts by antiviral therapy use (n = 39 antiviral; n = 19 no antiviral) (10.2 vs 9.7 mos for yes vs no antiviral). In pts taking antiviral therapy, regardless of HBV DNA serology, liver function was improved and liver injury/failure related AEs were less frequent. Conclusions: Our data reinforce the use of antiviral therapy to improve outcomes in pts with advanced HBV-associated HCC and elevated AFP. Clinical trial information: NCT02435433.
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Affiliation(s)
| | | | | | | | - Mark Karwal
- University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Tae-You Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | | | | | - Jiri Tomasek
- Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Jean Marc Phelip
- Saint Etienne University Hospital, Saint Priest en Jarez, France
| | | | - Su-Jin Koh
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Guido Stirnimann
- University Clinic for Visceral Surgery, Freiburgstrasse, Switzerland
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20
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Reig M, Galle PR, Kudo M, Finn RS, Llovet JM, Schelman WR, Liang K, Wang C, Widau RC, Abada P, Zhu AX. Pattern of progression in advanced HCC treated with ramucirumab/placebo: Results from two randomized phase III trials (REACH/REACH-2). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
544 Background: REACH (NCT01140347) and REACH-2 (NCT02435433) studied ramucirumab (RAM) in pts with advanced hepatocellular carcinoma (HCC) following sorafenib; REACH-2 enrolled pts with baseline alpha-fetoprotein (AFP) ≥400 ng/mL, and met its primary endpoint of overall survival (OS) for RAM vs placebo. This post-hoc analysis examined radiological progression patterns (RPP) incidence every 6 weeks per RECIST v1.1, and if RPP were related to OS and post-progression survival (PPS). Methods: Pts with advanced HCC, Child-Pugh A, and ECOG PS 0-1 with prior sorafenib were randomized (REACH 1:1; REACH-2 2:1) to receive RAM 8 mg/kg or placebo Q2W. Among pts with ≥1 RPP (new extrahepatic lesion [NEH], new intrahepatic lesion [NIH], extrahepatic growth [EHG], or intrahepatic growth [IHG]), results were analyzed by trial and for pooled individual patient data of REACH-2 and REACH (AFP ≥400 ng/mL). Cox models evaluated treatment effect of RPP on OS, and prognostic implications of RPP on OS (adjusting baseline ECOG PS, AFP, macrovascular invasion, arm) and on PPS (adjusting ECOG PS, AFP at progression). Results: RPP incidence in the pooled population was: NEH 39%; NIH 24%; EHG 39%; IHG 37%. When examining NEH vs other RPP, PPS was worse among those with NEH in REACH (HR 2.33, 95% CI 1.51, 3.60), REACH-2 (HR 1.49, 95% CI 0.72, 3.08), and the pooled data (HR 1.75, 95% CI 1.12, 2.74). Use of post-discontinuation therapy may have influenced results. OS was also significantly reduced in those with NEH across studies (Table). RAM provided OS benefit in the pooled population, including pts with NEH (HR 0.56, 95% CI 0.39, 0.80). Conclusions: Acknowledging limitations of post-randomization RPP analysis, the emergence of NEH on RAM or placebo may be an independent poor prognostic factor for PPS. The impact of RAM on OS was consistent across all RPP subgroups. Clinical trial information: NCT01140347 and NCT02435433. [Table: see text]
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Affiliation(s)
- Maria Reig
- Barcelona Clinic Liver Cancer Group, Liver Unit, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | | | | | | | | | | | - Kun Liang
- Eli Lilly and Company, Indianapolis, IN
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21
