Sorafenib as first- or second-line therapy in patients with metastatic renal cell carcinoma in a community setting

ABSTRACT Aim: The Italian Retrospective Analysis of Sorafenib as First or Second Target Therapy study assessed the efficacy and safety of sorafenib in metastatic renal cell carcinoma patients treated in the community. Patients & methods: Patients receiving first- or second-line single-agent sorafenib between January 2008 and December 2010 were eligible. Retrospective data collection started in 2012 and covers at least 1-year follow-up. The primary end point was overall survival (OS). Results: Median OS was 17.2 months (95% CI: 15.5–19.6): 19.9 months (95% CI: 15.9–25.3) in patients treated with first-line sorafenib and 16.3 months (95% CI: 13.1–18.2) with second-line sorafenib. Overall median (95% CI) progression-free survival was 5.9 months (95% CI: 4.9–6.7): 6.6 (95% CI: 4.9–9.3) and 5.3 months (95% CI: 4.3–6.0) in first- and second-line patients, respectively. Conclusion: The efficacy and safety of sorafenib in routine community practice was generally good, especially in relation to OS in patients treated in the second line, where results were similar to those seen in recent prospective clinical trials.

Potential value of rapid prostate-specific antigen decline in identifying primary resistance to abiraterone acetate and enzalutamide

ABSTRACT: 

Aim: To identify factors predicting primary resistance to new-generation hormonal agents (NHAs), abiraterone acetate and enzalutamide in patients with castration-resistant prostate cancer (CRPC). Patients & methods: Our hospital has conducted two successive named patient NHA programs. A total of 57 patients with progressive CRPC previously treated with first-line docetaxel-based chemotherapy received standard NHA doses: abiraterone acetate 1000 mg once-daily combined with prednisone (5 mg twice daily) or enzalutamide 160 mg once-daily. Patients, who were assessed monthly to check their hematological parameters and prostate-specific antigen (PSA) levels, also underwent imaging investigations every 3–4 months. In total, 24 variables were assessed as potential predictors of primary NHA resistance. Results: Univariate analysis indicated that baseline pain and lactate dehydrogenase levels, and PSA levels after 1 month’s treatment were predictive of primary NHA resistance. Only the predictive value of PSA levels after 1 month of treatment was confirmed at multivariate analysis. This factor strongly predicted progression-free and overall survival. Conclusion: Results suggest the use of a simple and rapid method of identifying patients with primary resistance to NHAs: patients not achieving a ≥50% reduction in PSA levels within the first treatment month should undergo intensive investigations to verify whether they have primary resistance to NHAs.

PI3KCA mutation status is of limited prognostic relevance in ER-positive breast cancer patients treated with hormone therapy

PI3K/AKT/mTOR pathway alterations are frequent in patients with infiltrating breast cancer (IBC). Their clinical and pathological relevance has been insufficiently documented. We evaluated PI3KCA for mutations and the expression of PTEN, AKT, mTOR and p70S6K by immunohistochemistry in 246 IBC patients treated with hormone therapy (median follow-up, 97 months). A PI3KCA mutation was observed in 50 out of 229 informative cases (21.8 %), PTEN loss in 107 out of 210 (51 %), moderate/high level of expression of AKT in 133 out of 188 (71 %), moderate/high level of expression of mTOR in 173 out of 218 (79 %) and moderate/high level of expression of p70S6K in 111 out of 192 cases (58 %). PI3KCA mutation was associated with the absence of Her2/neu amplification/overexpression and a low level of MIB1/Ki-67 labelling. The expression of p70S6K was associated with a high level of mTOR immunoreactivity, and high PTEN expression was associated with high AKT expression level. Univariate analysis showed that PI3KCA mutation status was not associated with clinical outcome in the series as a whole or in the node-negative subgroup. However, in the node-positive subgroup, exon 9 PI3KCA mutation was associated with unfavourable overall survival (OS), although its impact on the final model in multivariate analysis seemed to be limited. Of the other markers, only high p70S6K expression was associated with a significantly prolonged OS. PI3KCA mutation status is of limited prognostic relevance in oestrogen receptor-positive breast cancer patients treated with hormone therapy.

