Abstract OT1-12-03: RESCUE: Reaching for Evidence-baSed Chemotherapy Use in Endocrine sensitive breast cancer - A prospective health care study on risk assessment by the clinicomolecular test EndoPredict® and long-term patient outcome in early luminal breast cancer

Background: In node negative and 1-3 positive nodes breast cancer patients with hormone receptor positive (HR+), HER2-negative (HER2-) early-stage breast cancer the indication for chemotherapy is based on clinical and pathologic risk stratification (tumor size, nodal status, grading, quantitative ER, progesterone receptor and Ki67). For further decision-making, the EndoPredict test, which combines a molecular signature with the clinical risk factors tumor size and nodal status, stratifies patients into “low risk" or “high risk” groups. Level I-B- evidence demonstrates, that EndoPredict predicts the 10 year cumulative risk of relapse and metastases in patients with HR+/HER2- primary breast cancer with endocrine treatment.

Aim: In the RESCUE-Trial we document distant metastasis-free survival (DMFS), disease free survival (DFS) and overall survival (OS) events in patients who had an EndoPredict test. The primary objective is to show that 10-year DMFS of patients tested as “low risk” by EndoPredict and treated with adjuvant endocrine therapy alone is >90 %. Secondary endpoints among others include DMFS, DFS, OS in patients with EPclin “low risk” versus “high risk”. Also the proportion of patients whose treatment was concordant and non-concordant with EndoPredict test results, will be analyzed for survival. The prognostic performance of classical prognostic factors (like tumor size, nodal status, grading, quantitative ER, progesterone receptor and Ki67 level) with respect to survival will also be assessed.

Eligibility: Patient with HR+/HER2- primary invasive breast cancer stage I/II and T1 to T3 with 0 to 3 positive lymph nodes will be eligible, if they had an EndoPredict test within three months before inclusion.

Methods: The EndoPredict test results, tumor board decision and anti-tumor therapy will be assessed. After one year, annually (for 10 years), patients will be evaluated for treatment compliance, recurrence, metastases, and survival. The primary endpoint will be analyzed by a Kaplan-Meyer estimate for which a one-sided lower 95 % confidence interval will be given. Several secondary endpoints will be assessed in three interim analyses after completion of the 1st, 3rd, 5th year and then finally after 10 years.

Accrual: Start of accrual is planned for July 2018. At least 26 sites in Germany and one site in Switzerland will be active.

Sponsor: The study is sponsored by the North-Eastern-German Society of Gynecological Oncology (NOGGO) e.V.

Contact Information: For further information, contact NOGGO via studies@noggo.de or the leading physician Dr. Johannes Ettl via johannes.ettl@tum.de.

Citation Format: Ettl J, Blohmer J-U, Denkert C, Keller M, Klein E, Kronenwett R, Neuser P, Paepke S, Schade-Brittinger C, Schnuppe K, Untch M, Wittenberg M, Kiechle M. RESCUE: Reaching for Evidence-baSed Chemotherapy Use in Endocrine sensitive breast cancer - A prospective health care study on risk assessment by the clinicomolecular test EndoPredict® and long-term patient outcome in early luminal breast cancer [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 OT1-12-03.

Abstract P4-08-05: Prediction of distant recurrence using EndoPredict among women with ER-positive, HER2-negative breast cancer with a maximum follow-up of 16 years

Background: EndoPredict has been previously validated as a prognostic test in women with ER-positive, HER2-negative disease who received endocrine therapy only as part of the ABCSG6 and -8 trials. Here, we further evaluate the prognostic value of EndoPredict in this cohort with longer-term follow-up and compare 10-year distant recurrence (DR) and 5-15 years late recurrence according to nodal status.

Methods: This analysis included 1702 patients with ER-positive, HER2-negative disease who received endocrine therapy only. Prognostic value of EPclin score and EPclin risk category (high, low) on the risk of distant recurrence adjusted for patient and disease characteristics was evaluated using multivariable Cox proportional hazard models. Kaplan-Meier estimators were used to estimate DR according EPclin class and were compared using log rank test. Analyses were performed for the overall cohort, by nodal status, and for patients who were distant recurrence free at year 5 (late recurrence).

Results: The median follow-up was 9.6 years (range 0-16.6), an increase of 4.2 years over previous reports. Reanalysis with longer follow-up confirms that EPclin is a significant predictor of DR after adjusting for clinical factors, regardless of nodal status (Table 1). Overall, 62.6% of patients had low risk EPclin scores and 10-year DR was significantly improved relative to those with high risk scores (p<0.0001; Table 2). When nodal status was considered, 77.8% of node negative tumors and 34.9% of node positive (1-3 PLN) tumors had low risk EPclin scores. Regardless of nodal status, DR was significantly improved for those with low versus high risk EPclin scores (Table 2). Similar results were observed for the patients who were DR free at year 5 (5-15 year follow-up) (Table 2).

Conclusion: This reanalysis of previous EndoPredict data with a longer follow-up confirms that EPclin can identify a large group of patients at low risk of distant recurrence after 10 years who might be sufficiently treated with 5 years adjuvant endocrine therapy only, independent of nodal status. Replication of these results for the late distant recurrence between years 5-15 also shows that EPclin scores may also be informative in selecting patients who may safely forgo extended endocrine therapy.

Table 1.Multivariate analysis 0-15 year DR5-15 year DRCohortHR*p-valueHR*p-valueAll patients2.55<0.00012.56<0.0001Node negative1.680.00352.010.00881-3 positive nodes2.68<0.00013.430.0004*Hazard Ratio (HR) per unit score after adjusting for age, tumor grade, Ki67, ER, PR, and treatment

Table 2.DR according to EPclin score  Low risk EPclinHigh risk EPclin CohortHR*%0-10 year DR (95% CI)%0-10 year DR (95% CI)Log-rank p-valueAll patients N=17024.7762.60.96 (0.94, 0.97)37.40.80 (0.77, 0.84)<0.0001Node negative N=11653.4777.80.96 (0.94, 0.97)22.20.87 (0.83, 0.92)<0.00011-3 positive nodes N=4533.6534.90.96 (0.92, 0.99)65.10.81 (0.76, 0.87)0.0003CohortHR*%5-15 year DR (95% CI)%5-15 year DR (95% CI)Log-rank p-valueAll patients N=13864.5264.70.96 (0.93, 0.98)35.30.84 (0.79, 0.90)<0.0001Node negative N=9753.7678.30.97 (0.95, 0.99)21.70.85 (0.75, 0.96)<0.00011-3 positive nodes N=3623.0036.50.87 (0.72, 1.00)63.50.84 (0.77, 0.92)0.0337*HR for EPclin high risk versus low risk

Citation Format: Filipits M, Dubsky P, Rudas M, Greil R, Balic M, Fitzal F, Bago-Horvath Z, Singer C, Hlauschek D, Kronenwett R, Bernhisel R, Lancaster J, Gnant M. Prediction of distant recurrence using EndoPredict among women with ER-positive, HER2-negative breast cancer with a maximum follow-up of 16 years [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 P4-08-05.

Abstract P3-08-01: Prognostic performance of EndoPredict in invasive lobular carcinoma

Background: Invasive lobular carcinomas (ILC) account for around 15% of all oestrogen receptor (ER) positive invasive breast cancers. The EndoPredict assay (EPclin) is a multigene classifier to predict the likelihood of distant recurrence in ER-positive, HER2-negative breast cancer patients treated with adjuvant endocrine therapy and has been validated in several retrospective translational studies. However, these validation studies did not include an analysis of the histological subtypes. Here, we investigate the role of EPclin for the prediction of distant recurrence in women with ILC and compare the prognostication to those with invasive ductal carcinoma (IDC) in TransATAC.

