Pharmacogenomic (PG) analysis of Japan-SWOG common arm study in advanced stage non-small cell lung cancer (NSCLC): A model for testing population-related pharmacogenomics

7500

Background: We have previously reported differences in outcomes (increased survival, neutropenia & febrile neutropenia) in Japanese versus US patients (pts) treated with a paclitaxel-carboplatin “common arm” in a prospectively designed fashion in 3 phase III trials (FACS, LC03, S0003) in advanced NSCLC (Gandara, ASCO 05 & Crowley, ASCO 06). We hypothesized that these findings were due in part to PG alterations in paclitaxel disposition. Methods: Genomic DNA was prospectively collected from pts in 2 of these phase III trials (LC03 [N=78, 37 on common arm] & S0003 [N=78]) with identical eligibility, staging, treatment plan (paclitaxel 225 mg/m2 & carboplatin AUC 6), response & toxicity criteria. Analysis for genotypic variants of CYP3A4, CYP3A5, CYP2C8, NR1I2–206, ABCB1, ERCC2 was performed by pyrosequencing, and results assessed by Cox model for survival/PFS & logistics regression for response/toxicity. Results: There was a significant difference between Japan & US pts in genotypes: CYP3A4*1b (p=0.01), CYP3A5*3c (p=0.03), ERCC2 k751q (p <0.001), and CYP2C8 r139k (p=.01). Genotypic correlations were observed between CYP3A4*1b for PFS (HR 2.75, 1.06–7.08, p=0.04) & ERCC2 k751q for response (HR 0.33, 0.13–0.84, p=0.02). There were no other statistically significant associations, although for grade 4 neutropenia, the HR for ABCB1 3425c->T was 1.84 (0.77–4.48), p=0.19. The low number of events for febrile neutropenia within this data set precluded assessment of this parameter. Additional PG testing is ongoing & will be presented. Conclusions: 1) Differences in allelic distribution for genes involved in paclitaxel disposition or DNA repair were observed between Japanese & US pts. 2) Statistically significant genotype-associated correlations were present for PFS (CYP3A4*1b) & response (ERCC2 k751q), but not for neutropenia (p=0.19). 3) The small sample size limits interpretation of these data. Further studies based on this common arm approach are warranted for the prospective study of population-related PGs where ethnic/racial differences in anti-neoplastic drug disposition are anticipated.

[Table: see text]

A phase II randomized selection trial evaluating concurrent chemotherapy plus cetuximab or chemotherapy followed by cetuximab in patients with advanced non-small cell lung cancer (NSCLC): Final report of SWOG 0342

7545

Background: Randomized clinical trials have failed to show a survival benefit for small molecule epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors plus chemotherapy in unselected patients with metastatic NSCLC. In contrast, pilot trials of EGFR targeted antibodies plus chemotherapy have suggested enhanced anti-tumor activity. This randomized phase II selection trial was designed to select a cetuximab-chemotherapy regimen for future evaluation in a phase III setting. Methods: Untreated patients (pts) with advanced stage NSCLC were randomized to receive paclitaxel (P) 225 mg/m2 and carboplatin (Cb) AUC=6 every 3 weeks plus concurrent cetuximab (C) 400 mg/m2 loading dose followed by 250 mg/m2, weekly for 4 cycles followed by maintenance C or sequential PCb for 4 cycles followed by C. Treatment was continued until disease progression. Eligible patients were required to have stage IIIB (pleural effusion) or IV (without brain metastases) disease, a performance status of 0–1 and adequate organ function. The primary endpoint was overall survival. The regimen with superior median survival would be considered for further evaluation provided it met a 10-month minimum. Given a true hazard ratio of 1.3, the probability of correctly choosing the superior arm would be > 90%. Results: From July 2004 to June 2005, 242 eligible pts were enrolled onto the study, Final results are described below: Conclusions: Both regimens met efficacy criterion for continued evaluation though the concurrent regimen of PCb + C, had numerically higher survival, and was chosen for further study. Some toxicities were significantly increased with concurrent therapy. A phase II trial of PCb + Cetuximab + Bevacizumab is ongoing (SWOG 0536) in anticipation of a phase III trial. Molecular correlative studies of the EGFR signaling pathway including EGFR IHC, FISH and mutation analysis are underway.

No significant financial relationships to disclose.

