The Impact of Smoking and TP53 Mutations in Lung Adenocarcinoma Patients with Targetable Mutations-The Lung Cancer Mutation Consortium (LCMC2)

Purpose: Multiplex genomic profiling is standard of care for patients with advanced lung adenocarcinomas. The Lung Cancer Mutation Consortium (LCMC) is a multi-institutional effort to identify and treat oncogenic driver events in patients with lung adenocarcinomas.Experimental Design: Sixteen U.S. institutions enrolled 1,367 patients with lung cancer in LCMC2; 904 were deemed eligible and had at least one of 14 cancer-related genes profiled using validated methods including genotyping, massively parallel sequencing, and IHC.Results: The use of targeted therapies in patients with EGFR, ERBB2, or BRAF p.V600E mutations, ALK, ROS1, or RET rearrangements, or MET amplification was associated with a survival increment of 1.5 years compared with those with such mutations not receiving targeted therapy, and 1.0 year compared with those lacking a targetable driver. Importantly, 60 patients with a history of smoking derived similar survival benefit from targeted therapy for alterations in EGFR/ALK/ROS1, when compared with 75 never smokers with the same alterations. In addition, coexisting TP53 mutations were associated with shorter survival among patients with EGFR, ALK, or ROS1 alterations.Conclusion: Patients with adenocarcinoma of the lung and an oncogenic driver mutation treated with effective targeted therapy have a longer survival, regardless of prior smoking history. Molecular testing should be performed on all individuals with lung adenocarcinomas irrespective of clinical characteristics. Routine use of massively parallel sequencing enables detection of both targetable driver alterations and tumor suppressor gene and other alterations that have potential significance for therapy selection and as predictive markers for the efficacy of treatment. Clin Cancer Res; 24(5); 1038-47. ©2017 AACR.

Abstract 70: PARP1 as a potential therapeutic target in Merkel cell carcinoma

Background: Merkel cell carcinoma (MCC) is an aggressive neuroendocrine skin tumor. Patients with incurable disease are treated with the same chemotherapy agents utilized in small-cell lung cancer (SCLC) achieving similar responses. Overexpression of PARP1 is common in SCLC and promising antitumor activity of PARP inhibitors is being demonstrated in early clinical trials. Furthermore, PARP inhibitors are active in a subset of tumors harboring mutations in DNA-damage repair (DDR) genes and benefit correlates to response to platinum. Based on its similarities with SCLC, its association with DNA damage by UV light, and its sensitivity to platin, our study explores PARP1 as a therapeutic target in MCC.

Methods: We evaluated the prevalence of PARP1 expression by immunohistochemistry in 19 MCC. Polyoma virus (MCPyV) status was evaluated by staining with anti-MCPyV antibody in the tissue specimens. Exome-sequencing of 263 genes was performed in 14 patients' samples using next-generation sequencing. Only mutations predicted to impair protein function in 17 genes related to DDR or mismatch repair were included in our analysis. Fisher's exact test was used for statistical significance.

Results: The majority of MCC express PARP1 (84%), suggesting underlying defects in DNA damage repair. Approximately half of the tumors (47%) were associated with MCPyV. There was no statistical correlation between PARP1 expression and MCPyV status or primary site of disease. Mutations in genes predicted to impair DDR was identified in 9 samples (64%), occurred exclusively in head and neck primaries, and correlated with mutations in TP53 or RB1 (P=0.03). Mutations in ARID1A predictive to be loss-of-function and potentially confer sensitivity to PARP inhibitors were found in 36% of the patients, exclusively in MCPyV negative samples (P=0.003). Mutations in TP53 and/or RB1 were more frequent in MCPyV negative tumors (P=0.03).

Conclusions: In spite of the small sample size, the high prevalence of PARP1 expression in MCC samples, similarly to SCLC, suggests that patients with MCC might also benefit from PARP1 inhibitors. Furthermore, the frequent mutations in genes involved in DNA-damage repair and ARID1A, particularly in the MCPyV negative cases, merits further characterization. Taken together, we believe clinical trials with PARP inhibitors in MCC patients should be considered.

Citation Format: Renata Ferrarotto, Shirley Su, Lixia Diao, A Karina Eterovic, Victor Prieto, William Morrison, Jing Wang, Bonnie Glisson, Merrill Kies, Diana Bell. PARP1 as a potential therapeutic target in Merkel cell carcinoma [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 70.

Gefitinib for patients with incurable cutaneous squamous cell carcinoma: A single-arm phase II clinical trial

BACKGROUND

Preclinical data demonstrate a key role for the epidermal growth factor receptor (EGFR) in the carcinogenesis of cutaneous squamous cell carcinomas (CSCCs). There are, however, limited data on the efficacy of EGFR inhibitors in incurable, recurrent, and/or metastatic CSCC.