Methods: Data on EPclin and histological type of tumour were available for 928 postmenopausal women with ER-positive, HER2-negative disease treated with 5 years of tamoxifen or anastrozole. The primary endpoint was distant recurrence and the primary objective was to assess the prognostic value of EPclin for the prediction of distant recurrence in women with invasive lobular carcinoma. Kaplan–Meier and Cox regression analyses were used to determine distant recurrence risk for 0-10 years of follow-up. Likelihood ratio tests were used to assess the prognostic information provided by EPclin. Hazard Ratios (HR) are for a change in 1 Standard Deviation.

Results: 141 (15.2%) had ILC, 710 (76.5%) IDC, and the remaining 77 (8.3%) were of different histological type. EPclin provided highly significant prognostic value for distant recurrence in women with ILC (HR=3.33 (2.33-4.77), P<0.001; LR-χ2=38.4). For those with IDC, EPclin was highly prognostic for distant recurrence over 10 years of follow-up (HR=2.41 (2.04-2.84), P<0.001; LR-χ2=95.5). EPclin was more prognostic in IDC than ILC, and a significant interaction between EPclin and tumour type (ILC/IDC) was observed (P-interaction=0.038). 89 (63.1%) women with ILC were categorised into the low EPclin risk group and 52 (36.9%) into the high risk group. A highly significant separation between EPclin low and high risk groups was observed for ILC (10-year distant recurrence risk low: 6.2% (2.6-14.2) vs. high: 36.6% (24.2-52.1); HR=7.36 (2.71-20.01)). For women with IDC, 406 (57.2%) were categorised into the low risk group by EPclin and 304 (42.8%) were deemed high risk, with significant separation between risk groups (10-year distant recurrence risk low: 6.2% (4.1-9.3) vs. high: 28.5% (23.5-34.3); HR=5.59 (3.48-8.98)). We did not observe any differential efficacy of treatment between histological subtype and EPclin risk group.

Conclusions: This is the first analysis to focus on the role of EPclin for the prognostic assessment of women with ILC. Although numbers of women with ILC in TransATAC were small, EPclin provided highly significant prognostic information and risk stratification for this subgroup of women. 10-year distant recurrence risk in the EPclin low risk groups were similar between ILC and IDC, suggesting that chemotherapy is not indicated, irrespective of tumour type. Our results show that EPclin is informative in women with ILC.

Citation Format: Sestak I, Kronenwett R, Denkert C, Cuzick J, Dowsett M. Prognostic performance of EndoPredict in invasive lobular carcinoma [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-01.

Abstract S6-05: Comprehensive comparison of prognostic signatures for breast cancer in TransATAC

Background: A number of prognostic signatures have been developed for the prediction of breast cancer recurrence in the past decade. We have developed two signatures (Clinical Treatment Score (CTS), four immunohistochemical markers (IHC4)) and validated four prognostic signatures (Oncotype Dx Recurrence Score (RS), PAM50-based Prosigna (ROR), Breast Cancer Index (BCI), and EndoPredict (EPclin)) in the TransATAC cohort. Here, we compare the prognostic performance of these six signatures for distant recurrence (DR) in years 0-10, and specifically in years 5-10 after treatment cessation.

Methods: 1231 postmenopausal women with hormone receptor positive and HER2-negative breast cancer had at least one test performed. Of these, 818 women had data on all six signatures available. IHC4, RS and BCI (linear) are molecular only signatures whereas CTS, ROR and EPclin include clinicopathological factors. The primary endpoint was DR and the primary objective was to compare the prognostic value of the six signatures in terms of DR for years 0-10, 0-5, and 5-10. Secondary objectives included the comparison of the prognostic performance for node-negative and node-positive patients separately and the additional prognostic performance of each signature to the others. Likelihood ratio statistics (LR-χ2) were used to assess the prognostic information of each signature alone or in combination with other signatures.

Results: Median follow-up for this analysis was 9.94 years (IQR 8.01-10.09) and a total of 126 DR were recorded. 818 women with HER2-negative disease for whom data of all six signatures were available were included in this analysis. For all patients, CTS and EPclin were the most prognostic signatures in years 0-10 (CTS: LR-χ2=124.9; EPclin: LR-χ2=116.2) and years 5-10 (CTS: LR-χ2=59.6; EPclin: LR-χ2=56.8) in the univariate analysis. The other four signatures performed similarly well in years 0-5, but of those only BCI and ROR provided substantial prognostic information in years 5-10 (BCI: LR-χ2=25.3; ROR: LR-χ2=43.8). In multivariate analyses comparing the added information of the molecular signatures over CTS, IHC4 and BCI provided the most information (IHC4: ΔLR-χ2=19.0; BCI: ΔLR-χ2=19.8). In node-negative patients (72.3%), the ROR showed the most prognostic value in years 0-10 (LR-χ2=48.6) and years 5-10 (LR-χ2=31.3) whereas the RS was least prognostic in this patient group. For patients with node-positive disease (27.7%), the CTS and EPclin were the most prognostic and the other four signatures provided much less prognostic information for this patient population (data not shown).

Conclusion: Overall, the CTS and EPclin were the most prognostic signatures for DR and also added significant prognostic value to the other scores in women with HER2-negative disease, primarily due to the incorporation of nodal status in these signatures. For women with node-negative disease, the ROR, BCI, and EPclin signatures provided most prognostic value whereas for those with positive nodes CTS and EPclin were most prognostic. Our analyses showed that the inclusion of clinic-pathological factors into gene signatures is highly important for deriving an accurate prognostic assessment, particularly in node-positive patients.

Citation Format: Sestak I, Buus R, Cuzick J, Dubsky P, Kronenwett R, Ferree S, Sgroi D, Schnabel C, Baehner R, Mallon E, Dowsett M. Comprehensive comparison of prognostic signatures for breast cancer in TransATAC [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 S6-05.

The genomic expression test EndoPredict is a prognostic tool for identifying risk of local recurrence in postmenopausal endocrine receptor-positive, her2neu-negative breast cancer patients randomised within the prospective ABCSG 8 trial

Background:

The aim of this study was to examine whether EndoPredict (EP), a novel genomic expression test, is effective in predicting local recurrence (LR)-free survival (LRFS) following surgery for breast cancer in postmenopausal women. In addition, we examined whether EP may help tailor local therapy in these patients.

Methods:

From January 1996 to June 2004, 3714 postmenopausal patients were randomly assigned to either tamoxifen or tamoxifen followed by anastrozole within the prospective ABCSG 8 trial. Using assay scores from EP, we classified breast tumour blocks as either low or high risk for recurrence.

Results:

Data were gathered from 1324 patients. The median follow-up was 72.3 months and the cumulative incidence of LR was 2.6% (0.4% per year). The risk of LR over a 10-year period among patients with high-risk lesions (n=683) was significantly higher (LRFS=91%) when compared with patients with low-risk lesions (n=641) (10-year LRFS=97.5%) (HR: 1.31 (1.16–1.48) P<0.005). The groups that received breast conservation surgery (BCT) and mastectomy (MX) had similar LR rates (P=0.879). Radiotherapy (RT) after BCT significantly improved LRFS in the cohorts predicted by EP to be low-risk for LR (received RT: n=436, 10-year LRFS 99.8% did not receive RT: n=63, 10-year LRFS 83.6%, P<0.005).

Conclusions:

EndoPredict is an effective prognostic tool for predicting LRFS. Among postmenopausal, low-risk patients, EP does not appear to be useful for tailoring local therapy.

The EndoPredict score provides prognostic information on late distant metastases in ER+/HER2- breast cancer patients

Background:

ER+/HER2− breast cancers have a proclivity for late recurrence. A personalised estimate of relapse risk after 5 years of endocrine treatment can improve patient selection for extended hormonal therapy.

Methods:

A total of 1702 postmenopausal ER+/HER2− breast cancer patients from two adjuvant phase III trials (ABCSG6, ABCSG8) treated with 5 years of endocrine therapy participated in this study. The multigene test EndoPredict (EP) and the EPclin score (which combines EP with tumour size and nodal status) were predefined in independent training cohorts. All patients were retrospectively assigned to risk categories based on gene expression and on clinical parameters. The primary end point was distant metastasis (DM). Kaplan–Meier method and Cox regression analysis were used in an early (0–5 years) and late time interval (>5 years post diagnosis).