[Table: see text]

Final analysis of a multi-center, double-blind, placebo-controlled, randomized phase II trial of gemcitabine/cisplatin (GC) plus bevacizumab (B) or placebo (P) in patients (pts) with malignant mesothelioma (MM)

7526

Background: In phase II trials in MM, GC on a 21-day (D) schedule has response rates of 16%–26% and median overall survival (OS) of 9.6–13 months (mo). Since VEGF has a key role in MM biology, we added anti-VEGF antibody B to GC in a multi-center, double- blind, placebo-controlled randomized phase II trial. Methods: Eligible pts had unresectable MM; no prior chemotherapy; PS 0–1; no thrombosis, bleeding, or major vessel invasion. Primary endpoint: progression-free survival (PFS). Statistics: 90% power to detect HR 0.57. Stratification: PS (0/1), histology (epithelial/other). G 1,250 mg/m2 D 1, 8 Q21D, C 75 mg/m2 D1 Q21D, and B 15 mg/kg or P D1 Q21D was given × 6 cycles, then B or P Q21D until progression. Baseline plasma VEGF was measured. 115 pts enrolled 12/01- 07/05 at 11 sites, 108 (GCB/GCP) 53/55 were evaluable. Male 74%/84%; median age 62/65 (range 44–78/20–84); PS 1 55%/47%; epithelial 74%/67%; pleural 93%/91%; thrombocytosis 40%/40%. Results: Cycles: total 458/424, median 7/6, range 1–42/2–39. Statistically significantly different (SSD) toxicity (p <0.05), any grade: alopecia 60%/38%; epistaxis 62%/24%; hypertension 45%/22%; non-neutropenic infection 15%/4%; proteinuria 62%/47%; stomatitis 23%/7%. There were no SSD toxicities = grade 3. Median PFS 6.9/6.0 mo (HR 0.93, p=0.88). Median OS 15.6/14.7 mo (p=0.91). 1-year survival 59%/57%. Partial response 25%/22%; stable disease 51%/60%. Median VEGF (N=56) 131/154 pg/ml (range 31–1760/5–1786). Higher VEGF was associated with shorter PFS (p=0.02) and OS (p=0.0066). In pts with VEGF = the median, PFS (p=0.043) and OS (p=0.028) were significantly greater for GCB than GCP; in high VEGF strata this was not SSD. Conclusion: Adding B to GC in MM pts does not yield statistically significant differences in PFS, OS, response, or grade ¾ toxicity. GCB-treated pts with low VEGF levels had longer PFS and OS. Supported by NCI grant N01-CM-17102.

No significant financial relationships to disclose.

Enhanced detection of EGFR mutations in plasma from non-small cell lung cancer (NSCLC) patients using Scorpion primers

7682

Background: Activating epidermal growth factor receptor (EGFR) mutations identified in NSCLC patient tumors are often associated with rapid and profound response to EGFR tyrosine kinase inhibitors (TKIs). Conventional detection methods are cumbersome and may underestimate mutations frequencies due to limited sensitivity. We and others have shown that tumor-specific mutations such as KRAS can be detected in tumor DNA shed into patient plasma (Kimura, Ann N Y Acad Sci, 2004). Here we describe the performance of an allele- specific real-time PCR system utilizing Scorpion primers (kindly provided by DxS, UK) to detect EGFR mutations in plasma. Methods: DNA was extracted from archival tumor blocks, slides and plasma obtained from consenting patients. In order to determine the sensitivity of this technique both in terms of the ratio of mutant-to-wild-type genomic DNA as well as the minimum amount of DNA required for detection, a dilution experiment was conducted. Genomic DNA from cell lines containing either the exon 21 L858R point mutation or the exon 21 E746–750 deletion was diluted with wild-type genomic DNA at ratios ranging from 1:2 to 1:10,000. Clinical specimens including plasma and/or tissue from 35 advanced stage NSCLC patients treated with EGFR-TKIs were examined. Results: Mutant DNA was successfully detected when it comprised as little as 0.1% of the total sample or as low as 25 pg of mutant-positive genomic DNA in a pool of 2.5 μg of total DNA. EGFR mutations were identified by this approach in both plasma and tissue of 2 patients who were complete responders to EGFR-TKI therapy, only one of which was detectable by direct sequencing. For the 7 patients where only tissue was available, two were positive both with the Scorpion primers and direct sequencing while the rest were wild-type. Of 21 patients where only plasma was available, 6 mutations were detected using the Scorpion primers. Conclusions: Allele-specific Scorpion technology is 1) highly specific and sensitive for EGFR mutation analysis, 2) able to detect mutations that were not observable by direct sequencing in plasma and tissue, 3) capable of detecting mutations in shed tumor DNA in plasma of advanced NSCLC patients and 4) may be suitable for monitoring response or detecting recurrence.

No significant financial relationships to disclose.