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Herbst RS, Arkenau HT, Santana-Davila R, Calvo E, Paz-Ares L, Cassier PA, Bendell J, Penel N, Krebs MG, Martin-Liberal J, Isambert N, Soriano A, Wermke M, Cultrera J, Gao L, Widau RC, Mi G, Jin J, Ferry D, Fuchs CS, Petrylak DP, Chau I. Ramucirumab plus pembrolizumab in patients with previously treated advanced non-small-cell lung cancer, gastro-oesophageal cancer, or urothelial carcinomas (JVDF): a multicohort, non-randomised, open-label, phase 1a/b trial. Lancet Oncol 2019; 20:1109-1123. [PMID: 31301962 DOI: 10.1016/s1470-2045(19)30458-9] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pre-clinical and clinical evidence suggests that simultaneous blockade of VEGF receptor-2 (VEGFR-2) and PD-1 or PD-L1 enhances antigen-specific T-cell migration, antitumour activity, and has favourable toxicity. In this study, we aimed to assess the safety and preliminary antitumour activity of ramucirumab (an IgG1 VEGFR-2 antagonist) combined with pembrolizumab (an IgG4 PD-1 antagonist) in patients with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma, non-small-cell lung cancer, or urothelial carcinoma. METHODS We did a multicohort, non-randomised, open-label, phase 1a/b trial at 16 academic medical centres, hospitals, and clinics in the USA, France, Germany, Spain, and the UK. We enrolled adult patients aged 18 years or older with histologically confirmed gastric or gastro-oesophageal junction adenocarcinoma (cohorts A and B), non-small-cell lung cancer (cohort C), or urothelial carcinoma (cohort D), whose disease had progressed on one or two lines of previous therapy (for those with gastric or gastro-oesophageal junction adenocarcinoma) or one to three lines of previous therapy (for those with non-small-cell lung cancer and urothelial carcinoma) that included platinum (for all tumour types) or fluoropyrimidine or both (for gastric or gastro-oesophageal junction adenocarcinoma). Eligibility criteria included presence of measurable disease and an Eastern Cooperative Oncology Group performance status of 0-1. Patients with previously untreated gastric or gastro-oesophageal junction adenocarcinoma and non-small-cell lung cancer were also enrolled (in two additional separate cohorts); the results for these cohorts will be reported separately. The first 21-day treatment cycle was a dose-limiting toxicity observation period (phase 1a; safety run-in), followed by a phase 1b cohort expansion stage. Pembrolizumab 200 mg was administered intravenously on day 1, and intravenous ramucirumab was administered at 8 mg/kg on days 1 and 8 for cohort A or at 10 mg/kg on day 1 for cohorts B, C, and D, every 3 weeks, until disease progression or other discontinuation criteria were met. The primary endpoint was the safety and tolerability of ramucirumab in combination with pembrolizumab assessed by the incidence of adverse events in both phase 1a and 1b and as dose-limiting toxicities during phase 1a. The safety and activity analysis set included all patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT02443324, and is no longer enrolling patients. FINDINGS Between July 30, 2015 and June 24, 2016, we enrolled and treated 92 patients (41 with gastric or gastro-oesophageal junction adenocarcinoma, 27 with non-small-cell lung cancer, and 24 with urothelial carcinoma). Median follow-up was 32·8 months (IQR 28·1-33·6). During the first cycle of treatment (phase 1a safety run-in; n=11), one patient with gastro-oesophageal junction adenocarcinoma who received the 8 mg/kg dose of ramucirumab had grade 3 abdominal pain, colitis, hepatitis, interstitial lung disease, and jaundice, and grade 4 cholestasis, and died on treatment on day 40; the death was deemed related to progressive disease. No additional dose-limiting toxicities occurred and the decision was made to maintain the full planned doses of ramucirumab and pembrolizumab in phase 1b (n=81). Treatment-related adverse events occurred in 75 (82%) of 92 patients, the most common of which was fatigue (in 33 patients [36%]), predominantly of grade 1 or 2 severity. 22 patients (24%) had one or more treatment-related adverse events of grade 3 or worse, most commonly hypertension (six patients; 7%) and colitis (five patients; 5%). Serious adverse events occurred in 53 (58%) of 92 patients, and were deemed related to treatment in 22 (24%) patients. The most common treatment-related serious adverse events were abdominal pain in patients with gastric or gastro-oesophageal junction adenocarcinoma (in three [7%] of 41 patients); asthenia and myocardial infarction in patients with non-small-cell lung cancer (two [7%] of 27 patients), and colitis in patients with urothelial carcinoma (two [8%] of 24 patients). Six (7%) of 92 patients discontinued treatment because of treatment-related adverse events, and one death (from pulmonary sepsis in a patient with gastric or gastro-oesophageal junction adenocarcinoma) was deemed related to treatment. The number of patients achieving an objective response was three (7%; 95% CI 1·5-19·9) of 41 in the gastric or gastro-oesophageal junction adenocarcinoma cohort, eight (30%; 13·8-50·2) of 27 in the non-small-cell lung cancer cohort, and three (13%, 2·7-32·4) in the urothelial carcinoma cohort. INTERPRETATION Ramucirumab in combination with pembrolizumab showed a manageable safety profile with favourable antitumour activity in patients with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma, non-small-cell lung cancer, and urothelial carcinoma. Our results contribute to the growing evidence that supports dual inhibition of the VEGF-VEGFR2 and PD-1-PD-L1 pathways. This combination could be further explored with or without chemotherapy, especially for patients with tumours for which single-agent checkpoint inhibitors have shown no additional benefit over chemotherapy. FUNDING Eli Lilly and Company, and Merck and Co.
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Affiliation(s)
- Roy S Herbst
- Yale University School of Medicine, Yale Cancer Center, New Haven, CT, USA.
| | - Hendrik-Tobias Arkenau
- Drug Development Unit, Sarah Cannon Research Institute UK, London, UK; Cancer Institute, University College London, London, UK
| | | | - Emiliano Calvo
- Early Clinical Drug Development Program, START Madrid-HM Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Luis Paz-Ares
- Virgen del Rocio University Hospital, Seville, Spain
| | | | - Johanna Bendell
- Sarah Cannon Research Institute, Nashville, TN, USA; Tennessee Oncology, Nashville, TN, USA
| | - Nicolas Penel
- Centre Oscar Lambret, Lille, France; Department of Medical Oncology, Lille University, Lille, France
| | - Matthew G Krebs
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, NIHR Manchester Biomedical Research Centre and NIHR Manchester Clinical Research Facility, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan Martin-Liberal
- Vall d'Hebron Institute of Oncology, Barcelona, Spain; Catalan Institute of Oncology, Hospitalet, Barcelona, Spain
| | | | | | - Martin Wermke
- University Hospital Carl Gustav Carus, NCT/UCC Early Clinical Trial Unit, Dresden, Germany
| | | | - Ling Gao
- Eli Lilly and Company, New York, NY, USA
| | | | - Gu Mi
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Jin Jin
- Eli Lilly and Company, New York, NY, USA
| | | | - Charles S Fuchs
- Yale University School of Medicine, Yale Cancer Center, New Haven, CT, USA
| | - Daniel P Petrylak
- Yale University School of Medicine, Yale Cancer Center, New Haven, CT, USA
| | - Ian Chau
- Royal Marsden Hospital, Sutton, Surrey, UK
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Arkenau HT, Martin-Liberal J, Calvo E, Penel N, Krebs MG, Herbst RS, Walgren RA, Widau RC, Mi G, Jin J, Ferry D, Chau I. Ramucirumab Plus Pembrolizumab in Patients with Previously Treated Advanced or Metastatic Biliary Tract Cancer: Nonrandomized, Open-Label, Phase I Trial (JVDF). Oncologist 2018; 23:1407-e136. [PMID: 29853658 PMCID: PMC6292555 DOI: 10.1634/theoncologist.2018-0044] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/14/2018] [Indexed: 12/21/2022] Open
Abstract
LESSONS LEARNED Ramucirumab plus pembrolizumab revealed no unexpected safety findings in patients with advanced or metastatic biliary tract cancer, which is consistent with reports of other tumor cohorts within this phase Ia/b trial.Ramucirumab plus pembrolizumab did not demonstrate an improvement in overall survival when compared with historical controls in biomarker unselected, heavily pretreated patients with advanced or metastatic biliary tract cancer.Patients with programmed death-ligand 1 (PD-L1)-positive tumors had improved overall survival compared with patients with PD-L1-negative disease. BACKGROUND Few treatment options exist for patients with advanced biliary tract cancer (BTC) following progression on gemcitabine-cisplatin. Preclinical evidence suggests that simultaneous blockade of vascular