A phase 1b/2, dose-escalation, randomized, multicenter study of maintenance (maint) ivaltinostat (ival) plus capecitabine (cap) or capecitabine monotherapy in patients (pts) with metastatic pancreatic adenocarcinoma (PDAC) whose disease has not progressed on first-line FOLFIRINOX chemotherapy (CT)

TPS4181

Background: The mainstay of treatment (TX) for pts with advanced or mPDAC consists of CT, with FOLFIRINOX and gemcitabine (gem)/nab-paclitaxel currently representing the front-line standards of care. TX is generally continued until either dis progression (progr) or cumulative toxicity, with pts often reaching a plateau in response after 4-6 mos. For those who have achieved dis control (stable dis or better) on front-line CT, a maint TX strategy that can effectively delay dis progr while preserving quality of life with minimal cumulative toxicity is highly desirable. However, aside from PARP inhibition in the subset of PDAC pts with gBRCA mutated dis, there is no current standard of care in this maint setting. Ival is a pan-HDAC (histone deacetylation) inhibitor that increases histone acetylation (HA), suppresses PDAC cell proliferation, and promotes apoptosis in PDAC cell lines in a dose-dependent manner. It has demonstrated synergy with 5-FU in cholangiocarcinoma cell lines and shows promising antitumor activity when combined with cap in syngeneic PDAC mouse models. On these bases, we are conducting a ph1b/randomized ph2 trial of ival plus cap vs cap alone in the maint setting for pts with mPDAC who have not progressed on front-line FOLFIRINOX. Methods: Key eligibility criteria include pts with mPDAC; no evidence of dis progr following at least 16 wks of front-line FOLFIRINOX at full or modified doses; ECOG PS 0-1; and no known gBRCA1/2 mutation. The study includes an initial dose-esc ph1b evaluating 3 dose levels of ival, (60, 125, and 250mg/m2 iv weekly on days 1 and 8) in combination (comb) with cap (1000mg/m2 po BID on days 1-14) of a 21-day cycle, using a standard 3 + 3 dose-esc design. Of note, ival 250 mg/m2 represents the RP2D identified in prior clinical studies of this agent both as monotherapy in solid tumors and in comb with gem/erlotinib in advanced PDAC pts. In the ph2 portion, pts will be randomized 1:1 to receive either ival plus cap or cap alone, in 21-day cycles, until dis progr, with tumor assessments occurring at 6-wk intervals. Blood will be collected at pre-specified serial timepoints for pharmacodynamic assessments, including HA of PBMCs. Primary endpoint for ph2 is investigator-adjudicated PFS. The primary analysis will compare PFS distributions in the ival/cap and cap alone arms using a one-sided log rank test with an alpha = 0.10. The assumed true 6-mo PFS rates are 35% (cap), based on historic data, and 60% (ival/cap), which corresponds to an HR of 0.487. Assuming an accrual duration of 18 mos and a dropout/lost to follow-up rate of 10%, the estimated total number of pts in the randomized ph2 portion is 52 (26 per arm). Enrollment is expected to being in spring 2022 across 25 U.S. sites.

489 TWT-101: a phase 1 study of the novel HPK1 inhibitor CFI-402411 in patients with advanced cancer

Background

CFI-402411 is an orally available small molecule potent inhibitor of HPK1 (Hematopoietic progenitor kinase 1). T-cells are negatively-regulated at different junctures of cancer-immunity cycle by this regulatory kinase. HPK1, (also mitogen activated protein kinase kinase kinase kinase 1 (MAP4K1)) is a protein serine/threonine kinase predominantly expressed in hematopoietic cells. In T-cells, following T-cell receptor activation, HPK1 is recruited to the plasma membrane where it phosphorylates the adapter protein SH2 domain-containing leukocyte protein of 76 kDa (SLP-76), down-regulating signaling events required for T cell activation and proliferation. Selected for development based on its pharmacologic properties and preclinical activity in a variety of syngeneic cancer models and assays, with an IC50 = 4.0±1.3 nM, CFI-402411 is expected to relieve HPK1-mediated inhibition of T and B cells, facilitating an anti-tumor immune response.

Methods

Phase 1, 3 + 3 design in patients. Patients have acceptable laboratory, other parameters for study entry. Single agent dose daily oral escalation cohort (A1) in advanced tumors, then dose expansion (A3) with biomarker backfill (A2) in select advanced tumors; combination with PD-1 Inhibitor (pembrolizumab) (B1, pembrolizumab eligible tumors with no prior grade >=3 related to CPI)) and expansion (B2, PD-1/PD-L1 naïve pembrolizumab eligible tumors). DLT defined as any grade >=3 toxicity in first cycle of therapy (21d cycles). Standard assessments for response per RECIST v1.1 or iRECIST. The starting dose level was 80mg.

Results

At 10 June 2021 data is available for 12 patients from A1. Median age 61.5 years (range 33–73), 8 patients female, and 10 white. Diagnoses were pancreatic cancer, colorectal (3 pts), ovarian, basal cell, cholangiocarcinoma, sigmoid, salivary and breast cancer (1 pt). Six patients (50%) had 4 prior therapies, 1 patient (basal cell) had prior treatment with immune checkpoint inhibitor, pembrolizumab. Four doses studied: 80, 120, 180 and 270mg. TEAEs across all CTCAE grades, (in >2 patients) were diarrhea (6 patients), nausea (4 patients), dyspepsia (3 patients), fatigue (3 patients). No related grade 3–5 events, one immune related event (grade 1, weight loss). 3 grade 3 events all unrelated to study drug - pleural effusion, rash, thromboembolic event. Discontinuation due to disease progression was main reason (7 patients). PK and PD assessments will be updated at time of presentation.

Conclusions

CFI-402411 is a potent inhibitor of HPK1 that is well tolerated with a manageable adverse event profile and dose escalations continue. Further safety and efficacy results will be presented at the meeting including additional cohorts if available.