Pharmacodynamic separation of erlotinib and docetaxel (DOC) in advanced non-small cell lung cancer (NSCLC): Overcoming hypothesized antagonism

7618

Background: Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) given concurrently with chemotherapy do not improve patient (pt) outcomes compared with chemotherapy alone in advanced NSCLC. Based on our preclinical data, we hypothesized that G1 cell cycle arrest from EGFR-TKI antagonizes the cytotoxicity of concurrent chemotherapy, and that pharmacodynamic separation (PDS) by intermittent delivery of EGFR-TKIs with chemotherapy would increase efficacy (Gumerlock, ASCO 2003, Davies, ASCO 2005). To test this concept, we conducted a phase I-II study of intermittent erlotinib combined with DOC. Methods: 37 previously treated IIIB (pleural effusion) or IV NSCLC pts received DOC 70–75 mg/m2 IV on day 1 every 21 days and erlotinib orally days 2–16 (150–200 mg). Patients without progression after 6 cycles continued erlotinib alone. Primary endpoint was response rate. Results: Pt characteristics: Age: median/range 57/35–80; Sex: 14 M; KPS ≥90=13; smoker/non-smoker/unknown 20/13/4, Median cycles: 5. Adenoca: 18. Prior chemotherapy regimens: 1 - 26; >1 - 11. In 34 evaluable pts: 1 CR, 11 PR (35% response rate), 16 stable disease. Median time to progression (TTP) was 5.6 months (95% CI: 3.7 - 7.9). MST: not reached. Treatment was generally well tolerated. Most common grade (Gr) 3/4 toxicities included: neutropenia (60%), diarrhea (16%), infection (11%), febrile neutropenia (8%). Gr 1/2 acneform rash: 88%. PK analysis showed that PDS was achieved in nadir levels of erlotinib in 4 pts tested. Correlative studies examining biomarkers for response with EGFR TKIs are ongoing. Conclusions: 1) DOC every 3 weeks plus intermittent dosing of erlotinib (2 weeks on, 1 week off) achieved PDS in limited PK sampling. 2) This combination resulted in a favorable response rate and TTP in previously treated NSCLC, with MST not yet reached. 3) Febrile neutropenia necessitated the prophylactic use of G-CSF. 4). Further clinical study of this concept is warranted, and trials are currently ongoing.

[Table: see text]

Erlotinib as initial therapy in patients with advanced non-small cell lung cancer (NSCLC) and a performance status (PS) of 2: A SWOG phase II trial (S0341)

7536

Background: Patients (pts) with advanced NSCLC and PS 2 have an inferior survival compared with good PS pts. Single agent and combination chemotherapy have been used with modest success with toxicity often limiting treatment. Targeted agents such as the EGFR tyrosine kinase inhibitor erlotinib (E) offer an alternative which may confer comparable benefit with better tolerance. This phase II trial of E in unselected chemotherapy-naive pts with advanced NSCLC and PS 2 was performed to obtain preliminary data regarding efficacy and EGFR biology in this pt population, and to set the stage for a subsequent randomized trial of E vs.chemotherapy, in pts selected for EGFR expression. Methods: Eligibility: stage IIIB (pleural effusion)/IV NSCLC; measurable disease; PS 2; no prior chemotherapy/biologic treatment for NSCLC. Treatment: E 150 mg orally daily. Molecular correlative studies:EGFR protein expression (IHC), gene copy (FISH), mutation analysis. Results: Pts: 82; 73 eligible; 72 fully evaluable; age (median) 74.4; M/F 47%/53%; current/former smoker 91%; stage IIIB/V 12%/88%; adenoca 54%. Treatment was well tolerated. Five pts (7%) had a grade 4 toxicity (fatigue 3 pts; dyspnea 2 pts). Most common grade 3 toxicities: fatigue 9 pts (13%); rash 7 pts (10%); diarrhea 5 pts (7%); anorexia 5 pts (7%). There was 1 possible treatment related death due to pneumonitis. One complete (1%) and 5 (7%) partial responses were noted. Stable disease was seen in 25 pts (35%) for an overall disease control rate (DCR) of 43% (31 pts). Progression free survival: 2.1 months (95% CI 1.5 –3.1); Median survival: 5.0 months (95 % CI 3.5 –7.3). One year survival: 22% (95% CI 12 –32%). Analysis of molecular correlates is ongoing. Conclusions: Single agent erlotinib is a well tolerated treatment for chemotherapy- naive patients with advanced NSCLC and PS 2 with an overall DCR of 43% and median survival of 5 months. These efficacy results are comparable to the outcome seen in SWOG trial S0027 in PS 2 pts employing sequential vinorelbine and docetaxel. We hypothesize that pt selection by an EGFR biomarker strategy will improve results with E, and that E will be superior to chemotherapy in this selected population.This trial design is under development within SWOG at present.