Results:

EP is a significant, independent, prognostic parameter in the early and late time interval. The expression levels of proliferative and ER signalling genes contribute differentially to the underlying biology of early and late DM. The EPclin stratified 64% of patients at risk after 5 years into a low-risk subgroup with an absolute 1.8% of late DM at 10 years of follow-up.

Conclusion:

The EP test provides additional prognostic information for the identification of early and late DM beyond what can be achieved by combining the commonly used clinical parameters. The EPclin reliably identified a subgroup of patients who have an excellent long-term prognosis after 5 years of endocrine therapy. The side effects of extended therapy should be weighed against this projected outcome.

Evaluation of Mucin-1 protein and mRNA expression as prognostic and predictive markers after neoadjuvant chemotherapy for breast cancer

BACKGROUND

Mucin-1 (MUC1) is a promising antigen for the development of tumor vaccines. We evaluated the frequency of MUC1 expression and its impact on therapy response and survival after neoadjuvant chemotherapy for breast cancer.

PATIENTS AND METHODS

Pre-treatment core biopsies of patients from the GeparTrio neoadjuvant trial (NCT 00544765) were evaluated for MUC1 by immunohistochemistry (IHC; N = 691) and quantitative RT-PCR (qRT-PCR; N = 286) from formalin-fixed paraffin-embedded (FFPE) samples.

RESULTS

MUC1 protein and mRNA was detectable in the majority of cases and was associated with hormone-receptor-positive status (P < 0.001). High MUC1 protein and mRNA expression were associated with lower probability of pathologic complete response (P = 0.017 and P < 0.001) and with longer patient survival (P = 0.03 and P < 0.001). In multivariable analysis, MUC1 protein and mRNA expression were independently predictive (P = 0.001 and P < 0.001). MUC1 protein and mRNA expression were independently prognostic for overall survival (P = 0.029 and P = 0.015).

CONCLUSIONS

MUC1 is frequently expressed in breast cancer and detectable on mRNA and protein level from FFPE tissue. It provides independent predictive information for therapy response and survival after neoadjuvant chemotherapy. In clinical immunotherapy trials, MUC1 expression may serve as a predictive marker.

Prognostic significance of RACGAP1 mRNA expression in high-risk early breast cancer: a study in primary tumors of breast cancer patients participating in a randomized Hellenic Cooperative Oncology Group trial

PURPOSE

RACGAP1 is a Rac GTPase-activating protein involved in cell growth regulation, cell transformation and metastasis. The aim of the present study was to explore the prognostic and/or predictive significance of RACGAP1 mRNA expression on disease-free survival (DFS) and overall survival (OS) in high-risk early breast cancer patients and compare it to that of Ki67 protein expression and to the Nottingham prognostic index (NPI).

METHODS

A total of 595 high-risk breast cancer patients were treated in a two-arm trial evaluating postoperative dose-dense sequential chemotherapy with epirubicin followed by CMF with or without paclitaxel. RNA was extracted from 314 formalin-fixed paraffin-embedded primary tumor tissue samples followed by one-step quantitative RT-PCR for assessing RACGAP1 mRNA expression.

RESULTS

High RACGAP1 mRNA expression (above the median) was associated with poor DFS (log-rank, p = 0.002) and OS (p < 0.001). High histological grade, as well as high Ki67 protein expression, was more frequent in the high-expression group of RACGAP1. Results of the Cox multivariate regression analysis revealed that high RACGAP1 mRNA expression independently predicted poor overall survival (Wald's p = 0.008). High Ki67 protein expression was also an adverse prognostic factor for death (p = 0.016), while high NPI score values were not.

CONCLUSIONS

High RACGAP1 mRNA expression, as assessed by qRT-PCR, was found to be of adverse prognostic significance in high-risk early breast cancer patients treated with dose-dense sequential chemotherapy. The utility of RACGAP1 mRNA expression in patient selection for treatment with aggressive chemotherapy regimens should be further explored and validated in larger cohorts.

Thymosin beta 15A (TMSB15A) is a predictor of chemotherapy response in triple-negative breast cancer

Background:

Biomarkers predictive of pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) of breast cancer are urgently needed.

Methods:

Using a training/validation approach for detection of predictive biomarkers in HER2-negative breast cancer, pre-therapeutic core biopsies from four independent cohorts were investigated: Gene array data were analysed in fresh frozen samples of two cohorts (n=86 and n=55). Quantitative reverse transcription polymerase chain reaction (qRT–PCR) was performed in formalin-fixed, paraffin-embedded (FFPE) samples from two neoadjuvant phase III trials (GeparTrio, n=212, and GeparQuattro, n=383).

Results:

A strong predictive capacity of thymosin beta 15 (TMSB15A) gene expression was evident in both fresh frozen cohorts (P<0.0001; P<0.0042). In the GeparTrio FFPE training cohort, a significant linear correlation between TMSB15A expression and pCR was apparent in triple-negative breast cancer (TNBC) (n=61, P=0.040). A cutoff point was then defined that divided TNBC into a low and a high expression group (pCR rate 16.0% vs 47.2%). Both linear correlation of TMSB15A mRNA levels (P=0.017) and the pre-defined cutoff point were validated in 134 TNBC from GeparQuattro (pCR rate 36.8% vs 17.0%, P=0.020). No significant predictive capacity was observed in luminal carcinomas from GeparTrio and GeparQuattro.

Conclusion:

In TNBC, TMSB15A gene expression analysis might help to select patients with a high chance for pCR after NACT.

EndoPredict improves the prognostic classification derived from common clinical guidelines in ER-positive, HER2-negative early breast cancer

BACKGROUND

In early estrogen receptor (ER)-positive/HER2-negative breast cancer, the decision to administer chemotherapy is largely based on prognostic criteria. The combined molecular/clinical EndoPredict test (EPclin) has been validated to accurately assess prognosis in this population. In this study, the clinical relevance of EPclin in relation to well-established clinical guidelines is assessed.

PATIENTS AND METHODS

We assigned risk groups to 1702 ER-positive/HER2-negative postmenopausal women from two large phase III trials treated only with endocrine therapy. Prognosis was assigned according to National Comprehensive Cancer Center Network-, German S3-, St Gallen guidelines and the EPclin. Prognostic groups were compared using the Kaplan-Meier survival analysis.

RESULTS

After 10 years, absolute risk reductions (ARR) between the high- and low-risk groups ranged from 6.9% to 11.2% if assigned according to guidelines. It was at 18.7% for EPclin. EPclin reassigned 58%-61% of women classified as high-/intermediate-risk (according to clinical guidelines) to low risk. Women reclassified to low risk showed a 5% rate of distant metastasis at 10 years.

CONCLUSION

The EPclin score is able to predict favorable prognosis in a majority of patients that clinical guidelines would assign to intermediate or high risk. EPclin may reduce the indications for chemotherapy in ER-positive postmenopausal women with a limited number of clinical risk factors.

P1-06-26: The EndoPredict Score Is a Response Predictor for Neoadjuvant Chemotherapy in ER-Positive, HER2−Negative Breast Cancer

Background:

The EndoPredict (EP) score is a multigene classifier to predict the likelihood of distant recurrence in ER-positive, HER2−negative breast cancer patients treated with adjuvant endocrine therapy. Two large randomized phase III trials involving endocrine therapy only (n &gt; 1700) demonstrated additional prognostic information of the EP score independent from clinicopathological parameters by classifying 49% as low risk. However, the predictive role of the EP is not clear. Therefore, we examined whether the EP Score also predicts sensitivity towards neoadjuvant chemotherapy in ER-positive, HER2−negative breast cancer patients.

