Neratinib as adjuvant therapy in patients with HER2 positive breast cancer: expert opinion

Neratinib is a tyrosine kinase receptor inhibitor used in the extended adjuvant therapy of early-stage breast cancer. After adjuvant trastuzumab therapy, neratinib reduces the risk of recurrence and, if taken within 1 year from trastuzumab, significantly improves the invasive disease-free survival of patients with early-stage human epidermal growth factor receptor-2 positive (HER2+) breast cancer with no increased risk of long-term toxicity. Diarrhea, the most common adverse event associated with neratinib use, deters some clinicians from prescribing this drug. However, neratinib-related toxicity is predictable, short-lived, mostly limited to the first month of treatment and can be managed with dose-escalation and prophylactic strategies. Thus, close surveillance and prompt management, relying on supportive care and administration schedule modification, allows discontinuation of treatment to be avoided.

Male Breast Cancer: From Molecular Genetics to Clinical Management

MBC is a rare disease accounting for almost 1% of all cancers in men and less than 1% of breast cancer. Emerging data on the genetic drivers of predisposition for MBC are available and different risk factors have been associated with its pathogenesis. Genetic alterations, such as pathogenetic variants in BRCA1/2 and other moderate-/low-penetrance genes, along with non-genetic risk factors, have been recognized as pathogenic factors for MBC. Preventive and therapeutic implications could be related to the detection of alterations in predisposing genes, especially BRCA1/2, and to the identification of oncogenic drivers different from FBC. However, approved treatments for MBC remain the same as FBC. Cancer genetic counseling has to be considered in the diagnostic work-up of MBC with or without positive oncological family history. Here, we review the literature, reporting recent data about this malignancy with a specific focus on epidemiology, and genetic and non-genetic risk factors. We introduce the perspective of cancer genetic counseling for MBC patients and their healthy at-risk family members, with a focus on different hereditary cancer syndromes.

MO234LIFE THREATENING MALIGNANT HYPERCALCEMIA IN BREAST CANCER: CAN THE NEPHROLOGIST CHANGE THE PATIENT DESTINY?

Background

Malignant hypercalcemia is a common complication in cancer patients and can be predictive of poor prognosis and advanced malignancy. Cancer-related mechanisms of hypercalcemia depends either on ectopic hypersecretion of humoral factors (PTH, PTH-like molecules, Vit D) by the tumoral mass, or on osteolysis due to bone invasion. In consideration of the high renal and cardiac impact of severe hypercalcemia, its prompt recognition and treatment can be lifesaving. AKI is frequently associated with malignant hypercalcemia and recognizes a multifactorial pathogenesis (direct renal vasoconstriction, volume depletion, tubule-interstitial damage, etc.). Substitutive renal treatment can be necessary, but not always viable in patients with poor physical performance and is a difficult choice in cancer patients with advanced malignancies.

Case report

We present the case of a 46 years old woman with an infiltrating non special type (NST) carcinoma of the right breast (luminal B, ER 70%, PgR 60%, Ki67 35%, HER2 1+). Unfortunately, she quickly progressed after a neoadjuvant treatment with Epirubicin/Cyclophosfamide (4 cycles) followed by Paclitaxel (10 cycles). A first line hormonal treatment (Palbociclib, Letrozole and LHRH analogous) was then started, but a further rapid disease progression was observed. A new biopsy showed a muted and more aggressive cancer phenotype (high grade triple negative carcinoma with no PDL1 expression). Due to a rapid worsening of general conditions with cognitive impairment, the patient was admitted to the Oncology department. Blood test showed severe hypercalcemia (corrected calcium: 23.26 mg/dl) and severe hypokalemic metabolic alkalosis (blood pH 7.57; HCO-3 32 mmol/l; K+ 2.6 mmol/l) associated to AKI (creatinine doubled to 1.42 mg/dl; eGFR 45 ml/min/1,73 mq). Alkaline phosphatase and Vitamin D were normal and iPTH was < 2 pg/ml. ECG showed a significant QTc prolongation to 550 msec. Imaging exams revealed lung metastasis, lung carcinomatous lymphangitis and bilateral pleural effusion, while Bone Scan showed a low caption limited to right ribs. Oncologists and Intensive Care Physicians referred to our Nephrology and Dialysis Unit proposing Hemodialysis support. In consideration of the preserved diuresis, the advanced disease stage and the unstable hemodynamics, our advice was instead for a conservative medical approach. An i.v. infusion of 4000 ml NaCl 0.9% + KCl 60 mEq/24h; a continuous i.v. infusion of Furosemide 5mg/h were started and maintained for several days, leading to a progressive and full renal function recovery (creatinine decreased to 0.7 mg/dl) and metabolic alkalosis correction. However, corrected calcium remained largely over target, being 16.3 mg/dl. Sodium bicarbonate 80 mEq, Zoledronic acid 4 mg and Desametasone 4mg/day were administered and at day 16 even calcium was in normal range. We realized that this was a favourable window for acting on the underlaying cause of malignant hypercalcemia, that likely was the aberrant secretion of non-dosable PTH-like molecule(s). Thus, we suggested the Oncologist to start chemotherapy, and they were allowed to treat the patient with Carboplatin/Gemcitabine. The patient was successfully treated with stabilization of normocalcemia and is still alive.

Conclusion

Malignant hypercalcemia is a life-threatening complication in advanced malignancies. Our case report highlights the key role of the nephrologist in treating a complex and fragile oncologic patient, achieving the full correction of several severe renal disorders, hemodialysis avoidance and survival improvement.