[Table: see text]

S9900: Surgery alone or surgery plus induction (ind) paclitaxel/carboplatin (PC) chemotherapy in early stage non-small cell lung cancer (NSCLC): Follow-up on a phase III trial

7520

Background: Small randomized and non-randomized studies suggest induction chemotherapy may improve survival in early stage NSCLC. The primary objective of this study was to determine if induction PC could improve survival over surgery alone. Preliminary results of this trial were reported at ASCO 2005 (J Clin Oncol, ASCO Proc 23(16S) 2005:7012). Median time for patients alive at last contact is now 46 months (mos). Methods: Consenting patients with clinical stage T2N0, T1–2N1 and T3N0–1 NSCLC (excluding superior sulcus tumors) were stratified by clinical stage (IB/IIA vs. IIB/IIIA) and randomized to induction PC (P:225 mg/m2 over 3 hours, C:AUC=6) on day 1, every 3 weeks × 3 or surgery alone. Eligible patients had a performance status 0–1, age =18 years (yrs), predicted post- resection FEV1 =1.0L. Surgery was at least a lobectomy and mediastinal nodal sampling. The primary endpoint was a 33% increase in overall survival over expected 2.7 yrs median for surgery. Planned sample size was 600 patients, 81% power, 1-sided test, 0.025 significance. Results: S9900 closed 07/04 when adjuvant chemotherapy became standard. 354 patients had accrued; 174-surgery alone, 180- induction PC; 19 were ineligible. Median age 65 yrs, 66% male, 70% IB/IIA, 30% IIB/IIIA. Major radiographic response to induction PC was 41%. Treatment-related deaths: 3 during induction PC, 11 within 30 days of surgery (7-induction PC arm, 4-control). Progression-free survival (PFS), overall (OS) survival rates and hazard ratios (HR) are shown. Conclusions: PFS and OS continue to trend in favor of induction PC with HR similar to those observed in adjuvant trials, supporting the role of chemotherapy in operable NSCLC. Randomized trials comparing induction to adjuvant chemotherapy are warranted. Supported by SWOG CA30102.

[Table: see text] [Table: see text]

Vorinostat (suberoylanilide hydroxamic acid) as salvage therapy in metastatic breast cancer (MBC): A California Cancer Consortium phase II study

11502

Background: MBC patients (pts) have a median survival of 27 mo. Vorinostat is a small molecule inhibitor of histone deacetylase that exerts its targeted action during post-translational acetylation of core nucleosomal histones, affecting chromatin structure, thereby regulating genes implicated in cell survival, proliferation, differentiation, and apoptosis. The primary end point was to evaluate the response rate. Secondary endpoints included: time to progression, overall survival, toxicity, and assessment of biologic correlates. Method: From 6/05 to 3/06, we enrolled 14 pts with measurable MBC. Response and progression were evaluated using RECIST criteria. Two pts had no, 5 pts had one, and 7 pts had two prior regimens. Median age was 60.5 years (37- 89). Six were ER/PR positive, four were Her2neu overexpressers. Sites of metastatic disease included brain (1), liver, lungs, and bone (5), pelvic and chest wall (1), liver and bone (2), distant lymph nodes (3), pleura and bone (1). Pts received Vorinostat 200mg oral twice daily for 14 of 21 days per cycle. Tumor measurements were performed after every 2 cycles. Biopsies (pre and on-treatment) were collected from 6 of 14 pts. Results: The mean cycles delivered was 5 (range: 1–18). Four pts had SD for a median of >8.7 mo (4–13 mo); 1 pt with ER/PR/Her2neu negative tumor who received no prior treatment for MBC to mediastinal nodes and chest wall continues to receive treatment having completed cycle 18 with stable disease for >11.4 mo. The median duration on treatment for all pts is 3.2 mo (1–12 mo). Toxicities included gr 3 fatigue (1), gr 2–3 diarrhea (3), gr 2–3 nausea (2), gr 2 mucositis(1), gr 4 lymphopenia (1), gr 2–3 lymphopenia (6). Correlative studies of pre- and on-treatment tumor samples will be presented describing gene expression profiling using custom Agilent oligonucleotide microarrays optimized for analysis of RNA isolated from formalin fixed paraffin embedded tissues (FFPET). Conclusion: In this trial Vorinostat demonstrated disease stabilization rate in 4/14 (29%) pts by intention to treat analysis. With ease of administration, further investigation in combination with other agents is warranted. (NCI-NO1-CM- 62209)

No significant financial relationships to disclose.