Methods: Four publicly available gene expression data sets (Affymetrix HG-U133A) were retrieved from the gene expression omnibus (GEO) data repository. All analyzed breast cancer patients were treated with anthracycline or taxane/anthracycline-based neoadjuvant chemotherapy. Microarray cel files were MAS5 normalized with a global scaling procedure and a target intensity of 500. The analysis was restricted to ER-positive, HER2−negative breast cancer patients according to pre-specified cut-off levels for the respective ESR1/ERBB2 Affymetrix probesets. The EP score was calculated and patients were classified as having low or high risk according to the pre-specified validated cut-off value. Pathological complete response (pCR) — defined as no residual invasive cancer in the breast or lymph nodes — was used as the primary endpoint for the assessment of treatment response.

Results: The EP Score was examined in 221 ER-positive, HER2−negative breast cancer patients treated with neoadjuvant therapy. Among the 221 patients, 61 tumors (27.6%) were classified as EP-low-risk, whereas 160 tumors (72.4%) were EP-high-risk. Only one of the EP-low-risk tumors achieved a pCR after neoadjuvant therapy, whereas 24 of the 25 pCR events were classified as EP high risk. The sensitivity of the EP score was 96% and the negative predictive value 98% with an area under the receiver operating characteristic curve of 0.73.

Conclusions: The EP Score is a predictor of chemosensitivity in the neoadjuvant setting. The test correctly identified all but one of the patients achieving a pCR suggesting that the benefit of cytotoxic chemotherapy is limited to the EP high risk group.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-26.

Prognostic significance of UBE2C mRNA expression in high-risk early breast cancer. A Hellenic Cooperative Oncology Group (HeCOG) Study

BACKGROUND

The ubiquitin-proteasome system (UPS) plays a pivotal role in tumorigenesis. Components of the UPS have recently been implicated in breast cancer progression. In the present study, we sought to explore the prognostic and/or predictive significance of UBE2C messenger RNA (mRNA) expression on disease-free survival (DFS) and overall survival (OS) in high-risk operable breast cancer patients.

METHODS

Five hundred and ninety-five high-risk breast cancer patients were treated in a two-arm trial evaluating postoperative, dose-dense sequential chemotherapy with epirubicin followed by CMF (cyclophosphamide, methotrexate and 5-fluorouracil) with or without paclitaxel (Taxol). RNA was extracted from 313 formalin-fixed primary tumor tissue samples followed by one-step quantitative RT-PCR for assessment of mRNA expression of UBE2C.

RESULTS

High UBE2C mRNA expression was associated with poor DFS (Wald's P = 0.003) and OS (Wald's P = 0.005). High tumor grade, as well as high Ki67 protein expression, was more frequent in the high-expression group of UBE2C. Results of the Cox multivariate regression analysis revealed that high UBE2C mRNA expression remained an independent adverse prognostic factor for relapse (P = 0.037) and death (P = 0.05).

CONCLUSIONS

High UBE2C mRNA expression was found to be of adverse prognostic significance in high-risk breast cancer patients. These findings need to be validated in larger cohorts.

Comparison of different approaches for assessment of HER2 expression on protein and mRNA level: prediction of chemotherapy response in the neoadjuvant GeparTrio trial (NCT00544765)

Human epidermal growth factor receptor 2 (HER2) testing is an essential part of pathological assessment in breast cancer patients, as HER2 provides not only prognostic but also predictive information on response to targeted therapy. So far, HER2 test accuracy of immunohistochemistry/in situ-hybridization techniques is still under debate, and more reliable and robust technologies are needed. To address this issue and to evaluate the predictive value of HER2 on chemotherapy, we investigated a cohort of 278 patients from the GeparTrio trial, a prospective neoadjuvant anthracycline/taxane-based multicenter study. In the GeparTrio trial, patients were not treated with any anti-HER2 therapy, as this was not standard therapy at this time. The HER2 status was analyzed by three different approaches: local and central evaluation using immunohistochemistry combined with in situ-hybridization as well as evaluation of HER2 mRNA expression using kinetic RT-PCR from formalin-fixed, paraffin-embedded (FFPE) tissue samples using a predefined cutoff. HER2 overexpression/amplification was observed in 37.3% (91/244) and 17.9% (41/229) of the informative samples in the local and central evaluations, respectively. Positive HER2 mRNA levels were found in 19.8% (55/278). We observed a highly significant correlation between central HER2 expression and HER2 status measured by kinetic RT-PCR (r = 0.856, P < 0.0001) and an overall agreement of 95.6% (κ statistic, 0.862, CI 0.77-0.94). Further, central HER2 as well as HER2 mRNA expression were predictors for a pathological complete response after neoadjuvant anthracycline/taxane-based primary chemotherapy in a univariate binary logistic regression analysis (OR 3.29, P = 0.002; OR 2.65, P = 0.004). The predictive value could be confirmed for the central HER2 status by multivariate analysis (OR 3.04, P = 0.027). The locally assessed HER2 status was not predictive of response to chemotherapy. Our results suggest that standardized methods are preferable for evaluation of HER2 status. The kinetic RT-PCR from FFPE tissue might be an additional approach for assessment of this important prognostic and predictive parameter but has to be confirmed by other studies.

Abstract 3731: Elevated mRNA expression of CXCL13 predicts improved outcome in patients with high-risk early breast cancer: A possible molecular predictor of treatment benefit in the context of a Hellenic Cooperative Oncology Group trial

Chemokines are important in cell migration and are therefore thought to play a key role in metastasis. Chemokine (C-X-C motif) ligand 13 (CXCL13) was recently found to be overexpressed in breast cancer and its overexpression is thought to be associated with poor outcome. The aim of the present study was to explore the prognostic significance of CXCL13 on disease-free survival (DFS) and overall survival (OS) in high-risk operable breast cancer enrolled in a randomized phase III trial. The association of CXCL13 with hormonal receptor and HER family expression at the m-RNA level, as well as with other clinicopathological characteristics of patients was also investigated.

595 high-risk breast cancer patients were treated in a two-arm trial (HE10/97) investigating postoperative dose-dense sequential chemotherapy with epirubicin (E) followed by CMF with or without paclitaxel (T). RNA was extracted from 312 formalin-fixed paraffin-embedded primary tumor tissue samples followed by kinetic one-step RT-PCR for assessment of mRNA expression of CXCL13, ER, PgR, and HER2. Values of CXCL13 and HER2 mRNA above the 75th percentile were considered high expression. CXCL13 expression was correlated with known clinicopathological parameters, such as HER2, ER and PgR by IHC, tumor grade, and nodal involvement.

With a median follow up of 8 years the total number of events (disease relapses) was 109/312 (35%), and the total number of deaths 78/312 (25%). High CXCL13 mRNA expression was associated with improved DFS (log-rank, p=0.043). This remained unchanged when adjusted for treatment group (Wald, p=0.045). Furthermore, CXCL13 was found to be negatively correlated (p&lt;0.001) with ER and PgR mRNA expression. Results of the Cox multivariate regression analysis revealed that, in the presence of treatment group, high CXCL13 mRNA expression was associated with a significantly decreased risk for relapse (HR=0.50, 95% CI: 0.31-0.82, p=0.006) and a significantly decreased risk for death (HR=0.56, 95% CI: 0.31-0.99, p=0.047). The number of ER/PgR IHC positive patients was significantly lower in the high expression group of CXCL13 compared to the low expression group (67.5% vs 81.5%, p=0.017). Finally, higher tumor grade was more likely to be present in the high expression group of CXCL13 than in the low expression group (69.2% vs 42.7%, p&lt;0.001), as was HER2 mRNA overexpression (41.4% vs 26.5%, p=0.024). Furthermore, high expression of CXCL13 was associated with lower risk for relapse in HER2 mRNA overexpressing patients.

High CXCL13 mRNA expression is associated with a significantly decreased risk for relapse and death in high-risk breast cancer patients treated with dose-dense sequential chemotherapy. This association appears to be more pronounced in HER2 overexpressing patients.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3731.