endothelial growth factor receptor 2 (VEGFR-2) and programmed death 1 (PD-1) or programmed death-ligand 1 (PD-L1) enhances antitumor effects. We assessed the safety and efficacy of ramucirumab, an IgG1 VEGFR-2 antagonist, with pembrolizumab, an IgG4 PD-1 antagonist, in biomarker-unselected patients with previously treated advanced or metastatic BTC. METHODS Patients had previously treated advanced or metastatic adenocarcinoma of the gallbladder, intrahepatic and extrahepatic bile ducts, or ampulla of Vater. Ramucirumab 8 mg/kg was administered intravenously on days 1 and 8 with intravenous pembrolizumab 200 mg on day 1 every 3 weeks. The primary endpoint was safety and tolerability of the combination. Secondary endpoints included objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). RESULTS Twenty-six patients were treated at 12 centers in five countries. Hypertension was the most common grade 3 treatment-related adverse event (TRAE), occurring in five patients. One patient experienced a grade 4 TRAE (neutropenia), and no treatment-related deaths occurred. Objective response rate was 4%. Median progression-free survival and overall survival were 1.6 months and 6.4 months, respectively. CONCLUSION Ramucirumab-pembrolizumab showed limited clinical activity with infrequent grade 3-4 TRAEs in patients with biomarker-unselected progressive BTC.
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Affiliation(s)
- Hendrik-Tobias Arkenau
- Drug Development Unit, Sarah Cannon Research Institute UK, London, United Kingdom
- Cancer Institute, University College London, London, United Kingdom
| | - Juan Martin-Liberal
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
- Catalan Institute of Oncology (ICO), Barcelona, Spain
| | - Emiliano Calvo
- Early Clinical Drug Development Program, START Madrid-HM CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | | | - Matthew G Krebs
- The Christie NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
| | - Roy S Herbst
- Yale University School of Medicine, Yale Cancer Center, New Haven, Connecticut, USA
| | | | - Ryan C Widau
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Gu Mi
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Jin Jin
- Eli Lilly and Company, New York, New York, USA
| | - David Ferry
- Eli Lilly and Company, New York, New York, USA
| | - Ian Chau
- Royal Marsden Hospital, Sutton, United Kingdom
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23
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Ranoa DRE, Widau RC, Mallon S, Parekh AD, Nicolae CM, Huang X, Bolt MJ, Arina A, Parry R, Kron SJ, Moldovan GL, Khodarev NN, Weichselbaum RR. STING Promotes Homeostasis via Regulation of Cell Proliferation and Chromosomal Stability. Cancer Res 2018; 79:1465-1479. [PMID: 30482772 DOI: 10.1158/0008-5472.can-18-1972] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/08/2018] [Accepted: 11/21/2018] [Indexed: 12/19/2022]
Abstract
Given the integral role of stimulator of interferon genes (STING, TMEM173) in the innate immune response, its loss or impairment in cancer is thought to primarily affect antitumor immunity. Here we demonstrate a role for STING in the maintenance of cellular homeostasis through regulation of the cell cycle. Depletion of STING in human and murine cancer cells and tumors resulted in increased proliferation compared with wild-type controls. Microarray analysis revealed genes involved in cell-cycle regulation are differentially expressed in STINGko compared with WT MEFs. STING-mediated regulation of the cell cycle converged on NFκB- and p53-driven activation of p21. The absence of STING led to premature activation of cyclin-dependent kinase 1 (CDK1), early onset to S-phase and mitosis, and increased chromosome instability, which was enhanced by ionizing radiation. These results suggest a pivotal role for STING in maintaining cellular homeostasis and response to genotoxic stress. SIGNIFICANCE: These findings provide clear mechanistic understanding of the role of STING in cell-cycle regulation, which may be exploited in cancer therapy because most normal cells express STING, while many tumor cells do not.See related commentary by Gius and Zhu, p. 1295.
