Efficacy and tolerability of tremelimumab in patients with metastatic pancreatic ductal adenocarcinoma

470

Background: Clinical activity and tolerability of the anti-CTLA-4 antibody, tremelimumab, has yet to be established in metastatic pancreatic ductal adenocarcinoma (mPDAC). In a Phase 2, multicenter, open label study (NCT02527434), tremelimumab was evaluated in pts with advanced solid tumors. We report a planned analysis of the safety and efficacy of tremelimumab monotherapy in a cohort of pts with mPDAC. Methods: Eligible pts were adults with histologically or cytologically confirmed mPDAC with tumor progression following prior standard first-line 5-FU- or gemcitabine-containing chemotherapy. Pts received tremelimumab 750 mg IV Q4W for 7 doses, followed by 750 mg Q12W for 2 doses, for up to a total of 12 mo (total 9 doses in 12 mo) or until disease progression or unacceptable toxicity. Pts were radiographically assessed Q6 wks relative to first dose. The primary endpoints were safety (evaluated by CTCAE v4.0) and objective response rate (ORR) by investigator assessments (evaluated by RECIST v1.1). Results: As of April 5, 2017, 20 mPDAC pts had received treatment and were evaluable for efficacy analysis. Median treatment duration was 1.8 mo. There were no observed objective responses (ORR 0%; 95% CI, 0.0, 16.8%). Of 20 pts, 2 were not evaluable and 18 had progressive disease (PD). Based on the full analysis set (N = 20), progression occurred in target lesions in 14 (70%), non-target lesions in 7 (35%), and new lesions in 13 (65%) pts (not mutually exclusive categories). At the time of progression, 11 (61%) pts were on treatment and 7 (39%) had discontinued treatment. Median overall survival was 4 mo (95% CI 2.83 - 5.42). Two (10%) pts were still in follow up at 12 mo after treatment initiation. Treatment-related AEs (trAEs) occurred in 14 pts (70%); grade ≥3 trAEs occurred in 6 pts (30%). Three pts (15%) discontinued therapy due to trAEs. There were no treatment-related deaths. Conclusions: Tremelimumab monotherapy did not appear to be active in mPDAC pts who had tumor progression following prior standard first-line 5-FU- or gemcitabine-containing chemotherapy. Clinical trial information: NCT02527434.

Geriatric Assessment and Functional Decline in Older Patients with Lung Cancer

PURPOSE

Older patients with lung cancer are a heterogeneous population making treatment decisions complex. This study aims to evaluate the value of geriatric assessment (GA) as well as the evolution of functional status (FS) in older patients with lung cancer, and to identify predictors associated with functional decline and overall survival (OS).

METHODS

At baseline, GA was performed in patients ≥70 years with newly diagnosed lung cancer. FS measured by activities of daily living (ADL) and instrumental activities of daily living (IADL) was reassessed at follow-up to define functional decline and OS was collected. Predictors for functional decline and OS were determined.

RESULTS

Two hundred and forty-five patients were included in this study. At baseline, GA deficiencies were present in all domains and ADL and IADL were impaired in 51 and 63% of patients, respectively. At follow-up, functional decline in ADL was observed in 23% and in IADL in 45% of patients. In multivariable analysis, radiotherapy was predictive for ADL decline. No other predictors for ADL or IADL decline were identified. Stage and baseline performance status were predictive for OS.

CONCLUSIONS

Older patients with lung cancer present with multiple deficiencies covering all geriatric domains. During treatment, functional decline is observed in almost half of the patients. None of the specific domains of the GA were predictive for functional decline or survival, probably because of the high impact of the aggressiveness of this tumor type leading to a poor prognosis.

Adherence to geriatric assessment (GA)-based recommendations in older patients (pts) with cancer

10010

Background: In the general older population, GA-guided treatment plans improve overall survival, quality of life and functional status. In geriatric oncology, studies mainly focused on screening and assessment but not on geriatric interventions and follow-up. The aim of this study was to investigate the adherence to recommendations and subsequent interventions based on GA results in older pts with cancer. Methods: A prospective Belgian multicenter (n = 22) cohort study included pts ≥70 years with a malignant tumor when an oncological treatment decision had to be made. Pts with an abnormal G8 (≤14/17) underwent GA and were included in this study. Recommendations for interventions were formulated based on GA results. At follow-up adherence to GA-based recommendations was documented. Results: From 11-2012 till 2-2015, G8 screening was performed in 8451 pts. 5838 pts with an abnormal G8 were included in the study. Geriatric recommendations were given in 79.2% of pts with a median of 2/pt (range 0-10), most frequently consultation of a dietician (73%) for malnutrition, a social worker (54.8%) for social and functional status problems and a geriatrician (42.1%) for general geriatric problems. Follow-up data were available for 4167 pts. In the group of pts where recommendations were given, at least one intervention was performed in 69% with a median of 1/pt (range 0-6), most frequently dietician (43.4%), social worker (26.1%) and geriatrician (22.6%). A total of 7569 actions were undertaken for a total of 5725 geriatric recommendations. Recommendations were most frequently adhered to for malnutrition, social status and functional status problems. The most frequent actions undertaken were nutritional support and supplements, extended home care and psychological support. Conclusions: This large scale Belgian study focusses on the adherence to GA based interventions in older pts with cancer and contributes to the optimization of care for these pts. We identified the domains for which geriatric interventions are most frequently recommended and adhered to and which health care professionals and referrals are essential in the multidisciplinary approach of older pts with cancer.

Abstract P5-16-06: Neoadjuvant weekly carboplatin and paclitaxel followed by dose dense epirubicin and cyclophosphamide in triple negative breast cancer patients: A single arm phase II study from the Belgian Society of Medical Oncology

Introduction: Triple negative breast cancer (TNBC) remains a challenging disease with dismal prognosis. Platinum analogs have not yet shown to improve long term outcome in this setting, but are associated with increased pathological complete response rate (pCR) at the cost of higher toxicity.

Aim: To further increase or maintain the high pCR rate with platinum containing schedules while decreasing toxicity by administering low dose weekly carboplatin instead of high-dose 3 weekly carboplatin as in CALGB 40603.(1)

Patients and methods: We evaluated the tolerability and the impact of the addition of weekly carboplatin (CP) to paclitaxel (P) and dose dense epirubicin-cyclofosfamide (EC) on pCR in an open-label multicenter phase II study in stage II/III TNBC patients (pts). Sixty three pts received dose dense paclitaxel (P:80mg/m2/wk) concurrent with carboplatin (CP: AUC=2) for 12 wks, followed by two-weekly epirubicin (E:90mg/m2) and cyclophosphamide (C:600mg/m2) for 4 cycles. The primary endpoint is pCR in the breast and axilla. Additionally treatment deliveryand adverse events are recorded. A correlative assessment of germline mutations in homologous recombination (HR) genes is planned. Pts are monitored for response by magnetic resonance and mammography and also for relapse free survival and time to treatment failure. The study size sample has been calculated according to the optimal Simon's two-stage design method. The target sample size was 63 patients with 80% power to detect a pCR rate of ≥47% (α= 0.05).