OBJECTIVE

To determine the response rate to gefitinib in patients with CSCC not amenable to curative therapy including surgery or radiation.

METHODS

This was a single-arm phase II study. A total of 40 patients were treated with gefitinib, 250 mg orally daily, until disease progression or intolerable toxicities. The prespecified target response rate of interest was 20%.

RESULTS

The overall response rate was 16% (95% confidence interval, 0.06-0.32; 6 partial responses in 37 evaluable patients). An additional 13 patients (35%) had stable disease at 8 weeks. The median durations of response and progression-free survival were 31.4 months (95% confidence interval, 3.91-not applicable) and 3.8 months (95% confidence interval, 2.2-5.7), respectively. The side effect profile was consistent with the previous experience with gefitinib in other tumor types.

LIMITATIONS

This was a single-institution, single-arm study. The prespecified target response rate was not met.

CONCLUSION

Gefitinib demonstrated modest activity in incurable CSCC, with a favorable adverse event profile.

Abstract B72: Combining immune checkpoint inhibition and DNA damage repair (DDR) targeted therapy in small cell lung cancer (SCLC)

Background: Small cell lung cancer (SCLC) is a highly aggressive disease for which standard treatment remains virtually unchanged since the 1980s. SCLC has a relatively immunosuppressed phenotype with low levels of infiltrating T-cells and evidence of reduced antigen presentation. Only a minority of SCLC patients responds to programmed cell death protein 1 (PD-1) or programmed death ligand 1 (PD-L1) inhibitors as monotherapy. Therefore, though the clinical data is promising, there is a strong need to develop strategies to enhance the efficacy of immunotherapy in SCLC. Our group previously discovered that the DNA damage repair (DDR) protein, checkpoint kinase 1 (CHK1), is overexpressed in SCLC and that CHK1 inhibitors have activity in preclinical models of SCLC. Based on data from others and our group, we hypothesize that tumor associated neoantigen (TAA) expression is suppressed in SCLC by several mechanisms, including DDR machinery, and that targeting CHK1 may enhance antitumor immunity and response to immune checkpoint targeting.

Results: In SCLC models, inhibition of CHK1 by genetic knockdown and small molecule inhibition (LY2606368) induces DNA damage as demonstrated by increased γ-H2AX levels. We also observed increased protein levels of immune checkpoint ligand, PD-L1, following pharmacologic inhibition with LY2606368. We next tested whether co-targeting CHK1+PD-L1 enhances the anti-tumor effect in an immune-competent SCLC model. B6129F1 mice were injected in the flank with TKO.mTmG cells harboring conditional deletion of Trp53, Rb1 and p130. When the tumor volume reached 120mm3, mice were treated with either IgG (control), LY2606368 (10mg/kg, 2/7), anti-PD-L1 (300ug, 1/7) or combination of LY2606368 and anti-PD-L1 antibody. Single agent treatment with anti-PD-L1 antibody did not cause tumor regression in these models with T/C ratio=0.93 (p<0.001) at Day 21. Treatment of single agent LY2606368 at a sub-therapeutic dose significantly delayed tumor growth in these models with T/C=0.31 (p<0.001) at Day 21. However, 3 out of 5 mice treated with anti-PD-L1+LY2606368 had a complete tumor regression within 15 days of treatment with T/C=0.05 (p<0.001) at Day 21. Tumors were collected at the end of 21 days for RPPA analysis, RNA sequencing and flow cytometry to characterize tumor-infiltrating immune cells post treatment with the single agents versus the combination.

Discussion: SCLC has an immunosuppressed phenotype (despite a high mutational burden); however, only a minority of tumors expresses PD-L1, suggesting that immunosuppressive mechanisms other than the PD-1/PD-L1 pathway are likely to contribute. This study shows that targeting CHK1 (by genetic knockdown and pharmacological inhibition) leads to increased DNA damage and increased expression of immune checkpoint ligand, PD-L1. Combining CHK1 inhibition and PD-L1 targeting significantly enhanced the effect of PD-L1 antibody leading to tumor regression in an immune competent SCLC model. Biomarker analyses from these models are ongoing to confirm the expression of immune markers. PD-L1 inhibitors as monotherapy have led to objective responses in only a minority of SCLC patients. The CHK1 inhibitor LY2606368 is currently in clinical trial for SCLC patients. The complementary modes of action of the two promising modalities, immune checkpoint targeting and CHK1 inhibition, suggest intriguing possibilities for therapeutic synergy with combination treatment and warrants further clinical investigation.

Citation Format: Triparna Sen, Limo Chen, Bertha Leticia Rodriguez, Yongbin Yang, You Hong Fan, Catherine Allison Stewart, Bonnie Glisson, Helen Piwnica-Worms, Julien Sage, John V. Heymach, Don L. Gibbons, Lauren A. Byers. Combining immune checkpoint inhibition and DNA damage repair (DDR) targeted therapy in small cell lung cancer (SCLC). [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr B72.

Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer

PURPOSE

To report the long-term results of the Intergroup Radiation Therapy Oncology Group 91-11 study evaluating the contribution of chemotherapy added to radiation therapy (RT) for larynx preservation.

PATIENTS AND METHODS

Patients with stage III or IV glottic or supraglottic squamous cell cancer were randomly assigned to induction cisplatin/fluorouracil (PF) followed by RT (control arm), concomitant cisplatin/RT, or RT alone. The composite end point of laryngectomy-free survival (LFS) was the primary end point.

RESULTS

Five hundred twenty patients were analyzed. Median follow-up for surviving patients is 10.8 years. Both chemotherapy regimens significantly improved LFS compared with RT alone (induction chemotherapy v RT alone: hazard ratio [HR], 0.75; 95% CI, 0.59 to 0.95; P = .02; concomitant chemotherapy v RT alone: HR, 0.78; 95% CI, 0.78 to 0.98; P = .03). Overall survival did not differ significantly, although there was a possibility of worse outcome with concomitant relative to induction chemotherapy (HR, 1.25; 95% CI, 0.98 to 1.61; P = .08). Concomitant cisplatin/RT significantly improved the larynx preservation rate over induction PF followed by RT (HR, 0.58; 95% CI, 0.37 to 0.89; P = .0050) and over RT alone (P < .001), whereas induction PF followed by RT was not better than treatment with RT alone (HR, 1.26; 95% CI, 0.88 to 1.82; P = .35). No difference in late effects was detected, but deaths not attributed to larynx cancer or treatment were higher with concomitant chemotherapy (30.8% v 20.8% with induction chemotherapy and 16.9% with RT alone).

CONCLUSION

These 10-year results show that induction PF followed by RT and concomitant cisplatin/RT show similar efficacy for the composite end point of LFS. Locoregional control and larynx preservation were significantly improved with concomitant cisplatin/RT compared with the induction arm or RT alone. New strategies that improve organ preservation and function with less morbidity are needed.

Insulin-like growth factor binding protein-3 suppresses vascular endothelial growth factor expression and tumor angiogenesis in head and neck squamous cell carcinoma

Angiogenesis, the process by which new blood vessels are recruited to existing ones, is essential for tumor development. Insulin-like growth factor (IGF) binding protein-3 (IGFBP-3), which modulates bioavailability of IGF, has been studied for its potential role in angiogenesis during tissue regeneration and cancer development. In this study, we assessed the role of IGFBP-3 in tumor angiogenesis in head and neck squamous cell carcinoma (HNSCC) and human umbilical vein endothelial cells (HUVECs) using adenoviral (Ad-BP3) and recombinant (rBP3) IGFBP-3. Using an in vivo orthotopic tongue tumor model, we confirmed that both Ad-BP3 and rBP3 suppress the growth of UMSCC38 HNSCC cells in vivo. Ad-BP3 inhibited vascularization in tongue tumors and chorio-allantoic membrane, and suppressed angiogenesis-stimulating activities in UMSCC38 cells. In HUVECs, Ad-BP3 decreased migration, invasion, and tube formation. rBP3 also suppressed production of vascular endothelial growth factor (VEGF) in HUVECs and UMSCC38 cells. IGFBP-3-GGG, a mutant IGFBP-3 with loss of IGF binding capacity, suppressed VEGF production. In addition, we found that IGFBP-3 suppressed VEGF expression, even in mouse embryonic fibroblasts from an IGF-1R-null mouse. Finally, we demonstrated that IGFBP-3-GGG inhibits tumor angiogenesis and growth to the same degree as wild-type IGFBP-3. Taken together, these results support the hypothesis that IGFBP-3 has anti-angiogenic activity in HNSCC, at least in part due to IGF-independent suppression of VEGF production from vascular endothelial cells and cancer cells.

Abstract 1901: EGFR and K-Ras mutations and resistance of lung cancers to IGF-1R TKI

