Gene Expression Signatures Predictive of Bevacizumab/Erlotinib Therapeutic Benefit in Advanced Nonsquamous Non-Small Cell Lung Cancer Patients (SAKK 19/05 trial)

PURPOSE

We aimed to identify gene expression signatures associated with angiogenesis and hypoxia pathways with predictive value for treatment response to bevacizumab/erlotinib (BE) of nonsquamous advanced non-small cell lung cancer (NSCLC) patients.

EXPERIMENTAL DESIGN

Whole-genome gene expression profiling was performed on 42 biopsy samples (from SAKK 19/05 trial) using Affymetrix exon arrays, and associations with the following endpoints: time-to-progression (TTP) under therapy, tumor-shrinkage (TS), and overall survival (OS) were investigated. Next, we performed gene set enrichment analyses using genes associated with the angiogenic process and hypoxia response to evaluate their predictive value for patients' outcome.

RESULTS

Our analysis revealed that both the angiogenic and hypoxia response signatures were enriched within the genes predictive of BE response, TS, and OS. Higher gene expression levels (GEL) of the 10-gene angiogenesis-associated signature and lower levels of the 10-gene hypoxia response signature predicted improved TTP under BE, 7.1 months versus 2.1 months for low versus high-risk patients (P = 0.005), and median TTP 6.9 months versus 2.9 months (P = 0.016), respectively. The hypoxia response signature associated with higher TS at 12 weeks and improved OS (17.8 months vs. 9.9 months for low vs. high-risk patients, P = 0.001).

CONCLUSIONS

We were able to identify gene expression signatures derived from the angiogenesis and hypoxia response pathways with predictive value for clinical outcome in advanced nonsquamous NSCLC patients. This could lead to the identification of clinically relevant biomarkers, which will allow for selecting the subset of patients who benefit from the treatment and predict drug response.

Orlistat-induced fulminant hepatic failure

Orlistat was approved by the Food and Drug Administration in 1998 and has been shown to be superior to placebo in achieving weight loss. It is generally well tolerated. However, severe liver injury has been reported. We present a case of hepatic failure in a patient taking orlistat. A 54-year-old African-American woman with hypertension presented with hepatic failure. She had noticed increasing fatigue, jaundice and confusion. She used alcohol sparingly and denied tobacco or illicit drug use, but had been taking over-the-counter orlistat for the past two months. Physical examination revealed scleral icterus, jaundice, asterixis and slow speech. Laboratory testing showed markedly abnormal liver function tests with coagulopathy. Acute viral and autoimmune serologies were negative, as was toxicology screen. Liver biopsy showed necrotic hepatic parenchyma likely secondary to drug toxicity. Based upon her clinical presentation and time course, the pattern of liver injury seen on liver biopsy and lack of an alternative plausible explanation, her liver failure was most likely associated with orlistat use. She continued to deteriorate and ultimately underwent orthotopic liver transplantation. Fourteen cases of severe liver injury associated with orlistat use have been reported, four of which are detailed in the literature. This is the second published case of liver failure associated with over-the-counter orlistat usage. Clinicians should be aware of the growing number of cases associating liver injury and orlistat use and carefully monitor their patients on this medication for signs of hepatic dysfunction.

Circulating microRNA profiling in patients with advanced non-squamous NSCLC receiving bevacizumab/erlotinib followed by platinum-based chemotherapy at progression (SAKK 19/05)

OBJECTIVES

Molecular subclassification of non small-cell lung cancer (NSCLC) is essential to improve clinical outcome. This study assessed the prognostic and predictive value of circulating micro-RNA (miRNA) in patients with non-squamous NSCLC enrolled in the phase II SAKK (Swiss Group for Clinical Cancer Research) trial 19/05, receiving uniform treatment with first-line bevacizumab and erlotinib followed by platinum-based chemotherapy at progression.

MATERIALS AND METHODS

Fifty patients with baseline and 24 h blood samples were included from SAKK 19/05. The primary study endpoint was to identify prognostic (overall survival, OS) miRNA's. Patient samples were analyzed with Agilent human miRNA 8x60K microarrays, each glass slide formatted with eight high-definition 60K arrays. Each array contained 40 probes targeting each of the 1347 miRNA. Data preprocessing included quantile normalization using robust multi-array average (RMA) algorithm. Prognostic and predictive miRNA expression profiles were identified by Spearman's rank correlation test (percentage tumor shrinkage) or log-rank testing (for time-to-event endpoints).