Results: Accrual to the study is completed with 63 eligible pts with operable, noninflammatory stage II and III TNBC included. Most patients were between 40 and 60 yrs old and were clinical stageT2 tumors. Half of the pts were clinically node + and 70% were G3. Sixty six percent had breast conserving surgery. Sixteen out of 26 (61.5%) of the currently evaluable pts achieved a pCR rate in the breast and axilla. The other ongoing patients have not yet reached this endpoint. Four out of 21 evaluable pts that completed the chemotherapy missed two or more doses of CP due to neutropenia(NP) G3/4(2), general deterioration G3(1) and polyneuropathy(PNP) G3(1) and seven pts needed one dose reduction of P and/or CP due to NP G3-4 (3-2) and PNP G2(1) and one abdominal infection.

Conclusion: These preliminary data suggest that the addition of weekly carboplatinum to neoadjuvant paclitaxel and EC is feasible and has a promising pCR rate in the breast and axilla as high as 61.5% in early TNBC pts. More mature toxicity and outcome data and correlation with genome analysis will be presented.

(1) Impact of the addition of carboplatin and/or bevacizumab to neoadjuvant once per week paclitaxel followed by dose-dense doxorubicin and cyclophosphamide on pathologic complete response rates in stage II to III triple-negative breast cancer: CALGB 40603(Alliance) Sikov WM et al. J Clin Oncol 33:13-21; 2014.

Citation Format: Fontaine C, Cappoen N, Renard V, Vuylsteke P, Van Den Bulck H, Glorieux P, t'Kint de Roodenbeke D, Dopchie C, Decoster L, Vanacker L, De Grève J, Awada A, Wildiers H. Neoadjuvant weekly carboplatin and paclitaxel followed by dose dense epirubicin and cyclophosphamide in triple negative breast cancer patients: A single arm phase II study from the Belgian Society of Medical Oncology [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 P5-16-06.

Non-V600 BRAF mutations recurrently found in lung cancer predict sensitivity to the combination of Trametinib and Dabrafenib

Approximately half of BRAF-mutated Non-small cell lung cancers (NSCLCs) harbor a non-V600 BRAF mutation, accounting for ∼40,000 annual deaths worldwide. Recent studies have revealed the benefits of combined targeted therapy with a RAF-inhibitor (Dabrafenib) and a MEK-inhibitor (Trametinib) in treating V600 BRAF mutant cancers, including NSCLC. In contrast, sensitivity of non-V600 BRAF mutations to these inhibitors is not documented. Non-V600 mutations can either increase or impair BRAF kinase activity. However, impaired BRAF kinases can still activate the ERK pathway in a CRAF-dependent manner. Herein, beyond describing a cohort of BRAF mutant NSCLC patients and functionally analyzing 13 tumor-derived BRAF mutations, we demonstrate that both types of non-V600 BRAF mutations can be sensitive to clinically relevant doses of Dabrafenib and Trametinib in HEK293T cells, in lung epithelial cellular model (BEAS-2B) and in human cancer cell lines harboring non-V600 BRAF mutations. ERK activity induced by both types of these mutations is further reduced by combinatorial drug treatment. Moreover, the combination leads to more prolonged ERK inhibition and has anti-proliferative and pro-apoptotic effects in cells harboring both types of non-V600 BRAF mutations. This study provides a basis for the clinical exploration of non-V600 BRAF mutant lung cancers upon treatment with Trametinib and Dabrafenib.

Prospective Evaluation of First-Line Erlotinib in Advanced Non-Small Cell Lung Cancer (NSCLC) Carrying an Activating EGFR Mutation: A Multicenter Academic Phase II Study in Caucasian Patients (FIELT)

Introduction

Epidermal Growth Factor Receptor (EGFR) tyrosine kinase inhibition is the preferred first-line treatment of advanced adenocarcinoma of the lung that harbors EGFR activating tyrosine kinase domain mutations. Most data available pertain to Asian populations in which such mutations are more prevalent. We report on the long-term results of first-line treatment with erlotinib in Caucasian patients with advanced adenocarcinoma of the lung that have a somatic EGFR mutation in their tumor.

Methods

Multicenter academic prospective phase II study with erlotinib in patients with an activating EGFR tyrosine kinase (TK) domain somatic mutation (any exon encoding the kinase domain) in the tumor and no prior treatment for their advanced disease.

Results

Phenotypic preselecting of 229 patients led to a high EGFR mutation detection rate of 24% of which 46 patients were included in the phase II study. With a progression free survival (PFS) of 81% at three months the study met its primary endpoint for presumed superiority over chemotherapy. With an overall median PFS of 11 months and a median overall survival (OS) of 23 months, the results compare favorably with results obtained in randomized studies using TKI in first line in EGFR mutation positive adenocarcinoma of the lung.

Conclusion

The present study reinforces the use of EGFR tyrosine kinase inhibition (TKI) as a first line treatment of choice for advanced adenocarcinoma of the lung carrying an activating EGFR mutation. The mutation rate in preselected Caucasian patients is higher than previously reported. Issues relevant for clinical practice are discussed.

Trial Registration

ClinicalTrials.gov NCT00339586

Abstract PD7-04: Exome based germline mutation detection in a panel of 372 cancer associated genes in BRCA1/2-negative familial breast cancer patients

Background:

Ten to 20% percent of all breast cancers occur in a familial context and in 20-30% of these cases a mutation in the BRCA1 or BRCA2, CHEK2 genes or, more rarely, in PALB2 can be found. The remaining cases remain routinely undiagnosed with regard to a possible genetic cause.

We have examined a cohort of undiagnosed probands using exome germline sequencing in order to identify other potential breast cancer predisposition genes.

Methods:

In total, 63 BRCA1/2-negative high risk familial BC cases (BRCAX) were considered for pair-end whole exome germline DNA sequencing on a HiSeq1500 (Illumina). High quality reads were mapped (BWA-MEM) to the reference genome (hg19) and variants were called according to GATK best practice guideline. The variants detected within the panel of 372 cancer associated genes were annoted with ANNOVAR. Synonymous variant as well as variants with MAF>1% were discarded. In a first phase protein truncating variants were validated using another NGS method. Subsequent validation of non-synonymous missense mutations and non-frameshift indels is planned. Patients signed a multilayered informed consent also covering disclosure or not of different types of incidental findings.

