IgE blockade with omalizumab reduces pruritus related to immune checkpoint inhibitors and anti-HER2 therapies

Background:

Immunoglobulin E (IgE) blockade with omalizumab has demonstrated clinical benefit in pruritus-associated dermatoses (e.g. atopic dermatitis, bullous pemphigoid, urticaria). In oncology, pruritus-associated cutaneous adverse events (paCAEs) are frequent with immune checkpoint inhibitors (CPIs) and targeted anti-human epidermal growth factor receptor 2 (HER2) therapies. Thus, we sought to evaluate the efficacy and safety of IgE blockade with omalizumab in cancer patients with refractory paCAEs related to CPIs and anti-HER2 agents.

Patients and methods:

Patients included in this multicenter retrospective analysis received monthly subcutaneous injections of omalizumab for CPI or anti-HER2 therapy-related grade 2/3 pruritus that was refractory to topical corticosteroids plus at least one additional systemic intervention. To assess clinical response to omalizumab, we used the Common Terminology Criteria for Adverse Events version 5.0. The primary endpoint was defined as reduction in the severity of paCAEs to grade 1/0.

Results:

A total of 34 patients (50% female, median age 67.5 years) received omalizumab for cancer therapy-related paCAEs (71% CPIs; 29% anti-HER2). All had solid tumors (29% breast, 29% genitourinary, 15% lung, 26% other), and most (n = 18, 64%) presented with an urticarial phenotype. In total, 28 of 34 (82%) patients responded to omalizumab. The proportion of patients receiving oral corticosteroids as supportive treatment for management of paCAEs decreased with IgE blockade, from 50% to 9% (P < 0.001). Ten of 32 (31%) patients had interruption of oncologic therapy due to skin toxicity; four of six (67%) were successfully rechallenged following omalizumab. There were no reports of anaphylaxis or hypersensitivity reactions related to omalizumab.

Conclusions:

IgE blockade with omalizumab demonstrated clinical efficacy and was well tolerated in cancer patients with pruritus related to CPIs and anti-HER2 therapies.

PL3.2 Trabectedin for recurrent WHO grade II or III meningioma: a randomized phase II study of the EORTC Brain Tumor Group (EORTC-1320-BTG)

BACKGROUND

EORTC-1320-BTG investigated the activity, safety and quality of life of therapy with the tetrahydroisoquinoline alkaloid trabectedin (Yondelis®) in patients with recurrent higher-grade meningiomas. Trabectedin was originally derived from the Caribbean sea squirt, Ecteinascidia turbinata, and currently is manufactured by total synthesis.

METHODS

Adult patients with histological diagnosis of WHO grade II or III meningioma and radiologically documented progression after maximal feasible surgery and radiotherapy were randomly assigned in a 2:1 ratio to receive intravenous trabectedin (1.5 mg/m2every three weeks) or local standard of care (LOC). The primary endpoint was progression-free survival (PFS).

RESULTS

Within 22.1 months, we randomized a total of 90 patients (n=29 in LOC arm, n=61 in trabectedin arm) in 35 institutions and nine countries. In the LOC arm, the following treatments were administered: hydroxyurea (n=11), bevacizumab (n=9), none (n=4), chemotherapy (n=3), somatostatin analogue (n=1), combined chemotherapy and somatostatin analogue (n=1). With 71 PFS events, median PFS was 4.17 months in the LOC and 2.43 months in the trabectedin arm (hazard ratio [HR] for progression, 1.42; 80% CI, 1.00–2.03; p=0.204) with a PFS-6 rate of 29.1% (95% CI, 11.9%-48.8%) in the LOC and 21.1% (95% CI, 11.3%-32.9%) in the trabectedin arm. Median OS was 10.61 months in the LOC and 11.37 months in the trabectedin arm (HR for death, 0.98; 95% CI, 0.54–1.76; p=0.94).Grade 3 to 5 adverse events occurred in 44.4% (18.5% related, 4 serious adverse events, 0 lethal events) of the patients in the LOC and 59% (32.8% related, 57 serious adverse events and 2 toxic deaths) of patient in the trabectedin arm.

CONCLUSIONS

In this first prospective randomized trial performed in recurrent grade II or III meningioma, trabectedin did not improve PFS and OS and was associated with significantly higher toxicity as compared to LOC treatment. The data collected in this study may serve as benchmark for future clinical trials in this setting.

Abstract P6-20-03: Tumor epichaperome expression using 124I PU-H71 PET (PU-PET) as a biomarker of response for PU-H71 plus nab-paclitaxel in HER2 negative (HER2-) metastatic breast cancer (MBC)

Background: The epichaperome is a new cancer target required for tumor survival (Joshi et al. Nature Reviews Cancer 2018). PU-H71 is a synthetic, purine scaffold epichaperome inhibitor that binds to the ATP-binding site of HSP90 specifically when HSP90 is integrated into the epichaperome (Rodina et al. Nature 2016). It has demonstrated antitumor activity in multiple xenograft models. Furthermore, sequential administration of nab-paclitaxel and PU-H71 in TNBC xenograft models augmented epichaperome levels, and in turn resulted in super-synergistic drug action with ablation of xenografted tumors and cures in mice.

Methods: This is an open label phase1b study of PU-H71 + nab-paclitaxel in pts with HER2- MBC. Pts received nab-paclitaxel at a standard dose of 260mg/m2 IV Q 3weeks. PU-H71 was administered IV 6 hrs (+/-1 hr) post nab-paclitaxel Q3weeks in 2 escalating dose levels (225mg/m2 and 300 mg/m2). All pts underwent FDG PET/CT every 6 weeks. Additionally, patients had the option to enroll on a separate diagnostic PU-PET protocol to measure epichaperome expression prior to initiating treatment on the phase 1b study, wherein they received a single dose of up to 11mci of 124I-PU-H71 IV and underwent imaging at 3-4hrs and 20-24 hrs. Primary objective was to establish the MTD/RP2D of this regimen. Secondary objectives were to assess PK of PU-H71 + nab-paclitaxel and clinical efficacy. Exploratory analysis included correlation of epichaperome expression at baseline using PU-PET with tumor response.