Metabolic response by choline positron emission tomography (cPET) to enzalutamide (ENZ) in castration-resistant prostate cancer (CRPC) patients (pts): Preliminary results of a monoinstitutional prospective study

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Background: ENZ is a new generation hormone therapy, able to produce a survival improvement in CRPC pts pre-treated with docetaxel. In Italy, ENZ is not approved yet for the daily clinical practice but until few months ago it was available through a named patient programme (NPP). Since in our Hospital CRPC pts are regularly assessed by cPET to evaluate the treatment response, so pts treated with ENZ were monitored in the same way. Methods: Eligible pts received ENZ at the standard dose of 160 mg po daily until progression. The cPET was performed at baseline, at the 3rd treatment month and thereafter every 4 mos. For each cPET we recorded the median of the maximum standard uptake values (SUVmax) of the 5 most choline-avid region of interest (ROI) and the overall number of ROIs with SUVmax > 2.5. A progressive disease (PD) was defined as the increase ≥ 30% of median SUVmax or the appearance of at least two new ROIs; a partial response (PR) as the reduction ≤ 30% of median SUVmax compared to the baseline; otherwise we considered the disease as stable (SD). Results: Out of the 31 CRPC pts treated with ENZ in our hospital from 09/12 to 03/13, 28 had complete cPET data for evaluation. The baseline median SUVmax of all evaluable pts was 10.82. At 3 mos the median SUVmax decreased to 9.30 (7 PR, 12 SD, 9 PD). Among the 19 pts evauable at 7 mos, the median SUVmax was 7.15 (8 PR, 9 SD, 2 PD). The correlation between the best metabolic response and the prostate specific antigen (PSA) response is showed in the Table. Conclusions: Our preliminary data showed a good concordance between the cPET response and biochemical response in either responding or progressing pts, while most of the pts with stable metabolic parameters showed a good PSA reduction. This is to our knowledge the first report concerning the metabolic response to ENZ and its correlation to PSA response. Further studies are required to define the role and use of cPET in monitoring the treatment efficacy in pts receiving ENZ. [Table: see text]

Looking to possible predictive factors of primary resistance to abiraterone acetate (AA) and enzalutamide (ENZ) in pretreated patients (pts) with castration-resistant prostate cancer (CRPC)

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Background: Abiraterone acetate (AA) and enzalutamide (ENZ) are new generation hormonal agents (NHA) which demonstrated a survival gain in patients (pts) with castration-resistant prostate cancer (CRPC) pre-treated with docetaxel. Although all patients eventually became resistant to these NHAs, some of them show primary resistance, defined as an early progression within the first 3 months, which leads to an early treatment interruption. In the present analysis we have tried to identify which factor, if any, may predict primary resistance to AA and ENZ. Methods: We evaluated a consecutive series of 57 pts, treated in our hospital in two successive named patient programs conducted in our hospital to allow pre-treated CRPC patients to receive NHAs before their approval in Italy: 26 received AA (1,000 mg po + prednisone 10 mg po daily) and 31 ENZ (160 mg po daily). For each pt we have recorded the pre- and post-NHA clinical history, the treatment details and outcomes. We have also assessed the ability of a series of 24 selected clinical factors to predict NHAs resistance, through a logistic regression analysis. Continuous variables were categorized by quartiles and chosen for the initial model after a univariate chi-square analysis. Results: Among the 24 factors, the presence of pain at baseline, high baseline lactate dehydrogenase levels and prostate-specific antigen (PSA) levels after one month of treatment were predictive of primary NHA resistance at the univariate analysis. However, only PSA levels were confirmed at the multivariate analysis [exp(beta) 0.115; p = 0.007], as patients failing to achieve a 50% or more reduction in baseline PSA levels, were more likely to show primary NHA resistance (48% vs. 15%). Conclusions: Our results suggest that PSA trend may represent a simple and rapid method of identifying patients with primary resistance to NHAs, so patients failing to achieve a 50% or more reduction within the first month of treatment should undergo intensive investigations, to verify whether they have primary resistance to NHAs. These data should be confirmed in a larger patient population.

Metastatic renal cell carcinoma: how to make the best sequencing decision after withdrawal for intolerance to a tyrosine kinase inhibitor

With seven agents approved for metastatic renal cell carcinoma (RCC) within the past few years, there has undoubtedly been progress in treating this disease. The treatment safety of these new agents, however, now represents a crucial concern, which requires a search for the best possible balance between the minimization of the treatment burden and the need for maintaining appropriate drug dosages able to induce the best clinical benefit. In this review we have analyzed safety data of all approved targeted agents for metastatic RCC available as first- or second-line therapy to provide suggestions aimed at establishing the most appropriate second-line or later treatment on the basis of toxicities that have arisen in therapy. Based on the characteristics and comorbidities of the patients and on the toxicity profile of each treatment, it is possible to plan different therapeutic options. We, therefore, have compiled a list of points that are important to keep in mind when considering the use of the targeted drugs for the treatment of advanced RCC.