Toxicity and survival by sex in patients with advanced non-small cell lung carcinoma (NSCLC) on modern Southwest Oncology Group (SWOG) trials

7549

Background: The older lung cancer clinical trial literature suggests that women have better survival than men, possibly due to sex-related changes in drug metabolism based on estrogen levels. A detailed analysis of this issue has not been conducted in the modern chemotherapy era. Thus, the SWOG Lung Committee analyzed outcomes in recent trials, with the hypotheses that either sex-specific toxicity profiles and/or age (as a surrogate for estrogen level) may explain outcome differences. Methods: A data base of eligible patients with complete toxicity data enrolled on 6 consecutive SWOG phase II or III advanced stage NSCLC trials was formed. Treatment was platin-based, plus either gemcitabine, vinorelbine, or a taxane. Toxicities were categorized by type, number and grade with alpha=0.01 (multiple comparisons). Kaplan-Meier survival estimates and Cox multivariate models were computed (alpha=0.05), plus exploratory age by sex interaction analyses. Results: There were1,324 patients (36% women). No difference by sex was found in either maximum toxicity grade, number of toxicities, or specific toxicity types, except for marginally more severe or worse metabolic (12% vs 9%, p=0.02) and life- threatening or worse neurologic (2% vs 1%, p=0.04) toxicities in women. Median, 1- and 2-year survivals were significantly better for women (11 mos, 46%, 19%) vs men (8 mos, 35%, 13%). After adjustment for prognostic factors, women had 14% reduced risk of death (HR 0.86; 95% CI: 0.75, 0.98; p=0.02). The exploratory age by sex cutpoint analysis found women age 60 or older had better survival (11 vs 8 mos, p=0.006), whereas survival was similar by sex for those under age 60. No other age cutpoint was significant. Conclusions: Women with advanced NSCLC survive longer than men after adjustment for other prognostic factors in the modern chemotherapy era. There was no difference in toxicity profile by sex to explain this finding. The survival benefit for women appeared limited to patients age 60 and older, suggesting that estrogen levels may interact with the efficacy of current chemotherapy prescriptions or other as yet undefined factors. This finding, if validated, could be potentially exploited in designing new therapies.

No significant financial relationships to disclose.

Updated analysis of SWOG 0023: A randomized phase III trial of gefitinib versus placebo maintenance after definitive chemoradiation followed by docetaxel in patients with locally advanced stage III non-small cell lung cancer

7513

Background: Early clinical studies with gefitinib (G) showed promising efficacy and mild toxicity in patients (pts) with advanced NSCLC. Thus, G was an ideal agent to evaluate in a maintenance setting in stage III disease following definitive treatment. Methods: Untreated pts with stage III NSCLC, a PS of 0–1 and adequate organ function were eligible. Patients received the SWOG 9504 core regimen (cisplatin 50 mg/m2, d1 & 8 plus etoposide 50 mg/m2 day 1–5, every 28 days for 2 cycles with concurrent thoracic radiation, 1.8–2 Gy fractions/day, total dose 61 Gy, followed by 3 cycles of docetaxel 75 mg/m2). Non- progressing pts were randomized to G 250 mg per day or placebo (P) until disease progression, intolerable toxicity or 5 years. The planned sample size was 672, to confer power of 0.89 to detect a 33% increase over the expected median survival of 21 months (one-sided 0.025 level logrank test). Randomization was stratified by stage and histology. Results: Enrollment began in July 2001. An unplanned interim analysis prompted by outside data was conducted in April 2005 and the alternative hypothesis of improved survival was rejected at the 0.0015 level for 243 randomized patients. The study closed and preliminary results were reported (ASCO 2005). Now with a median follow up of 27 months, median survival for the G arm (n=118) was 23 months and was 35 months for the P arm (n=125) (two sided p=0.013). Overall survival for the 571eligible patients was 19 months. ≥ Grade 3 toxicities in the G arm were rash (7%), diarrhea (7%) and pneumonitis (3%). Conclusion: In this unselected population G did not improve survival. Decreased survival was due to cancer not G toxicity. Three year survival estimates will be presented. Molecular studies of the EGFR pathway are underway and will be correlated with outcomes.

No significant financial relationships to disclose.

Origin and prognostic value of circulating KRAS mutations in lung cancer patients

Because of the current controversy on the origin and clinical value of circulating KRAS codon 12 mutations in lung cancer, we screened 180 patients using a combined restriction fragment-length polymorphism and polymerase chain reaction (RFLP-PCR) assay. We detected KRAS mutations in 9% plasma samples and 0% matched lymphocytes. Plasma KRAS mutations correlated significantly with poor prognosis. We validated the positive results in a second laboratory by DNA sequencing and found matching codon 12 sequences in blood and tumor in 78% evaluable cases. These results support the notion that circulating KRAS mutations originate from tumors and are prognostically relevant in lung cancer.

Combination of EGFR gene copy number and protein expression predicts outcome for advanced non-small-cell lung cancer patients treated with gefitinib

BACKGROUND

Biological markers for optimal selection of patient to epidermal growth factor receptor (EGFR)-targeted therapies are not established in advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

EGFR/HER2 gene copy number by FISH, EGFR protein and pAKT expression by immunohistochemistry (IHC) and EGFR and KRAS mutations were tested in 204 gefitinib-treated NSCLC patients.