Acknowledgements

Treadwell Therapeutics thanks all sites, importantly their patients and their families.

Trial Registration

ClinicalTrials.

gov Identifier: NCT04521413

Ethics Approval

This study obtained has obtained ethics approvals at multiple institutions globally including;USAWCG IRB - Western Institutional Review Board - MOD00002618 (Submission ID)IntegReview Institutional Review Board - N/AAdvarra Central IRB - SSU00130103IntegReview Institutional Review Board N/AAdvarra Central IRB - SSU00137751Advarra Central IRB - SSU00143275The University of Texas MD Anderson Cancer Center Institutional Review Board - 2020–0678 (IRB ID Number)Hong KongJoint Chinese University of Hong Kong - New Territories East Cluster Clinical Research Ethics Committee - 2020.367 (Ref Number)CanadaOntario Cancer Research Ethics Board - 3320 (Project ID)Health Research Ethics Board of Alberta, HREBA Cancer Committee - HREBA.CC-20–0504 (Ethics ID Number)South KoreaimCORE - Seoul National University Hospital Institutional Review Board - H-2012-094-1182 (IRB Number)National Cancer Institute Review Board - 2020–0525–0001 (Receipt Number)All participants gave informed consent before taking part in this clinical trial.

Association of Combination of Conformation-Specific KIT Inhibitors With Clinical Benefit in Patients With Refractory Gastrointestinal Stromal Tumors: A Phase 1b/2a Nonrandomized Clinical Trial

IMPORTANCE

Many cancer subtypes, including KIT-mutant gastrointestinal stromal tumors (GISTs), are driven by activating mutations in tyrosine kinases and may initially respond to kinase inhibitors but frequently relapse owing to outgrowth of heterogeneous subclones with resistance mutations. KIT inhibitors commonly used to treat GIST (eg, imatinib and sunitinib) are inactive-state (type II) inhibitors.

OBJECTIVE

To assess whether combining a type II KIT inhibitor with a conformation-complementary, active-state (type I) KIT inhibitor is associated with broad mutation coverage and global disease control.

DESIGN, SETTING, AND PARTICIPANTS

A highly selective type I inhibitor of KIT, PLX9486, was tested in a 2-part phase 1b/2a trial. Part 1 (dose escalation) evaluated PLX9486 monotherapy in patients with solid tumors. Part 2e (extension) evaluated PLX9486-sunitinib combination in patients with GIST. Patients were enrolled from March 2015 through February 2019; data analysis was performed from May 2020 through July 2020.

INTERVENTIONS

Participants received 250, 350, 500, and 1000 mg of PLX9486 alone (part 1) or 500 and 1000 mg of PLX9486 together with 25 or 37.5 mg of sunitinib (part 2e) continuously in 28-day dosing cycles until disease progression, treatment discontinuation, or withdrawal.

MAIN OUTCOMES AND MEASURES

Pharmacokinetics, safety, and tumor responses were assessed. Clinical efficacy end points (progression-free survival and clinical benefit rate) were supplemented with longitudinal monitoring of KIT mutations in circulating tumor DNA.

RESULTS

A total of 39 PLX9486-naive patients (median age, 57 years [range, 39-79 years]; 22 men [56.4%]; 35 [89.7%] with refractory GIST) were enrolled in the dose escalation and extension parts. The recommended phase 2 dose of PLX9486 was 1000 mg daily. At this dose, PLX9486 could be safely combined with 25 or 37.5 mg daily of sunitinib continuously. Patients with GIST who received PLX9486 at a dose of 500 mg or less, at the recommended phase 2 dose, and with sunitinib had median (95% CI) progression-free survivals of 1.74 (1.54-1.84), 5.75 (0.99-11.0), and 12.1 (1.34-NA) months and clinical benefit rates (95% CI) of 14% (0%-58%), 50% (21%-79%), and 80% (52%-96%), respectively.

CONCLUSIONS AND RELEVANCE

In this phase 1b/2a nonrandomized clinical trial, type I and type II KIT inhibitors PLX9486 and sunitinib were safely coadministered at the recommended dose of both single agents in patients with refractory GIST. Results suggest that cotargeting 2 complementary conformational states of the same kinase was associated with clinical benefit with an acceptable safety profile.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02401815.

Cerdulatinib Pharmacodynamics and Relationships to Tumor Response Following Oral Dosing in Patients with Relapsed/Refractory B-cell Malignancies

PURPOSE

Preclinical studies suggest SYK and JAK contribute to tumor-intrinsic and microenvironment-derived survival signals. The pharmacodynamics of cerdulatinib, a dual SYK/JAK inhibitor, and associations with tumor response were investigated.

PATIENTS AND METHODS

In a phase I dose-escalation study in adults with relapsed/refractory B-cell malignancies, cerdulatinib was administered orally to sequential dose-escalation cohorts using once-daily or twice-daily schedules. The study enrolled 8 patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), 13 with follicular lymphoma, 16 with diffuse large B-cell lymphoma (DLBCL), and 6 with mantle cell lymphoma. Correlation of tumor response with pharmacodynamic markers was determined in patients with meaningful clinical responses.

RESULTS

Following cerdulatinib administration, complete SYK and JAK pathway inhibition was achieved in whole blood of patients at tolerated exposures. Target inhibition correlated with serum cerdulatinib concentration, and IC₅₀ values against B-cell antigen receptor (BCR), IL2, IL4, and IL6 signaling pathways were 0.27 to 1.11 μmol/L, depending on the phosphorylation event. Significant correlations were observed between SYK and JAK pathway inhibition and tumor response. Serum inflammation markers were reduced by cerdulatinib, and several significantly correlated with tumor response. Diminished expression of CD69 and CD86 (B-cell activation markers), CD5 (negative regulator of BCR signaling), and enhanced expression of CXCR4 were observed in 2 patients with CLL, consistent with BCR and IL4 suppression and loss of proliferative capacity.