Results:

For each exome, the mean breath of coverage was about 96 % at 10X or more and the mean depth of coverage for targeted region was about 126X. In total, 3570709 SNPs (∼56678 SNPs/sample) and 477801 INDELs (7584 INDELs/sample) were called. Of them, 20829 SNPs (331 SNPs/sample) and 16071 INDELs (255 INDELs/sample) passed quality filter. In total, 445 variants were found in the publicly available cancer genes panel. Twenty-seven stop-gain/loss, frame-shift insertion/deletion and splice site variants were considered for validation with 454 Roch Junior, among which 22 variants in genes ABCC11, AFP, BARD1, BBS10, CD96, CYP1A1, DNAH11, ESCO2, EXO1, FANCI, FLCN, FLT4, HPS6, MYH8, NME8, PALB2, PDE11A, RECQL4, TTC8 were validated as true positive. Some of these genes have been found earlier to be associated with breast cancer and/other cancer types. Functional prioritization of the remaining 416 non-synonymous and non-frameshift insertion/deletions was also done in-silico before further sequencing validation, which is ongoing. The mutations found are further clinically validated by examining other affected and non-affected family members and mining the literature. Some of the mutations in known cancer predisposing genes are considered for prudent application in clinical counseling. Genotype-phenotype correlations are being examined.

Conclusion:

Next-generation sequencing enabled us to detect variants with high/low penetrance in known cancer predisposing genes in > 35% of BRAX families, in addition to many novel variants in many other genes not yet tied to cancer predisposition occurring singly or in combination with known cancer gene mutations. Validated variants are further examined in the families for co-segregation with the disease and potential application in counseling.

Citation Format: Shahi RB, Caljon B, De Brakeleer S, Decoster L, Fontaine C, Vanacker L, Vanhoeij M, Pauwels I, Bonduelle M, Vandooren S, Croes D, Teugels E, De Greve J. Exome based germline mutation detection in a panel of 372 cancer associated genes in BRCA1/2-negative familial breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD7-04.

Corrigendum to "Implementation of geriatric assessment-based recommendations in older patients with cancer: A multicenter prospective study" [J. Geriatr. Oncol. 6 (2015) 401-410]

The authors regret: A calculation error was corrected in Table 3. As mentioned under the table, the percentage of patients under ‘Baseline’ was calculated from the total no. of patients with geriatric recommendations data (n = 932 pts). This was mistakenly calculated from the number of patients with available GA data (n = 979). Percentages have been recalculated. The corrected table is reproduced here (Table 3). We emphasize that these percentages are not mentioned in the text of the paper nor do they change any of the conclusions. The authors would like to apologize for any inconvenience caused.

A Belgian Survey on Geriatric Assessment in Oncology Focusing on Large-Scale Implementation and Related Barriers and Facilitators

OBJECTIVES

The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate.

RESULTS

Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration.

CONCLUSION

Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.

Shifts in subsets of CD8+ T-cells as evidence of immunosenescence in patients with cancers affecting the lungs: an observational case-control study

Background

Shifts in CD8+ T-cell subsets that are hallmarks of immunosenescence are observed in ageing and in conditions of chronic immune stimulation. Presently, there is limited documentation of such changes in lung cancer and other malignancies affecting the lungs.

Methods

Changes in CD8+ T-cell subsets, based on the expression of CD28 and CD57, were analysed in patients with various forms of cancer affecting the lungs, undergoing chemotherapy and in a control group over six months, using multi-colour flow cytometry.

Results

The differences between patients and controls, and the changes in the frequency of CD8+ T-cell subpopulations among lung cancer patients corresponded to those seen in immunosenescence: lower CD8-/CD8+ ratio, lower proportions of CD28+CD57- cells consisting of naïve and central memory cells, and higher proportions of senescent-enriched CD28-CD57+ cells among the lung cancer patients, with the stage IV lung cancer patients showing the most pronounced changes. Also observed was a tendency of chemotherapy to induce the formation of CD28+CD57+ cells, which, in line with the capacity of chemotherapy to induce the formation of senescent cells, might provide more evidence supporting CD28+CD57+ cells as senescent cells.

Conclusion

Immunosenescence was present before the start of the treatment; it appeared to be pronounced in patients with advanced cases of malignancies affecting the lungs, and might not be averted by chemotherapy.

Biomarker Analysis in a Phase II Study of Sunitinib in Patients with Advanced Melanoma

AIM

To investigate the efficacy of sunitinib in patients with advanced melanoma and to correlate angiogenic biomarkers with response and survival.

PATIENTS AND METHODS

We performed a phase II study in patients with advanced pre-treated melanoma. The primary endpoint was tumor response. Blood samples for biomarker analysis including vascular endothelial growth factor (VEGF), and its receptors VEGFR1 and -2, placental growth factor (PlGF) and circulating endothelial cells (CEC) were collected at baseline and during the first cycle.

RESULTS

Four out of 39 patients (13%) achieved a partial response and eight (26%) stable disease. Time to progression was at least six months in seven patients. High baseline VEGFR1 levels and high baseline PlGF levels were both associated with a non-significant worse survival (p=0.08 for both).

CONCLUSION

Sunitinib demonstrates limited activity in unselected patients with refractory advanced melanoma, but a minority of patients experienced long-term disease control. Identification of these patients remains a challenge.

Implementation of geriatric assessment-based recommendations in older patients with cancer: A multicentre prospective study

PURPOSE

The main objective of this study was to describe geriatric recommendations based on a geriatric assessment (GA) and to evaluate the implementation of these recommendations.

PATIENTS AND METHODS

A two-step approach of screening followed by a GA was implemented in nine hospitals in Belgium. Patients ≥ 70 years were included at diagnosis or at disease progression/relapse. Concrete geriatric recommendations were systematically documented and reported to the treating physicians and consisted of referrals to professional health care workers. Patient charts were reviewed after one month to verify which geriatric recommendations have been performed.

RESULTS

From August 2011 to July 2012, 1550 patients were included for analysis. The median age was 77 (range: 70-97) and 57.0% were female. A solid tumour was diagnosed in 91.4% and a haematological malignancy in 8.6%. Geriatric screening with the G8 identified 63.6% of the patients for GA (n=986). A median of two geriatric recommendations (range: 1-6) were given for 76.2% (95%CI: 73.4-78.8) of the evaluable patients (n=710). A median of one geriatric recommendation (range: 1-5) was performed in 52.1% (95%CI: 48.4-55.8) of the evaluable patients (n=689). In general, 460 or 35.3% (95%CI: 32.8-38.0) of all the geriatric recommendations were performed. Geriatric recommendations most frequently consisted of referrals to the dietician (60.4%), social worker (40.3%), and psychologist (28.9%).