Evaluation of tumor-associated lymphocytes as a predictor of response to neoadjuvant chemotherapy in breast cancer: Results from the GeparDuo and GeparTrio trial

11054

Background: Preclinical investigations suggest an involvement of the immune system in chemotherapy response; however, this contribution has not been validated in prospective clinical trials so far. Methods: We investigated the inflammatory infiltrate in a total of 1058 pretherapeutic breast cancer core biopsies from two neoadjuvant anthracycline-taxane-based studies. As a training cohort, we used 218 core biopsies from the GeparDuo study. The results were validated in a completely independent cohort of 840 samples from the GeparTrio study. In addition, molecular parameters of lymphocyte recruitment and activation in breast cancer tissue were evaluated by kinetic PCR. Results: While the overall rate of pathological complete response (pCR) in the GeparDuo cohort was 12.8%, it was significantly increased to 42.7% in the tumors with more than 60% intratumoral or stromal lymphocytes. In a multivariate regression analysis, the percentage of intratumoral lymphocytes (iTu-Ly) was an independent significant parameter for pCR (P = 0.013) in the GeparDuo cohort. In the validation set from the GeparTrio trial, the inflammatory infiltrate was a strong predictor of pCR in univariate (P < 0.0005) and multivariate logistic regression (P < 0.0005). For tumors with 60% iTu-Ly the pCR rate was 40% with an odds ratio (OR) of 8.5 (4.0–18.2) which were similar to those values in hormone receptor negative samples (pCR: 36%; OR: 6.0 [4.0–9.1]). The expression of inflammatory marker genes and chemokines related to B and T infiltration in tumor tissue was significantly linked to the presence of a lymphocytic infiltrate and mRNA expression data showed a significant association of T cell markers with a pCR (P < 0.003). Conclusions: An increased lymphocytic inflammatory infiltrate in breast cancer is a new independent predictor of response to anthracyclin-taxane neoadjuvant chemotherapy and might be helpful to identify patients with benefit from cytotoxic chemotherapy.

[Table: see text]

Quantitative determination of predictive cancer biomarkers in formalin-fixed, paraffin-embedded tissue using a new, fully automated method for RNA isolation

11032

Background: Personalized cancer therapy depends on the evaluation of tissue-based biomarkers in routine tumor samples. As many new biomarkers are measured on the mRNA level, standardized procedures for mRNA analysis in formalin-fixed, paraffin-embedded (FFPE) tissue are needed. In this study, we present a novel, standardized, and fully automated method for fast isolation of total RNA from FFPE tissue sections. Methods: Tissue samples (n = 501) from 167 breast carcinomas which had been stored between 2 months and 21 years were investigated. Total RNA was extracted from tissue sections using a new method based on silica-coated iron oxide beads in combination with a specific liquid-handling robot. Novel and unique features of the method are an automated extraction-integrated deparaffinization step and a bead-based negative selection step to eliminate any undigested tissue. Yield of RNA was assessed using the Ribogreen assay. mRNA fragment lengths were estimated by reverse transcription PCR (RT-PCR) for G6PDH. Expression of the breast cancer biomarkers ESR1, PGR and HER2 was measured by kinetic RT-PCR (kPCR) and compared with immunohistochemistry (IHC). Results: RNA was successfully isolated from all samples, with a mean yield of 1.4 μg/sample (range: 0.1–7.8 μg) and fragment lengths of at least 150 bp in 99% of samples. PCR analyses could be performed in all samples. Investigating three sections of each tumor, we observed a low section-to-section variability of kPCR results (root of mean squared errors of relative ESR1, PGR or HER2 expression in three sections: 0.2–0.5 Ct values). Comparing kPCR results with IHC, we detected a good concordance between both methods, with agreements of 98.4% (standard error [SE]: 2.7%) for ESR1, 84.4% (SE: 5.3%) for PGR and 89.9% (SE: 8.9%) for HER2. Conclusions: This novel RNA extraction method is a major technical improvement for implementation of reproducible, high-throughput and cost-efficient testing of cancer biomarkers in the clinical routine and in gene-expression research studies using archived FFPE material in molecular labs.

[Table: see text]

Utility of a multigene prognostic algorithm in combination with TP53 expression for prediction of benefit from adjuvant taxane-containing chemotherapy in node-positive breast cancer patients

593

Background: Recently, we have shown that the Siemens Prognostic Score (SPS) based on mRNA expression of nine informative genes predicted outcome in node-positive (N+) patients with breast cancer (SABCS 2008, abstract 6044). The aim of this retrospective biomarker study was to examine the utility of the SPS in combination with TP53 expression to predict benefit from adjuvant taxane therapy. Methods: The 211 N+ patients included in this study were treated in the context of a randomized two-arm phase III study (E-T-CMF vs. E-CMF) investigating adjuvant dose-dense sequential chemotherapy with epirubicin (E) followed by CMF with or without paclitaxel (T). RNA was isolated from formalin-fixed, paraffin-embedded tissue samples, using a Siemens proprietary method, followed by kinetic one-step RT-PCR for assessment of mRNA expression of the nine SPS genes, TP53 and two normalization genes. The continuous SPS was calculated using a linear combination of expression values of the SPS genes. Patients were separated into a high- and low-risk group using a cutoff at the median of the SPS. Optimal cutoff for low or high TP53 expression was defined on the basis of a ROC curve in SPS high-risk patients. Distant metastasis-free survival (MFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test. Results: For patients with high SPS or high TP53 expression, we observed a trend for a better MFS in the E-T-CMF arm (SPS: p = 0.18; HR = 0.66; TP53: p = 0.23; HR = 0.67; n = 211). Combining both parameters, patients with high SPS and high TP53 expression (n = 44) had a significantly better MFS following E-T-CMF compared to E-CMF (5-year MFS 80% vs. 40%, p = 0.003, HR = 0.21; OS: p = 0.09; HR = 0.34). On the other hand, patients with high SPS and low TP53 expression (n = 32) showed a trend for a worse outcome with E-T-CMF (MFS: p = 0.09; HR = 3.54; OS: p = 0.35, HR = 1.90). Conclusions: Our prognostic algorithm combined with TP53 mRNA expression predicts the benefit from the addition of paclitaxel to E-CMF and might be used for identification of patients who should be considered for adjuvant taxane therapy. This hypothesis needs to be confirmed in an independent clinical study.

[Table: see text]

The hematopoietic stem cell in chronic phase CML is characterized by a transcriptional profile resembling normal myeloid progenitor cells and reflecting loss of quiescence

We found that composition of cell subsets within the CD34+ cell population is markedly altered in chronic phase (CP) chronic myeloid leukemia (CML). Specifically, proportions and absolute cell counts of common myeloid progenitors (CMP) and megakaryocyte-erythrocyte progenitors (MEP) are significantly greater in comparison to normal bone marrow whereas absolute numbers of hematopoietic stem cells (HSC) are equal. To understand the basis for this, we performed gene expression profiling (Affymetrix HU-133A 2.0) of the distinct CD34+ cell subsets from six patients with CP CML and five healthy donors. Euclidean distance analysis revealed a remarkable transcriptional similarity between the CML patients' HSC and normal progenitors, especially CMP. CP CML HSC were transcriptionally more similar to their progeny than normal HSC to theirs, suggesting a more mature phenotype. Hence, the greatest differences between CP CML patients and normal donors were apparent in HSC including downregulation of genes encoding adhesion molecules, transcription factors, regulators of stem-cell fate and inhibitors of cell proliferation in CP CML. Impaired adhesive and migratory capacities were functionally corroborated by fibronectin detachment analysis and transwell assays, respectively. Based on our findings we propose a loss of quiescence of the CML HSC on detachment from the niche leading to expansion of myeloid progenitors.