Background: Most patients with non-small cell lung cancer (NSCLC) have responded poorly to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). We investigated the involvement of insulin-like growth factor 1 receptor (IGF-1R) signaling in primary resistance to EGFR TKIs and the molecular determinants of resistance to IGF-1R TKIs. Methods: Phosphorylated IGF-1R/insulin receptor (pIGF-1R/IR) was immunohistochemically evaluated in a NSCLC tissue microarray. We analyzed the antitumor effects of an IGF-1R TKI (PQIP or OSI-906), either alone or in combination with a small-molecular inhibitor (PD98059 or U0126) or with siRNA targeting K-Ras or MAPK/extracellular signal-regulated kinase kinase (MEK), in vitro and in vivo in NSCLC cells with variable histologic features and EGFR or K-Ras mutations. Results: pIGF-1R/IR expression in NSCLC specimens was associated with a history of tobacco smoking, squamous cell carcinoma histology, mutant (mut) K-Ras, and wild-type (wt) EGFR, all of which have been strongly associated with poor response to EGFR TKIs. IGF-1R TKIs exhibited significant antitumor activity in NSCLC cells with wt EGFR and wt K-Ras but not in those with mutations in these genes. Introduction of mut K-Ras attenuated the effects of IGF-1R TKIs on NSCLC cells expressing wt K-Ras. Conversely, inactivation of MEK restored sensitivity to IGF-TKIs in cells carrying mut K-Ras. Conclusions: The mutation status of both EGFR and K-Ras could be predictive markers of response to IGF-1R TKIs. Also, MEK antagonism can abrogate primary resistance of NSCLC cells to IGF-1R TKIs.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1901. doi:1538-7445.AM2012-1901

Epidermal growth factor receptor and K-Ras mutations and resistance of lung cancer to insulin-like growth factor 1 receptor tyrosine kinase inhibitors

BACKGROUND

Most patients with nonsmall cell lung cancer (NSCLC) have responded poorly to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). The authors investigated the involvement of insulinlike growth factor 1 receptor (IGF-1R) signaling in primary resistance to EGFR TKIs and the molecular determinants of resistance to IGF-1R TKIs.

METHODS

Phosphorylated IGF-1R/insulin receptor (pIGF-1R/IR) was immunohistochemically evaluated in an NSCLC tissue microarray. The authors analyzed the antitumor effects of an IGF-1R TKI (PQIP or OSI-906), either alone or in combination with a small-molecular inhibitor (PD98059 or U0126) or with siRNA targeting K-Ras or mitogen-activated protein kinase/extracellular signal-regulated kinase kinase (MEK), in vitro and in vivo in NSCLC cells with variable histologic features and EGFR or K-Ras mutations.

RESULTS

pIGF-1R/IR expression in NSCLC specimens was associated with a history of tobacco smoking, squamous cell carcinoma histology, mutant K-Ras, and wild-type (WT) EGFR, all of which have been strongly associated with poor response to EGFR TKIs. IGF-1R TKIs exhibited significant antitumor activity in NSCLC cells with WT EGFR and WT K-Ras but not in those with mutations in these genes. Introduction of mutant K-Ras attenuated the effects of IGF-1R TKIs on NSCLC cells expressing WT K-Ras. Conversely, inactivation of MEK restored sensitivity to IGF-TKIs in cells carrying mutant K-Ras.

CONCLUSIONS

The mutation status of both EGFR and K-Ras could be a predictive marker of response to IGF-1R TKIs. Also, MEK antagonism can abrogate primary resistance of NSCLC cells to IGF-1R TKIs.

Akt/mTOR counteract the antitumor activities of cixutumumab, an anti-insulin-like growth factor I receptor monoclonal antibody

Recent reports have shown limited anticancer therapeutic efficacy of insulin-like growth factor receptor (IGF-1R)-targeted monoclonal antibodies (mAb), but the resistance mechanisms have not been completely identified. Because cooperation between epidermal growth factor receptor (EGFR) and IGF-IR could cause resistance to inhibitors of individual receptor tyrosine kinases, we investigated the involvement of EGFR signaling in resistance to IGF-1R mAb and the underlying mechanisms of action. Most head and neck squamous cell carcinoma (HNSCC) tissues had coexpression of total and phosphorylated IGF-1R and EGFR at high levels compared with paired adjacent normal tissues. Treatment with cixutumumab (IMC-A12), a fully humanized IgG1 mAb, induced activation of Akt and mTOR, resulting in de novo synthesis of EGFR, Akt1, and survivin proteins and activation of the EGFR pathway in cixutumumab-resistant HNSCC and non-small cell lung cancer (NSCLC) cells. Targeting mTOR and EGFR pathways by treatment with rapamycin and cetuximab (an anti-EGFR mAb), respectively, prevented cixutumumab-induced expression of EGFR, Akt, and survivin and induced synergistic antitumor effects in vitro and in vivo. These data show that resistance to IGF-1R inhibition by mAbs is associated with Akt/mTOR-directed enhanced synthesis of EGFR, Akt1, and survivin. Our findings suggest that Akt/mTOR might be effective targets to overcome the resistance to IGF-1R mAbs in HNSCC and NSCLC.