CONCLUSION

This implementation study provides insight into GA-based recommendations/interventions in daily oncology practice. Geriatric recommendations were given in about three-fourths of patients. About one-third of all geriatric recommendations were performed in approximately half of these patients.

Abstract P1-12-11: Prospective study of aromatase inhibitor-induced bone loss and lipid levels in early hormone sensitive breast cancer treated with AI during 8 years

Introduction: AI’s are the preferred adjuvant hormonal treatment for postmenopausal(PM) estrogen receptor positive (ER+) disease because of the improved efficacy over tamoxifen in terms of disease free survival and reduction in distant recurrence. AI’s have been associated with increased bone loss by blocking peripheral tissue estrogen synthesis, arthralgia and a negative effect on lipid metabolism. In this prospective study we wanted to assess the amount of bone loss and the changes in lipid levels in early breast cancer(EBC) patients (pts) treated with 3yrs of extended letrozole as part of the SOLE study after 5 yrs of adjuvant AI. Objectives: the primary objective of the study is to calculate the mean percentage change in bone mineral density(BMD)(g/cm2) after 8 yrs of letrozole and to compare between the continuous(C) and intermittent(I) intake of letrozole. The secondary objectives are to correlate the mean change in BMD with the initial value, BMI and to describe the evolution of the lipid levels in both groups. Patients and methods: BMD was measured at the lumbar spine (L2-4) and hip by dual energy X-ray absorptiometry (DEXA) in PM pts. with ER+ EBC. We also measured the fasting lipid levels baseline and after 8 yrs of an AI. Differences between the two groups were assessed by the independent samples T-test and the correlation by the linear regression analysis. Results: Fifty four pts were included in the study with a mean age of 62.5 yrs(+/-8.6 yrs). Seventeen pts are too early to be evaluable, 8 pts stopped letrozole due to adverse events and 2 pts had no baseline DEXA values. Two pts received tamoxifen 2 to 5 yrs before inclusion in the SOLE study. The remaining 25 pts showed a mean change in BMD for the lumbar spine of -1.1 (10.6SD) and for the hip -4.4 (7.04SD). Currently 13 pts in the C arm demonstrated a mean decrease in BMD for the (LS) of -2.7(10.2SD), and for the hip of -2.7(5.5SD). Twelve pts included in the I arm experienced a mean increase in BMD for the LS of 0.65(SD11.2) and a mean decrease in BMD for the hip of -4.9(9.1SD). The difference between the two treatment groups was not significant for the LS measurements after 8yrs (p=0.4) nor for the hip (p=0.23) neither was it at baseline (p=0.9; 0.1). Only three pts had fractures due to trauma. The overall fracture rate was only 0.05%.There was no correlation with the BMI, but there was a significant correlation with baseline BMD.(p=0.002)The mean fasting cholesterol levels at 8yrs in the C arm was 214mg/dl(41.3SD) and in the I arm was 218mg/dl(35.6SD)and was not significantly different(p=0.8), nor was it at baseline(p=0.5). Conclusion: This first prospective long term BMD and lipid follow-up study in PM EBC pts taking adjuvant letrozole beyond 5 yrs shows a decline in BMD. Until now no significant differences were observed between continuous and intermittent letrozole. An updated and detailed follow-up on more patients will be presented.

Citation Format: Christel Fontaine, Lore Decoster, Denis Schallier, Leen Vanacker, Jacques De Grève, Marian Vanhoeij, Guy Verfaillie, Jan Lamote. Prospective study of aromatase inhibitor-induced bone loss and lipid levels in early hormone sensitive breast cancer treated with AI during 8 years [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-12-11.

Chemotherapy-induced changes and immunosenescence of CD8+ T-cells in patients with breast cancer

BACKGROUND

Changes in sub-populations of cytotoxic (CD8+) T-cells, which are observed in aging and in conditions of chronic immune stimulation, are not well-documented in cancer.

MATERIALS AND METHODS

Using flow cytometry, CD8+ T-cell subsets were analyzed in patients with breast cancer undergoing DNA-damaging chemotherapy and in an older female control group during a six-month longitudinal study, to explore shifts in CD8+ T-cells and the effect of DNA-damaging chemotherapy on different T-cell sub-populations.

RESULTS

As expected, there was a consistent decrease in absolute numbers of leukocytes, lymphocytes, T-cells and CD8+ T-cells during chemotherapy in patients with cancer. Among the T-cells, there was a lower CD8-/CD8+ ratio, persisting over the six months, in patients with cancer compared to controls. The proportion of CD28-CD57+ cells also remained higher among patients with cancer throughout the sampling duration. The number of CD28+CD57- and CD28-CD5- cells decreased faster during DNA-damaging chemotherapy than CD28+CD57+ and CD28-CD57+ cells, while only CD28-CD57- cells showed a significant reconstitutive capacity after six months.

CONCLUSION

Immunosenescence appeared to be pronounced in patients with breast cancer, with senescent CD8+ T-cells playing a role. The normal condition was not restored after six months of chemotherapy.

Phase II study of afatinib, an irreversible ErbB family blocker, in demographically and genotypically defined lung adenocarcinoma

OBJECTIVES

Afatinib, an oral irreversible ErbB family blocker, has demonstrated efficacy in patients with epidermal growth factor receptor (EGFR) mutation-positive advanced lung adenocarcinoma. Other potential biomarkers predicting response to afatinib, such as human epidermal growth factor receptor-2 (HER2) mutations and EGFR gene amplification, have not been validated yet. This phase II study investigated whether afatinib conferred clinical benefit in cohorts of adenocarcinoma patients with: (1) EGFR mutation and failing on erlotinib/gefitinib; or (2) increased copy number of EGFR by fluorescence in situ hybridization (FISH); or (3) HER2 mutation.

MATERIALS AND METHODS

Patients started daily afatinib 50mg monotherapy. Upon disease progression, patients could continue, at the investigator's discretion, afatinib (40mg) with the addition of paclitaxel (80mg/m(2) weekly for 3 weeks/4-week cycle). Endpoints included confirmed objective response (OR), progression-free survival (PFS), disease control, and safety.

RESULTS

Of 41 patients treated (cohort 1: n=32; cohort 2: n=2; cohort 3: n=7), 33 received afatinib monotherapy; eight subsequently received afatinib plus paclitaxel. With afatinib monotherapy, one patient achieved a confirmed OR (partial response [PR]; cohort 2). Two further patients achieved unconfirmed PRs (one each in cohort 1 and cohort 3). Disease control was achieved by 17/32 (53%), 2/2 (100%) and 5/7 (71%) patients in cohorts 1, 2 and 3, respectively. In patients receiving combination therapy (median PFS: 6.7 weeks), one (cohort 3) had confirmed PR of 41.9 weeks. The most common afatinib-related adverse events were diarrhea (95%) and rash/acne (80%).