Results: 12 patients (5 ER+/HER2- ; 7 TNBC) were enrolled (6 at 225mg/m2 of PU-H71 and 6 at 300mg/m2). Median Age: 54 yrs (range: 37-71). Median ECOG: 0. Median lines of therapy in the metastatic setting: 6 (range 1-11) including prior taxanes in 75% of pts. Most common toxicities included diarrhea G1 58%; G2 7%, G3 7%) that was easily managed with anti-diarrheal agents, G1 fatigue (25%), G1/2 peripheral neuropathy (17%), G1 hyperglycemia (67%), G1 increases in alk phos (58%), AST (50%) and ALT (42%). Hematological toxicities included G3 leukopenia (42%), G3/4 neutropenia (67%), G3 anemia (50%) and G2 thrombocytopenia (17%). There were no DLTs. 33% (4/12) had PR, 58% (7/12) achieved SD with only 1 PD at the time of first scan; 5 pts are currently ongoing including 2 TNBC pts with PR who have been on therapy &gt; 7 months. PK data will be presented. 8/12 patients also underwent PU-PET at baseline. A higher tumor to muscle SUV ratio at 24 hrs on PU-PET predicted response and increased PU-H71 retention on PU-PET at 24 hrs correlated with a longer duration of response.

Conclusion: The RP2D of PU-H71 was 300mg/m2 with 260mg/m2 of nab-paclitaxel administered IV every 3 weeks. The regimen is well tolerated with promising clinical activity in this heavily pre-treated cohort. Tumor epichaperome expression at baseline using PU-PET has the potential to serve as a predictive biomarker of response. A Phase 2 trial of this combination along with baseline PU-PET is currently planned.

Citation Format: Jhaveri K, Dunphy M, Wang R, Comen E, Fornier M, Moynahan ME, Bromberg J, Ma W, Patil S, Taldone T, Rodina A, Sterlin V, Khoshi S, Lewis J, Norton L, Chiosis G, Modi S. Tumor epichaperome expression using 124I PU-H71 PET (PU-PET) as a biomarker of response for PU-H71 plus nab-paclitaxel in HER2 negative (HER2-) metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-20-03.

Real Time Central Assessment of Kidney Transplant Indication Biopsies by Microarrays: The INTERCOMEX Study

The authors conducted a prospective trial to assess the feasibility of real time central molecular assessment of kidney transplant biopsy samples from 10 North American or European centers. Biopsy samples taken 1 day to 34 years posttransplantation were stabilized in RNAlater, sent via courier overnight at ambient temperature to the central laboratory, and processed (29 h workflow) using microarrays to assess T cell- and antibody-mediated rejection (TCMR and ABMR, respectively). Of 538 biopsy samples submitted, 519 (96%) were sufficient for microarray analysis (average length, 3 mm). Automated reports were generated without knowledge of histology and HLA antibody, with diagnoses assigned based on Molecular Microscope Diagnostic System (MMDx) classifier algorithms and signed out by one observer. Agreement between MMDx and histology (balanced accuracy) was 77% for TCMR, 77% for ABMR, and 76% for no rejection. A classification tree derived to provide automated sign-outs predicted the observer sign-outs with >90% accuracy. In 451 biopsy samples where feedback was obtained, clinicians indicated that MMDx more frequently agreed with clinical judgment (87%) than did histology (80%) (p = 0.0042). In 81% of feedback forms, clinicians reported that MMDx increased confidence in management compared with conventional assessment alone. The authors conclude that real time central molecular assessment is feasible and offers a useful new dimension in biopsy interpretation. ClinicalTrials.gov NCT#01299168.

Abstract P2-08-03: Targeting inflammatory pathways: A phase 2 trial of the JAK-inhibitor ruxolitinib in combination with exemestane for aromatase inhibitor-resistant, estrogen receptor-positive breast cancer

Background: In vitro mechanisms link IL-6 to poor outcome in breast cancer via inflammatory pathways, activated JAK/STAT tumor signaling and upregulation of aromatase, leading to an aggressive tumor phenotype. Epidemiological data from our group and others support these mechanisms in women with ER-positive (+) disease. We therefore hypothesized that the JAK inhibitor, ruxolitinib (RUX, INCB018424; Incyte), would enhance activity of exemestane (EXE) in women with ER+ breast cancer who relapsed after non-steroidal aromatase inhibitor therapy, particularly among carriers of a germ-line polymorphism in IL-6, conferring elevated levels of IL-6 in the tumor microenvironment.

Methods: The “JAKEE trial” is a phase II trial to determine the safety and efficacy of RUX + EXE in postmenopausal women with relapsed, ER+ advanced breast cancer. Eligible patients were required to have progressed on a non-steroidal AI and either measureable or bone-only disease. CRP, a putative biomarker of tumor microenvironment inflammation, was measured at baseline and serially during treatment. Using a Simon 2-stage design, we treated 15 patients with RUX at 25 mg BID and EXE at 25mg daily on a continuous 28-day schedule. First stage results were previously presented (AACR, 2014). Accrual proceeded to second stage after no patient met the pre-defined stopping rule of grade (G) 3/4 toxicity requiring discontinuation from the study within the first treatment cycle. Due to the substantial rate of anemia requiring dose reductions, however, RUX dose was reduced to 15 mg BID in second stage.