Abstract 4127: EGFR and K-Ras mutations and resistance of lung cancer to the IGF-1R tyrosine kinase inhibitors

Background: The majority of patients with non-small cell lung cancer (NSCLC) has responded poorly to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). We investigated (1) the involvement of insulin-like growth factor 1 receptor (IGF-1R) signaling in primary resistance to EGFR TKIs and (2) the molecular determinants of resistance to IGF-1R TKIs. Methods: Phosphorylated IGF-1R/insulin receptor (pIGF-1R/IR) was immunohistochemically evaluated in NSCLC tissue microarrays. The antitumor effects of IGF-1R TKIs (PQIP, OSI906), either alone or in combination with small-molecular inhibitors or siRNA targeting K-Ras or MAPK/extracellular signal-regulated kinase kinase (MEK) were analyzed in vitro and in vivo in 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)-transformed human bronchial epithelial (HBE) cells and in NSCLC cells with variable histologic features and mutations in EGFR or K-Ras. Results: pIGF-1R/IR expression in NSCLC specimens was positively correlated with presence of a history of tobacco smoking, squamous cell carcinoma, mutant (mut) K-Ras, and wild-type (wt) EGFR, all of which have been strongly associated with poor response to EGFR TKIs. IGF-1R TKIs exhibited significant antitumor activity in NNK-transformed HBE cells and in NSCLC cells harboring wt EGFR and wt K-Ras, but not those with mutations in these genes. Introduction of mut K-Ras attenuated the effects of IGF-1R TKIs on wt K-Ras-expressing NSCLC cells. Conversely, inactivation of MEK restored sensitivity to IGFR-TKI in cells carrying mut K-Ras. Conclusions: The mutation status of both EGFR and K-Ras could be a predictive marker for response to IGF-1R TKIs. Also, MEK antagonism can abrogate primary resistance of NSCLC to IGF-1R TKIs. This work was supported by NIH grants R01 CA-109520-01 and CA-100816 (all to H-YL.) and in part by DOD grant W81XWH-04-1-0142 VITAL and W8XWH-06-1-0303 BATTLE (W-K H.)

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 4127.

Intensity-modulated radiation therapy with or without chemotherapy for nasopharyngeal carcinoma: radiation therapy oncology group phase II trial 0225

PURPOSE

To investigate the feasibility of intensity-modulated radiation therapy (IMRT) with or without chemotherapy, and to assess toxicities, failure patterns, and survivals in patients with nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

Radiation consisted of 70 Gy given to the planning target volumes of primary tumor plus any N+ disease and 59.4 Gy given to subclinical disease, delivered over 33 treatment days. Patients with stage T2b or greater or with N+ disease also received concurrent cisplatin (100 mg/m(2)) on days 1, 22, and 43 followed by adjuvant cisplatin (80 mg/m(2)) on day 1; fluorouracil (1,000 mg/m(2)/d) on days 1 through 4 administered every 4 weeks for three cycles. Tumor, clinical status, and acute/late toxicities were assessed. The primary objective was to test the transportability of IMRT to a multi-institutional setting.

RESULTS

Between February 2003 and November 2005, 68 patients with stages I through IVB NPC (of which 93.8% were WHO types 2 and 3) were enrolled. Prescribed IMRT (target delineation) was given to 83.8%, whereas 64.9% received chemotherapy per protocol. The estimated 2-year local progression-free (PF), regional PF, locoregional PF, and distant metastasis-free rates were 92.6%, 90.8%, 89.3%, and 84.7%, respectively. The estimated 2-year PF and overall survivals were 72.7% and 80.2%, respectively. Acute grade 4 mucositis occurred in 4.4%, and the worst late grade 3 toxicities were as follows: esophagus, 4.7%; mucous membranes, 3.1%; and xerostomia, 3.1%. The rate of grade 2 xerostomia at 1 year from start of IMRT was 13.5%. Only two patients complained of grade 3 xerostomia, and none had grade 4 xerostomia.

CONCLUSION

It was feasible to transport IMRT with or without chemotherapy in the treatment of NPC to a multi-institutional setting with 90% LRPF rate reproducing excellent reports from single institutions. Minimal grade 3 and lack of grade 4 xerostomia were encouraging.

Phase I study of pemetrexed in recurrent/metastatic head and neck squamous cell cancer (HNSCC) and to assess the need for steroid premedication