CONCLUSION

Afatinib demonstrated signs of clinical activity in heavily pretreated patients with activating HER2 or EGFR mutations or EGFR FISH-positive tumors.

Fall predictors in older cancer patients: a multicenter prospective study

BACKGROUND

In the older population falls are a common problem and a major cause of morbidity, mortality and functional decline. The etiology is often multifactorial making the identification of fall predictors essential for preventive measures. Despite this knowledge, data on falls within the older cancer population are limited. The objective of this study was to evaluate the occurrence of falls within 2 to 3 months after cancer treatment decision and to identify predictors of falls (≥1 fall) during follow-up.

METHODS

Older patients (70 years or more) with a cancer treatment decision were included. At baseline, all patients underwent geriatric screening (G8 and Flemish Triage Risk Screening Tool), followed by a geriatric assessment including living situation, activities of daily living (ADL), instrumental activities of daily living (IADL), fall history in the past 12 months, fatigue, cognition, depression, nutrition, comorbidities and polypharmacy. Questionnaires were used to collect follow-up (2-3 months) data. Univariate and multivariate analyses were performed to identify predictors for falls (≥1 fall) during follow-up.

RESULTS

At baseline, 295 (31.5%) of 937 included patients reported at least one fall in the past 12 months with 88 patients (29.5%) sustaining a major injury. During follow-up (2-3 months), 142 (17.6%) patients fell, of whom 51.4% fell recurrently and 17.6% reported a major injury. Baseline fall history in the past 12 months (OR = 3.926), fatigue (OR = 0.380), ADL dependency (OR = 0.492), geriatric risk profile by G8 (OR = 0.471) and living alone (OR = 1.631) were independent predictors of falls (≥1 fall) within 2-3 months after cancer treatment decision.

CONCLUSION

Falls are a serious problem among older cancer patients. Geriatric screening and assessment data can identify patients at risk for a fall. A patient with risk factors associated with falls should undergo further evaluation and intervention to prevent potentially injurious fall incidents.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Pemetrexed-induced radiation recall dermatitis of the breast

Pemetrexed (Alimta™) is a frequently used multi-targeted antifolate drug for the treatment of inoperable and metastatic non-squamous cell lung cancer and mesothelioma, administered as a single-agent or in combination with platinum analogs. In some patients, radiotherapy to any part of the body precedes administration of pemetrexed. This drug has been associated with hematological toxicity and cutaneous side-effects. Most skin toxicities are benign, mainly presenting as a diffuse rash and occurring shortly after treatment. In the present case report we present a rare cutaneous side-effect namely radiation recall dermatitis. A grade 2 dermatitis strongly mimicking mastitis of the breast was observed in a patient treated with a second cycle of single-agent pemetrexed, used as maintenance treatment post-induction chemotherapy with cisplatin and pemetrexed for newly-diagnosed non-squamous cell lung cancer. Fifteen years earlier, the patient had undergone irradiation of the whole breast after breast-conserving surgery. In previously published cases, there were initial symptoms of pain, dysesthesia or burning sensation in the previously-irradiated skin area after the initial pemetrexed administration in the absence of visible cutaneous signs. Although this was not the case for our patient, such symptoms should alert physicians to subsequent potentially more severe clinical dermatitis if the drug is continued. Prevention studies are required to overcome this rare but potentially severe side-effect.

Abstract P1-13-06: Correlation between aromatase-induced arthralgia and inflammatory cytokines in postmenopausal patients with early breast cancer treated with surgery followed by adjuvant hormone therapy: A prospective open-label single center study

Introduction: Nine randomized trials in early breast cancer(EBC) have demonstrated an advantage of aromatase inhibitors(AI’s) over tamoxifen in disease-free survival. Joint symptoms are common toxicities and lead to treatment interruption in up to 20% in case of severe aromatase-induced arthralgia(AIA). During menopause levels of markers of inflammation such as IL-1b, TNF-alpha and IL-6 increase. We hypothesized that estrogen deprivation by aromatase inhibition could be associated with similar changes in these markers and that this could play a role in AIA. In an earlier study, similar toxicities were observed in patients(pts) treated with a recombinant form of IL-6. In several cell types it has been shown that ligand activated estrogen receptor blocks nuclear factor kappa beta controlled gene transcription of IL-6.

Aim of the study: We initiated a prospective open-label study to examine the role of inflammatory cytokines and other serum markers(CRP and hormones) in the pathogenesis of AIA.

Methods: 29 evaluable postmenopausal pts with hormone sensitive, Her 2 negative EBC stage I-III, with baseline G0-1 arthralgia were included. Before chemotherapy, at baseline, at month 3, 6, 9, 12 and 18 after AI initiation, serum samples were taken for CRP and hormones (estradiol, androstenedion) and cytokines were analyzed with a human cytokine 25-plex panel. A detailed rheumatologic questionnaire and Visual Analog Scale(VAS) was performed at each visit. Arthralgia grading was assessed using the CTCAE criteria 4.0. The T-test and the Wilcoxon Signed Rank test were used to look for the difference in terms of IL-6, Il-1b, IL-8, TNF, CRP, estradiol and androstenedion between G0 versus G1-2-3 arthralgia.

Results: The mean age was 56 yrs. (34-72yrs). All patients were treated with surgery followed by concomitant chemoradiation and letrozole (31) or anastrazole (1). In 16 pts G1 arthralgia was present before the start of the chemotherapy. Grade 2 and 3 arthralgia appeared at mth 3. The proportion of pts with grade 2 remained more or less the same, while grade 3 pts declined from month 6 onwards and disappeared at month 18.

Grade of arthralgia at different time pointsArthralgiamth omth 3mth 6mth 9mth 12mth 18G045231911618G1553954615955G202319222927G30158560

There was a significant correlation between the grade of arthralgia and the VAS score at all-time points (p<0.05). CRP levels were significantly higher in the patients with arthralgia at month 3 (p<0.001) and 6 (p<0.005). Patients with G2-3 arthralgia had higher estradiol levels at mth 3 (p<0.001) and 6 (p<0.001).Cytokine results are currently available for the first 12 patients only. In these preliminary data, IL-6 levels were significant higher in the pts with arthralgia before initiation of AI ‘s. The examination of correlations during AI treatment needs the analysis of the full cohort.

Conclusion: This study indicates that both menopause and AIA have inflammatory mediators (IL6 and CRP) that correlate with the degree of lowering of estradiol levels. This is consistent with the regulation of IL-6 by the ligand activated ER through NFkB in vitro.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-06.