Results: A total of 25 patients were enrolled; 24/25 had progressed on AI in metastatic setting; 1 relapsed on adjuvant AI. RUX+EXE was well-tolerated overall, with only 2 G4 events (creatinine elevation, hepatic failure); both were due to disease progression. 16% had G3 fatigue, anemia or hypertension; 12% had G3 neutropenia or depression. Other lower grade toxicities in &gt;20% included musculoskeletal pain, increased ALT, and headache. Overall, patients stayed on therapy for a median of 3 cycles (range 2 – 21). There were no CR or PR, but 6/25 (24%) had prolonged disease control (SD&gt; 6 months). Median CRP at study entry was 6.4 (range 0.3-38.9), with 8/25 (32%) having CRP&gt;10. Achieving SD&gt;6 months was not associated with baseline CRP (CRP&gt;10 in 32% with vs. 33% without SD&gt;6 months, p(exact)=1.0). A novel pharmacodynamic assay to assess STAT3 phosphorylation in peripheral blood mononuclear cells after RUX exposure demonstrated differential effects in patients with response.

Conclusions: Targeting JAK/STAT signaling in AI-resistant breast cancer with RUX+EXE was safe and well-tolerated. 24% of patients had prolonged SD, but baseline CRP level did not predict response. Correlative studies to determine whether host and/or tumor biomarkers predict response to therapy, including germline IL-6 genotype, immune profiles, p-STAT3 and estradiol levels, are currently underway.

Citation Format: DeMichele AM, Clark AS, Holmes R, Volpe M, Medrano C, Troxel A, Fox K, Domchek S, Matro J, Bradbury A, Shih N, Feldman M, Hexner E, Bromberg J. Targeting inflammatory pathways: A phase 2 trial of the JAK-inhibitor ruxolitinib in combination with exemestane for aromatase inhibitor-resistant, estrogen receptor-positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-08-03.

Association Between Duration of Human Immunodeficiency Virus (HIV)-1 Viral Suppression Prior to Renal Transplantation and Acute Cellular Rejection

Renal transplant has become an important option for human immunodeficiency virus (HIV)-infected patients with end-stage renal disease; however, these patients experience a high rate of acute cellular rejection (ACR). Guidelines do not currently exist for the optimal duration of viral suppression prior to transplantation. In a retrospective cohort analysis of 47 HIV-infected renal transplant recipients, we compared the rate of ACR between patients based on the length of time of viral suppression prior to transplantation. Of the patients who achieved viral suppression for >6 months but less than 2 years prior to transplantation (n = 15), 60% experienced ACR compared to 41% of patients suppressed at least 2 years or more (n = 32) prior to transplant (p = 0.21). Patients suppressed <2 years experienced ACR at 2.48 times the rate of those suppressed 2 years or longer. Induction immunosuppression, HLA mismatch and panel-reactive antibodies (PRAs) did not significantly differ between the two groups.

First-line treatment and outcome of elderly patients with primary central nervous system lymphoma (PCNSL)--a systematic review and individual patient data meta-analysis

BACKGROUND

To investigate prognosis and effects of first-line therapy in elderly primary central nervous system lymphoma (PCNSL) patients.

PATIENTS AND METHODS

A systematic review of studies about first-line therapy in immunocompetent patients ≥60 years with PCNSL until 2014 and a meta-analysis of individual patient data from eligible studies and international collaborators were carried out.

RESULTS

We identified 20 eligible studies; from 13 studies, we obtained individual data of 405 patients, which were pooled with data of 378 additional patients (N = 783). Median age and Karnofsky Performance Score (KPS) was 68 years (range: 60-90 years) and 60% (range: 10%-100%), respectively. Treatments varied greatly, 573 (73%) patients received high-dose methotrexate (HD-MTX)-based therapy. A total of 276 patients received whole-brain radiotherapy (median 36 Gy, range 28.5-70 Gy). KPS ≥ 70% was the strongest prognostic factor for mortality [hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.41-0.62]. After a median follow-up of 40 months, HD-MTX-based therapy was associated with improved survival (HR 0.70, 95% CI 0.53-0.93). There was no difference between HD-MTX plus oral chemotherapy and more aggressive HD-MTX-based therapies (HR 1.39, 95% CI 0.90-2.15). Radiotherapy was associated with an improved survival, but correlated with an increased risk for neurological side-effects (odds ratio 5.23, 95% CI 2.33-11.74).

CONCLUSIONS

Elderly PCNSL patients benefit from HD-MTX-based therapy, especially if combined with oral alkylating agents. More aggressive HD-MTX protocols do not seem to improve outcome. WBRT may improve outcome, but is associated with increased risk for neurological side-effects. Prospective trials for elderly PCNSL patients are warranted.

RECK controls breast cancer metastasis by modulating a convergent, STAT3-dependent neoangiogenic switch

Metastasis is the primary cause of cancer-related death in oncology patients. A comprehensive understanding of the molecular mechanisms that cancer cells usurp to promote metastatic dissemination is critical for the development and implementation of novel diagnostic and treatment strategies. Here we show that the membrane protein RECK (Reversion-inducing cysteine-rich protein with kazal motifs) controls breast cancer metastasis by modulating a novel, non-canonical and convergent signal transducer and activator of transcription factor 3 (STAT3)-dependent angiogenic program. Neoangiogenesis and STAT3 hyperactivation are known to be fundamentally important for metastasis, but the root molecular initiators of these phenotypes are poorly understood. Our study identifies loss of RECK as a critical and previously unknown trigger for these hallmarks of metastasis. Using multiple xenograft mouse models, we comprehensively show that RECK inhibits metastasis, concomitant with a suppression of neoangiogenesis at secondary sites, while leaving primary tumor growth unaffected. Further, with functional genomics and biochemical dissection we demonstrate that RECK controls this angiogenic rheostat through a novel complex with cell surface receptors to regulate STAT3 activation, cytokine signaling, and the induction of both vascular endothelial growth factor and urokinase plasminogen activator. In accordance with these findings, inhibition of STAT3 can rescue this phenotype both in vitro and in vivo. Taken together, our study uncovers, for the first time, that RECK is a novel regulator of multiple well-established and robust mediators of metastasis; thus, RECK is a keystone protein that may be exploited in a clinical setting to target metastatic disease from multiple angles.

