CXCL7 is a predictive marker of sunitinib efficacy in clear cell renal cell carcinomas

Background:

Sunitinib is one of the first-line standard treatments for metastatic clear cell renal cell carcinoma (ccRCC) with a median time to progression shorter than 1 year. The objective is to discover predictive markers of response to adapt the treatment at diagnosis.

Methods:

Prospective phase 2 multi-centre trials were conducted in ccRCC patients initiating sunitinib (54 patients) or bevacizumab (45 patients) in the first-line metastatic setting (SUVEGIL and TORAVA trials). The plasmatic level of CXCL7 at baseline was correlated with progression-free survival (PFS).

Results:

The cut-off value of CXCL7 for PFS was 250 ng ml⁻¹. Patients with CXCL7 plasmatic levels above the cut-off at baseline (250 ng ml⁻¹) had a significantly longer PFS (hazard ratio 0.323 (95% confidence interval 0.147–0.707), P=0.001). These results were confirmed in a retrospective validation cohort. The levels of CXCL7 did not influence PFS of the bevacizumab-treated patients.

Conclusions:

CXCL7 may be considered as a predictive marker of sunitinib efficacy for ccRCC patients.

Efficacy and safety of nivolumab in patients with metastatic renal cell carcinoma (mRCC) and brain metastases: Preliminary results from the GETUG-AFU 26 (Nivoren) study

4563

Background: Nivolumab (N) has been shown active in patients (pts) with mRCC after failure of 1 or 2 TKIs. Efficacy and safety of N in pts with brain metastases (BM) from RCC is still unknown. The aim of this study is to report preliminary data of the Nivoren study in pts with BM. Methods: GETUG-AFU 26 (Nivoren) is a prospective phase 2 study assessing safety and efficacy of N in a broader mRCC patient population than those recruited in the pivotal phase 3, including pts with BM (previously treated or not, but not requiring steroids), with previous mTOR inhibitor, with PS 2 as well as in previously highly pretreated pts. N was given every 2 weeks at 3mg/kg, until disease progression or unacceptable toxicity. Treatment was allowed beyond progression in case of clinical benefit. All pts had brain CT scan or MRI at baseline. Results: Up to December 2016 , 588 pts have been enrolled including 55 pts with BM (35 (67%) ,6 (12%) and 11 (21%) with 1, 2 or > 2 BM, respectively. Of those 55 pts, 10 pts (23%) were PS 2 and 25 (58%) PS 1, and 16 patients (29%) had received more that 2 lines of therapy. No previous treatment for BM was performed in 67% (n = 37), while 9% had previous brain surgery (n = 5 ;) or brain radiation (n = 17 (31%). 2/55 pts never received N. Median duration of therapy in BM pts was 2.4 months (varying from 0 to 9) with a 3-months PFS of 60% (IC95% = 45 – 73). Median OS is not reached at the time of this analysis. Among 44 pts with assessment of response on BM, 10 (23%) had objective response while 21 (48%) had local progressive disease. Neurologic deterioration requiring steroids was observed in 15 pts (32%) . Updated data will be presented at the meeting. Conclusions: This is the first large study to report preliminary safety and efficacy of N in RCC pts with BM. Safety of N in this pt population appears to be acceptable, although some pts do require steroids because of brain progressive disease. Objective response in the brain was observed in 23% of pts. Further follow up is required to determine the real benefit of N in this group of mRCC pts. Clinical trial information: NCT03013335.

Impact of pharmacokinetics (PK) of sunitinib (SU) and its metabolite SU12662 on clinical outcome and toxicity in metastatic renal cell cancer (mRCC) patients