CONCLUSIONS

Cerdulatinib potently and selectively inhibited SYK/JAK signaling at tolerated exposures in patients with relapsed/refractory B-cell malignancies. The extent of target inhibition in whole-blood assays and suppression of inflammation correlated with tumor response. (ClinicalTrials.gov ID:NCT01994382).

Diagnosis of Glaucoma by Indirect Classifiers

Objectives: Demonstration of the applicability of a framework called indirect classification to the example of glaucoma classification. Indirect classification combines medical a priori knowledge and statistical classification methods. The method is compared to direct classification approaches with respect to the estimated misclassification error.

Methods: Indirect classification is applied using classification trees and the diagnosis of glaucoma. Misclassification errors are reduced by bootstrap aggregation. As direct classification methods linear discriminant analysis, classification trees and bootstrap aggregated classification trees are utilized in the problem of glaucoma diagnosis. Misclassification rates are estimated via 10-fold cross-validation.

Results: Indirect classification techniques reduce the misclassification error in the context of glaucoma classification compared to direct classification methods.

Conclusions: Embedding a priori knowledge into statistical classification techniques can improve misclassification results. Indirect classification offers a framework to realize this combination.

[Diffusion tensor imaging of the visual pathway in glaucomatous optic nerve atrophy]

In Germany more than one million inhabitants suffer from glaucoma, more than 100,000 are threatened with blindness because glaucoma is often diagnosed too late or not at all. Diagnosis and monitoring is usually carried out "only" by examination of the retina and not the whole visual pathway. However, the eye is just "the tip of the iceberg" of the actual visual pathway, which extends through the brain to the visual cortex. The interdisciplinary holistic assessment of the whole visual pathway in glaucoma is of crucial importance because glaucoma is a complex neurodegenerative disease. Subtypes, such as normal tension glaucoma (NTG), seem to originate from primary damage to the intracranial visual pathway with secondary retrograde retinal degeneration. Recent studies including glaucoma patients and healthy controls could show that diffusion tensor imaging with calculation of diffusion coefficients, i.e. fractional anisotropy (FA), mean and radial diffusivity (MD and RD) as markers of axonal integrity, provide the potential to assess the intracranial visual pathway with a high correlation to established ophthalmological examinations. In particular, calculation of FA maps of the visual pathway and accompanying voxel-based approaches, can be integrated into clinical routine. Thus, detection of glaucoma-related intracranial alterations, even in early stages of the disease, as well as differentiation of different glaucoma subtypes, is made possible. Furthermore, the diagnosis of normal tension glaucoma seems to be possible much earlier with these new imaging techniques compared to established ophthalmological work-up. Moreover, holistic imaging provides new insights into the pathophysiology of this form of glaucoma. This review article gives an overview of these novel magnetic resonance imaging techniques for assessment of the visual pathway in glaucomatous optic nerve atrophy and reveals the potential of an interdisciplinary approach.

Abstract CT144: Preclinical and clinical studies and modeling and simulation to identify phase II dose for cerdulatinib: a dual SYK/JAK inhibitor for the treatment of B-cell malignancies

Background. Subsets of B cell lymphomas appear to rely on B-cell receptor (BCR) and/or cytokine JAK/STAT signaling for survival. SYK is upstream of BTK, PI3Kδ, and PLCγ2 on the BCR signaling pathway, and thus a potential therapeutic target. Additional survival support appears to be mediated by cytokine-induced JAK/STAT pathways. Cerdulatinib is a dual SYK/JAK inhibitor being evaluated in patients with relapsed/refractory B cell malignancies in a dose escalation study. Patient PK and PD parameters indicated nonlinearity at doses above 30 mg QD. Exposure at the 45 mg dose was 3-fold higher than at 30 mg QD. As the dose was further increased up to 100 mg QD, the Cssmax and AUC values plateaued. PD results also appeared to plateau achieving approximately 50-90% target inhibition in peripheral blood assays at steady-state Cmin to Cmax, respectively. The target therapeutic exposure for oncology, based on pre-clinical models, is a Cssmin >1.5uM which would lead to >90% SYK/JAK inhibition at the trough concentration

Objective. Pre-clinical and clinical PK/PD relationships and correlations between SYK/JAK inhibition and tumor response will be presented. A physiological-based PK (PBPK) model was developed to elucidate the relationship between dose, dosing schedule, and exposure. The goal of developing a PBPK model was to provide a strategy to increase exposure in patients to therapeutic target levels.

Methods. This is a 3+3 dose escalation study with 28-day cycles and doses studied from 15 mg to 100 mg QD, and up to 45 mg BID. PK, PD, and safety were monitored. SYK and JAK inhibition was determined by multiple whole blood assays measuring signaling via the B cell antigen receptor, IL2, IL4, IL6, and GM-CSF. Serum markers of tumor burden - CCL3, CCL4, and other markers of inflammation, were also measured. Physiochemical parameters and in vitro ADME parameters were used to construct a PBPK model.

Results. Exposure correlated well with PD and tumor responses in the dose escalation study. Low pH dependent solubility was identified as the rate-limiting factor in increasing plasma concentrations. The PBPK model predicted BID dosing would result in significantly higher plasma levels. The Cssmin concentration of QD doses from 40 to 100 mg QD was ∼0.70 uM while for the 45 mg BID dose for the first 3 patients the Cssmin was ∼1.5 uM. Complete target inhibition at this Cssmin was achieved with good tolerability.

Conclusions. The preliminary PBPK model identified the pH dependent low solubility of cerdulabinib as the rate-limiting factor of absorption with increasing doses. Subsequent evaluation of 45 mg BID doses in patients provided higher Cmin, Cmax, and AUC values for all patients treated at this dose level and PD markers indicated complete inhibition of both pathways. We are now enrolling additional patients at this dose, in preparation for selecting our final phase II dose.