Abstract BS03-1: Tumor-derived exosomes promote pre-metastatic niche formation and organotropism

Metastasis is the most deadly aspect of cancer due to a lack of appropriate therapies. Tumor-secreted factors have been recently recognized to be one of the main culprits for metastatic progression. Tumor-secreted factors such as VEGF-A, PlGF, TGFb, TNF-a, and LOX have been shown to play active roles in the recruitment of bone marrow (BM)-derived cells to the primary tumor microenvironment and pre-metastatic niches. We have found that tumor-derived exosomes are abundantly secreted into the circulation in highly metastatic murine models and in patients with stage IV metastatic disease. Tumor-derived exosomes induce vascular leakiness, and hypoxic and pro-inflammatory changes at pre-metastatic sites. Moreover, tumor-derived exosomes preferentially fuse and “educate” BM-derived progenitor cells to a pro-vasculogenic phenotype characterized by upregulation of Tie-2, VEGF-A, VEGFR2, TSP1 and ADAM10. We found that B16-F10 melanoma-derived exosomes help establish pre-metastatic niches, including the recruitment of “educated” BM cells, in specific organs destined to be involved in future metastasis whereas LLC lung cancer-derived exosomes predominant in the lung as the main organ of metastasis. These results suggest that tumor-derived exosomes may have a role in metastatic organotropism, whereby cancer metastasizes to specific organs, as proposed by Stephen Paget's ‘seed and soil’ hypothesis more than a 100 years ago. We believe that the identification of exosomes proteins, with their prognostic and therapeutic potential, may also partially explain the specific receptor-ligand binding of exosomes to a pre-metastatic niche defining an organotropic site for future metastasis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr BS03-1.

Microarray diagnosis of antibody-mediated rejection in kidney transplant biopsies: an international prospective study (INTERCOM)

In a reference set of 403 kidney transplant biopsies, we recently developed a microarray-based test that diagnoses antibody-mediated rejection (ABMR) by assigning an ABMR score. To validate the ABMR score and assess its potential impact on practice, we performed the present prospective INTERCOM study (clinicaltrials.gov NCT01299168) in 300 new biopsies (264 patients) from six centers: Baltimore, Barcelona, Edmonton, Hannover, Manchester and Minneapolis. We assigned ABMR scores using the classifier created in the reference set and compared it to conventional assessment as documented in the pathology reports. INTERCOM documented uncertainty in conventional assessment: In 41% of biopsies where ABMR features were noted, the recorded diagnoses did not mention ABMR. The ABMR score correlated with ABMR histologic lesions and donor-specific antibodies, but not with T cell-mediated rejection lesions. The agreement between ABMR scores and conventional assessment was identical to that in the reference set (accuracy 85%). The ABMR score was more strongly associated with failure than conventional assessment, and when the ABMR score and conventional assessment disagreed, only the ABMR score was associated with early progression to failure. INTERCOM confirms the need to reduce uncertainty in the diagnosis of ABMR, and demonstrates the potential of the ABMR score to impact practice.

Potential impact of microarray diagnosis of T cell-mediated rejection in kidney transplants: The INTERCOM study

We previously developed a microarray-based test for T cell-mediated rejection (TCMR) in a reference set of 403 biopsies. To determine the potential impact of this test in clinical practice, we undertook INTERCOM, a prospective international study of 300 indication biopsies from 264 patients (ClinicalTrials.gov NCT01299168). Biopsies from six centers-Baltimore, Barcelona, Edmonton, Hannover, Manchester and Minneapolis-were analyzed by microarrays, assigning TCMR scores by an algorithm developed in the reference set and comparing TCMR scores to local histology assessment. The TCMR score correlated with histologic TCMR lesions-tubulitis and interstitial infiltration. The accuracy for primary histologic diagnoses (0.87) was similar to the reference set (0.89). The TCMR scores reclassified 77/300 biopsies (26%): 16 histologic TCMR were molecularly non-TCMR; 15 histologic non-TCMR were molecularly TCMR, including 6 with polyoma virus nephropathy; and all 46 "borderline" biopsies were reclassified as TCMR (8) or non-TCMR (38). Like the reference set, discrepancies were primarily in situations where histology has known limitations, for example, in biopsies with scarring and inflammation/tubulitis potentially from other diseases. Neither the TCMR score nor histologic TCMR was associated with graft loss. Thus the molecular TCMR score has potential to add new insight, particularly in situations where histology is ambiguous or potentially misleading.

A phase I study of dasatinib and weekly paclitaxel for metastatic breast cancer

BACKGROUND

SRC plays an important role in the pathogenesis of metastatic breast cancer (MBC). In preclinical models, paclitaxel and the oral SRC inhibitor dasatinib showed greater antitumor activity than either agent. To determine the maximum tolerated dose of this combination, we conducted a phase I study.

PATIENTS AND METHODS

Patients with MBC; Eastern Cooperative Oncology Group performance status of zero to one; normal hepatic, renal and marrow function were eligible. Paclitaxel 80 mg/m(2) was given 3 weeks of 4. The starting dasatinib dose was 70 mg and was increased, using a standard 3 + 3 dose-escalation scheme.