506

Background: Pharmacological activity of SU is usually attributed to SU and its active metabolite SU12662, known to exhibit similar potency in inhibiting tyrosine kinase activity and cellular proliferation in vitro. However, equivalence is not clearly demonstrated towards clinical endpoints. The objective of this phase 2 study was to determine the impact of SU and SU12662 on clinical outcomes and toxicity in mRCC patients (NCT00943839). Methods: Patients with mRCC, eligible for SU in the first line setting, were prospectively included. SU was given orally at 50 mg qd for 4 weeks on/2 weeks off until progression or unacceptable toxicity. Minimal concentration at steady-state (CSSmin) was evaluated by high-performance liquid chromatography at day 28 of each cycle for both SU and SU12662. Data for tumor response, survival, and toxicity were recorded. Kaplan-Meyer’s curves with log-rank tests and cox regression models were used to identify relationships between PK parameters and survival. Chi2 tests and student t-tests were used to identify relationships with toxicity. Results: 41 patients in 7 French centers were included between 2009 and 2012. 16 patients had favourable prognosis, 13 intermediate prognosis, and 1 poor prognosis according to IMDC risk groups (Heng, J Clin Oncol 2009). Median follow-up was 30.6 months. Median progression-free survival (PFS) was 20.2 months and median overall survival (OS) was 39.5 months. Mean CSSmin for SU and SU12662 were 57.2 and 29.8 ng/ml, respectively. CSSmin of SU12662 was independently correlated to poor PFS and OS (p = 0.01 and 0.003 respectively). Patients with a mean CSSmin of SU12662 higher than 42.5 ng/ml had a worse PFS and OS compared to patients with lower concentrations: 5.7 months and 5.7 months versus 20.6 months and 39.5 months (p = 0.01 and 0.002 respectively). High CSSmin of both SU and SU12662 were associated with increased incidence of asthenia (p<0.001). Conclusions: High exposure to SU12662 was associated with poor outcomes and increased asthenia for patients with mRCC treated with SU in the first line setting. It may be related to a higher metabolism and unequal activity between SU and SU12662 in vivo. Clinical trial information: NCT00943839.

Sunitinib Stimulates Expression of VEGFC by Tumor Cells and Promotes Lymphangiogenesis in Clear Cell Renal Cell Carcinomas

Sunitinib is an antiangiogenic therapy given as a first-line treatment for renal cell carcinoma (RCC). While treatment improves progression-free survival, most patients relapse. We hypothesized that patient relapse can stem from the development of a lymphatic network driven by the production of the main growth factor for lymphatic endothelial cells, VEGFC. In this study, we found that sunitinib can stimulate vegfc gene transcription and increase VEGFC mRNA half-life. In addition, sunitinib activated p38 MAPK, which resulted in the upregulation/activity of HuR and inactivation of tristetraprolin, two AU-rich element-binding proteins. Sunitinib stimulated a VEGFC-dependent development of lymphatic vessels in experimental tumors. This may explain our findings of increased lymph node invasion and new metastatic sites in 30% of sunitinib-treated patients and increased lymphatic vessels found in 70% of neoadjuvant treated patients. In summary, a therapy dedicated to destroying tumor blood vessels induced the development of lymphatic vessels, which may have contributed to the treatment failure. Cancer Res; 77(5); 1212-26. ©2017 AACR.

High-dose chemotherapy with carmustine, etoposide, cytarabine and melphalan followed by autologous stem cell transplant is an effective treatment for elderly patients with poor-prognosis lymphoma

Autologous stem cell transplant (ASCT) after high-dose chemotherapy (HDT) increases overall survival when used in relapsed non-Hodgkin lymphoma (NHL) in patients under 65 years old. Limited experience is available for older patients. We present a retrospective analysis of 73 consecutive patients aged over 65 years treated for aggressive or relapsed lymphoma by HDT with carmustine, etoposide, cytarabine and melphalan (BEAM) at full dosage followed by ASCT. Patient data were obtained from medical charts from two institutions. Median age was 67 years (65-74). Significant comorbidities were present in 24.7% of patients. The median number of days for grade 4 neutropenia was 9 (5-18). The early treatment-related mortality rate (<100 days) was 2.7%. The estimated 2-year progression-free survival and overall survival rates were 67.2% and 78.5%, respectively. In conclusion, the full-dose HDT-ASCT regimen is feasible, safe and efficient in selected patients over 65 years old.

Abstract 5546: Impact of DNA repair and apoptosis gene polymorphisms on clinical outcome in head and neck cancer patients treated with radiotherapy

Introduction: The effects of single nucleotide polymorphisms (SNPs) in DNA repair (ERCC1, ERCC2, ERCC5, XRCC1) and apoptosis genes (TP53, MDM2) on response rate, survival and toxicity were tested in a group of squamous cell head and neck cancer (SCCHN) patients receiving a radiotherapy (RT)-based treatment.