Citation Format: Janet M. Leeds, Greg Coffey, Anjali Pandey, Pam B. Conley, Karen Rowland Yeo, Alice B. Ke, John T. Curnutte, Glenn Michelson. Preclinical and clinical studies and modeling and simulation to identify phase II dose for cerdulatinib: a dual SYK/JAK inhibitor for the treatment of B-cell malignancies. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT144.

Phase IIa Trial of Trastuzumab Emtansine With Pertuzumab for Patients With Human Epidermal Growth Factor Receptor 2–Positive, Locally Advanced, or Metastatic Breast Cancer

Purpose

Our phase IIa study characterized the safety and efficacy of two human epidermal growth factor receptor 2 (HER2) –targeted agents, trastuzumab emtansine (T-DM1) and pertuzumab, in patients with HER2-positive metastatic breast cancer (MBC).

Patients and Methods

Patients with HER2-positive locally advanced breast cancer or MBC were treated with 3.6 mg/kg T-DM1 plus pertuzumab (840-mg loading dose, then 420 mg subsequently) once every 3 weeks. The primary efficacy end point was investigator-assessed objective response rate (ORR).

Results

Sixty-four patients (43 patients in the second-line or greater setting [advanced MBC]; 21 patients in the first-line setting [first-line MBC]) were enrolled. Patients with advanced MBC had received trastuzumab and a median of six prior nonhormonal treatments for MBC; 86% of first-line MBC patients had received trastuzumab in the (neo)adjuvant setting. The ORR was 41% overall, 33% in patients with advanced MBC, and 57% in first-line patients. Median progression-free survival was 6.6, 5.5, and 7.7 months, respectively. The most common adverse events were fatigue (61%), nausea (50%), and diarrhea (39%). The most frequent grade ≥ 3 adverse events were thrombocytopenia (13%), fatigue (11%), and liver enzyme elevations (increased ALT: 9%; increased AST: 9%). One patient had left ventricular ejection fraction of less than 40% after study drug discontinuation. Exploratory biomarker analyses demonstrated that patients with above-median tumor HER2 mRNA levels had a numerically higher ORR than patients with below-median levels (44% v 33%, respectively).

Conclusion

T-DM1 and pertuzumab can be combined at full doses with no unexpected toxicities. The preliminary efficacy in patients in the first-line and advanced MBC settings warrants further investigation.

Addition of liraglutide in patients with Type 2 diabetes well controlled on metformin monotherapy improves several markers of vascular function

AIMS

The aim of this study was to investigate the vascular effects of liraglutide in patients well controlled on metformin monotherapy.

METHODS

Forty-four patients with Type 2 diabetes were included in the study. Main inclusion criteria were: pretreatment with metformin on a stable dosage, HbA(1c) < 53 mmol/mol (7.0%), age 30-65 years. Patients were randomized to receive additional liraglutide or to remain on metformin monotherapy. After 6 weeks (1.2 mg) and after 12 weeks (1.8 mg), venous blood was taken for the measurement of several laboratory markers characterizing vascular and endothelial function. In addition, retinal microvascular endothelial function and arterial stiffness were measured.

RESULTS

HbA(1c) levels declined from 45 ± 4 mmol/mol (6.3 ± 0.4%; mean ± SD) to 40 ± 3 mmol/mol (5.8 ± 0.3%) during liraglutide treatment. Asymmetric dimethylarginin was reduced by liraglutide treatment from 0.39 ± 0.08 to 0.35 ± 0.06 μmol/l, E-selectin from 43.6 ± 15.4 to 40.8 ± 15.1 ng/ml, plasminogen activator inhibitor 1 from 861.6 ± 584.3 to 666.1 ± 499.4 ng/ml and intact proinsulin from 9.0 ± 7.2 to 7.0 ± 4.8 pmol/l at 12 weeks of treatment. The microvascular response to flicker light increased from 7.0 ± 15.1 to 15.4 ± 11.5% after 6 weeks and to 11.1 ± 9.9% after 12 weeks. No change could be observed for high-sensitivity C-reactive protein, monocyte chemotactic protein 1, vascular cell adhesion molecule or arterial stiffness parameters.

CONCLUSIONS

In patients with Type 2 diabetes, well controlled with metformin monotherapy, addition of liraglutide improves several cardiovascular risk markers beyond glycaemic control.

[Retinal microangiopathy in arterial hypertension as an early marker of a cerebral macroangiopathy]

HISTORY AND ADMISSION FINDINGS

A 54-year-old man reported having had nonspecific attacks of dizziness. His BMI was 27.7. Since 11 years he had been treated for arterial hypertension and had received oral medication for type 2 diabetes for one year. The latest blood pressure value was 134/109 mm Hg during treatment with a combination of atenolol, chlortalidone und hydralazine-HCl; furthermore hr received simvastatin, metformin, glimepirid und ramipril. A standardized telemedical imaging of the retina ("talkingeyes (®) ") was undertaken, revealing focal and generalized arteriolar narrowing of the retinal vessels and a retinal microinfarction (cotton wool spot) in the right eye. The arterial/venous ratio was decreased to 0.74 in the right and 0.77 in the left eye.

INVESTIGATIONS

Optical coherence tomographie (OCT) revealed an ischemic microinfarction of the retina with marked axonal swelling. The digital subtraction angiography of the cerebral vessels revealed a 40 % stenosis of the right internal carotid artery and a proximal, highgrade stenosis of the basilary artery.

TREATMENT AND COURSE

Angioplasty with stent insertion of the basilary artery was performed. Long-term observation showed no restenosis and a reduction in the size of the the retinal microinfarct.

CONCLUSION

Retinal microinfarctions denote localized retinal areas of hypoxia and underperfusion. They may act as markers of a generalized micro- and macroangiopathy. Patients with severe retinal microangiopathic changes should be examined thoroughly to detect early macroangiopathic changes. These can be treated by interventional procedures thus avoiding irreversible end-organ damages.