RESULTS

Increased EGFR and HER2 gene copy number (FISH+), EGFR protein overexpression (IHC+), EGFR mutations and pAKT overexpression were all associated with significantly higher response rates (33%, 29%, 22%, 39% and 20% respectively). EGFR FISH+ (32%) and IHC+ (61%) correlated with improved survival, while EGFR mutations (27%), KRAS mutations (26%) and pAKT expression (69%) did not. In multivariate survival analysis EGFR FISH and IHC were independent predictive markers. EGFR FISH+/IHC+ patients (23%) had a median survival of 21 months versus 6 months for double-negative patients (30%).

CONCLUSION

Combination of EGFR FISH and IHC is effective predictor for benefit from gefitinib. Patients with double-negative results are unlikely to benefit in western NSCLC populations.

Independent review of fatal interstitial lung disease (ILD) in TRIBUTE: paclitaxel + carboplatin ± erlotinib in advanced non-small cell lung cancer (NSCLC)

7071

Background: ILD is a rare but serious complication of EGFR tyrosine kinase inhibitor (TKI) therapy, fatal in about 1/3 of cases. The incidence, severity & risk factors for ILD remain poorly understood, but it is reported to be more common in Asian patients receiving gefitinib. Whether the risk of ILD with gefitinib exceeds that of erlotinib is unclear. Whether concurrent chemotherapy increases the risk of ILD is also unclear. Methods: This study was designed to determine the incidence of ILD leading to death in 1,059 TRIBUTE patients randomized to chemotherapy plus erlotinib or placebo (Herbst: JCO, 2005). A blinded review of fatal SAEs was performed by an independent 3 person panel comprised of a medical oncologist (DRG), radiologist (DS), and pulmonologist (KY) unassociated with the study. Fatal respiratory SAEs (41 met criteria) were assigned to 1 of 4 potential attributions: progressive NSCLC; concurrent illness; toxicities not related to study drug; or ILD. Each panel member first made an independent assignation based on case report forms/source documents; then each case was discussed jointly. If needed, consensus was reached by vote. Results: Fatal SAEs were reported in 80/1059 patients (7.6%): 53/526 patients on erlotinib (10.1%) & 27/533 on placebo (5.1%) (p = 0.002). Consensus assignation for 41 respiratory SAEs was as follows: NSCLC: 18 (44%), concurrent illness: 15 (37%), toxicities not related to study drug: 5 (12%), ILD: 3 (7%). There were no statistical differences in assignation by study arm. However, all 3 ILD cases occurred in the erlotinib arm (3/523; overall incidence 0.6%). Case details will be provided. Conclusions: 1) To our knowledge, this analysis of TRIBUTE is the only independent blinded assessment of respiratory SAEs & ILD related to an EGFR TKI (erlotinib) + chemotherapy. 2) Overall, there were 41 fatal respiratory SAEs (3.9%). Fatal ILD occurred in 0.6% of cases treated with the combination. Using estimates that 1/3 of EGFR TKI-induced ILD cases are fatal, the overall incidence in this study arm was likely around 1.5–2%, not inconsistent with prior reports of TKIs alone. 3) Further studies designed to better define the underlying pathophysiology and risk factors for ILD are needed.

[Table: see text]

A randomized phase II non-comparative study of Ispinesib given weekly or every three weeks in metastatic colorectal cancer. A California Cancer Consortium Study (CCC-P)

3595

Background: Ispinesib(SB-715992) is a polycyclic, nitrogen-containing heterocycle that inhibits the mitotic kinesin spindle protein (KSP). KSP is essential for mitotic spindle assembly and function during mitosis, and is a rational target of anti-cancer therapy. This phase II study used two different dosing schedules; the primary objective was to determine the response rate (RR) and the secondary objectives were to determine time to tumor progression (TTP), progression free survival (PFS), overall survival (OS) and toxicity. Methods: Patients (pts) were randomized to receive (Arm A) ispinesib 7 mg/m2 every week for 3 weeks, every 28 days or (Arm B) 18 mg/m2 every 21 days. Response was assessed every 6 weeks. Chemotherapy was administered until disease progression or intolerance. Results: A total of 64 pts were accrued. The median number of cycles was 2 for both arms. Five pts had stable disease and 48 had progressive disease. PFS was 49 days in Arm A (44 to 51) and 37 days in Arm B (35 to 42 days). The most common grade 3/4 toxicities in arms A and B respectively included neutropenia (3 and 20), nausea and vomiting (3 and 1), neurologic (1 and 2). Of these, only 1 pt had febrile neutropenia and 1 pt had peripheral sensory neuropathy. The toxicity data is not available on 2 patients. Eleven pts are not evaluable for response yet. Conclusions: Ispinesib did not demonstrate significant activity in heavily pretreated patients with advanced/metastatic colorectal cancer at the dose and schedule employed in this trial. Correlative studies are in progress. Supported by NO1 CM17101

[Table: see text]

No significant financial relationships to disclose.