Materials and Methods: A retrospective cohort of 122 locally advanced SCCHN patients non-eligible for surgery, treated by RT (N=38) or chemoRT (CRT, N=84) between 1992 and 2006 was selected. The following SNPs were analyzed on tumor DNA: ERCC1 259Lys&gt;Thr (rs735482), ERCC2 751Lys&gt;Gln (rs13181), ERCC5 46His C&gt;T (rs1047768), XRCC1 399Arg&gt;Gln (rs25487), TP53 72Arg&gt;Pro (rs1042522) and MDM2 309T&gt;G (rs2279744). Tumor response 6 months after treatment cessation (ORR), progression-free survival (PFS), cancer-specific survival (CSS) and RT-related toxicity (G0-2 vs G3-4 according to CTCAE v4.0) were assessed.

Results: ORR was 70%. Median PFS was 15.8 months and median CSS was 33.1 months. In total, 104/114 patients (91 %) experienced RT-related G3-4 toxicity at any time. 99/122 (81 %) patients had acute side-effects (during RT), among them 46 had epithelitis. 98/116 (85%) developed an early G3-4 DMEX toxicity (dysphagia, mucocitis, epithelitis and/or xerostomia up to 3 months after end of RT). 29/95 patients (31%) developed any G3-4 late toxicity (3 months after end of RT), with skin fibrosis for 3 patients and xerostomia for 13 patients. No relationship was found between any SNPs and ORR, PFS or CSS. The presence of the G allele of MDM2 or the Thr allele of ERCC1 were associated with a higher risk of early DMEX. Focusing on each toxicity separately, MDM2 GG genotype was related to a higher risk of acute G3-4 epithelitis. The ERCC5 TT genotype was associated with more frequent G3-4 late cervical skin fibrosis or xerostomia.

Conclusion: SNPs in ERCC1 and ERCC5 DNA repair genes, as well as MDM2 apoptosis gene may influence RT-induced toxicity.

Genotypes and G3-4 toxicity

G0-2G3-4RR (95% CI)Global pEarly DMEXMDM2 309T&gt;GTT113110.018TG3491.28 (1.05-1.55)GG3181.16 (0.90-1.49)Early DMEXERCC1 259Lys&gt;ThrLys/Lys166810.038Lys/Thr + Thr/Thr1311.20 (1.06-1.35)Acute EpithelitisMDM2 309T&gt;GTT2241910.037TG40140.59 (0.33-1.03)GG10121.23 (0.74-2.05)Late Skin FibrosisERCC5 46His C&gt;TCC280Not assessable0.012CT450TT203Late XerostomiaERCC5 46His C&gt;TCC23510.023CT4320.25 (0.05-1.20)TT1761.46 (0.51-4.18)

Citation Format: Marie-Christine Etienne-Grimaldi, Delphine Borchiellini, Laurence LLorca, Jean-Louis Formento, Patricia Formento, Yann Château, Gérard Milano. Impact of DNA repair and apoptosis gene polymorphisms on clinical outcome in head and neck cancer patients treated with radiotherapy. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5546. doi:10.1158/1538-7445.AM2014-5546

Induction chemotherapy with docetaxel, cisplatin, and 5FU (TPF) in unresectable advanced head and neck squamous cell carcinoma: Retrospective analysis of 300 cases and proposal for a prognostic index

e16055

Background: Phase III studies have demonstrated that induction chemotherapy with TPF followed by cisplatin-based chemoradiation (CRT) is a valid option for the treatment of advanced unresectable head and neck squamous cell carcinoma. These studies have been done in highly selected patients. The aim of our study is to confirm these data in unselected patients and to identify prognostic factors of tolerance and survival. Methods: Between October 2005 and June 2010, 300 patients from 5 institutions with locally advanced neck and head cancer received at least one induction cycle, followed by locoregional radiotherapy (R) associated or not with platinum (P) or cetuximab (C)-based chemotherapy. Results: Mean age was 56 years old (range 31-76). Performance status was 0 or 1 in 97% of patients and 50 % of them presented current alcohol intoxication. 69% (n=208) received 3 cycles of TPF, and 91% (n=268) underwent R associated or not with P (n=167) or C (n=51). 52% of patients (n=156) received the conform treatment (ie 3TPF + RP or RC). Grade 3-4 toxicities have been reported in 19% (n= 57), including 3% febrile neutropenia (n=9) and 7% kidney failure (n=22). Grade 3-4 toxicity, during TPF induction, led systematically to permanently discontinuation of the chemotherapy. Overall response rate after TPF induction was of 88% with 23% of complete response. After a median follow-up of 21 months, median progression-free survival and cause-specific survival (SS) were not reached. Median overall survival (OS) was 49 months (95% CI 31.2-66.8). SS and OS were significantly improved (p<0.0001) in patients who received the conform treatment. In multivariate analysis the probability of death related to cancer or to toxicities induced by treatment was increased for hemoglobin level ≤ 12.6g/dl or GGT level ≥ 77U/I [HR = 3.45 (95% CI: 1.50-7.93) p=0.0029]. Conclusions: We propose to use a biological index based on baseline hemoglobin and GGT levels to select patient for induction therapy in SCCHN. This simple index, predictive of treatment conformity and specific survival, needs further prospectives investigations.