RESULTS

Fifteen patients enrolled (median age 54 years, range 35-74). No dose-limiting toxic effects (DLTs) occurred at dasatinib doses of 70-120 mg. One DLT (grade 3 fatigue) occurred in the dasatinib 150-mg cohort, which was expanded (six patients) with no further DLTs. However, due to cumulative toxic effects (rash, fatigue, diarrhea), the recommended phase II dose is dasatinib 120 mg. Of 13 assessable patients, a partial response was seen in 4 patients (31%), including 2 patients previously treated with taxanes; all received ≥120 mg dasatinib. An additional five patients (29%) had stable disease.

CONCLUSION

In combination with weekly paclitaxel, the recommended phase II dose of dasatinib is 120 mg daily and preliminary activity has been seen in patients with MBC.

Abstract P6-12-09: A Phase I-II Trial of Dasatinib (D) in Combination with Weekly (w) Paclitaxel (P) for Patients (Pts) with Metastatic Breast Carcinoma (MBC)

Background: Inhibition of SRC is a novel approach for MBC. D is an inhibitor of multiple tyrosine kinases, including the SRC family. Pre-clinical data show D inhibits multiple breast cancer cell lines, including those of “basal-like” subtype. In preclinical models D + P had superior antitumor activity to either agent alone. We designed this phase I-II study to translate this observation.

Methods: For phase I: pts with MBC, ECOG PS 0-1, normal hepatic, renal, marrow function were eligible. Pts with pleural/pericardial effusions were excluded. For phase II: pts had measurable, HER2-negative MBC, ≥2 prior rx for MBC. Prior taxanes, stable brain metastases and baseline neuropathy grade ≥1 were allowed. Cycle (C) consisted of wP 80 mg/m2 IV 3/4 weeks + D 70mg orally daily; escalating to 100 mg, 120 mg and 150 mg in cohorts of 3pts. Toxicity was assessed by CTCAE v3.0, response by RECIST.

Results: 17 pts enrolled (15 phase I; 2 phase II); median age 54 (range 35-74), median PS=1 (range 0-1). 12 (71%) pts rcvd prior adjuvant chemoRx. Pts rcvd a median of 3 prior rx for MBC (range 0-12). Pts rcvd median of 2 C of D + P (range 1-14). One DLT occurred at 150mg (G3 fatigue); this cohort was expanded with no further DLTs. However 3 pts on this dose level withdrew;1 pt delayed hypersensitivity rash (grade 1), 1 pt febrile neutropenia (grade 3), 1 pt paclitaxel pneumonitis (grade 3). Therefore the phase II dose is D 120mg. Overall the most common toxicities have been hematologic and low G (table). 13 pts are assessable for response; 4 patients (31%) had a PR, including 3 patients previously treated with taxanes. 5 pts (29%) had stable disease.

Toxicities &gt; Grade 1

Conclusion: Treatment with wP and D is feasible in pts with MBC. In the phase I study, 1 DLT occurred at D 150mg but due to cumulative toxicities the recommended dose for the ongoing phase II study is 120mg. Preliminary evidence of activity has been seen in taxane-pretreated pts at the phase II dose. Identification of biomarkers to select appropriate pts for this therapeutic approach is the subject of ongoing correlative studies.

Outcome of combined liver and kidney transplantation in hepatitis C: a single-center long-term follow-up experience

INTRODUCTION

Hepatitis C (HCV) cirrhosis is the prevalent liver disease requiring liver transplantation in the United States. Candidates who also have end-stage renal disease, chronic renal disease stage 4, or prolonged hepatorenal syndrome are considered for combined liver and kidney transplantation (CLKT).

MATERIALS AND METHODS

We performed a retrospective study of HCV(+) and HCV(-) CLKT patients with more than 12 months of follow-up and HCV(+) patients with isolated liver transplant (OLT) to compare the outcomes of various groups.

RESULTS

Since 1988, 2983 OLTs were performed at our institution including 58 CLKTs. Of these, 23 were HCV(+) subjects who were significantly older than HCV(-) CLKT patients. Race, pretransplant dialysis time, renal indication for CLKT, Model for End-stage Liver Disease score, donor age, liver and kidney rejection as well as occurrence of posttransplant hypertension were similar among HCV(+) and HCV(-) CLKT patients. Posttransplant diabetes was observed in 80% of the HCV(+) group and 30% of the HCV(-) group (P = .01). Renal function seemed to be better in HCV(-) when compared with HCV(+) subjects at 5 years (P = .09). Overall patient survival for HCV(+) CLKT, HCV(-) CLKT, and HCV(+) OLT groups at 1, 2, and 5 years were not significantly different (P = .6).

CONCLUSION

HCV positivity should not exclude appropriate candidates for CLKT.

Factors associated with failure to list HIV-positive kidney transplant candidates

With improved survival in the antiretroviral era, data from ongoing studies suggest that HIV patients can be safely transplanted. The disproportionate burden of HIV-related end-stage renal disease in minority populations may impose additional obstacles to successful completion of the transplant evaluation. We retrospectively reviewed 309 potentially eligible HIV patients evaluated for kidney transplant at our institution since 2000. Only 20% of HIV patients have been listed, compared to 73% of HIV-negative patients evaluated over the same period (p < 0.00001). Failure to provide documentation of CD4 and viral load (36% of candidates) was the most common reason for failure to progress beyond initial evaluation. Other factors independently associated with failure to complete the evaluation included CD4 < 200 at initial evaluation (OR 15.17; 95% CI 1.94-118.83), black race (OR 2.33; 95% CI 1.07-5.06), and history of drug use (OR 2.56; 95% CI 1.22-5.37). More efficient medical record sharing and an awareness of factors associated with failure to list HIV-positive transplant candidates may enable transplant centers to more effectively advocate for these patients.