RESULTS

Data preprocessing kept 49 patients and 424 miRNA for further analysis. Ten miRNA's were significantly associated with OS, with hsa-miR-29a being the strongest prognostic marker (HR=6.44, 95%-CI 2.39-17.33). Patients with high has-miR-29a expression had a significantly lower survival at 10 months compared to patients with a low expression (54% versus 83%). Six out of the 10 miRNA's (hsa-miRN-29a, hsa-miR-542-5p, hsa-miR-502-3p, hsa-miR-376a, hsa-miR-500a, hsa-miR-424) were insensitive to perturbations according to jackknife cross-validation on their HR for OS. The respective principal component analysis (PCA) defined a meta-miRNA signature including the same 6 miRNA's, resulting in a HR of 0.66 (95%-CI 0.53-0.82).

CONCLUSION

Cell-free circulating miRNA-profiling successfully identified a highly prognostic 6-gene signature in patients with advanced non-squamous NSCLC. Circulating miRNA profiling should further be validated in external cohorts for the selection and monitoring of systemic treatment in patients with advanced NSCLC.

Efficacy of cetuximab in metastatic castration-resistant prostate cancer might depend on EGFR and PTEN expression: results from a phase II trial (SAKK 08/07)

PURPOSE

The EGF receptor (EGFR) is overexpressed in the majority of metastatic castration-resistant prostate cancers (mCRPC) and might represent a valid therapeutic target. The combination of docetaxel and cetuximab, the monoclonal antibody against EGFR, has not been tested in patients with prostate cancer.

EXPERIMENTAL DESIGN

Patients with mCRPC progressing during or within 90 days after at least 12 weeks of docetaxel were included in this phase II trial. Treatment consisted of docetaxel (75 mg/m(2) every 3 weeks or 35 mg/m(2) on days 1, 8, 15 every 4 weeks) in combination with cetuximab (400 mg/m(2) on day 1 and then 250 mg/m(2) weekly). The primary endpoint was progression-free survival (PFS) at 12 weeks defined as the absence of prostate-specific antigen (PSA), radiographic, or clinical progression. Evaluation of known biomarkers of response and resistance to cetuximab (EGFR, PTEN, amphiregulin, epiregulin) was conducted.

RESULTS

Thirty-eight patients were enrolled at 15 Swiss centers. Median age was 68 years and median PSA was 212 ng/mL. PFS at 12 weeks was 34% [95% confidence interval (CI), 19%-52%], PFS at 24 weeks was 20%, and median overall survival (OS) was 13.3 months (95% CI, 7.3-15.4). Seven patients (20%) had a confirmed ≥ 50% and 11 patients (31%) a confirmed ≥ 30% PSA decline. About 47% of enrolled patients experienced grade 3 and 8% grade 4 toxicities. A significantly improved PFS was found in patients with overexpression of EGFR and persistent activity of PTEN.

CONCLUSIONS

EGFR inhibition with cetuximab might improve the outcome of patients with mCRPC. A potential correlation between EGFR overexpression, persistent expression of PTEN, and EGFR inhibition should be investigated further.

Abstract 4607: A translational study of Tumor Treating Fields in non small cell lung cancer