Biochemical and objective response to abiraterone acetate withdrawal: incidence and clinical relevance of a new scenario for castration-resistant prostate cancer

OBJECTIVE

To describe the incidence and clinical relevance of biochemical and objective responses to abiraterone acetate (AA) withdrawal (AAWD) in patients with castration-resistant prostate cancer (CRPC).

MATERIALS AND METHODS

Twenty-six patients with progressive CRPC treated with first-line docetaxel-based chemotherapy were administered with AA at the standard dose of 1000 mg/day in combination with prednisone until progression. The patients were regularly followed up during treatment and after AAWD.

RESULTS

Nineteen of the 26 patients discontinued AA because of progression. Three of the patients undergoing AAWD experienced a biochemical response, which was accompanied by a metabolic and radiological response as revealed by choline positron emission tomography in 2 cases.

CONCLUSION

Regardless of the underlying molecular bases, AAWD response does not occur rarely. It is sometimes long-lasting and accompanied by a metabolic and radiographic improvement. AAWD response should be taken into account when further therapeutic strategies are planned in patients with CRPC with progressive disease during abiraterone therapy.

Clinical outcome (CO) and predictive factors (PRE) evaluation of young (≤ 60 years) castration-resistant prostate cancer (CRPC) patients, treated with docetaxel (DOC): Preliminary results of an Italian multicenter retrospective study (CYCLOP study)

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Background: CRPC is rare in pts ≤ 60 yrs and clinical outcomes of these pts are not clearly defined despite there is a common feeling of a worse prognosis for them. The present study is aimed to assess CO and PRE in this specific population. Methods: In this multicentric retrospective study, after Ethical Committee approval, we have reviewed the clinical records of all < 60 yrs CRPC pts from participating institutions, treated with DOC. We recorded the pre and post-DOC clinical history, the DOC treatment details and outcomes. We have also assessed the ability of a series of selected 18 clinical factors to predict DOC response through a logistic regression analysis. Continuous variables were categorized by quartiles and chosen for the initial model after a univariate chi-square analysis. Results: To date we have collected a consecutive series of 98 pts from 16 Italian hospitals. The median age was 57 yrs (range 41-60). The median baseline PSA was 84 ng/ml (range 2-2721); 93% of the pts had bone metastases while 49%, 9%, and 13% showed nodal, liver and lung metastases, respectively. All but 8 pts received DOC with a 3-week standard schedule: the median number of received DOC courses was 8 (range 1-14). The main grade 3-4 toxicities were anemia (4 pts), neutropenia (15 pts), febrile neutropenia (1 pt), peripheral neuropathy(1 pt). A PSA reduction > 50% was observed in 61% of the pts while 14% and 7% of the cases showed a partial and complete response, respectively. Having a Gleason score (GS) <8 [p= 0.032], a hemoglobin initial value >12 [p= 0.052], no nodal involvement [p= 0.101], resulted to be independently predictive of a PSA reduction > 50%. The median PFS and OS were 7 mos and 19 mos, while the 1-year PFS and OS rates were 17.3% and 70%, respectively. Conclusions: From these preliminary results, we failed to confirm a worse prognosis for younger CRPC since their survival outcomes are similar to those observed in the pivotal trials. Low GS, absence of nodal involvement and good hemoglobin levels are the only predictive factors.

Brain metastases from prostate cancer: an emerging clinical problem with implications for the future therapeutic scenario

Brain metastases from prostate cancer (PC) seem to be more frequent than in the past, possibly because advances in the treatment of patients with castration-resistant PC have prolonged their survival. Furthermore, docetaxel (the drug of choice for the first-line treatment of castration-resistant PC) cannot cross the blood-brain barrier and control metastatic foci. However, this problem may be overcome by new active drugs such as cabazitaxel.