Factors associated with failure to list HIV-positive kidney transplant candidates

With improved survival in the antiretroviral era, data from ongoing studies suggest that HIV patients can be safely transplanted. The disproportionate burden of HIV-related end-stage renal disease in minority populations may impose additional obstacles to successful completion of the transplant evaluation. We retrospectively reviewed 309 potentially eligible HIV patients evaluated for kidney transplant at our institution since 2000. Only 20% of HIV patients have been listed, compared to 73% of HIV-negative patients evaluated over the same period (p < 0.00001). Failure to provide documentation of CD4 and viral load (36% of candidates) was the most common reason for failure to progress beyond initial evaluation. Other factors independently associated with failure to complete the evaluation included CD4 < 200 at initial evaluation (OR 15.17; 95% CI 1.94-118.83), black race (OR 2.33; 95% CI 1.07-5.06), and history of drug use (OR 2.56; 95% CI 1.22-5.37). More efficient medical record sharing and an awareness of factors associated with failure to list HIV-positive transplant candidates may enable transplant centers to more effectively advocate for these patients.

Dose-dense (DD) doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (P) with trastuzumab (T) and lapatinib (L) in HER2/neu-positive breast cancer is not feasible due to excessive diarrhea: updated results

Abstract #2108

Background: DD q 2 weekly (w) AC → P + T x 1 year (y) has an acceptable safely profile w/ congestive heart failure (CHF) rate of 1/70 pts (Dang, JCO 2008). Lapatinib (L) is effective in HER2 (+) BC. We conducted a pilot study of dd AC → w P + T + L to determine its feasibility and cardiac safety.&#x2028; Methods: Enrolled pts had HER2 (+) BC; LVEF &gt; 50%. Rx consisted of AC at 60/600 mg/m2 x 4 q 2 w (w/ pegfilgrastim 6 mg day 2) → P at 80 mg/m2 x 12 q w + T x 1 y; L (1000 mg daily beginning w/ P + T and continued x 1 y). MUGA is obtained at baseline and at months (mo) 2, 6, 9, and 18. Rx is considered feasible if 1) &gt; 80% pts can complete the PTL phase without a dose delay or reduction and 2) the cardiac event rate (CHF or cardiac death) is &lt; 4%. Pts can remain on-Rx w/ one dose reduction of L (1000 mg → 750 mg) for a G 3 event or &lt; G 3 toxicity (unacceptable).&#x2028; Results: From March 2007 to April 2008, we enrolled 95 pts. Median (med) age was 45 years (range, 28-73). At a med follow-up of 7 months, 90 are evaluable. Of the 90 pts, 34 (37%) withdrew from study during the PTL phase; 29 for a 2nd event of G 3 or unacceptable &lt; G 3 toxicities (15 G 3 diarrhea, 4 G 1/2 diarrhea, 1 G 3 rash, 2 G 2 rash, 1 G 3 dyspnea and also had G 3 diarrhea, 1 G 3 ↑QTc also had G 3 diarrhea, 1 G 3 ↑ALT also had G 3 diarrhea, 1 G 3 paronychia, 1 G 3 pneumonitis, 1 asymptomatic LVEF ↓, 1 myocarditis) and 5 for other reasons (2 personal reason, 1 PCP pneumonia, 1 progression, 1 P hypersensitivity). Overall, 25/90 (27%) pts had G 3 diarrhea and 31/90 (34%) pts required a dose reduction of lapatinib. Med LVEF at baseline is 67% (N=95), at mo 2 is 68% (N=90), at mo 6 is 65% (N=53), and mo 9 is 65% (N=28). To date there are no patient drop-outs due to significant LVEF declines after dd AC; one patient dropped during PTL out due to an asymptomatic LVEF decline.&#x2028; Discussion: L at 1000 mg/day is not feasible combined w/ weekly P and T by protocol stipulation (&gt; 20% pts required L dose reduction) primarily due to excessive G 3 diarrhea. These results have led to the modification of Design 2 (Arm D) of ALTTO. We will report updated results.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2108.

Identification of Ultrastructural Changes in Liver Allografts of Patients Experiencing Primary Nonfunction

BACKGROUND

Primary nonfunction (PNF) after liver transplantation is fatal without timely retransplantation. PNF has been associated with many risk factors, but the etiology remains unknown in most cases. Using electron microscopy, we examined the hepatic ultrastructure of donor allografts in patients experiencing PNF and compared the findings with a well-matched group of other donor allografts.

MATERIALS AND METHODS

Archival paraffin-embedded pre- and post-reperfusion donor liver biopsies were examined by electron microscopy in 10 patients with PNF and in 10 controls, matched by donor age +/- 5 years, gender, cold ischemic time +/- 1 hour, and donor cause of death. Mitochondria, endoplasmic reticulum, sinusoidal endothelial cells, and the glycogen content of the cells were assessed. The donors' serum peak transaminases, bilirubin and sodium levels, as well as the recipient age and serum creatinine were compared.

RESULTS

There were no significant differences in recipient age at the time of transplantation, peak recipient serum creatinine, donor peak serum transaminase, sodium or bilirubin levels. In all cases, the endoplasmic reticulum and sinusoidal endothelial cells were ultrastructurally normal. Hepatocytes had variable degrees of glycogen pooling. Hepatic steatosis and intramitochondrial inclusions cells were present in 5/10 PNF compared to 0/10 controls patients on preperfusion liver biopsy (P = .17).

CONCLUSION

Liver allografts from patients suffering from PNF can have mitochondrial ultrastructural changes on preperfusion biopsies.