e17009

Background: Pemetrexed is a novel antimetabolite that inhibits both purine and pyrimidine biosynthesis. Because its mechanism of action is similar to that of both methotrexate and 5-FU, it may also have activity in recurrent/metastatic HNSCC, a disease with limited treatment options and very poor median survival. Pemetrexed is traditionally prescribed with steroids due to skin toxicities observed in early studies; however vitamin supplementation (B12 and folic acid) was not standard at the time of those studies. No study to date has evaluated the optimal use of steroids with pemetrexed in the era of vitamin supplementation. Methods: All patients had metastatic or recurrent HNSCC, were treated with at least one prior chemotherapy regimen, and had ECOG PS of 0–2. The first cohort of patients received pemetrexed 500 mg/m2 every 3 weeks and the next receiving 600 mg/m2 based on a predefined standard dose escalation design. Within each dose level, patients were randomized to one of 3 premedication regimens: no dexamethasone, 20 mg IV on day 1, or standard 4 mg orally bid for 3 days. All patients received vitamin supplementation. The primary endpoint of the study was to determine the maximum tolerated dose of pemetrexed based on steroid premedication. Results: From October 2005 to March 2008, 36 patients were enrolled and 31 were available for evaluation. Median age was 57 years (range 42–82). 51.5% of patients had more than one prior chemotherapy regimens, 81.8% of patients had prior radiation therapy, and 48.5% of patients had prior surgery. Incidence of rash and combined skin toxicities were: 1/11 (9%) and 3/11 (27%) of patients without steroids, 1/11 (9%) and 3/11 (27%) with single IV dose, and 4/9 (44%) and 5/9 (55%) with oral steroids. No treatment-related grade 3 toxicities were observed. One patient initially received no steroid and required dose reduction and addition of steroid due to grade 2 rash. A partial response was observed in one patient (3.2%), and stable disease in 8 patients (25.8%) for a disease control rate of 29%. Conclusions: This is the first study to report the role of steroids as a premedication for pemetrexed. Our data suggests that no steroid premedication is needed with pemetrexed and vitamin supplementation.

[Table: see text]

Phase II study of dasatinib in the treatment of head and neck squamous cell carcinoma (HNSCC)

6022

Background: Dasatinib is a potent inhibitor of src-family kinases, ephA2, PDGFR, Abl, and c-kit. A single-center, open-label, phase II trial was conducted to evaluate the safety, tolerability, pharmacokinetics (PK), and efficacy of dasatinib in recurrent or metastatic HNSCC. Methods: Pts with measurable disease by RECIST, who received 0 or 1 prior regimen for recurrent or metastatic HNSCC with an ECOG performance status 0–1 and tumor tissue appropriate for IHC and FISH were eligible. Dasatinib 100 mg bid was given for 28-day cycles. Primary endpoints were 12-wk progression-free survival (PFS) and objective response rate (ORR). Pts who took at least 1 dose of dasatinib and who died or left study before 12 wks were counted as progressive disease (PD). A 2 stage design, closure after accrual of 15 pts was required if PFS was 45% or less and ORR was 0. Otherwise, planned accrual was 35. Response was assessed at 4 and 12 wks. PK was studied in pts receiving dasatinib per PEG. Biomarkers relevant to Src pathway were planned in tissue and blood. Results: Fifteen pts were accrued. To date, 13 pts are evaluable for response, and 15 pts for toxicity. No grade 3/4 hematologic toxicities were noted. Grade 2–4 nonhematologic toxicities(n): pleural effusion(2), nausea/vomiting(2), dehydration(1), diarrhea(1), dyspnea(1). Toxicity led to hospitalization of 4 pts and drug discontinuation in 5 pts. ORR was 0. One pt was stable at 12 wks (PFS: 7.6%). This pt stopped drug at 15 wks due to toxicity, but also had PD. One pt died on study and cause was deemed unlikely related. Conclusions: Dosed at 100mg bid, dasatinib led to a characteristic toxicity profile in this pt population. Rates of hospitalization and discontinuation for toxicity were fairly high. Final efficacy parameters are pending evaluation of 2 pts. Evaluation of PK and tissue/blood biomarkers is ongoing.

No significant financial relationships to disclose.

IMRT reirradiation of head and neck cancer-disease control and morbidity outcomes

PURPOSE

Institutional and cooperative group experience has demonstrated the feasibility of reirradiation for head and neck cancer. Limited data are available regarding the use of intensity-modulated radiotherapy (IMRT) for this indication. We reviewed our initial experience using IMRT for previously irradiated head and neck cancer patients.

METHODS AND MATERIALS

Records of 78 consecutive patients reirradiated with IMRT for head and neck cancer between 1999 and 2004 were reviewed; 74 cases were analyzed. Reirradiation was defined as any overlap between original and new radiation treatment volumes regardless of the time interval between initial and subsequent treatment. Severe reirradiation-related toxicity was defined as toxic events resulting in hospitalization, corrective surgery, or patient death. Longitudinal estimates of survival were calculated by Kaplan-Meier technique.

RESULTS

Twenty (27%) patients underwent salvage surgical resection and 36 (49%) patients received chemotherapy. Median follow-up from reirradiation was 25 months. Median time interval between initial radiation and reirradiation was 46 months. Median reirradiation dose was 60 Gy. Median lifetime radiation dose was 116.1 Gy. The 2-year overall survival and locoregional control rates were 58% and 64%, respectively. Severe reirradiation related toxicity occurred in 15 patients (20%); one treatment-related death was observed.