[Electronic patient records and teleophthalmology : part 1: introduction to the various systems and standards]

Electronic storage of patient-related data will replace paper-based patient records in the near future. Some steps in medical practice can even now not be achieved without electronic data processing. Both systems, conventional paper-based and electronic-based records, have advantages and disadvantages which have to be taken into consideration. The advantages of electronic-based records are e.g. good availability of data, structured storage of data, scientific analysis of long-term data and possible data exchange with colleagues in the context of teleconsultation systems. Problems have to be solved in the field of data security, initial high investment costs and time consumption in learning to use the system as well as in incompatibility of existing IT systems.

[Comparison of early retinal microvascular changes and microalbuminuria as indicators for increased cardioascular risk]

INTRODUCTION

Prevention of cardiovascular disease is an important goal in clinical medicine and public health. In the process, the diagnosis of early end-organ damage is a priority beside the treatment of classic cardiovascular risk factors. To achieve this, the ophthalmoscopic examination of the retinal vessels plays a prominent role. Alternatively, the quantification of low quantities of albumin in the urine (microalbuminuria) allows the detection of early vascular damage in the kidney. The question is addressed as to whether these two methods are interchangeable or are rather complementary.

PATIENTS AND METHODS

We examined 226 members of the staff of the University Hospital Erlangen who volunteered to participate in a preventive campaign. A comprehensive history was taken, and height, weight and blood pressure were measured. Analysis of serum lipids and determination of the urinary albumin/creatinine ratio were performed. Fotos of the central fundus were taken with a non-mydriatic camera and analysed by an experienced ophthalmologist in a standardised fashion. The risk for cardiovascular mortality within the next ten years was estimated from age, sex, blood pressure and serum cholesterol using the euroSCORE tables for Germany.

RESULTS

There was no signficant correlation between the arteriovenous ratio of the retinal vessels and the urinary albumin/creatinine ratio. Neither parameter correlated with the euroSCORE Germany. Arteriovenous crossings and focal narrowing of the retinal vessels were associated signficantly with an elevated euroSCORE risk.

CONCLUSIONS

In large population-based studies, the arteriovenous ratio and the urinary albumin/creatinine ratio have been confirmed as markers of cardiovascular risk. In our study, there was no correlation between these two parameters. Thus, they seem to present independent risk markers. The presence of arteriovenous crossings and focal narrowing seems to be linked more closely to the classic cardiovascular risk factors from which the euroSCORE is calculated. The ophathlmolscopic examination of retinal vessels and the analysis of urinary albumin/creatinine ratio seem to complement rather than replace each other.

[Prevalence of glaucomatous optic nerve atrophy among a working population in Germany diagnosed by a telemedical approach]

PURPOSE

The aim of this study was to determine the prevalence of glaucomatous optic nerve atrophy among a working population in Germany by secondary evaluation of a study conducted to estimate the prevalence of retinal microangiopathic abnormalities by telemedical examination of the retina.

PATIENTS AND METHODS

From August 2002 until January 2004 the retina and optic nerve head were examined in 19,294 Caucasians using a non-mydriatic fundus camera (Kowa, nonmyd-alpha 45), which produces colour images with 45 degrees. The images of the retina and optic nerve head were evaluated telemedically by glaucoma specialists in respect to optic nerve pathologies and microangiopathic abnormalities by a standardised procedure. Glaucomatous optic nerve atrophy was diagnosed when specific glaucomatous morphological alterations of the optic nerve head were present. A complete medical history including reported elevated intraocular pressure (IOP) and blood pressure was obtained.

RESULTS

The intra-observer and inter-observer reliability were 0.884 and 0.740, respectively. Cronbach's alpha for two evaluation cycles each of two observers was 0.870. The prevalences of glaucomatous optic nerve atrophy in the different age groups were 0.07 % (45 - 49 years), 0.40 % (50 - 54 years), 0.45 % (55 - 59 years) and 0.82 % (60 - 64 years). Age could be established as an important risk factor for glaucomatous optic nerve atrophy, while no influence of gender or family history was found.

CONCLUSION

Telemedical evaluation of colour images of the retina and optic nerve acquired by a non-mydriatic fundus camera allows a fast and efficient screening of many subjects with medium reliability.

[Validation of telemedical fundus images from patients with retinopathy]

BACKGROUND

The degree of retinal microangiopathy is important foran estimation of the vascular risk and for the optimisation of therapy in hypertensive and diabetic patients. Retinal microangiopathy may be determined by examination of the retinal fundus. We examined the reliability of the ophthalmoscopic diagnosis and of the telemedical judgement of fundus images in relation to the presence and the degree of retinopathy.

PATIENTS AND METHODS

This comparative observational study included 47 inpatient hypertensive and/or diabetic subjects. The fundus was judged ophthalmoscopically and subsequently, a fundus image was generated by use of a KOWA camera. The images were sent to the Interdisciplinary Center of Ophthalmologic Preventive Medicine. The reliability of the two diagnostic methods was calculated for one of the two eyes, which was selected by a random generator.

RESULTS

The largest concordance of the two diagnosis methods was achieved, in descending order, for retinal bleeding, stage of diabetic retinopathy and the papilla findings. Additionally, there were no differences for the stage of hypertensive retinopathy und tortuosity. The reliability of arterio-venous nicking related to the right and the left eye was low or absent, respectively.

CONCLUSIONS

The teleophthalmologic diagnosis achieves good results as compared to the ophthalmoscopic judgement in relation to retinopathy assessment criteria.