Review article: hepatitis C virus and calcineurin inhibition after renal transplantation

The impact of hepatitis C virus on patient and graft survival after renal transplantation remains controversial. However, recent studies have given emphasis on the detrimental role of hepatitis C on long-term patient and graft survival after renal transplantation. Various mechanisms can promote the lower survival in hepatitis C virus-positive recipients, i.e. post-transplant diabetes mellitus, liver disease and infections. Novel evidence has been accumulated showing the inhibitory activity of ciclosporin on the hepatitis C virus replication rate in human hepatocytes; ciclosporin has been shown in vitro to suppress hepatitis C virus replication as effectively as interferon alpha. This effect has not been seen with tacrolimus and is separate from its immunosuppressive activity. Data from patients with normal kidney function or after bone marrow transplantation show that ciclosporin inhibits hepatitis C virus replication. It appears that the progression of liver fibrosis is slower in hepatitis C virus-positive liver transplant recipients treated with ciclosporin than tacrolimus. In contrast, the clinical outcome of hepatitis C in hepatitis C virus-positive patients after liver transplantation treated with ciclosporin vs. tacrolimus has given mixed results. No information after renal transplantation is available. Various parameters can promote the worsening of hepatitis C after renal transplantation but choice of calcineurin inhibition is one of the few risk factors that can potentially be modified by the physician. Prospective, comparative trials of ciclosporin and tacrolimus with large size and adequate follow-up after renal transplantation are in progress.

Human immunodeficiency virus type 1 Nef mediates activation of STAT3 in immature dendritic cells

Replication of immunodeficiency viruses (HIV-1 and SIV) in immature dendritic cell (DC)-T cell cocultures is dependent on Nef. In contrast, mature DCs promote the replication of wild-type and nef-defective SIV in concert with CD4(+) T cells. Transcription factor activation occurs on DC maturation and this study aimed to investigate whether Nef triggers similar events in immature DCs, rendering them more like mature DCs. Recombinant HIV nef-expressing adenovirus was used to selectively introduce nef into immature human or macaque DCs. These data provide the first evidence that the expression of HIV nef in immature DCs induced selective activation of STAT3 and, to a lesser extent, NF-kappaB. This highlights how Nef can signal primary immature DCs, suggesting one way in which Nef may modulate immature DCs to drive virus replication in the DC-T cell milieu.

The role of STATs in transcriptional control and their impact on cellular function

The STAT proteins (Signal Transducers and Activators of Transcription), were identified in the last decade as transcription factors which were critical in mediating virtually all cytokine driven signaling. These proteins are latent in the cytoplasm and become activated through tyrosine phosphorylation which typically occurs through cytokine receptor associated kinases (JAKs) or growth factor receptor tyrosine kinases. Recently a number of non-receptor tyrosine kinases (for example src and abl) have been found to cause STAT phosphorylation. Phosphorylated STATs form homo- or hetero-dimers, enter the nucleus and working coordinately with other transcriptional co-activators or transcription factors lead to increased transcriptional initiation. In normal cells and in animals, ligand dependent activation of the STATs is a transient process, lasting for several minutes to several hours. In contrast, in many cancerous cell lines and tumors, where growth factor dysregulation is frequently at the heart of cellular transformation, the STAT proteins (in particular Stats 1, 3 and 5) are persistently tyrosine phosphorylated or activated. The importance of STAT activation to growth control in experiments using anti-sense molecules or dominant negative STAT protein encoding constructs performed in cell lines or studies in animals lacking specific STATs strongly indicate that STATs play an important role in controlling cell cycle progression and apoptosis. Stat1 plays an important role in growth arrest, in promoting apoptosis and is implicated as a tumor suppressor; while Stats 3 and 5 are involved in promoting cell cycle progression and cellular transformation and preventing apoptosis. Many questions remain including: (1) a better understanding of how the STAT proteins through association with other factors increase transcription initiation; (2) a more complete definition of the sets of genes which are activated by different STATs and (3) how these sets of activated genes differ as a function of cell type. Finally, in the context of many cancers, where STATs are frequently persistently activated, an understanding of the mechanisms leading to their constitutive activation and defining the potential importance of persistent STAT activation in human tumorigenesis remains. Oncogene (2000).

Expression of the alpha6beta4 integrin provides prognostic information in bladder cancer

Integrins are cell surface receptors for extracellular matrix components that may participate in metastatic processes. Normal urothelial tissues show a polarized expression of alpha6beta4 integrin on basal cells at their junction with the lamina propria. We have previously shown that bladder cancers frequently overexpress one member of the integrin family, the alpha6beta4 integrin. In this study, we evaluated the level of alpha6beta4 integrin expression in bladder cancer specimens from 57 patients and correlated the expression level with patient survival. Expression was evaluated by immunoperoxidase staining. Three patterns of alpha6beta4 expression were observed: negative (13 patients); strong overexpression throughout the tumor cells (21 patients); and weak expression that most closely resembled expression in normal urothelium (23 patients). Individuals with weak staining tumors had a statistically significantly better survival (p=0.041) than patients whose tumors exhibited either no expression or strong overexpression. These data indicate that evaluation of the expression of alpha6beta4 integrin may provide valuable prognostic information on clinical outcome in patients with bladder cancer.

Signal transducers and activators of transcription as regulators of growth, apoptosis and breast development

STAT transcription factors were discovered 10 years ago as mediators of interferon-induced gene expression. They now form an important group, comprising seven members, that are activated by virtually every cytokine and growth factor. Their critical role in development and normal cell signaling has been largely determined through the analysis of transgenic mice lacking individual STAT genes. In addition, cell culture work has further delineated their importance in cellular transformation, apoptosis, differentiation and growth control. This review discusses the specific phenotypes of STAT-deficient animals with a focus on STAT5 and STAT3, as these two STAT molecules are required for normal breast development and involution, respectively, and may play an important role in breast carcinogenesis.