CONCLUSIONS

The use of IMRT for reirradiation of recurrent or second primary head and neck cancers resulted in encouraging local control and survival. Reirradiation-related morbidity was significant, but may be less severe than previously published reports using conventional techniques.

A phase II trial of ZD 1869 for advanced cutaneous squamous cell carcinoma of the head and neck

6038

Background: Advanced HN CSSC carries a 30–40% risk of death by 2 years with standard therapies. A number of patients (pts) with clinically aggressive CSCC tend to have a poor prognosis when treated with standard approaches using surgery and radiation (RT), thus novel therapies are needed. CSSC over expresses the epidermal growth factor receptor (EGFR) and these compounds have activity in head and neck cancers. We are studying the use of gefitinib as an induction therapy in a high-risk patient group prior to definitive therapy to determine the overall efficacy, toxicity and feasibility. Methods: Eligible pts must have HN CSSC >2cm, regional nodal metastases, peri-neural invasion, or deep invasion into cartilage, muscle or bone and must be candidates for definitive local-regional therapy with surgery and/or radiation. Two 30-day cycles of gefitinib 250mg administered orally are given daily prior to definitive therapy. Pts are assessed clinically after the first 30-day cycle. If a response is noted, gefitinib is continued. For patients with stable disease, the dose is escalated to 500mg daily. Pts with progressive disease go off study. Biomarker evaluations including EGFR and Akt expression prior to and after induction are planned. Results: To date, 14 pts have been enrolled. 10 are evaluable for response and 13 for toxicity. A complete clinical response (CR) was noted in 3 pts (30%, one pathological CR), partial response in 2 patients (20%), stable disease in 2 (20%) and progressive disease in 3 (30%). Therapy was well tolerated with 2 patients having grade 3 toxicity (rash, diarrhea, or elevated liver enzymes). Conclusions: Standard definitive surgery and RT are inadequate for patients with advanced HN CSSC. The emergence of targeted therapies has given new hope for many patients with high-risk cancers. The preliminary results from our study suggest that gefitinib is an active agent for HN CSCC, and is well tolerated. Correlative studies may help identify patients most likely to respond to anti- EGFR therapy.

[Table: see text]

Toxicities in a phase II study of accelerated high dose thoracic radiation therapy (TRT) with concurrent chemotherapy for limited small cell lung cancer (LSCLC) (RTOG 0239)

7717

Background: Accelerated fractionation proved beneficial in INT0096, but the total dose was low and local recurrence was high with higher acute grade (Gr.) 3+ esophagitis. RTOG 0239 was a phase II trial to improve local control and survival with LSCLC with acceptable acute Gr. 3+ esophagitis using accelerated high dose TRT and concurrent cisplatin/etoposide. This is the first report of acute Gr.3+ esophagitis and Gr.5 toxicities. Methods: Patients (pts) with LSCLC without pleural effusion, contralateral hilar or contralateral supraclavicular nodes and PS 0–1 were enrolled. TRT was given to large fields to 28.8 Gy at 1.8 Gy per fraction, 5 days per week for 16 fractions followed by BID with large field in AM, boost in PM, then off-cord boost BID for last 5 days, all at 1.8 Gy per fx for a total dose of 61.2 Gy in 34 fx in 5 weeks. Concurrent chemotherapy was started with TRT with cisplatin, 60 mg/m2 i.v. day 1; etoposide, 120 mg/m2 i.v. day 1; etoposide, 240 mg/m2 p.o. per day or 120 mg/m2 i.v. per day on days 2 or 3. Cycles were repeated q.3 wks during and for 2 cycles after TRT. Pts who have achieved complete response one month after completion of 4 cycles of chemotherapy were asked to participate in a prophylactic cranial irradiation (PCI) study. Common toxicity criteria (CTC) 2.0 was used for acute toxicity. Results: From 10/2003 to 5/2006, 72 pts were accrued. Median age was 63 yrs with 52% females. Survival data is still maturing. Acute toxicity information is available for 68 pts. Eleven pts (16%) experienced acute Gr. 3 and 1 pt (1%) had acute Gr. 4 esophagitis. 47 pts (69%) had grade 4 blood/bone marrow toxicities. There were 2 (3%) Gr. 5 toxicities reported [1 infection with neutropenia; 1 pulmonary (pneumonia)]. Conclusions: This accelerated high dose TRT with concurrent chemotherapy for LSCLC resulted in 17% acute Gr.3+ esophagitis compared to 27% with BID TRT with 45Gy in 3 weeks by INT0096. There were 3% grade 5 toxicities. This preliminary report suggests that RTOG-0239 has tolerable toxicity. The acute Gr3+ esophageal toxicity correlated with V20 and V40 will be presented. Pts continue to be followed for the primary endpoint of 2-year survival.