Concurrent chemotherapy plus cetuximab or chemotherapy followed by cetuximab in advanced non-small cell lung cancer (NSCLC): A randomized phase II selectional trial SWOG 0342

7015

Background: Randomized clinical trials have failed to show a survival benefit for small molecule EGFR tyrosine kinase inhibitors plus chemotherapy in patients with advanced NSCLC. In contrast, pilot trials of EGFR targeted antibodies plus chemotherapy have suggested enhanced anti-tumor activity. This large randomized phase II trial was designed to select a cetuximab -chemotherapy regimen for future evaluation in a phase III setting. Methods: Untreated patients (pts) with stage IIIB (by pleural effusion) or IV (without brain metastases) NSCLC, with a performance status of 0–1 and adequate organ function were randomized to received paclitaxel (P) 225 mg/m2 and carboplatin (Cb) AUC=6 every 3 weeks plus cetuximab (C) 400 mg/m2 loading dose followed by 250 mg/m2, weekly for 4 cycles followed by maintenance C or the same doses of PCb for 4 cycles followed by C. C was continued until disease progression or 1 year of therapy. The primary endpoint was overall survival; the statistical design required a median survival of ≥ 10 months for a regimen to be selected for subsequent phase III trial evaluation. The probability of correctly choosing the superior arm is 91% when the true hazard ratio is 1.3. Results: From July 2004 to June 2005, 225 eligible pts were enrolled into the study. Preliminary results are described below: Conclusions: At the time of this analysis, efficacy and toxicity were similar in the two treatment arms; both regimens were well tolerated. Assuming these results are sustained, the concurrent regimen of PCb + cetuximab has met the criteria for continued evaluation. A phase II trial of PCb + cetuximab + bevacizumab (B) is in development in anticipation of a phase III trial testing PCbB ± cetuximab. Molecular correlative studies of the EGFR signaling pathway are ongoing.

[Table: see text]

[Table: see text]

Escalating weekly doses of cetuximab: A phase I trial in advanced solid tumors

13012

Background: Cetuximab, an IgG1 monoclonal antibody directed against the epidermal growth factor receptor (EGFR), is FDA-approved at a 400 mg/m2 loading dose, followed by 250 mg/m2 weekly maintenance. Clinical activity of cetuximab has been reported to correlate with grade of skin toxicity, and skin toxicity is reported to increase with increasing dose. We therefore examined the safety and feasibility of escalating weekly cetuximab doses. We hypothesized that increased dose would correlate with rash severity as a surrogate for tumor response. Methods: Four dose levels were tested: cetuximab loading 400 mg/m2 and 250,300,350,400 mg/m2 weekly maintenance. Dose limiting toxicity (DLT) was defined as: grade 4 platelets, grade 3 platelets with bleeding, febrile neutropenia, grade 4 cutaneous toxicity, grade 3 cutaneous toxicity necessitating holding cetuximab for > 4 weeks or any other grade ≥ 3 non-hematologic toxicity. Rash was evaluated using two additional validated dermatology methods: acne lesion counting and global acne grading scale (Int J Derml.1997;36:416–18, J Am Acad Derm.1996;35:559–65, Arch Derm.1982;118:23–25). Results: Twelve patients with advanced solid tumors were treated, including 3 H&N, 2 pancreas, 2 breast, 2 lung, 2 colorectal and 1 bladder. Patient characteristics: age range 44–84, median 62; gender: 10 M; KPS ≥80/<80=7/5; prior chemo ≤1:>1=5:7; median cycles 2 (1–8). Treatment was generally well tolerated. There were no DLTs. The most common grade 3/4 toxicities were acneiform rash (1) and lymphopenia (2). The majority of patients (6) had a Grade 2 rash. In 10 evaluable patients, there were no responses; 3 patients had stable disease. Correlative science studies are ongoing evaluating EGFR expression and polymorphisms, pEGFR, pMAPK, pAKT, Ki67, p27 levels and K-ras mutations. Conclusions: 1) Cetuximab 400 mg/m2 loading dose and 400 mg/m2 weekly maintenance is feasible and well tolerated. Doses up to 400 mg/m2 did not portend increased toxicity and a MTD was not reached on this schedule. 2) Grade of rash did not increase with increasing doses of weekly cetuximab in this limited population. 3) To date, cetuximab has not demonstrated RECIST response in this cohort of pretreated patients with solid tumors. 20 additional patients are being evaluated at the highest dose level.