Abstract P1-13-05: A prospective study to evaluate joint changes by ultrasound and magnetic resonance imaging induced by adjuvant chemotherapy followed by aromatase inhibitors in postmenopausal early breast cancer patients developing G3 arthralgia

Introduction: Aromatase inhibitors (AI) are a well-established component of the adjuvant hormonal therapy in postmenopausal (PM) EBC patients (pts). AI have been associated with joint symptoms in 20 to 40% of pts adversely affecting quality of life and compliance. The subjective nature of these toxicities warrants objective correlates. In this study we have compared synovial changes on MRI with ultrasound (US).

Aim of the study: The primary aim was to assess joint changes in PM EBC pts by MRI and US at baseline and at occurrence of arthralgia G3 during AI therapy. The secondary aim was to investigate the relationship between clinical severity of articular symptoms and markers of bone metabolism.

Methods: PM EBC pts, stages I-III, with a grade 0, 1 arthralgia (CTCAE version 4.0) at baseline were recruited for the study. At baseline and at 3, 6, 9, 12 and 18 months (mths) a rheumatologic questionnaire was performed. At the same time points serum samples for bone markers (Ca, ostase, intact PTH, alkaline phosphatase and vit. D), rheumatoid factor (RF) and urine samples for urinary N-telopeptide (uNTX) were taken. Pain was assessed by the Visual Analog Scale (VAS). Before start of AI, osteoarthritis was quantified by plain radiography (hands, wrists and knees), joint changes were assessed baseline and at occurrence of arthralgia G3 by MRI and US (hands and wrists), and bone density by DEXA.

Results: 29 evaluable PM EBC pts were included in the study. At baseline, 60% of the pts had a mean VAS score of 2 (0/10-5/10), which increased to 2.5 after the adjuvant chemotherapy and to 4.5 (0-8) at mth 12 (p = 0.013) of AI therapy, and subsequently dropped to 2.5 at mth 18 (p = 0.2). The most commonly affected joints at baseline were knees (47%), shoulders (41%), and ankles/feet (29%); whereas during AI therapy it involved mainly knees (53%), shoulders (46%) and hands/wrists (32%). Fifty percent of the pts had signs of osteoarthritis of the hands (25%), knees (16%) and both (8%) on plain radiographs obtained at baseline. Grade 0-1 arthralgia was not significantly correlated with the imaging of osteoarthritis or grade of osteoporosis. At baseline intra-articular fluid was detected on MRI of the hands/wrists in 6 pts, 14 pts had synovial changes and 4 had both. Six out of 29 pts had also signs of synovitis with hyperaemia on US before the start of an AI. G3 arthralgia occurred in five pts of which only three agreed to the repeat radiological imaging. In two of these pts a worsening of imaging both by MRI and US was observed, whereas in the third pt imaging was unchanged.

Markers of bone metabolism and uNTX did not differ significantly between groups with arthralgia and without (p>0.05). RF was positive in only two pts, one with arthralgia G1 at baseline and one pt at the moment of G3 arthralgia.

Conclusions: This study is the first to prospectively report on synovial changes by combined MRI and US before initiation of adjuvant AI in PM women and at occurrence of arthralgia G3. Only 17% of pts developed G3 arthralgia which corresponded to worsening imaging signs. From the small sample size it seems that baseline MRI changes predicts the development of G3 arthralgia with higher sensitivity than baseline US. Sensitivity of US improved during AI therapy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-05.

Performance of two geriatric screening tools in older patients with cancer

PURPOSE

To compare the diagnostic characteristics of two geriatric screening tools (G8 and Flemish version of the Triage Risk Screening Tool [fTRST]) to identify patients with a geriatric risk profile and to evaluate their prognostic value for functional decline and overall survival (OS).

PATIENTS AND METHODS

Patients ≥ 70 years old with a malignant tumor were included if a new cancer event occurred requiring treatment decision. Geriatric screening with G8 and fTRST (cutoff ≥ 1 [fTRST (1)] and ≥ 2 [fTRST (2)] evaluated) was performed in all patients, as well as a geriatric assessment (GA) evaluating social situation, functionality (activities of daily living [ADL] + instrumental activities of daily living [IADL]), cognition, depression, and nutrition. Functionality was re-evaluated 2 to 3 months after cancer treatment decision, and death rate was followed. Functional decline and OS were evaluated in relation to normal versus abnormal score on both screening tools.

RESULTS

Nine hundred thirty-seven patients were included (October 2009 to July 2011). G8 and fTRST (1) showed high sensitivity (86.5% to 91.3%) and moderate negative predictive value (61.3% to 63.4%) to detect patients with a geriatric risk profile. G8 and fTRST (1) were strongly prognostic for functional decline on ADL and IADL, and G8, fTRST (1), and fTRST (2) were prognostic for OS (all P < .001). G8 had the strongest prognostic value for OS (hazard ratio for G8 normal v abnormal, 0.38; 95% CI, 0.27 to 0.52).

CONCLUSION

Both geriatric screening tools, G8 and fTRST, are simple and useful instruments in older patients with cancer for identifying patients with a geriatric risk profile and have a strong prognostic value for functional decline and OS.

The influence of clinical assessment (including age) and geriatric assessment on treatment decisions in older patients with cancer

OBJECTIVES

The aim of this prospective study in older patients with cancer was to evaluate how clinical assessment (including age) determines the physician's treatment decisions, and how geriatric assessment (GA) further influences these decisions.

PATIENTS AND METHODS

Patients aged ≥70years old with cancer were included if a new therapy was considered. All patients underwent a GA and results were communicated to the treating physician. After the final treatment decision, a predefined questionnaire was completed by the physician.

RESULTS

In total, 937 patients with median age of 76years old were included. A total of 902 (96.3%) questionnaires were completed by the treating physicians. In 381/902 patients (42.2%) clinical assessment led to a different treatment decision compared to younger patients without co-morbidities. This difference was most prominent for chemotherapy/targeted therapy decisions. In 505/902 cases (56%) the treating physician consulted GA results before the final treatment decision. In these patients, the treatment decision was influenced by clinical assessment in 44.2%. In 31/505 patients (6.1%) the GA further influenced treatment, mostly concerning chemotherapy/targeted therapy. In eight patients GA influenced the physician to choose a more aggressive chemotherapy.

CONCLUSIONS

Physicians use different treatment regimens in older versus younger patients, based on clinical assessment, including age. GA results further influence treatment decisions in a minority of patients and may trigger the use of less aggressive as well as more aggressive treatments. GA information is not always utilized by oncologists, indicating the need for better education and sensitization.

Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study

BACKGROUND

To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions.

PATIENTS AND METHODS

Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above.

RESULTS

One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%).

CONCLUSION

Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment.