No significant financial relationships to disclose.

Long-term results of Intergroup RTOG 91–11: A phase III trial to preserve the larynx—Induction cisplatin/5-FU and radiation therapy versus concurrent cisplatin and radiation therapy versus radiation therapy

5517

Background: The 2-year results of Intergroup RTOG 91–11 were published in 2003 (NEJM 349:2091–8,2003). We now present the 5-year results (after median follow-up for surviving patients of 6.9 years) of 515 eligible pts with resectable stage III or IV (excluding T1 and high volume T4), cancer of the glottic or supraglottic larynx. Methods: Patients were randomized to induction cisplatin/5-FU (CF) with responders then receiving RT (I+RT) (n = 173); or concurrent cisplatin (100 mg/m2 q 21 days × 3) and RT (CRT) (n = 171); or RT alone (R) (n = 171). Laryngectomy was performed for < partial response to induction CF, for persistent/recurrent disease or for laryngeal dysfunction. Results: At 5 years, laryngectomy-free survival (LFS) was significantly better with either I+RT (44.6%, p = 0.011) or CRT (46.6%, p = 0.011) compared to R (33.9%). There was no difference in LFS between I+RT and CRT (p = 0.98). Laryngeal preservation (LP) was significantly better with CRT (83.6%) compared to I+RT (70.5%, p = 0.0029) or R (65.7%, p = 0.00017). Local-regional control (LRC) was significantly better with CRT (68.8%) compared to I+RT (54.9%, p = 0.0018) or R (51%, p = 0.0005). I+RT compared to R for LP and LRC showed no significant difference (p = 0.37 and 0.62, respectively). The distant metastatic rate was low (I+RT 14.3%, CRT 13.2%, R 22.3%) with a trend (p ∼0.06) for benefit from chemotherapy. Disease-free survival (DFS) was significantly better with either I+RT (38.6%, p = 0.016) or CRT (39%, p = 0.0058) compared to R (27.3%). Overall survival rates were similar for the first 5 years (I+RT 59.2%, CRT 54.6%, R 53.5%); thereafter I+RT had a non-significant lower death rate. Compared to CRT, significantly more pts in the R group died of their cancer (34% vs 58.3%, p = 0.0007); the rate for I+RT was 43.8%. Conclusion: These 5-year results differ from the 2-year analysis by a significant improvement in LFS now seen for both I+RT and CRT treatments compared to R. For the endpoints of LP and LRC, CRT is still the superior treatment with no advantage seen to the addition of induction CF to R. There is no significant difference in overall survival.

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Yttrium-90 microsphere treatment for liver dominant hepatic metastases from lung cancer

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Background: Hepatic metastases are a common manifestation of primary lung malignancies; the primary and other extrahepatic sites are often less responsive to systemic therapy. A new method of regional therapy for hepatic metastases, called SIR-Spheres, a 32μ resin sphere incorporating a pure Beta emitter, Yttrium - 90, has advantages to older forms of regional hepatic therapy, used to treat colorectal liver metastases. The effectiveness and relatively response durability suggests a favorable alternative to chemotherapy for patients with liver-dominant metastatic lung cancers. We report our experience using SIR-Spheres in this setting. Methods: 6 patients (2 well differentiated carcinoid, 2 well & 1 poorly differentiated adenocarcinoma, 1 poorly differentiated small cell carcinoma) with unresectable hepatic metastases were treated with 8 infusions of SIR-Spheres after failing systemic chemotherapy, radiofrequency ablation or arterial embolization were included in the study. SIR-Spheres were administered as 2nd-6th line therapy. Median interval from diagnosis to SIR-Spheres treatment was 20.5 months (6–51 m). Results: Abdominal visceral arteriography demonstrated vasculature conducive for SIR-Spheres delivery in all patients. The median dose of 36.1 mCi (12.9–54 mCi) was delivered. SPECT - CT fusion Bremsstrahlung scans post therapy confirmed preferential deposition of SIR-Spheres within metastases. Responses to therapy included a decrease in the size of the hepatic metastases in one patient and stable disease in two patients. One patient had a mixed response and two patients had progression of disease. One Gr. III and one Gr. IV hepatic toxicity occurred. All patients experienced transient Gr. 1 or 2 fatigue. Time to progression of liver disease ranged from 3 to 9 months. Conclusion: SIR-Spheres is a feasible alternative to systemic therapy for patients with liver dominant metastases from lung cancers. Although serious hepatotoxicity was noted in patients with advanced liver metastases, the treatment was tolerated with only reversible fatigue in the majority of patients. When the treatment was effective, the duration of local disease control after one treatment equaled or exceeded what would be expected with chemotherapy.

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