The orthopedic and social outcome of open tibia fractures in children

To determine whether the accepted principles of management of open tibia fractures apply to children, 40 consecutive open fractures of the tibial shaft in skeletally immature patients were retrospectively reviewed. Attempts were made to evaluate the functional and social impact of open tibia fractures in children. All open fractures were initially treated by rapid irrigation and debridement which was repeated every 48 hours until soft tissues stabilized. The average age was 10.1 years and average follow up was 26 months (range: 18 to 84). There were 16 grade I, 10 grade II, and 14 grade III open fractures. The grade III fractures were further subdivided into 6 grade IIIA, 7 grade IIIB, and 1 grade IIIC. The average time to union was 7.5 and 11.0 weeks in the grade I and II fractures respectively, with no infections and no delayed unions. In grade III fractures, the average time to union was 15 weeks, with 1 infection and 3 delayed unions. Bone grafting using autogenous iliac crest was performed on 2 patients. The children surveyed missed an average of 4.1 months of school and 33% had to repeat a year. Twenty-five percent of the children complained of nightmares involving the events of the accident. Chronic pain despite solid union was found in 30% of patients. Forty percent of those surveyed (7 grade III fractures) complained of a limp. The low incidence of soft tissue complications and infections in the study population supports applying in children the same basic soft tissue management principles of open fracture treatment as used in adults. While bone stabilization options are limited in children, the rate of successful union without adjunctive bone grafting is much higher than that of adults treated under similar protocols. Routine early iliac crest bone grafting is unnecessary. The prevalence of gait abnormality despite fracture union should be taken into account during the patient's rehabilitation. The extensive time missed from school and resulting scholastic setback should not be underestimated.

Declining prevalence of cervicovaginal human papillomavirus infection with age is independent of other risk factors

BACKGROUND AND OBJECTIVES

Human papillomavirus (HPV) infection of the female genital tract is the most common sexually transmitted disease. Although the prevalence of HPV in women without detectable cervical disease has been shown to decline with increasing age, the relationship to sexual behavior has not been investigated.

GOAL

To identify risk factors for, and associated with the age-dependent decline in, genital HPV infection in women.

STUDY DESIGN

The prevalence of HPV was determined in a cohort of 439 sexually active inner-city women between the ages of 18 and 50 years recruited in Brooklyn, New York. Cervicovaginal cells were collected by lavage, and HPV was detected by low-stringent Southern blot hybridization.

RESULTS

The prevalence of HPV infection ranged from 36% in women younger than 25 years of age to 2.8% in women 45 years or older. Logistic regression analysis identified an increased risk for cervical HPV infection to be independently associated with number of sex partners in the past year (odds ratio [OR], 1.04 per yearly increase in age; 95% confidence interval [CI], 1.00 to 1.08), younger age (OR, 0.92 per year increase in age; 95% CI, 0.88 to 0.95), and not living with partner (OR, 2.28; 95% CI, 1.40 to 4.22).

CONCLUSIONS

The lower prevalence of HPV infection in older women compared to younger women was found to be independent of sexual behavior. These results suggest that a biologic effect, such as HPV immunity acquired over time and with multiple exposures, may mediate the inverse relationship between age and HPV prevalence.

Xerostomia, xerogenic medications and food avoidances in selected geriatric groups

OBJECTIVE

To study the relationship between complaints of xerostomia and salivary performance and food avoidances in four geriatric groups chosen to reflect a broad spectrum of individuals along the health-disease continuum. To determine whether xerogenic medications taken by these individuals could be associated with either complaints of xerostomia or with food avoidances.

DESIGN

Cross-sectional survey. Clinical examinations and interview.

SETTING

A VA dental clinic and a retirement home.

PATIENTS AND OTHER PARTICIPANTS

Subjects were 529 individuals older than 56 years of age, living both in institutions and in the community (average age 70 years). Two hundred eight persons were recruited from a VA Dental Clinic, 114 from a residential retirement home, and 132 from a nursing/long-term-care facility; 75 were from an acute care ward and had a diagnosis of a cerebral vascular accident or other neurological condition.

OUTCOME MEASURES

Prevalence of xerostomia, dental morbidity, salivary flow, and food avoidances.

RESULTS

About 72% of the subjects experienced xerostomia sometime during the day. Stimulated salivary flow was found to be significantly lower in individuals who complained of xerostomia than in those who did not. Fifty-five percent of participants reported using one or more xerogenic medications, with an 86% prevalence in the nursing/long-term-care facility. Individuals with xerostomia had difficulty in chewing and in starting a swallow and were significantly more likely to avoid crunchy foods such as vegetables, dry foods such as bread, and sticky foods such as peanut butter in their diets. Specific medications such as the inhalants ipratropium and triamcinolone and the systemic agents oxybutynin and triazolam could be statistically associated with xerostomia and/or low salivary flow, and/or specific food avoidances.

CONCLUSION

Xerostomia apparently affects the ability to chew and start a swallow. This leads to avoidance of certain foods, which raises the possibility that xerostomia could contribute to undernutrition in older persons. The topically applied ipratropium and triamcinolone and the systemic agents amitriptyline, oxybutynin and triazolam could be statistically associated with one or more complaints of xerostomia.

DNA and PCNA content of renal cell carcinoma and prognosis

Robson stage I or II renal carcinomas have a heterogenous clinical outcome. A variety of morphologic features and other parameters have been proposed as prognostically useful. The authors measured the DNA content and PCNA expression of 47 stage I or II renal carcinomas, and assessed the association of these measures with pathologic stage, nuclear grade, and clinical course. Approximately 56% of stage I neoplasms and 40% of stage II neoplasms were diploid. Five of 9 neoplasms in which multiple samples were analyzed manifested both aneuploid and diploid regions. PCNA expression was noted in 20 of 32 stage I neoplasms and 9 of 15 stage II neoplasms, and varied greatly among the neoplasms. Neither ploidy nor PCNA expression is associated with clinical behavior in these data. These results are different from some of those previously reported by others. These discrepancies are likely to be due to differences in methodology and the fact that there were only eight cases of metastatic disease. No single parameter will serve as a completely accurate prognostic indicator. Most individuals with these neoplasms will do well because all of the tumor has been excised.