The effect of a varied exercise program (VEP) on shoulder function and lymphedema (LE) in breast cancer survivors (BCs): A pilot study

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Background: A common physical sequel after adjuvant therapy is a decrease in shoulder movement of the upper-limb of the affected side and the development of LE. Resistance exercise is known to be safe and does not increase the risk of LE. The objective of this study is to evaluate the effect of a VEP on shoulder range of motion and upper-limb LE after adjuvant therapy in BCs. Methods: 22 BCs treated with surgery and adjuvant therapy were randomly assigned to the VEP (n=12) or the control (n=10). The VEP aimed at improving aerobic endurance, joint mobility and muscle strength. The frequency of the VEP was 2 times a week, during 3 months, with a total of 30 sessions. Primary endpoints included the range shoulder motion and arm volumes of both arms. The secondary outcome was quality of life (QoL) as measured by the EORTC QLQ-C30. All outcome measures were assessed at baseline and after 3 months. Results: After ending the VEP, in the exercise group, the movements such as abduction (p=0.04), external rotation (p=0.02), extension (p=0.03) and flexion (p=0.01) of the affected arm increased significantly but there was no change for internal rotation (0.27). No significant changes in arm volume (p=0.06) were found after 3 months compared to baseline, whereas the quality of life did improve significantly (p=0.01). After 3 months the range of motion of the shoulder of the affected arm (sum of abduction, external rotation, extension and flexion) in the exercise group tended to be better although this was not significant (p=0.50). The arm volume difference between the two groups was not significant (p=0.10) but it was for the QoL (p=0.02). Conclusions: A VEP lead to significant specific improvements in arm mobility compared to baseline. These BCs also compared favourably to the control cohort, but this was not significant. The study confirms that exercising the ipsilateral arm and shoulder has no detrimental effect on LE and has a positive impact on the QoL. Standard guidelines concerning physical therapy to ameliorate shoulder function and LE are not available. Additional patients will be enrolled to develop standard recommendations for physical therapy to improve shoulder and limb function in BCs.

The influence of age plus standard clinical approach with or without comprehensive geriatric assessment (CGA) on treatment decisions in older cancer patients: Final results

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Background: The aim of this prospective study was to examine how age and standard clinical approach with and without CGA results determine treatment decisions in older cancer patients (pts). Methods: This study,conducted in 2 Belgian university hospitals, included pts ≥ 70 years with a malignant tumor (breast, colorectal, ovarian, lung, prostate and hematological) if a new cancer therapy was considered. All pts underwent a uniform CGA. Results were communicated to the treating physician. After the treatment decision, an interview with the treating physician was performed, using a predefined questionnaire: 1/ What would be your oncological treatment proposal in case the pt was 55y without other comorbidity? 2/ Is this different from your treatment proposal for this pt according to age and standard clinical approach without CGA results? 3/ Is this different from your treatment proposal for this pt with CGA results? Results: From October 2009 till July 2011, 937 pts were included in the study. Median age was 76y (range 70-95) and 63.5% was female. A total of 902 (96.3%) questionnaires were completed and 56.2% of the physicians were aware of the CGA results at treatment decision. In 381 pts (42.2%; 95%CI 39.0-45.5) age and standard clinical approach led to a different treatment decision compared to younger pts without comorbidity. This influence was most prominent for chemotherapy decisions: 309 patients did not receive standard chemotherapy (reduced dose (13), less toxic regimen (163), less toxic regimen at reduced dose (5) or no chemotherapy (128)). When the physician was aware of the CGA, these results influenced their treatment in 6.7% (95%CI: 4.5-8.9), mostly concerning chemotherapy. In 8 pts CGA results encouraged the treating physician to choose a more aggressive chemotherapy regimen and in 11 pts CGA results led to a decision of palliative care. Conclusions: Based on this prospective trial, we conclude that physicians use adapted treatment regimens in older versus younger pts, only based on age and standard clinical approach. CGA results change the treatment decision in 6.7% and sometimes trigger the use of a more aggressive treatment.

Clinical activity of afatinib (BIBW 2992) in patients with lung adenocarcinoma with mutations in the kinase domain of HER2/neu

Human epidermal growth factor receptor (HER)2/neu kinase domain mutations are found in approximately 1-4% of lung adenocarcinomas with a similar phenotype to tumors with epidermal growth factor receptor (EGFR) mutations. Afatinib is a potent irreversible ErbB family blocker. We determined the tumor genomic status of the EGFR and HER2 genes in non- or light smokers with lung adenocarcinoma in patients who were entered into an exploratory Phase II study with afatinib. Five patients with a non-smoking history and metastatic lung adenocarcinomas bearing mutations in the kinase domain of HER2 gene were identified, three of which were evaluable for response. Objective response was observed in all three patients, even after failure of other EGFR- and/or HER2-targeted treatments; the case histories of these patients are described in this report. These findings suggest that afatinib is a potential novel treatment option for this subgroup of patients, even when other EGFR and HER2 targeting treatments have failed.

Docetaxel in the treatment of metastatic castration-resistant prostate cancer (mCRPC): an observational study in a single institution

BACKGROUND

Treatment with docetaxel in combination with prednisone is the standard first-line treatment in patients with metastatic castration-resistant prostate cancer (mCRPC). For patients failing first-line docetaxel no standard has emerged.

OBJECTIVES

The outcome in routine daily clinical practice of a cohort of unselected chemotherapy-naïve mCRPC patients treated with docetaxel plus methylprednisolone as first- and further-line treatment in a single institution was investigated.

PATIENTS AND METHODS

Data from the medical records of patients treated with docetaxel plus methylprednisolone either in a three-weekly (75 mg/m(2)) (D3) or a three-of-four-weekly (35 mg/m(2))(D1) schedule as first- or further-line treatment were analysed with respect to clinical and prostate-specific antigen (PSA) response, time-on-treatment (TOT), treatment-free interval (TFI), overall survival time (OS) and toxicity and were compared to the results of the registration study TAX 327.

RESULTS

Out of 41 patients, 28 and 13 received first-line docetaxel according to the D3 and the D1 schedules respectively. An overall PSA response ≥50% was achieved in thirty patients (73%). In ten patients (24%) the PSA level was normalised. The median OS of the total population was 18.7 months. No significant differences were observed between the D3 and the D1 regimens with respect to PSA response, duration of PSA response, TOT, TFI and OS. Patients obtaining a normalisation of PSA level achieved a significantly superior OS, TOT and TFI compared to those without normalisation of PSA. Second-line treatment with docetaxel in nine patients induced a normalisation in PSA level in two (22%). The TOT and TFI from the start of second-line treatment, was significantly superior in docetaxel compared to non-docetaxel treated patients. Treatment with docetaxel was well-tolerated and only two patients were withdrawn for non-haematological toxicity during first- and further-line treatment. There were no differences in either subjective or objective side-effects between both treatment schedules.