A phase I trial of sns-314, a novel and selective pan-aurora kinase inhibitor, in advanced solid tumor patients

2536

Background: Aurora Kinases are a family of serine/threonine kinases (Aurora Kinases (AK) A, B, and C) critical for mitosis. Elevated AKs expression occurs in a high percentage of melanoma, colon, breast, ovarian, gastric, and pancreatic tumors; in a subset of these tumors the AURKA locus (20q13) is amplified. SNS-314 is a selective pan-AK inhibitor with low nanomolar IC50s. Methods: Study design is 3+3 phase 1 dose escalation by modified Fibonacci. Patients (pts) with advanced solid tumors received SNS-314 by 3 hour infusion qweek X 3 (28 day cycle). Primary endpoints: safety, tolerability, and DLT assessment. Secondary endpoints: MTD, pharmacokinetics (PK), pharmacodynamics, and antitumor activity. Pharmacodynamic endpoint was inhibition of Histone H3 phosphorylation (pHH3) evaluated by immunohistochemistry of skin punch biopsies taken pre- and 2 hours post-infusion. Results: Thirty-two pts (16M/16F; median age = 58.5 years) were enrolled into 8 cohorts: dose range 30–1800 mg/m2. Median cycles received =2. SNS-314 was generally well tolerated with Grade 1–2 toxicities ≥ 15% incidence: nausea (31%), fatigue (28%), vomiting, constipation, and pain (16% each), and no Grade 3+ toxicities of ≥ 15% incidence. A DLT of Grade 3 neutropenia preventing administration of all 3 doses was observed at 1440 mg/m2. Plasma PK were dose proportional for exposure with no accumulation of SNS-314 following weekly administration. Clearance was moderate (5.65 L/hr/m2, CV 39.4%); Vss approximated total body water (21.5 L/m2, CV 78.1%); terminal half-life was 10.4 hours (CV 66.8%). Six patients had stable disease as their best response. Inhibition of pHH3 by SNS-314 was observed in skin biopsies of patients treated at doses of 240 mg/m2 and greater. Conclusions: SNS-314 is a novel inhibitor of AKs A, B, and C. The compound has been generally well tolerated; MTD was not established. No objective responses were observed. Pharmacodynamic activity was demonstrated by inhibition of pHH3.

[Table: see text]

Phase Ib/II pharmacokinetic/pharmacodynamic (PK/PD) study of combination voreloxin and cytarabine in relapsed or refractory AML patients

7005

Background: Voreloxin is a naphthyridine analog that intercalates DNA and inhibits topoisomerase II, inducing apoptosis. Clinical activity is observed in ovarian cancer and AML. Voreloxin combined with cytarabine (Ara-C) show supra-additive activity preclinically. Interim results from a phase Ib/II study in relapsed or refractory AML are reported. Methods: Dose-escalation in relapsed/refractory AML patients (pts) with ≤ 3 prior induction regimens; phase II expansion in first-relapse pts (CR1 ≥ 3 months) at MTD. Voreloxin given d1 and d4, combined with: A) continuous infusion 400 mg/m2/d x 5d Ara-C (CIV), or B) bolus 1 g/m2/d IV x 5d Ara-C. Voreloxin starting dose: A) 10 mg/m2/dose; B) 70 mg/m2/dose. Treatment: induction, reinduction if needed, and up to 2 courses for consolidation. DLT, PK, and PD were assessed in cycle 1. Pts’ PBMC were evaluated for induction of DNA damage response markers. Ex vivo sensitivity of pt BMA to voreloxin and Ara-C were evaluated by CellTiter-Glo proliferation assay. Results: 52 pts treated to date (A: 41 pts, dose-escalation; 5 pts Phase 2; B: 6 pts dose-escalation). A) MTD is 80 mg/m2/dose voreloxin. Infections are the most common G3 or higher toxicity. Voreloxin PK were dose proportional to 50 mg/m2, then plateaued. Evaluation of PBMC pre- and posttreatment suggests modulation of pDNA-PKcs and pChk2 may reflect response. Ex vivo BMA assay results suggest that voreloxin is the primary contributor to the majority of CRs observed. Phase Ib: 9 CRs + CRp were observed in multiply relapsed or 1° refractory pts. B) 70 mg/m2/dose voreloxin, no DLT; too early to evaluate activity. Conclusions: Voreloxin in combination with CIV Ara-C is generally well-tolerated, with CR in relapsed/refractory pts. Enrollment continues: A) phase II; B) phase Ib. Ex vivo activity assay results suggest that voreloxin is the primary contributor to the majority of CR. Induction of pDNA-PKcs and pChk2 in PBMCs from treated pts may reflect response.

[Table: see text]

A phase II trial of voreloxin in women with platinum-resistant ovarian cancer

5559

Background: Voreloxin is a naphthyridine analog that intercalates DNA and inhibits topoisomerase II, inducing apoptosis. Clinical activity has been observed in ovarian cancer and AML. Results are reported from a fully enrolled phase II study of 3 dose levels of single agent voreloxin in patients (pts) with 1° or 2° platinum-resistant or refractory ovarian cancer. Methods: Pts may have received ≤ 3 prior platinum regimens plus one additional non-platinum regimen. PS of 0–1 was required. Voreloxin regimens: Cohort A 48 mg/m2q3weeks (wk) (N = 65), Cohort B 60 mg/m2q4wk (N = 35), and Cohort C 75 mg/m2q4wk (N = 35) by short IV infusion. BRCA status is reported by pt consent. Results: Cohort A: 2CRs, 5PRs; ORR 11%; median PFS 82 days (52–98 days 95%CI); Cohort B: 1CR, 3PRs; ORR 11%, median PFS too early to evaluate (TETE); Cohort C - TETE. Cohort A: Febrile neutropenia (FN) incidence was low (8%). Other common G3 or G4 AEs reported (≥ 5%) were fatigue (14%) and nausea (5%). Dose delays or reductions (40%) occurred typically at Cycle 1, largely due to neutropenia. Cohort B: Dose was increased to 60 mg/m2 and dosing interval was lengthened to 4 wk, maintaining dose intensity (DI) and allowing adequate time for marrow recovery. ANC dosing criterion was changed from ANC ≥ 1,500 to ≥ 1,000. There was a marked decrease in dose delays and reductions (14%) with only 3% incidence of FN. Common G3 or 4 AEs reported (≥ 5%) were fatigue (11%) and nausea (5%). The safety profile supported further dose escalation to 75 mg/m2q4wk (Cohort C- DI increased by 25%). Data are TETE. Conclusions: Preliminary data suggest Cohorts A and B have similar safety and efficacy profiles as anticipated based on comparable DI. Fewer dose reductions and delays occurred in Cohort B, due to revised dosing criteria and increased cycle length to 4 wk. Accrual to Cohort C is complete. Efficacy and safety data for all cohorts will be reported.