Local versus central HER2 immunohistochemistry correlates with kinetic RT-PCR but only central immunohistochemistry and RT-PCR predict pathological complete response: results from the neoadjuvant multicenter GeparTrio trial

Abstract #1070

Background: There are several methods for determination of HER2 overexpression. Immunohistochemistry (IHC) has been set up as the gold standard in routine diagnostics to identify patients eligible for anti-HER2 therapy. Nonetheless, there is still controversy about the predictive value of HER2 overexpression and pathological response to neoadjuvant anthracycline/taxane-based chemotherapy.&#x2028; Methods: In this study, we investigated the HER2 expression levels in formalin-fixed, paraffin-embedded pre-treatment punch biopsies by kinetic one-step RT-PCR (kRT-PCR); local IHC performed at the pathological institutes of the participating centers; and centrally performed IHC in 150 patients from the neoadjuvant GeparTrio study (NCT00544765), where patients were treated with docetaxel, doxorubicin and cyclophosphamide (TAC) but received no trastuzumab therapy regardless of the individual HER2 status. HER2 was considered positive for IHC if expression was 3+ and for mRNA expression if normalized level was &gt;/= 18.0 arbitrary units (as defined by bimodal expression for this cohort). We evaluated the associations by Spearman's rho correlation between the different methods as well as the best method that might predict a pathological complete response to this neoadjuvant chemotherapy.&#x2028; Results: A randomly selected subset out of 150 of 2,090 patients was included in this analysis. This is a representative collective of TAC-treated patients from the GeparTrio trial with a pCR rate (ypT0; ypTis/ypN0) of 23%. The different methods revealed a HER2 positivity of 31% for the local analyses, 16% for the central HER2 testing and 20% positivity for kRT-PCR analyses for this study collective, compared to 28% for the entire trial population. Local determination of HER2 showed a correlation with central laboratory (RS=.418, P&lt;.001, N=106) and kRT-PCR results (RS=.428, P&lt;.001, N=120), and centrally assessed HER2 expression correlated with the results of kRT-PCR (RS=.923, P&lt;.001, N=115). Binary logistic regression with the locally determined HER2 expression revealed no significant results in prediction of a pathological complete response (P=.802, N=121), whereas the results from central IHC (P=.038, OR 2.84, N=119) as well as the results from kRT-PCR (P=.047, OR 2.47, N=134) were significant.&#x2028; Conclusions: The value of HER2 expression and response to neoadjuvant chemotherapy is still controversial. Our results on this subset of patients show that kRT-PCR of HER2 mRNA expression and centrally performed IHC but not local HER2 assessment predicts pCR for neoadjuvant TAC chemotherapy. Theses results need further confirmation on a larger group of patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1070.

Prognostic algorithm identified in node-negative early breast cancer patients predicts outcome also in node-positive patients treated with adjuvant chemotherapy

Abstract #6044

Background: Recently, we identified and validated a prognostic multigene score, which predicted outcome in early node-negative breast cancer patients that did not receive systemic therapy. The aim of this study was to examine the performance of our prognostic multigene algorithm in node-positive patients treated with adjuvant chemotherapy.&#x2028; Patients and Methods: Patients were treated with adjuvant anthracycline-based chemotherapy in the context of a randomized Phase III study. This was a two-arm trial (E-CMF vs. E-T-CMF) investigating postoperative dose-dense sequential chemotherapy with epirubicin (E) followed by CMF with or without paclitaxel (T). RNA was isolated from 222 formalin-fixed, paraffin-embedded tumor tissue samples, using a Siemens proprietary automated method based on silica-coated magnetic beads, followed by kinetic one-step RT-PCR for mRNA expression analysis of 9 informative genes and 2 normalization genes. For each patient a risk score was calculated using a linear combination of expression values. Patients were separated into high, intermediate and low risk by applying two thresholds of the score. As used in node-negative patients, distant metastasis-free survival (MFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test. Cox analysis for MFS and OS was also performed.&#x2028; Results: The prognostic score could be calculated for 213 patients (102 E-T-CMF; 111 E-CMF). Looking at all patients independently of type of chemotherapy, the score could classify the patients into three distinct risk groups, which were significantly different in terms of MFS (log-rank test, p=0.004) and OS (p=0.01). The separation of the risk groups was even better when focusing on patients with more than three involved lymph nodes (MFS: p=0.0001; OS: p=0.0015; n=166). The respective analysis of the two treatment arms showed that the separation of the risk groups was only significant in E-CMF-treated patients (E-CMF: p=0.002; E-T-CMF: p=0.37). Interestingly, the subgroup of patients with more than three involved lymph nodes and classified as intermediate or high risk (n=77) had a nearly significant better MFS when treated with E-T-CMF in comparison with E-CMF (p=0.07; HR: 0.53; 95% CI: 0.2685 to 1.060).&#x2028; Conclusions: Our prognostic algorithm, identified and validated in node-negative patients that had not been systemically treated, predicts outcome also in node-positive chemotherapy-treated patients. Our findings suggest that the prognostic score may also be predictive of benefit from the addition of taxanes to adjuvant chemotherapy. This hypothesis needs to be confirmed in a larger cohort of samples from an independent clinical study.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6044.

Molecular signature of CD34+ hematopoietic stem and progenitor cells of patients with CML in chronic phase

In this study, we provide a molecular signature of highly enriched CD34+ cells from bone marrow of untreated patients with chronic myelogenous leukemia (CML) in chronic phase in comparison with normal CD34+ cells using microarrays covering 8746 genes. Expression data reflected several BCR-ABL-induced effects in primary CML progenitors, such as transcriptional activation of the classical mitogen-activated protein kinase pathway and the phosphoinositide-3 kinase/AKT pathway as well as downregulation of the proapoptotic gene IRF8. Moreover, novel transcriptional changes in comparison with normal CD34+ cells were identified. These include upregulation of genes involved in the transforming growth factorbeta pathway, fetal hemoglobin genes, leptin receptor, sorcin, tissue inhibitor of metalloproteinase 1, the neuroepithelial cell transforming gene 1 and downregulation of selenoprotein P. Additionally, genes associated with early hematopoietic stem cells (HSC) and leukemogenesis such as HoxA9 and MEIS1 were transcriptionally activated. Differential expression of differentiation-associated genes suggested an altered composition of the CD34+ cell population in CML. This was confirmed by subset analyses of chronic phase CML CD34+ cells showing an increase of the proportion of megakaryocyte-erythroid progenitors, whereas the proportion of HSC and granulocyte-macrophage progenitors was decreased in CML. In conclusion, our results give novel insights into the biology of CML and could provide the basis for identification of new therapeutic targets.

The proteasome inhibitor bortezomib acts differently in combination with p53 gene transfer or cytotoxic chemotherapy on NSCLC cells

In this report, the effects of a combined treatment with the proteasome inhibitor bortezomib and either a recombinant adeno-associated virus type 2 (rAAV-2)-mediated p53 gene transfer or chemotherapeutic agents, docetaxel and pemetrexed, were tested on p53 positive and p53negative non-small cell lung cancer (NSCLC) cell lines. The combination of bortezomib and rAAV-p53 led to a significant synergistic inhibition of cell growth between 62-82% depending on the p53 status of the cell line and drug concentration. Surviving cells of the combined treatment showed a significant reduced ability to form colonies. Enhanced cell toxicity was associated with a 5.3-14.4-fold increase of the apoptotic rate and intracellular p53 level up to 50.4% following vector-mediated p53 restoration and bortezomib treatment. In contrast, an antagonistic effect on tumor cell growth and colony formation was observed for the combination of bortezomib and docetaxel or pemetrexed as a reduction of cell growth between 31 and 48% was found in comparison to 50% using the single agents. Lower cytotoxic effects were associated with significantly reduced apoptosis and an increase of clonogenic growth. The observed antagonistic effects between bortezomib and docetaxel or pemetrexed might influence clinical trials using these compounds. Conversely, p53 restoration and bortezomib treatment led to enhanced, synergistic tumor cell toxicity.