CONCLUSION

The results of the retrospective analysis of non-selected patients with mCRPC treated with docetaxel chemotherapy are in line with the data from TAX 327. Normalisation of PSA during first-line treatment with docetaxel is associated with a better survival irrespective of second- or further-line treatment used. Retreatment with docetaxel in second- or further-line remains a treatment option in docetaxel-sensitive patients.

P2-17-08: rospective Study of Aromatase Inhibitor Induced Bone Loss and Lipid Levels in Early Postmenopausal (PM) Hormone Receptor Positive (HR+) Breast Cancer (BC) Patients Treated with Adjuvant Letrozole Extended beyond 5 Years (yrs)

Introduction/Aim: Adjuvant treatment with aromatase inhibitors (AI) is associated with accelerated bone loss and increase in lipid levels. The effectiveness and tolerance of extended treatment with AI beyond 5 years is currently under investigation. In the SOLE study, five years of continuous (C) extended letrozole is compared to interrupted therapy (9 months on, 3 months off letrozole) after 5 yrs of tamoxifen, AI or sequential hormonal therapy. We have evaluated the bone mineral density and lipid levels during the extended use of letrozole beyond 5 yrs in a cohort of patients included in the SOLE study.

Patients and methods: Postmenopauzal women with HR+ BC, receiving extended continuous (C) or intermittent (I) letrozole for 5 yrs after 5 yrs of tamoxifen, 5 yrs of an AI, or switch therapy within the first 5 years, were included. Bone mineral density was measured at the lumbar spine (L2-4) and total hip BMD (g/cm2), by dual energy X-ray absorptiometry (DXA). The mean percentage change in BMD at 12, 36 and 60 months (mths) was compared between the C and I treatment with letrozole and with baseline values. Differences between the treatment groups were assessed by the independent samples T test. We also compared the evolution ofthe serum lipid levels in both arms. Results: Thirty two patients (pts) were included with a mean age of 62 yrs (+/− 8.7 yrs). Thirty pts were valuable because of missing baseline DXA values in 2. In their first 5 years of adjuvant letrozole, prior to inclusion in the current study, twenty three pts had a mean percentage decrease of −0,76 (13,25 SD) and 7 pts who had received preventive zoledronate in the ZOFAST study, had a mean percentage increase in BMD of 4,4 (6,08 SD).

Currently 12 pts receiving the continuous letrozole are evaluable after a first one year extension of adjuvant letrozole. They had a mean percentage increase in BMD for the lumbar spine of 1.8 (3.3 SD), and a mean percentage increase in BMD for the hip of 0.85 (SD 1.93). Eight pts included in the intermittent arm are evaluable. They experience a mean percentage decrease in BMD for the lumbar spine of −0.32(2.7 SD) and a mean decrease in BMD for the hip of −2.9(SD 3.6) The difference between the two treatment groups was not significant for the lumbar spine measurements (p=0.14), but it was significant for the hip (p=0.02). The mean fasting cholesterol levels at 12 months in the C arm (12pts) was 228mg/dl (24.4 SD) and in the I arm (11pts) was 225,5mg/dl(32,3 SD) (p=0.37).

Conclusion: This is the first prospective BMD and lipid follow-up study during adjuvant letrozole extended beyond 5 yrs in PM early breast cancer pts. After the first year of extended intake of continuous or intermittent letrozole a possible difference in bone mineral density between the two arms is emerging, but the two groups are too small to make final conclusions. An updated longer follow-up on more patients will be presented. After one year no differential effect on cholesterol levels has been observed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-17-08.

Vaccination therapy for non-small-cell lung cancer: review of agents in phase III development

The historical results of cancer vaccination for non-small-cell lung cancer (NSCLC) were disappointing. In the current decade, however, new insights in the interaction between tumours and the immune system have led to the development of immunotherapy as a fundamentally new concept for the treatment of NSCLC. Modern NSCLC vaccine strategies rely on better identification of antigenic targets, addition of strong immunoadjuvants, and use of more efficient delivery systems. These treatments have convincingly demonstrated to elicit potent immune responses and have shown promising efficacy signals and excellent tolerability in phase II randomised studies. This-together with recent positive phase III data in indications other than NSCLC-has helped to establish the proof of principle for cancer vaccination. In NSCLC, ongoing phase III trials are investigating this approach in different treatment settings: the Melanoma AntiGEn A3 vaccine in resected early-stage NSCLC, the L-BLP25 vaccine in locally advanced NSCLC after chemoradiotherapy, and belagenpumatucel-L, the epidermal growth factor and the TG4010 vaccine in advanced stage, either as an adjunct to chemotherapy or as maintenance after completion of chemotherapy. Mode of action, development, available clinical data, and currently ongoing phase III studies are reviewed.

Pemetrexed-induced hyperpigmentation of the skin

Pemetrexed (Alimta™) is used frequently for the treatment of lung cancer and is associated with various types and grades of cutaneous side-effects. We report here one patient who presented with asymptomatic hyperpigmentation of the skin, localized on the palms of the hands and the soles of the feet after administration of pemetrexed for lung cancer despite receiving standard pre-medication. This type of skin toxicity was completely reversible after withdrawal of the drug (without pharmacologic intervention) and has to our knowledge not been reported before.

Pemetrexed-induced eyelid edema: incidence and clinical manifestations

BACKGROUND

Pemetrexed-induced eyelid edema is a rare side-effect of pemetrexed treatment.

PATIENTS AND METHODS

Retrospective analysis of the incidence and severity of eyelid edema was conducted in patients treated with pemetrexed in a single institution.

RESULTS

Eighty-six patients received pemetrexed-containing chemotherapy either as a single agent (45 patients) or in combination with cis- or carboplatin (41 patients). Two patients (2.3%) with stage IV non-small cell lung cancer (NSCLC) presented the edema typically localized in the lower eyelid after first-line treatment with carboplatin-pemetrexed. The edema remained identical in both patients during treatment and regressed in one patient in whom treatment was withdrawn. No other localizations of edema were observed in these patients.

CONCLUSION

Pemetrexed-induced eyelid edema may be more frequent than originally reported. The physiopathological mechanism and, as a consequence, the treatment and/or prevention of this apparently benign side-effect remains unknown.

Langerhans cell histiocytosis: two case reports in adults and review of the literature

Langerhans Cell histiocytosis is a rare proliferative histiocytic disorder in which pathologic Langerhans cells accumulate in a variety of organs. The clinical presentation, evolution and therapeutic options are highly variable. Because of its relative rarity and the broad clinical spectrum, the diagnosis of Langerhans cell histiocytosis is often delayed or missed. At present, many questions with respect to aetiology, pathogenesis and treatment remain unanswered. In the present article we want to raise the awareness of this rare disease in adults and its diversity by the means of two case reports. In addition, the clinical manifestations, diagnosis and the current management are reviewed.