Background Lung cancer is the second most common cancer and the leading cause of cancer related death in the US. Non-small-cell-lung cancer (NSCLC) accounts for approximately 80% of all cases of lung cancer. Prognosis of NSCLC remains poor despite extensive research. Tumor Treating Fields (TTF, TTFields) are low intensity, intermediate frequency alternating electric fields that have been demonstrated to disrupt cancer cell replication. A phase III clinical trial has previously demonstrated the efficacy of TTF in glioblastoma patients. Objectives This study was designed to test the effects of TTF in NSCLC, both as a single therapy and in combination with chemotherapies, from bench to the bedside. Methods H1299 (Human NSCLC) and LLC1 (murine Lewis lung carcinoma) cells were cultured while being subjected to different frequencies of low intensity (1-2 V/cm) TTF alone or in combination with different chemotherapies (cisplatin, pemetrexed, erlotinib and paclitaxel). An autologous model of C57BL/5 mice bearing LLC1 tumors was used to test the in vivo application of continuous TTF. A phase II clinical trial of TTF in combination with pemetrexed (standard regimen) was performed in 42 stage IIIB and IV NSCLC patients following progression after at least one line of chemotherapy. Treatment was made using 2 pairs of insulated, non-invasive transducer arrays applied to the skin of the thorax. Results In-vitro: The treatment of H1299 and LLC1 cultures with TTF for 72 hours had a significant inhibitory effect on proliferation in both cell lines, compared to control cultures. The optimal frequency for culture growth inhibition was 150 kHz. The combination of optimal frequency-TTF with different concentrations of chemotherapeutic agents led to further decrease in culture growth rate, compared to TTF-naïve cultures. In-vivo: TTF resulted in a significant reduction of approximately 30% in tumor volume and weight in mice bearing NSCLC tumors, as a monotherapy. This therapeutic effect almost doubled in mice that were treated with pemetrexed concomitant to the TTF. No pathological changes could be demonstrated in healthy tissues excised from TTF-treated animals. Clinical: NSCLC human patients with advanced-stage disease were treated with TTF (median of 11.2 hours/day) using the NovoTTF-100L System (NovoCure Ltd.) in combination with pemetrexed. Median progression-free survival was 23 weeks, median overall survival was 13 months and 1-year-survival was 54% - an improvement over pemetrexed-treated historical controls. The only device-related adverse event was mild to moderate contact dermatitis. Conclusions The inhibitory effect of TTF in different NSCLC models was demonstrated both as a single treatment and in combination with chemotherapies. The promising efficacy and low toxicity of TTF therapy combined with pemetrexed in NSCLC patients should lead to further clinical investigation of TTF as a potential treatment for NSCLC patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4607. doi:1538-7445.AM2012-4607

A phase I study of the oral platinum agent satraplatin in sequential combination with capecitabine in the treatment of patients with advanced solid malignancies

BACKGROUND

The broad spectrum of antitumor activity of both the oral platinum analogue satraplatin (S) and capecitabine (C), along with the advantage of their oral administration, prompted a clinical study aimed to define the maximum tolerated dose (MTD) of the combination.

PATIENTS AND METHODS

Four dose levels of S (mg/m(2)/day) and C (mg/m(2)/day) were evaluated in adult patients with advanced solid tumors: 60/1650, 80/1650, 60/2000, 70/2000; a course consisted of 28 days with sequential administration of S (days 1-5) and C (days 8-21) followed by one week rest.

RESULTS

Thirty-seven patients were treated, 24 in the dose escalation and 13 in the expansion phase; at the MTD, defined at S 70/C 2000, two patients presented dose limiting toxicities: lack of recovery of neutropenia by day 42 and nausea with dose skip of C. Most frequent toxicities were nausea (57%), diarrhea (51%), neutropenia (46%), anorexia, fatigue, vomiting (38% each). Two partial responses were observed in platinum sensitive ovarian cancer and one in prostate cancer.

CONCLUSION

At S 70/C 2000 the combination of sequential S and C is tolerated with manageable toxicities; its evaluation in platinum and fluorouracil sensitive tumor types is worthwhile because of the easier administration and lack of nephro- and neurotoxicity as compared to parent compounds.

Non-small-cell lung cancer: multimodality approach in stage-III resectable disease

The long-term results of surgery +/- radiotherapy in patients with operable disease of locally advanced non-small-cell lung cancer are discouraging. In the vast majority, disseminated microscopic disease, resulting in the later occurrence of distant metastases, contributes substantially to this poor long-term outcome. The further development of multimodality treatment approaches in randomised trials, including effective systemic therapy, is necessary. These approaches and the current status of multimodality treatment strategies of resectable locally advanced non-small-cell lung cancer are discussed.

Development of treatment strategies in locally advanced non-small cell lung cancer (take home messages)

In the last decade combined modality treatment approaches contributed to the progress of therapy in locally advanced non-small cell lung cancer. With this management strategies younger patients (<70 years) with locally advanced disease and a good performance status (ECOG 0,1) have survival benefits compared to sole locoregional treatment. Further development of these treatment concepts is warranted. To adopt optimal tailored therapy to prognostic consistent patient groups exact staging of disease is mandatory. Moreover, refinements of the staging system would be helpful to identify in defined anatomical stages, patient subgroups who will benefit from systemic treatment options different from chemotherapy (i.e. tyrosine kinase-inhibition of the epidermal growth factor receptor family, anti-angiogenic treatment). The current status of developing treatment strategies in locally advanced non-small cell lung cancer is discussed.