Inactivating mutations and X-ray crystal structure of the tumor suppressor OPCML reveal cancer-associated functions

OPCML, a tumor suppressor gene, is frequently silenced epigenetically in ovarian and other cancers. Here we report, by analysis of databases of tumor sequences, the observation of OPCML somatic missense mutations from various tumor types and the impact of these mutations on OPCML function, by solving the X-ray crystal structure of this glycoprotein to 2.65 Å resolution. OPCML consists of an extended arrangement of three immunoglobulin-like domains and homodimerizes via a network of contacts between membrane-distal domains. We report the generation of a panel of OPCML variants with representative clinical mutations and demonstrate clear phenotypic effects in vitro and in vivo including changes to anchorage-independent growth, interaction with activated cognate receptor tyrosine kinases, cellular migration, invasion in vitro and tumor growth in vivo. Our results suggest that clinically occurring somatic missense mutations in OPCML have the potential to contribute to tumorigenesis in a variety of cancers.

Human epidermal growth factor receptor 2 dual blockade with trastuzumab and pertuzumab in real life: Italian clinical practice versus the CLEOPATRA trial results

OBJECTIVES

Given their inclusion and exclusion criteria, randomized clinical trials (RCT) might not include a population that truly mirrors real life (RL). This raises concerns about the applicability of RCT results in clinical practice. We evaluated the efficacy of anti-HER2 treatment with pertuzumab combined with trastuzumab and a taxane as first-line treatment for HER2-positive metastatic breast cancer in a RL setting, and compared the safety results obtained in our population versus the experimental cohort of the CLEOPATRA RCT, which led to the approval of this therapy.

MATERIALS AND METHODS

Patients treated with trastuzumab, pertuzumab and a taxane were enrolled in this retrospective study. We compared the tumor features and the patients' characteristics of the RL cohort to those of the CLEOPATRA cohort. We also compared the median progression-free survival (PFS) in the RL population versus specific patients' subgroups.

RESULTS

RL patients were more frequently HR-positive, less likely to have visceral metastases (P < .001 for both) and had more frequently received (neo)adjuvant hormone therapy or trastuzumab than CLEOPATRA patients (P = .004 and P < .001, respectively). The median number of anti-HER2 cycles was 8 vs 24 and the median number of cycles was 7 vs 8 for docetaxel in the RL versus CLEOPATRA population, respectively. Adverse reactions of all grades were less frequent in RL. Median PFS was 27.8 months in the RL population and the treatment was equally effective in all patients' subgroups.

CONCLUSION

This study provides compelling evidence that pertuzumab, trastuzumab and a taxane are effective and safe also in a clinical scenario.

Nab-paclitaxel and gemcitabine in advanced pancreatic cancer: The one-year experience of the National Cancer Institute of Naples

497

Background: Pancreas adenocarcinoma is the sixth cause of cancer-related death worldwide and the mortality is increasing in the Western Countries. Recently, the association between nab-paclitaxel (nab-P) and gemcitabine (GEM) has significantly improved progression-free (PFS) and overall survival (OS) compared to GEM monotherapy (PFS: 5.5 vs 3.7 months; OS: 8.5 vs 6.7 months). Methods: Patients affected by metastatic pancreas adenocarcinoma were treated at the Department of Abdominal Oncology of the National Cancer Institute of Naples from July 2015 to July 2016 with nab-P at 125 mg per square meter of body-surface area followed by GEM at 1000 mg per square meter on days 1, 8, and 15 every 4 weeks. Computed tomography (CT) was done every three months of therapy. Toxicity was graded with NCI-CTC criteria v4.0. Objective responses were evaluated with RECIST. Analysis of time-to-progression is only descriptive. Pain was evaluated with a visual analogic scale. Results: Twenty-three patients were treated. Median age was 67 years (range: 45-81); 8 patients were ≥ 70 years old. Performance Status (PS) ECOG was 2 in 8 patients, 1 in 10 and 0 in 5. Twelve patients presented with diffuse hepatic metastases, 4 with carcinosis, 7 with more than one organ involvement. They received a median number of 13 administrations (range: 3-32) of therapy. During therapy Nab-P was reduced at 100 mg per square meter in all patients. The most common G3/G4 adverse events were neutropenia (13.0% G4, 8.6% G3, none was febrile), neuropathy (30.4% G3) and asthenia (G3 17.3%). The disease control rate was 43.4% (PR+SD 10/23); PR was registered in three patients (response rate: 13.0%). Twelve patients progressed and seven dead at September 20. The median time-to-progression was 7.9 months (95% confidence interval 5.8-11.2). After three months of therapy the PS improved in 14 patients as well as pain in 18 patients. Conclusions: We present an experience with nab-P and GEM association in a series with poor PS and highly metastatic disease relatively to the previous randomized study. The schedule is feasible with nab-P at 100 mg per square meter and it achieves a good disease control rate as well as a clinical benefit.

Capecitabine plus gemcitabine in thymic epithelial tumors: final analysis of a Phase II trial

ABSTRACT 

Background: A multi-institutional Phase II trial was initiated in 2005 to test the combination gemcitabine and capecitabine in patients with thymic epithelial malignancies (TETs). Patients & methods: Patients with histologic confirmation of TET diagnosis by central review who had received >1 systemic chemotherapy treatment were included. Patients received oral capecitabine (650 mg/mq twice daily on days 1–14) and intravenous gemcitabine (1000 mg/mq on days 1 and 8 every 3 weeks). Results: Of the 30 patients included (18 men, 12 women; median age: 57 years, range: 48–61 years), the majority (73%) had thymoma, and the remaining thymic carcinoma. Eight patients developed grade 3–4 neutropenia. A total of 12 patients had a response. Median progression-free survival was 11 months (range: 6.5–16.5). Conclusion: Capecitabine and gemcitabine is highly active in TETs.