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[Web-based electronic patient record as an instrument for quality assurance within an integrated care concept]

OBJECTIVE

A prerequisite for integrated care programmes is the implementation of a communication network meeting quality assurance standards. Against this background the main objective of the integrated care project between the University Eye Hospital Erlangen and the health insurance company AOK Bayern was to evaluate the potential and the acceptance of a web-based electronic patient record in the context of cataract and retinal surgery.

METHODS

Standardised modules for capturing pre-, intra- and post-operative data on the basis of clinical pathway guidelines for cataract- and retinal surgery have been developed. There are 6 data sets recorded per patient (1 pre-operative, 1 operative, 4-6 post-operative). For data collection, a web-based communication system (Soarian Integrated Care) has been chosen which meets the high requirements in data security, as well as being easy to handle. This teleconsultation system and the embedded electronic patient record are independent of the software used by respective offices and hospitals. Data transmission and storage were carried out in real-time.

RESULTS

At present, 101 private ophthalmologists are taking part in the IGV contract with the University Eye Hospital Erlangen. This corresponds to 52% of all private ophthalmologists in the region. During the period from January 1st 2006 to December 31st 2006, 1844 patients were entered. Complete documentation was achieved in 1390 (75%) of all surgical procedures. For evaluation of this data, a multidimensional report and analysis tool (Cognos) was used. The deviation from target refraction as one quality indicator was in the mean 0.09 diopter.

CONCLUSIONS

The web-based patient record used in this project was highly accepted by the private ophthalmologists. However there are still general concerns against the exchange of medical data via the internet. Nevertheless, the web-based patient record is an essential tool for a functional integration between the ambulatory and stationary health-care units. In addition to the telemedicine functions of the system, we achieved the export of the data to a data warehouse system in order to provide a flexible and powerful tool for quality assurance analysis and reporting.

A phase I pharmacokinetic and pharmacodynamic study of TKI258, an oral, multitargeted receptor tyrosine kinase inhibitor in patients with advanced solid tumors

PURPOSE

To determine the maximum tolerated dose (MTD) dose-limiting toxicity, and pharmacokinetic and pharmacodynamic profile of TKI258 (formerly CHIR-258).

EXPERIMENTAL DESIGN

A phase I dose escalating trial in patients with advanced solid tumors was performed. Treatment was initially as single daily doses on an intermittent 7-day on/7-day off schedule. Following a protocol amendment, a second schedule comprised, during cycle 1, 7-day on/7-day off treatment followed by 14 days of continuous daily dosing; subsequent cycles comprised 28 days of daily dosing. Pharmacokinetics and evaluation of phosphorylated extracellular signal-regulated kinase (ERK) in peripheral blood mononuclear cells were done during the first 28 days of each schedule.

RESULTS

Thirty-five patients were treated in four intermittent (25-100 mg/d) and three continuous (100-175 mg/d) dosing cohorts. Observed drug-related toxicities were nausea and vomiting, fatigue, headache, anorexia, and diarrhea. Dose-limiting toxicities were grade 3 hypertension in one patient at 100 mg continuous dosing, grade 3 anorexia in a second patient at 175 mg, and grade 3 alkaline phosphatase elevation in a third patient at 175 mg. One patient had a partial response (melanoma) and two patients had stable disease >6 months. TKI258 pharmacokinetics were linear over the dose range of 25 to 175 mg. Five of 14 evaluable patients had modulation of phosphorylated ERK levels.

CONCLUSIONS

The MTD was defined as 125 mg/d. Evidence of antitumor activity in melanoma and gastrointestinal stromal tumors warrants further investigation, and other phase I studies are ongoing. Further pharmacodynamic evaluation is required in these studies to evaluate the biological effects of TKI258.

Visual field defect during therapy with valproic-acid

Visual field defect because of antiepileptic drug (AED) treatment has been widely reported during the clinical application of vigabatrin. But other gamma-aminobutyric acid (GABA)-ergic and non-GABA-ergic AEDs could also affect the visual field with different mechanisms of action. Here we report a case of a 22-year-old female patient, who suffered from bilateral concentric visual field defect during the long-term therapy with valproic-acid (VPA). A VPA-related metabolic dysfunction was found through blood and urine examination. Reduced B-waves were shown by electroretinography and a bilateral concentric visual field defect was confirmed by both manual and automated perimetry. In conclusion, the concentric visual field defect related to VPA treatment is rare but possible.

A phase 2 study of rituximab in combination with recombinant interleukin-2 for rituximab-refractory indolent non-Hodgkin's lymphoma

PURPOSE

The incidence of non-Hodgkin's lymphoma (NHL), the fifth most common malignancy in the United States, has increased over 70% in the last 30 years. Fifty percent to 75% of patients with low-grade or follicular NHL respond to rituximab therapy. However, responses are generally of limited duration, and complete responses are rare. Preclinical work suggests that human recombinant interleukin-2 (rIL-2; aldesleukin, Proleukin) enhances rituximab efficacy. Antibody-dependent cellular cytotoxicity (ADCC) is an important mechanism of action of rituximab. rIL-2 induces expansion and activation of Fc receptor (FcR)-bearing cells, thereby enhancing ADCC. Therefore, a large, multicenter phase 2 trial to assess the effects of rIL-2 on rituximab therapy in patients with rituxumab-refractory low-grade NHL was conducted.