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Affiliation(s)
- Diana Rose E Ranoa
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Ryan C Widau
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Stephen Mallon
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Akash D Parekh
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Claudia M Nicolae
- Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Xiaona Huang
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Michael J Bolt
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Ainhoa Arina
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
| | - Renate Parry
- Translational Medicine, Varian Medical Systems Inc., Palo Alto, California
| | - Stephen J Kron
- Department of Molecular Genetics and Cellular Biology, The University of Chicago, Chicago, Illinois.,The Ludwig Center for Metastasis Research, The University of Chicago, Chicago, Illinois
| | - George-Lucian Moldovan
- Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Nikolai N Khodarev
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois. .,The Ludwig Center for Metastasis Research, The University of Chicago, Chicago, Illinois
| | - Ralph R Weichselbaum
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois. .,The Ludwig Center for Metastasis Research, The University of Chicago, Chicago, Illinois
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Reck M, Garon EB, Paz-Ares L, Ponce S, Jaime JC, Juan O, Nadal E, Kiura K, Widau RC, He S, Dalal R, Lee P, Nakagawa K. Randomized, Double-Blind Phase Ib/III Study of Erlotinib With Ramucirumab or Placebo in Previously Untreated EGFR-Mutant Metastatic Non-Small-Cell Lung Cancer (RELAY): Phase Ib Results. Clin Lung Cancer 2018; 19:213-220.e4. [PMID: 29317191 DOI: 10.1016/j.cllc.2017.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/17/2017] [Accepted: 11/10/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite the likelihood of an initial response to an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), EGFR-mutant non-small-cell lung cancer (NSCLC) patients develop disease progression. Antiangiogenic agents in combination with an EGFR TKI might provide additional benefit in patients with EGFR-mutant NSCLC. In this article we report safety, exposure, and progression-free survival (PFS) results for part A (phase Ib) of RELAY, a randomized, double-blind, phase Ib/III study investigating safety and efficacy of erlotinib (EGFR TKI) with ramucirumab (anti-vascular endothelial growth factor receptor-2 antibody) or placebo in first-line EGFR-mutant stage IV NSCLC. PATIENTS AND METHODS Eligible patients had untreated stage IV NSCLC, Eastern Cooperative Oncology Group performance status of 0 to 1, and activating EGFR mutation (exon 19 deletion or exon 21 L858R substitution). Patients received ramucirumab 10 mg/kg on day 1 of a repeating 14-day cycle and erlotinib 150 mg/d. Treatment continued until disease progression or unacceptable toxicity. The primary objective was to assess safety and tolerability, in terms of dose-limiting toxicities (DLTs), during the first 2 cycles. RESULTS Fourteen patients were treated and 12 were evaluable for DLTs. One patient experienced a DLT of Grade 3 elevated alanine aminotransferase during the DLT assessment period. Adverse events were reported in all patients, but were generally mild and manageable. The most common Grade 3 adverse events were hypertension, rash, and diarrhea. No serious or Grade 4 to 5 events occurred. Median PFS was 17.1 months (95% confidence interval, 8.8-not reached). Five patients continue receiving study treatment. CONCLUSION Ramucirumab with erlotinib showed no unexpected toxicities and encouraging clinical activity in part A. Phase III enrollment has been initiated, maintaining ramucirumab 10 mg/kg every 2 weeks with erlotinib 150 mg/d.