A phase II study for selection of clinical and molecular predictors for survival in patients (pts) with advanced NSCLC treated with erlotinib

17066

Background: The primary objective of the ongoing phase II study was to find clinical and molecular predictors for survival. Consequently, we prospectively examined gene and protein expression and EGFR mutation profiles of tumor cells, and clinical variables. Methods: Pts with advanced NSCLC (stage IIIb/IV) previously treated with platinum-based chemotherapy received 150mg/day erlotinib (Tarceva an EGFR tyrosine-kinase inhibitor) orally until disease progression. For molecular analyses, biopsies were taken from the primary lung tumor prior to erlotinib treatment. Pure tumor cells were isolated using laser-capture microdissection. For expression analysis, a microarray of 8793 genes (Human Focus Array, Affymetrix) was used. Data were analyzed using VSN method and significance analysis of microarrays. Results: In an interim analysis, clinical data were available for 36 of 43 so far included pts in the ongoing phase II study. For 36 pts, the tumor responses were: 1 CR (3%), 4 PR (11%), 11 SD (30%) and 19 PD (53%), and the median survival was 20 wks. Overall survival was significantly better in pts with rash than without rash: 9.2 vs 4.3 months. In a 14 months follow up, all of the responding pts survived while the median survival for pts with SD or PD was 11.4 and 4.0 months, respectively. Comparing gene expression profiles of tumors from 6 pts with a response or SD with those from 13 pts with tumor progression, we could not identify genes that were differentially expressed with sufficient significance. In 20 tumor samples evaluated for EGFR protein expression and mutation analysis, 19 expressed EGFR (IHC). A base exchange in exon 18 (2166G>A; A722A) and 20 (2547A>G; Q787Q) of the EGFR already described as a single nucleotide polymorphism was seen in 4 samples performing SSCP gel electrophoresis and sequencing. Conclusions: Rash, a side effect with erlotinib, was significantly associated with better survival. No activating EGFR mutations were found indicating that the response in 14% of pts is independent of mutations. For identification of genes predictive for response to erlotinib, a larger sample number is necessary.

No significant financial relationships to disclose.

Successful transplantation of peripheral blood stem cells mobilized by chemotherapy and a single dose of pegylated G-CSF in patients with multiple myeloma

Following induction therapy and 4 g/m(2) cyclophosphamide, a single dose of 12 mg polyethyleneglycol-conjugated G-CSF (pegfilgrastim; n=12) or daily doses of unconjugated G-CSF (8.5 mug/kg/day) (n=12) were administered to myeloma patients. Pegfilgrastim was associated with an earlier leukocyte recovery (12 vs 14 days) and peripheral blood CD34+ cell peak (12 vs 15 days). The peripheral blood CD34+ cell peak was lower in the pegfilgrastim group (78 vs 111/mul). Following high-dose melphalan (200 mg/m(2)) and autografting, leukocyte and platelet reconstitution was similar in both groups and stable blood counts were observed 100 days post transplant. In summary, a single dose of pegfilgrastim after chemotherapy is capable of mobilizing a sufficient number of CD34+ cells for successful autografting with early engraftment and sustained hematological reconstitution in patients with myeloma. These data provide the basis for randomized studies evaluating the optimal dose and time of pegfilgrastim as well as long-term outcome in larger cohorts of patients.

Transplantation of allogeneic CD34+-selected cells followed by early T-cell add-backs: favorable results in acute and chronic myeloid leukemia

BACKGROUND

The aim of this study was to investigate preservation of anti-leukemic activity and protection from opportunistic infections after transplantation of allogeneic + cells in patients with hematologic malignancies and bad prognosis. Methods Thirty-three patients [median age 42 years, range 23-55 years, diagnosis AML/myelodysplastic syndrome (MDS) 14, ALL nine, CML seven and multiple myeloma (MM) three] received myeloablative conditioning followed by infusion of selected CD34+ cells from matched unrelated donors (31) or HLA-identical siblings (two). Early donor lymphocyte infusions (DLI; 0.5 and 1.0 x 10(6) CD3+ cells/kg) were given while patients were on immunosuppressive therapy.

RESULTS

Ninety-seven per cent of patients engrafted and 24 of 29 patients surviving more than 30 days received at least one pre-emptive DLI. Three patients (10%) developed acute (a)GvHD (two grade I-II, one grade III-IV) spontaneously, and 16 patients (67%) developed aGvHD after DLI (12 grade I-II, four grade III-IV). Eight of 24 evaluable patients developed chronic (c)GvHD (33%, six limited, two extensive). After a median follow-up of 590 days (range 138-1610 days) 18 patients were alive (55%), 16 in complete remission (CR), one in hematologic and one in molecular relapse. Seven patients died after relapse (21%) and eight died from transplantation-related causes (24%). Patients with myeloid malignancies had a significantly better survival than patients with ALL or MM (74%+/-10 vs. 30%+/-13, P<0.05).

DISCUSSION

Early pre-emptive low-dose DLI following transplantation of selected CD34+ cells from unrelated donors after myeloablative conditioning is feasible and effective without undue toxicity, especially in patients with myeloid malignancies.

Treatment of severe steroid refractory acute graft-versus-host disease with infliximab, a chimeric human/mouse antiTNFalpha antibody

Acute graft-versus-host disease (aGVHD) is a serious complication of allogeneic peripheral blood stem cell transplantation (PBSCT). Patients with severe aGVHD not responding to treatment with steroids have a poor prognosis. We treated four patients with severe aGVHD refractory to steroids with infliximab, a chimeric human/mouse antiTNFalpha antibody. Patients (CML 2, MM 1, AML 1) developed grade III-IV GVHD at a median of 34 days (range 15-76) after myeloablative PBSCT (two), donor lymphocyte infusion for relapsed CML (one) or non-myeloablative PBSCT (one), respectively. All patients had severe intestinal involvement in addition to skin and/or liver disease and had received treatment with high-dose steroids (four) for a median of 11 days (range 5-17) in addition to CsA (four) and MMF (three). Infliximab (10 mg/kg) was given once a week until clinical improvement. In three of four patients a complete resolution of diarrhea and significant improvement of skin and liver disease were observed. Two patients received one, one patient two and one patient three infliximab infusions. At present two patients are alive >200 days after therapy, one with limited cGVHD. Two patients died, one of progressive malignant disease without GVHD and one of refractory GVHD. Infliximab is apparently an active drug for the treatment of aGVHD.

Combining G-CSF with a blockade of adhesion strongly improves the reconstitutive capacity of mobilized hematopoietic progenitor cells

OBJECTIVE

Mobilization of hematopoietic progenitor cells is achieved mainly by application of growth factors and, more recently, by blockade of adhesion. In this report, we describe the advantages of a combined treatment with granulocyte colony-stimulating factor (G-CSF) and anti-VLA4 (CD49d)/anti-CD44 as compared to treatment with the individual components.

MATERIALS AND METHODS

Mobilization by intravenous injection of anti-CD44, anti-VLA4, or G-CSF was controlled in spleen and bone marrow with regard to frequencies of multipotential colony-forming unit (C-CFU), marrow repopulating ability, long-term reconstitution, recovery of myelopoiesis, and regain of immunocompetence.

RESULTS

Mobilization by anti-CD44 had a strong effect on expansion of early progenitor cells in the bone marrow, while the recovery in the spleen was poor. In anti-CD49d-mobilized noncommitted and committed progenitors, progenitor expansion was less pronounced, but settlement in the spleen was quite efficient. Thus, anti-CD44 and anti-CD49d differently influenced mobilization. Accordingly, mobilization and recovery after transfer were improved by combining anti-CD44 with anti-CD49d treatment. Mobilization by G-CSF was most efficient with respect to recovery of progenitor cells in the spleen. However, when transferring G-CSF-mobilized cells, regain of immunocompetence was strongly delayed. This disadvantage could be overridden when progenitor cells were mobilized via blockade of adhesion and when expansion of these mobilized progenitor cells was supported by low-dose G-CSF only during the last 24 hours before transfer.