EXPERIMENTAL DESIGN

The combination of rituximab and rIL-2 was studied in 57 patients with rituximab-refractory low-grade NHL (i.e., patients must have received a single-agent course of rituximab and showed no tumor response, or had a response lasting <6 months). I.V. rituximab was given at 375 mg/m(2) (weeks 1-4). S.C. rIL-2 was given thrice a week at 14 MIU (weeks 2-5) and at 10 MIU (weeks 6-9).

RESULTS

Rituximab plus rIL-2 combination therapy was safe and generally well tolerated, but responses were low. Fifty-seven patients were enrolled with 54 evaluable for response; however, only five responses (one complete and four partial) were observed. Correlative data indicate that rIL-2 expanded FcR-bearing cells and enhanced ADCC. However, other factors, such as FcgammaR polymorphisms in patients refractory to single-agent rituxumab and heterogeneous tumor biology, may have influenced the lack of clinical efficacy seen with this combination therapy.

CONCLUSIONS

rIL-2 expands FcR-bearing cellular subsets in vivo and enhances in vitro ADCC of rituxumab. However, these findings do not directly translate into meaningful clinical benefit for patients with rituxumab-refractory NHL.

A phase 1, pharmacokinetic (PK) and pharmacodynamic (PD) study of CHIR-258, a novel oral multiple receptor tyrosine kinase (RTK) inhibitor

3043

Background: CHIR-258 is a potent small molecule inhibitor of VEGF, FGF, PDGF and c-KIT RTKs with IC50≤10nM that demonstrates activity in a variety of angiogenesis, tumour and metastasis models. Methods: Patients (pts) with histologically confirmed advanced solid tumors, ECOG PS 0–2 were treated in cohorts of 3–6 with CHIR-258. Treatment was as single daily doses on a repeated 7 days (d) on/7d off schedule (25–100mg), with a subsequent protocol amendment to continuous (cont) daily dosing. The objectives were to determine maximum tolerated dose (MTD) and dose limiting toxicity (DLT), evaluate PK and PD endpoints - ERK phosphorylation in PBL - and describe anti-tumour activity. Results: 35pts (median age 56.5 yrs; 15F/20M) were treated in 4 intermittent dosing cohorts (25, 50, 75, 100 mg/d) and 3 continuous dosing cohorts (100,125, 175 mg/d). The most common drug related adverse events were (grade [gr], number of pts): nausea (gr 1–3, 12); fatigue (gr 1–2, 9); headache (gr 1–3, 8); vomiting (gr 1–2, 7); anorexia (gr 1–2, 7); diarrhoea (gr 1–2, 6); dysgeusia (gr1–2, 6); anaemia (gr 2–3, 4); hypertension (gr 1–3, 3) and reversible asymptomatic drop in left ventricular ejection fraction (gr 2, 2). DLTs were gr 3 hypertension (HTN) in 1 pt with pre-existing HTN (100mg, cont); asymptomatic uncomplicated grade 2 elevation in cardiac troponin I (125mg); gr 3 anorexia/fatigue and gr 3 rise in alkaline phosphatase (both at 175mg). 3 pts have had prolonged stable disease (all 4m+; parotid, renal and imatinib-refractory GIST). The plasma PKs of CHIR-258 were linear over the dose range of 25–175 mg with respect to Cmax and AUC. On d1, the mean Cmax was 13.5(5.3) ng/mL to 109 (26) ng/mL, the mean AUC (0–24) was 224(97.4)ng*h/mL to 1740(466)ng*h/mL, and the t½ was 17h. Trough CHIR-258 concentrations at doses >50 mg/d were above the concentrations known to inhibit target receptor activation in vitro. Data on evaluable samples demonstrate up to 90% inhibition of basal ERK phosphorylation. Conclusions: CHIR-258 was safely administered at continuous daily doses up to 175mg/d. Modulation of p-ERK was demonstrated. Treatment is associated with disease stabilization.

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Phase I trial of chir-258 in multiple myeloma

17502

Background: CHIR-258 is an orally active small molecule receptor tyrosine kinase (RTK) inhibitor which has potent activity against multiple RTKs involved in tumor growth and angiogenesis (IC50 ≤13 nM for FGFR, VEGFR, PDGFR, C-KIT, and FLT3). Approximately 15% of newly diagnosed MM patients harbor a t(4;14) translocation, which results in ectopic expression of FGFR3 and MMSET and is associated with poor treatment outcome [0]and reduced survival. CHIR-258 inhibits proliferation and induces apoptosis in FGFR3-expressing MM tumor xenografts as well as FGFR3-expressing primary MM cells (Trudel et al, Blood 2005). CHIR-258 was synergistic with dexamethasone (dex) in vitro. Methods: CHIR-258 was administered once daily in a dose-escalating phase 1 study to patients with relapsed/refractory MM. Drug tolerability and safety, pharmacokinetics (PK) and pharmacodynamics (PD) were assessed. Results: as of December 2005, 9 total pts have been treated (50, 100, and 200mg qd cohorts) [6M, 3F; median age: 58 (range: 44–68), median of 3 prior therapies(range:1–7)]. Prior tx: 9/9 pts-thalidomide; 8/9 -Velcade; 8/9-transplant; 8/9- had progressed through dex. 4 of 9 pts treated were FGFR3+ and 4 pts remain on study (3 are FGFR3+). No CR or PR have been observed; stable disease has been noted. CHIR-258 has been generally well tolerated, and most drug related AEs were CTC grade 1 or 2, including: headache, dysgeusia, fatigue and anorexia. No neuropathy. One DLT has been observed to date: neutropenia (200mg cohort). Five pts had dex added to CHIR-258 of which 3 are ongoing (all FGFR3+). FGFR3+ pts receiving dex and CHIR-258 have a greater decline in urine and serum paraproteins (pp) vs CHIR-258 alone. Plasma exposure and Cmax increased proportionally across the doses. Conclusions: CHIR-258 is a novel inhibitor of RTKs involved in MM growth and proliferation. FGFR3+ pts have a more marked reduction in pp than FGFR3- pts. CHIR-258 has generally been well tolerated and further accrual continues.

[Table: see text]