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Affiliation(s)
- Martin Reck
- Lungen Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | | | - Luis Paz-Ares
- Hospital Universitario Doce de Octubre and IIS i+12, CNIO, Universidad Complutense and Ciberonc, Madrid, Spain
| | - Santiago Ponce
- Hospital Universitario Doce de Octubre and IIS i+12, CNIO, Universidad Complutense and Ciberonc, Madrid, Spain
| | | | - Oscar Juan
- Hospital Universitario La Fe, Valencia, Spain
| | - Ernest Nadal
- Institut Català d'Oncologia, L'Hospitalet, Barcelona, Spain
| | | | | | - Shuang He
- Eli Lilly and Company, Indianapolis, IN
| | | | - Pablo Lee
- Eli Lilly and Company, Bridgewater, NJ
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Petrylak DP, de Wit R, Chi KN, Drakaki A, Sternberg CN, Nishiyama H, Castellano D, Hussain S, Fléchon A, Bamias A, Yu EY, van der Heijden MS, Matsubara N, Alekseev B, Necchi A, Géczi L, Ou YC, Coskun HS, Su WP, Hegemann M, Percent IJ, Lee JL, Tucci M, Semenov A, Laestadius F, Peer A, Tortora G, Safina S, Del Muro XG, Rodriguez-Vida A, Cicin I, Harputluoglu H, Widau RC, Liepa AM, Walgren RA, Hamid O, Zimmermann AH, Bell-McGuinn KM, Powles T. Ramucirumab plus docetaxel versus placebo plus docetaxel in patients with locally advanced or metastatic urothelial carcinoma after platinum-based therapy (RANGE): a randomised, double-blind, phase 3 trial. Lancet 2017; 390:2266-2277. [PMID: 28916371 DOI: 10.1016/s0140-6736(17)32365-6] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Few treatments with a distinct mechanism of action are available for patients with platinum-refractory advanced or metastatic urothelial carcinoma. We assessed the efficacy and safety of treatment with docetaxel plus either ramucirumab-a human IgG1 VEGFR-2 antagonist-or placebo in this patient population. METHODS We did a randomised, double-blind, phase 3 trial in patients with advanced or metastatic urothelial carcinoma who progressed during or after platinum-based chemotherapy. Patients were enrolled from 124 sites in 23 countries. Previous treatment with one immune-checkpoint inhibitor was permitted. Patients were randomised (1:1) using an interactive web response system to receive intravenous docetaxel 75 mg/m2 plus either intravenous ramucirumab 10 mg/kg or matching placebo on day 1 of repeating 21-day cycles, until disease progression or other discontinuation criteria were met. The primary endpoint was investigator-assessed progression-free survival, analysed by intention-to-treat in the first 437 randomised patients. This study is registered with ClinicalTrials.gov, number NCT02426125. FINDINGS Between July, 2015, and April, 2017, 530 patients were randomly allocated either ramucirumab plus docetaxel (n=263) or placebo plus docetaxel (n=267). Progression-free survival was prolonged significantly in patients allocated ramucirumab plus docetaxel versus placebo plus docetaxel (median 4·07 months [95% CI 2·96-4·47] vs 2·76 months [2·60-2·96]; hazard ratio [HR] 0·757, 95% CI 0·607-0·943; p=0·0118). A blinded independent central analysis was consistent with these results. An objective response was achieved by 53 (24·5%, 95% CI 18·8-30·3) of 216 patients allocated ramucirumab and 31 (14·0%, 9·4-18·6) of 221 assigned placebo. The most frequently reported treatment-emergent adverse events, regardless of causality, in either treatment group (any grade) were fatigue, alopecia, diarrhoea, decreased appetite, and nausea. These events occurred predominantly at grade 1-2 severity. The frequency of grade 3 or worse adverse events was similar for patients allocated ramucirumab and placebo (156 [60%] of 258 vs 163 [62%] of 265 had an adverse event), with no unexpected toxic effects. 63 (24%) of 258 patients allocated ramucirumab and 54 (20%) of 265 assigned placebo had a serious adverse event that was judged by the investigator to be related to treatment. 38 (15%) of 258 patients allocated ramucirumab and 43 (16%) of 265 assigned placebo died on treatment or within 30 days of discontinuation, of which eight (3%) and five (2%) deaths were deemed related to treatment by the investigator. Sepsis was the most common adverse event leading to death on treatment (four [2%] vs none [0%]). One fatal event of neutropenic sepsis was reported in a patient allocated ramucirumab. INTERPRETATION To the best of our knowledge, ramucirumab plus docetaxel is the first regimen in a phase 3 study to show superior progression-free survival over chemotherapy in patients with platinum-refractory advanced urothelial carcinoma. These data validate inhibition of VEGFR-2 signalling as a potential new therapeutic treatment option for patients with urothelial carcinoma. FUNDING Eli Lilly and Company.