Retrospective analysis of sorafenib as first or second target therapy in mRCC patients in Italian centers: An update

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Background: With several agents available for the treatment of metastatic renal cell carcinoma (mRCC) a better understanding of their use in daily clinical practice is fundamental in the decision-making process. Methods: The REtrospective analysis of Sorafenib (So) as 1st or 2nd targET therapy (RESET) in mRCC was a retrospective, observational field study that assessed the use and safety of So in clinical practice in Italian centers. Treatments were determined by physicians per local prescribing guidelines. Patients (pts) treated with So single agent as 1st or 2nd target therapy (TT) for mRCC between 1st Jan 2008 and 31st Dec 2010 were eligible for inclusion. Endpoints included safety, overall survival (OS), progression-free survival, response rate and treatment duration. Subgroup analyses included age, ECOG performance status, prior therapy, number of metastases and line of TT with So. Results: From Feb to Jul 2012, 358 pts from 37 Italian centers were enrolled. The most common ≥ grade 3 drug-related adverse events were hand-foot skin reaction (6.7%), rash (2.2%), hypertension, fatigue and diarrhea (1.7% each). In the overall population, median OS was 17.2 months (mos) (95% CI 15.4 – 19.6 mos) and median PFS was 5.9 mos (95% CI 4.9-6.7 mos). Median duration of treatment with So was 5.03 mos. Disease control (complete response + partial response + stable disease) was observed in 198(56%) pts. In pts receiving So as first or as second TT median OS was 19.9 mos (95% CI 15.9-25.3 mos) and 16.3 mos (95% CI 13.0-18.2 mos) respectively. In the subgroup of pts treated with So 1st TT followed by sunitinib (Su) 2nd TT (44 pts) and Su 1st TT followed by So 2nd TT (173 pts), median OS was 30.4 mos (95% CI 22.0-34.8 mos) and 16.6 mos (95% CI 13.1-18.2 mos) respectively. There were 269(76%) pts that received a total of 2 lines of therapy for mRCC, 133(38%) pts 3 lines and 43(12%) pts 4 lines of therapy. Conclusions: The efficacy and safety profile of So in the setting of Italian community-based daily clinical practice was similar to data reported in prospective clinical trials. The efficacy of So was observed in both the subgroups of pts receiving So as either the first or second TT for mRCC, with intriguing OS data in first line.

Clinical outcome (CO) evaluation of very old (≥ 80 years) castration resistant prostate cancer (CRPC) patients (pts) treated with docetaxel (DOC): Preliminary results of an Italian multicenter retrospective study (DELPHI study)

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Background: Since prostate cancer is mainly diagnosed in pts over 65 yrs of age, castration resistance is usually observed in older pts. In the case of very old pts (≥ 80 years), fear of high toxicity degree limit chemotherapy use due to both pts frailty and several comorbidities occurrence. Moreover, if treated these pts usually receive an adapted chemotherapy, often with a weekly schedule, which in TAX327 trial failed to show survival advantage compared to mitoxantrone. The present retrospective study is aimed to assess CO in this very elderly CRPC population. Methods: In this multicentric retrospective study, after Ethical Committee approval, we have reviewed the clinical records of all ≥ 80 yrs CRPC pts from participating institutions, treated with DOC in clinical practice, recording the pre and post-DOC clinical history, the DOC treatment details and outcomes. Results: To date we collected a consecutive series of 81 pts from 17 Italian hospitals. The median age was 82 yrs (range 80-90). The median baseline PSA was 107 ng/ml (range 3-1597); 81% of the pts had bone metastases, while nodal, lung and liver metastases were observed in 37%, 6%, and 6% of the pts, respectively. Median Cumulative Illness Rating Scale score was 3 (range 0-11), median Activity Daily Living index score was 0 (range 0-5), median Instrumental Activities of Daily Living score was 0 (range 0-5). The DOC was administered on 3-week or weekly schedule basis (41%/59%). A PSA reduction > 50% and an objective response were observed in 74% and 11% of the pts, respectively. Grade 3-4 toxicities were: neutropenia (11%) , fatigue (8%), diarrhea (1%), renal (2%), and febrile neutropenia (1%). The median PFS and OS were 7 mos and 22 mos, while the 1-year PFS and OS rates were 17.3% and 43.9%, respectively. Conclusions: This data suggests that DOC treatment, both on 3-week or weekly schedule, is able to produce good survival outcomes, comparable to pivotal trials (18 mos), also in highly selected very older (≥ 80 yrs) CRPC pts.