No significant financial relationships to disclose.

Preclinical evaluation of the dual specific Src/Abl kinase inhibitor AZD0530 in lung cancer

13108

Background: AZD0530 is a highly selective, orally available, dual specific Src/Abl kinase inhibitor in clinical development. We tested this agent in multiple lung cancer cell lines in vitro. We hypothesized that activity of AZD0530 may depend on the level of activated (pY416-)Src, and that Src inhibition may decrease Bcl-xL protein levels and lower the barrier to apoptosis. Methods: NSCLC (A549, Calu-1, Calu-6) and SCLC (H69, H526) cells were incubated with 0.001–100 μM AZD0530 for 1–72hrs. Proliferation (MTT), DNA-content (flow cytometry), and protein levels of Src, pY416-Src, PARP, and Bcl-xL (Western blotting) were assessed. Results: Basal pY416-Src was detectable in most cell lines except H526. AZD0530 decreased pY416-Src levels at submicromolar concentrations in pY416-Src positive cells. In A549, Calu-1 and Calu-6, AZD0530 blocked cell growth in a time- and dose-dependent way (IC50 = 7–25 μM) by arrest in G1, retaining a cytostatic effect at submicromolar concentrations in A549 and Calu-1. AZD0530 induced apoptosis in 10–22% of these cells at micromolar concentrations, accompanied by a decrease of Bcl-xL protein in A549 and Calu-1. In H69 and H526, growth inhibition by AZD0530 was limited (IC50 >100 μM). Conclusions: 1) AZD0530 induced apoptosis at micromolar concentrations, and inhibited cell growth at micromolar to submicromolar concentrations in some cell lines. 2) pY416-Src is a potential marker for drug responsiveness, but other factors should also be tested. 3) Decrease of Bcl-xL by AZD0530 may render cancer cells more sensitive to chemotherapy. These data suggest that Src kinase inhibitors merit further testing in lung cancer, both alone and in combination with other agents. (Support: Swiss National Science Foundation, Swiss Cancer League, AstraZeneca).

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Phase II study of lapatinib, a dual inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase 1 and 2 (Her2/Neu) in patients (pts) with advanced biliary tree cancer (BTC) or hepatocellular cancer (HCC). A California Consortium (CCC-P) Trial

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Background: Advanced BTC (gallbladder, bile duct) and HCC respond poorly to systemic chemotherapy. Lapatinib is an oral inhibitor of EGFR and Her/2-neu with evidence of activity in a number of tumor types. Both BTC and HCC overexpress EGFR 1 and 2. In addition, Her2/neu somatic mutations have been reported in HCC, and may predict response to EGFR targeted agents (Bekaii-Saab et al, A 4037, ASCO 2005). This trial conducted by the CCC-P and Univ. Chicago, is designed to determine the efficacy of lapatinib in BTC and HCC pts. Methods: A two-stage design is utilized and pts are stratified by tumor type (BTC or HCC); the study has a 90% power to detect a true response rate ≥20%. Two initial groups of 17 patients for BTC and HCC were accrued; one response from each was required to proceed with accrual to a total of 37 patients in each group. Adequate hematologic, renal, and hepatic function is required. Eligible pts are in Child A group and have ECOG PS of 0–2. One prior treatment regimen is allowed. Lapatinib dose is 1,500 mg/d orally without interruption. One cycle is 28 days and radiological assessment is done every 8 weeks. Results: 49 pts have been accrued (BTC 19 and HCC 30). Pt Characteristics: Male 59%, ECOG PS 0 (18 pts), ECOG PS 1 (22 pts). Median age 66 yrs (range19–82). Median cycles 2 (range 1–12). Grade 3/4 toxicity was noted in 19 pts and included fatigue in 4 pts, elevation of liver enzymes in 4 pts and diarrhea in 2 pts. Nausea, vomiting, rash, anemia and thrombocytopenia were noted in 1 pt each. There was no evidence of cardiac dysfunction. In 17 evaulable pts with BTC, no responses were observed, 5 had stable disease (SD). Among the first 17 pts with HCC, 2 confirmed partial responses have been recorded. In addition 8 pts have SD. The progression free survival is 1.8 mo for both BTC and HCC. Tumor and blood specimens are being analyzed for expression of EGFR, HER-2/neu, status of downstream signal pathway molecules, and correlation to response. Conclusions: Lapatinib is well-tolerated. No activity in BTC was noted and that cohort is closed. Lapatinib activity in HCC is encouraging, and study is close to completion. Source of support: NCI-NO1-CM-57018–16.

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