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Affiliation(s)
| | | | - Kim N Chi
- British Columbia Cancer Agency, Vancouver, BC, Canada
| | | | | | | | | | - Syed Hussain
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | - Evan Y Yu
- University of Washington, Seattle, WA, USA
| | | | | | - Boris Alekseev
- PA Herzen Moscow Oncological Research Institute, Moscow, Russia
| | - Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Lajos Géczi
- National Institute of Oncology, Budapest, Hungary
| | - Yen-Chuan Ou
- Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Wen-Pin Su
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
| | | | | | - Jae-Lyun Lee
- Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Marcello Tucci
- Division of Medical Oncology, Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Andrey Semenov
- RBHI Ivanovo Regional Oncology Dispensary, Ivanovo, Russia
| | | | | | - Giampaolo Tortora
- University of Verona and Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Xavier Garcia Del Muro
- Institut Català d'Oncologia L'Hospitalet, IDIBELL, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | - Oday Hamid
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | - Thomas Powles
- Barts Cancer Institute, Queen Mary University of London, London, UK
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Zhang L, Widau RC, Herring BP, Gallagher PJ. Delta-like 1-Lysine613 regulates notch signaling. Biochim Biophys Acta 2011; 1813:2036-43. [PMID: 21985982 DOI: 10.1016/j.bbamcr.2011.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 08/25/2011] [Accepted: 08/26/2011] [Indexed: 11/26/2022]
Abstract
Delta ligands are important for regulating Notch signaling through transcellular stimulation of Notch receptors. The cytoplasmic tails of Delta ligands have multiple potential regulatory sites including several lysine residues that are putative targets for ubiquitination by the E3 ubiquitin ligases, Mind Bomb and Neuralized. To identify possible roles for specific lysine residues in the cytoplasmic tail of the Notch ligand Dll1 a mutational and functional analysis was performed. Examination of a panel of individual or clustered lysine mutants demonstrated that lysine 613 (K613) in the cytoplasmic tail of Dll1 is a key residue necessary for transcellular activation of Notch signaling. Multi-ubiquitination of the Dll1 mutant Dll1-K613R was altered compared to wild type Dll1, and the K613R mutation blocked the ability of Dll1 to interact with Notch1. Finally, mutation of K613 did not affect the stability of Dll1 or its ability to traffic to recycle to the plasma membrane, but did enhance the fraction associated with lipid rafts. Collectively these results suggest that the transcellular defect in Notch signaling attributed to residue K613 in cytoplasmic tail of Dll1 may result from altering its multi-ubiquitination and increasing its retention in lipid rafts.