CONCLUSION

Mobilization of pluripotent progenitor cells via antibody blockade of CD44 or CD49d or via G-CSF relies on distinct mechanisms. Therefore, the reconstitutive capacity of a transplant can be significantly improved by mobilization regimens combining antibody with low-dose G-CSF treatment.

The role of cytokines and adhesion molecules for mobilization of peripheral blood stem cells

CD34(+) hematopoietic stem cells from peripheral blood are commonly used for autologous or allogeneic transplantation following high-dose therapy in malignant diseases. The introduction of hematopoietic growth factors such as G-CSF has greatly facilitated the mobilization of CD34(+) cells. The mechanism of stem cell mobilization is not yet clear. It seems to be a multistep process with a crosstalk between cytokines and adhesion molecules. In this review, the role of hematopoietic growth factors, chemokines, and adhesion molecules for mobilization and homing of CD34(+) cells is summarized. In addition, factors influencing the cytokine-induced mobilization in patients and healthy donors are described. The review closes with an overview of new classes of mobilizing drugs such as monoclonal antibodies, specific peptides, or antisense oligonucleotides targeting adhesion molecules.

Intercellular adhesion molecular 1 on monocytes mediates adhesion as well as trans-endothelial migration and can be downregulated using antisense oligonucleotides

The intercellular adhesion molecule 1 (ICAM-1) on endothelial cells is involved in the recruitment of leukocytes to inflammatory sites. In contrast to ICAM-1 expression on endothelial cells, little is known about its function in leukocytes in inflammation. Using ICAM-1-directed anti-sense oligodeoxyribonucleotides (ODNs), we examined the role of ICAM-1 expression on monocytes and lymphocytes for adhesion and trans-endothelial migration. As determined by flow cytometry, a downregulation of the ICAM-1 expression of 50% was observed on peripheral blood mononuclear cells (PBMCs) after their transfection with anti-sense ODNs using cationic lipids. The decrease in the level of ICAM-1 expression in PBMCs was associated with a 36% inhibition of adhesion to interleukin-1beta-stimulated endothelial cells and a 40% reduction of trans-endothelial migration. Gating on particular subsets of the PBMC, the downregulation of ICAM-1 and the functional effects could be ascribed to monocytes, while no significant inhibition was found for lymphocytes. This could be explained by differences in cellular ODN uptake. Since the ligands of ICAM-1 are not expressed on endothelial cells, the results suggest a homotypic interaction among monocytes. In conclusion, in addition to ICAM-1 expression on endothelial cells, ICAM-1 expression on monocytes mediates adhesion and transendothelial migration. This might be relevant for the clinical use of ICAM-1-directed anti-sense ODNs for the treatment of inflammatory diseases, because monocytes appear to be suitable target cells in which to achieve anti-inflammatory effects.

[Bone marrow involvement in hematologic neoplasms and solid tumors]

Bone marrow involvement is often observed in patients with hematological malignancies and solid tumors. Sensitive immunological and molecular biological methods allow the detection of isolated transformed cells in bone marrow samples. Like normal hematopoietic cells, tumor cells interact with bone marrow stroma through adhesion molecules. Since adhesion molecules play an essential role in the invasion and proliferation of malignant cells, new therapeutic approaches involving the inhibition of cell-cell and cell-matrix interactions are conceivable.

Mobilization of CD34+ haematopoietic stem cells is associated with a functional inactivation of the integrin very late antigen 4

The beta1 integrin very late antigen 4 (VLA-4) plays a central role in mobilization and homing of CD34+ cells. In this study, we examined the activation state of VLA-4 on CD34+ cells from bone marrow (BM) and peripheral blood (PB) by flow cytometry using a vascular cell adhesion molecule I-immunoglobulin (VCAM-I/IgG) fusion protein as soluble ligand. In an intraindividual analysis, we found a significantly reduced affinity and avidity of the VLA-4 receptor on CD34+ cells from PB during granulocyte colony-stimulating factor (G-CSF)-enhanced marrow recovery in comparison with steady-state BM. Moreover, the amount of circulating CD34+ cells during marrow recovery was inversely related to the activation state but not to the expression level of VLA-4, suggesting that a modulation of the functional state of VLA-4 is involved in the mobilization of CD34+ cells. Moreover, VLA-4 function on CD34+ cells from BM was associated with the maturation state of CD34+ cells as high-affinity VLA-4 receptors were observed on the vast majority of more primitive CD34+ cells. In addition, we found that Mg2+ ions as well as co-incubation of CD34+ cells with endothelial cells resulted in an activation of the VLA-4 receptor. In conclusion, modulation of the functional state of VLA-4 appears to be of relevance for the mobilization and homing of CD34+ haematopoietic stem cells.

A theoretical approach to select effective antisense oligodeoxyribonucleotides at high statistical probability

Up to now, out of approximately 20 antisense oligodeoxyribonucleotides (as ODN) selected and tested against a given target gene, only one species shows substantial suppression of target gene expression. In part, this seems to be related to the general assumption that the structures of local target sequences or antisense nucleic acids are unfavorable for efficient annealing. Experimental approaches to find effective as ODN are extremely expensive when including a large number of antisense species and when considering their moderate success. Here, we make use of a systematic alignment of computer-predicted secondary structures of local sequence stretches of the target RNA and of semi-empirical rules to identify favorable local target sequences and, hence, to design more effective as ODN. The intercellular adhesion molecule 1 (ICAM-1) gene was chosen as a target because it had been shown earlier to be sensitive to antisense-mediated gene suppression. By applying the protocol described here, 10 ICAM-1-directed as ODN species were found that showed substantially improved inhibition of target gene expression in the endothelial cell line ECV304 when compared with the most effective published as ODN. Further, 17 out of 34 antisense species (50%) selected on the theoretical basis described here showed significant (>50%) inhibition of ICAM-1 expression in mammalian cells.

The human immunodeficiency virus (HIV)-type 1 coreceptor CXCR-4 (fusin) is preferentially expressed on the more immature CD34+ hematopoietic stem cells

In synergy with the CD4 antigen, the chemokine receptor CXCR-4 functions as a coreceptor for T-cell-tropic HIV-1 strains. Using two- and three-color immunofluorescence analysis, we examined the expression of CXCR-4 on CD34+ cells in 21 samples obtained from leukapheresis (LP) products of cancer patients who underwent G-CSF-supported cytotoxic chemotherapy. In addition, eight samples from bone marrow (BM) were obtained. CXCR-4 was expressed on the surface of CD34+ cells from samples of both hematopoietic sources. The mean proportion of CD34+/CXCR-4+ cells from LP products was 1.7-fold greater in comparison with those from bone marrow (65.9+/-4.1% vs. 37.5+/-8.6% [+/- SEM], p < 0.05). For an intraindividual comparison, LP products and bone marrow from six patients were obtained on the same day, confirming the significantly greater proportion of CD34+ cells coexpressing CXCR-4 cells in LP products. In order to examine whether the CXCR-4 expression was related to the stage of maturation and differentiation of CD34+ cells, six samples from LP products and four samples from bone marrow were assessed using three-color immunofluorescence analysis. We found that the subset of CD34+/CD38low and CD34+/HLA-DRlow cells representing a population of more immature progenitor cells were brightly positive for CXCR-4, while there was a decrease in the level of CXCR-4 expression in the population of CD34+/HLA-DRbright and CD34+/CD38bright cells. Based on the assessment of ten LP products, we found that the mean proportion of CD34+ cells coexpressing CD4 and CXCR-4 was 6.2+/-2.3% [+/- SEM], suggesting that a small population of CD34+ cells are, in principle, susceptible for an infection with T-cell-tropic HIV-1 strains. In conclusion, our data suggest that CXCR-4 is present on the surface of hematopoietic progenitor cells--particularly more primitive CD34+ cells. CXCR-4 could play a role in the homing of CD34+ cells to stromal elements of the bone marrow via its natural ligand stromal-derived factor-1 (SDF-1).