Clinical outcome (CO) and predictive factors (PRE) evaluation of a cohort of castration resistant prostate cancer (CRPC) patients (pts) treated with abiraterone acetate (AA) in a named patient program (NPP): Preliminary results from a retrospective study

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Background: AA provided a survival advantage compared to placebo, in pts who had received docetaxel for CRPC. Before the regulatory authority approval, AA was made available in Italy through a NPP supervised by the local ethic committees. The present retrospective study is aimed to assess PRE and CO in an unselected CRPC population which received AA by NPP. Methods: We retrospectively reviewed the clinical records of all pts treated with AA by NPP in our Institutions. For each pt we have recorded the pre and post-AA clinical history, the treatment details and outcomes. We have assessed the ability of a series of selected 22 clinical factors to predict AA response through a logistic regression analysis. Continuous variables were categorized by quartiles and chosen for the initial model after a univariate chi-square analysis. Results: To date we have collected a consecutive series of 136 pts from 13 Italian hospitals. The median age was 72 yrs (range 52-87). The median baseline PSA was 154 ng/ml (range 0.33->100.000); 80% and 16.7% of the pts showed bone and measurable lesions respectively. The median duration of AA treatment was 15 wks (range 1-73); 59 treatments are ongoing. Grade 3-4 toxicities were anemia (5 pts), nausea (1 pt), fatigue (4 pts), bone pain (3 pts), and hypokaliemia (1 pt). A PSA reduction > 50% was observed in 37.5% of the pts. Having a performance status (PS) 0-1 [(exp(beta) 4.541; p= 0.018], a previous ormonotherapy lasting >40 months [(exp(beta) 3.299; p= 0.020], baseline hemoglobin >12 g/dl [(exp(beta) 2.595; p= 0.074], no visceral organ involvement [(exp(beta) 1.929; p= 0.097] resulted to be independently predictive of a PSA reduction > 50%. The median PFS and OS were 5 mos and 14 mos, respectively; the 1-year PFS and OS rates were 25.7% and 53%, respectively. Conclusions: Our preliminary results have confirmed the efficacy of AA in second line CRPC outside clinical trials. Pts with good PS, with good hemoglobin levels, with long-lasting hormosensitivity, and without visceral organ involvement have higher probability to achieve a biochemical response to AA.

Postoperative radiotherapy (RT) with or without chemotherapy (CT) in anaplastic astrocitoma (AA) patients

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Background: Although the evidence for the benefit of adding temozolamide (TMZ) to RT is limited to glioblastoma patients (pts), there is currently an increased tendency toward a combined RT + TMZ approach also in AA patients. Methods: We report in this study the survival outcome of 2 groups of pts, treated at in 2 different periods at our institution with RT after surgery ± CT. GROUP A (years 1984-2001): pts treated with surgery followed by RT; GROUP B (YEARS 2004-2009): pts treated with surgery followed by radical RT and CT according to the STUPP’s protocol; Results: Data were retrospectively collected on a consecutive series: GROUP A: 17 pts: 10 Males (M), 7 Females (F); median age 50 years (range: 31-65). Ten out of 17 pts received radical surgery and 7 subtotal surgery. All were treated with postoperative RT, median dose 5082 cGy (range: 2160-6300). The mean time between surgery and beginning of RT was 44.7 days (range 20-87). GROUP B: 17 pts: 10 M, 7 F; median age 44 years (25-72). Eleven out 17 pts received radical surgery and 6 subtotal surgery. All were treated with postoperative RT, median dose 5800 cGy (range: 4000-600). The mean time between surgery and beginning of RT was 56.3 days (range 26-111). All patients received TMZ 75 mg/mq for a median of 6 weeks (range 3-7), followed by adjuvant treatment with TMZ (200 mg/mq) for a median of 5 cycles (range 0-13). At a median follow-up of 45 mos , the median OS was 29.1 mos for the group A and 49,1 mos for the group B. Among pts treated with RT + CT after surgery, median OS was significantly longer (p= 0.03), compared to those treated with only RT after surgery. Conclusions: The limited sample sizes of 2 groups and differences such as the median RT dose and the median time between surgery and RT, does not allow any conclusion. However, our data suggest that the combined RT-CT treatment is feasible in AA pts after surgery and may possibly contribute to a prolonged control of disease. These suggestions should be explored in a prospective randomized trial.