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Affiliation(s)
- Liguo Zhang
- Department of Celluar & Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
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Widau RC, Zelivianskaia A, Skapek SX. Abstract 1141: p19Arf represses Pdgfrβ-driven pericyte proliferation in vivo. Cancer Res 2011. [DOI: 10.1158/1538-7445.am2011-1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
p19Arf, encoded by the mouse Arf gene, is a critical tumor suppressor with roles regulating cell cycle arrest in embryo development and suppressing oncogenesis. Previous studies established that p19Arf controls pericyte-like cells in the hyaloid vascular system (HVS) in the primary vitreous of the developing eye. Arf-deficient mice have hyperplasic expansion of pericytes in the vitreous, a developmental defect driven by excessive Pdgfrβ signaling. We have used complementary studies of cultured cells and mouse embryos to further explore the functional interactions between p19Arf and Pdgfrβ. To address whether Pdgfrβ acts as a mitogenic or a survival factor in the Arf-deficient mouse eye, we quantified cell proliferation and apoptosis at 13.5 days post coitum (dpc) in ArfGFP/GFP embryos that had or lacked Pdgfrβ. Cell proliferation, measured by BrdU incorporation, was increased by two-fold in the vitreous in the presence of Pdgfrβ. The presence or absence of Pdgfrβ did not change the small number of apoptotic cells in the vitreous of the eye. To explore mechanisms by which Arf expression impeded Pdgfrβ signaling, we used the 10T1/2 pericyte-like cell culture model to show that retroviral expression of p19Arf significantly repressed Pdgfrβ protein. Conversely, shRNA-mediated knockdown of p19Arf enhanced Pdgfrβ in serial-passaged mouse embryo fibroblasts (MEFs). In vivo measurements of Arf mRNA extracted from vitreous samples isolated by laser capture microdissection (LCM) from mouse embryos at 13.5 dpc demonstrated increased Pdgfrβ mRNA in Arf-deficient embryos as compared to wild-type. To confirm that p19Arf repressed Pdgfrβ transcription, we demonstrated that both mature and primary Pdgfrβ RNA transcripts were repressed in 10T1/2 cells. Co-transfection of p19Arf with a luciferase reporter plasmid driven by the Pdgfrβ promoter demonstrated that a 1.6kb segment of DNA conferred Arf-dependent regulation. Chromatin immunoprecipitation (ChIP) showed that p19Arf reduced RNA Pol II binding to the proximal Pdgfrβ promoter. Overall our data show that, in the absence of Arf, Pdgfrβ drives excess proliferation in cells that would normally express Arf in the developing eye. p19Arf acts to repress Pdgfrβ transcription, in part by blocking RNA Pol II binding to the proximal Pdgfrβ promoter. We are currently using additional ChIP assays to identify how the presence or absence of Arf influences the binding of several transcription factors known or suspected of regulating Pdgfrβ expression, and we are exploring the importance of the Arf-Pdgfrβ pathway deregulation in cancer models.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1141. doi:10.1158/1538-7445.AM2011-1141
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Widau RC, Jin Y, Dixon SA, Wadzinski BE, Gallagher PJ. Protein phosphatase 2A (PP2A) holoenzymes regulate death-associated protein kinase (DAPK) in ceramide-induced anoikis. J Biol Chem 2010; 285:13827-38. [PMID: 20220139 DOI: 10.1074/jbc.m109.085076] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The tumor suppressor, death-associated protein kinase (DAPK), is a Ca(2+)/calmodulin-regulated Ser/Thr kinase with an important role in regulating cytoskeletal dynamics. Autophosphorylation within the calmodulin-binding domain at Ser-308 inhibits DAPK catalytic activity. Dephosphorylation of Ser-308 by a previously unknown phosphatase enhances kinase activity and proteasome-mediated degradation of DAPK. In these studies, we identified two holoenzyme forms of protein phosphatase 2A (PP2A), ABalphaC and ABdeltaC, as DAPK-interacting proteins. These phosphatase holoenzymes dephosphorylate DAPK at Ser-308 in vitro and in vivo resulting in enhanced kinase activity of DAPK. The enzymatic activity of PP2A also negatively regulates DAPK levels by enhancing proteasome-mediated degradation of the kinase. Overexpression of wild type DAPK induces cell rounding and detachment in HEK293 cells; however, this effect is not observed following expression of an inactive DAPK S308E mutant. Finally, activation of DAPK by PP2A was found to be required for ceramide-induced anoikis. Together, our results provide a mechanism by which PP2A and DAPK activities control cell adhesion and anoikis.
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Affiliation(s)
- Ryan C Widau
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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