Induction TPF followed by chemoradiation or radiotherapy-cetuximab in nonresectable advanced head and neck squamous cell carcinoma: A retrospective study in 164 patients

e16044

Background: Induction chemotherapy with docetaxel, cisplatin, and 5FU (TPF) followed by cisplatin-based chemoradiation (CRT) is a valid option for the treatment of advanced head and neck squamous cell carcinoma (LASCC). Radiotherapy (RT) associated with cetuximab (RT-cetux) is superior to RT alone and has less systemic toxicity than CRT. Recent data suggest RT-cetux could be an alternative treatment to CRT after induction TPF. The aim of this study was to report the outcome of these pts in clinical practice. Methods: A multicentric retrospective analysis was conducted in LASCC pts treated with induction TPF (T 75mg/m2 day 1, P 75mg/m2 day 1, F 750mg/m2/d day 1 to 4 – q3w), followed by CRT (cisplatin 100mg/m2 – q3w) or RT-cetux (400mg/m2 loading dose and 250mg/m2 – q1w). Exploratory endpoints were progression-free survival (PFS), cancer specific survival (CSS) and overall survival (OS). Results: 164 pts treated from October 2005 to June 2010 were eligible. 113 pts had TPF followed by CRT and 51 pts had TPF followed by RT-cetux. Clinical characteristics were similar in each group, regarding gender (men 84% vs 92%), mean age (56 vs 57 yrs), BMI (23.4 vs 23 kg/m2), alcohol consumption under treatment (41% vs 49%), non laryngeal tumor site (77% vs 73%), T3-T4 tumor size (84% vs 80%) and N+ status (71% vs 77%). There was a difference in performance status 0 and 1 between pts in CRT group (73% and 26%) and RT-cetux group (47% and 51%) (p=0.005). 2-yr PFS rate was 68% in CRT group vs 42% in RT-cetux group (p=0.002). After a median follow-up of 23 months, the median PFS was not reached in CRT pts vs 13 months (95% CI : 8.1-17.9 months) for RT-cetux group. At 2 years, CSS and OS rate was 84% and 78% vs 54% and 50%, respectively (p<0.0001). Median CSS ans OS were not reached in CRT group as compared to 25 months (95% CI : 14.6-35.4 months) and 23 months (95% CI : 10.7-35.3 months) in the RT-cetux group, respectively. Conclusions: In daily practice, outcome after induction TPF for LASCC pts seems to be superior with standard CRT than RT-cetux. The higher proportion of PS 1 pts in the RT-cetux group could explain this difference. These data suggest that selection of pts should be carefully considered.

Blastic plasmacytoid dendritic cell neoplasm: a report of four cases and review of the literature

BACKGROUND

Blastic plasmacytoid dendritic cell neoplasm (BPDCN), formerly known as agranular CD4(+) /CD56(+) haematodermic neoplasm (CD4/CD56 HN), is a rare distinct form of lymphoma-like entity known of dermatologists because of its marked predilection for cutaneous involvement, and its aggressive behaviour. Moreover, the association or the evolution to an acute leukaemia entity that still expresses CD4 and CD56 markers is almost systematic. This new described entity of 'CD4(+) /CD56(+) leukaemia' or 'leukaemia of plasmacytoid dendritic cell lineage' has a poor prognostic and may lead to include haematopoietic stem cell transplantation in the treatment strategy as early as possible.

REPORT OF CASES

We report here four cases presenting with skin lesions and haematological signs. One of the patients underwent allogeneic stem cell transplantation, with a relapse-free survival of 40 months. We discuss the diagnosis features as well as the treatment options.

CONCLUSION

A collaborative work between dermatologists and onco-haematologists is essential to give patients the best chance of complete and long-term response.