Abstract P6-10-02: MLN8237 (alisertib), an investigational Aurora A Kinase inhibitor, in patients with breast cancer: Emerging phase 2 results

Background: Aurora A Kinase (AAK) is a key mitotic regulator amplified or overexpressed in a variety of tumor types including pre-invasive and invasive breast cancer. In mouse mammary epithelium, AAK overexpression induces genetic instability and tumor formation. In breast cancer patients (pts), AAK overexpression is often associated with poor prognosis. Therefore, AAK is an attractive target in cancer treatment. MLN8237 is an oral, selective AAK inhibitor under evaluation in pts with different advanced tumors. An ongoing multi-indication phase 2 (NCT01045421) trial evaluates MLN8237 in pts with solid tumors; here we present preliminary phase 2 data on the breast cancer cohort.

Methods: Eligible pts were female ≥18 years of age with stage IV breast cancer, ECOG PS 0–1, measurable disease by RECIST, and ≤4 prior cytotoxic chemotherapy regimens. Stratification on receptor subtype was performed to ensure 8–10 pts with triple negative disease and 8–10 patients with HER2 positive disease. Oral MLN8237 50 mg was administered twice-daily for 7 days, followed by 14 days' rest in 21-day cycles. The primary objective was overall response rate; response was determined by RECIST v1.1. Secondary objectives included assessment of safety. A Simon's optimal 2-stage design was used; 20 pts were initially enrolled, and this cohort was expanded if ≥2 partial responses (PR) were observed in response-evaluable pts.

Results: In the first 20 pts, 2 had PR and the cohort was expanded to a total of 53 (data cut-off: March 29, 2012). Median age was 60 years (range 33–81). Pts received a median of 3 cycles (range 1–14) and 20 pts (38%) received ≥6 treatment cycles. Of 45 response-evaluable pts, 6 pts (13%) had a best response of PR and 26 (58%) had stable disease (SD). Median duration of SD was 68 days, of which 2 pts (4%) had SD for ≥6 months (clinical benefit rate [PR+SD ≥6 months] = 18%). One HER2+ patient with 2 prior lines of therapy (carboplatin/docetaxel/trastuzumab + trastuzumab maintenance; gemcitabine/lapatinib/ trastuzumab) had PR 6 months. Fifty-three pts were evaluable for toxicity. Drug-related adverse events (AEs) were reported in 49 pts (92%) and were commonly grade 1–2 in severity. The most frequent drug-related AEs included alopecia (n = 26, 49%), neutropenia (n = 25, 47%), diarrhea (n = 23, 43%), fatigue (n = 21, 40%), and stomatitis (n = 19, 36%). A total of 34 pts (64%) reported grade ≥3 drug-related AEs, including neutropenia (n = 23, 43%) and leukopenia (n = 8, 15%). Two pts (4%) discontinued due to AEs; there were no on-study deaths. Treatment is ongoing in 21 pts.

Conclusions: Emerging phase 2 data reported here provide preliminary evidence of antitumor activity of oral MLN8237 in pts with relapsed/refractory breast cancer. AEs were frequent but generally reversible and manageable by dose reduction and supportive care.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-10-02.

Skin toxicity and efficacy of sunitinib and sorafenib in metastatic renal cell carcinoma: a national registry-based study

BACKGROUND

A retrospective, registry-based analysis to assess the outcomes of metastatic renal cell cancer (mRCC) patients treated with sunitinib and sorafenib who developed dermatologic adverse events was performed.

PATIENTS AND METHODS

Data on mRCC patients treated with sunitinib or sorafenib were obtained from the Czech Clinical Registry of Renal Cell Cancer Patients. Outcomes of patients who developed hand-foot syndrome (HFS) of any grade and/or grade 3/4 rash during the treatment were compared with patients without HFS and no, mild, or moderate rash.

RESULTS

The cohort included 705 patients treated with sunitinib and 365 patients treated with sorafenib. For sunitinib, the median overall survival (OS) was 43.0 months versus 31.0 months (P = 0.027) and median progression-free survival (PFS) 20.8 months versus 11.1 months (P = 0.007) for patients with versus without dermatologic toxicity, respectively. For sorafenib, the median OS and PFS were 27.9 and 24.6 months (P = 0.244), and 12.2 and 8.8 months (P = 0.050), respectively. In multivariable Cox regression, the skin toxicity was significantly associated with longer OS in the sunitinib cohort.

CONCLUSION

The presence of skin toxicity is associated with improved OS and PFS in patients with mRCC treated with sunitinib.

Hepatic arterial infusion of oxaliplatin, 5-fluorouracil and leucovorin in patients with liver metastases from colorectal carcinoma

PURPOSE

Limited data are available regarding the efficacy of hepatic arterial infusion (HAI) of oxaliplatin in patients with liver metastases from colorectal carcinoma (CRC). The aim of the present study was to evaluate the results of HAI of oxaliplatin combined with 5-fluorouracil (5-FU) and leucovorin (LV) in patients with such metastases.

METHODS

A retrospective analysis of 22 CRC patients treated with HAI of combination of oxaliplatin and 5-FU and LV was performed.

RESULTS

Partial response (PR) was observed in 4 (18%) patients and stable disease (SD) in 7, with an overall disease control rate of 50%. The median progression-free (PFS) and overall survival (OS) were 7 and 11 months, respectively. Two patients treated with first-line treatment underwent subsequent liver resection. In 2 patients, HAI of oxaliplatin, 5-FU and LV was combined with systemic administration of bevacizumab.

CONCLUSION

Our data demonstrate reasonable efficacy of HAI with oxaliplatin, 5-FU and LV in patients with liver metastases from CRC.

Significance of the resection margin and risk factors for close or positive resection margin in patients undergoing breast-conserving surgery

PURPOSE

While positive resection margin (RM) in women undergoing breast-conserving surgery (BCS) represents a clear indication for re-resection, there is no unequivocal recommendation regarding the extent of the clear RM. The aim of this study was to define the optimal extent of the RM and the risk factors for close or positive RM.

METHODS

Patients scheduled for BCS had diagnosis confirmed before BCS (lumpectomy and quadrantectomy) by core biopsy. Sentinel lymph node biopsy followed BCS, and in case of positive findings axillary lymph node dissection followed. According to RM patients were categorized into 4 groups: 1) Patients with positive RM; 2) Clear RM < 2 mm; 3) Clear RM of 2-5 mm; and 4) RM > 5 mm. In the first 3 groups where re-resection was indicated, the presence of tumor cells in the re-resection specimen was determined. All patients were followed for local recurrence.

RESULTS

330 patients undergoing BCS were studied. Median follow up was 39.6 months (range 12-70). Lumpectomy was performed in 111 cases and quadrantectomy in 219. In 19 cases the final procedure was mastectomy due to the impossibility to achieve negative RM. In 78 cases re-resection followed the primary procedure due to close or positive RM. Clear RM was < 2 mm in 12 cases (15%), 2-5 mm in 56 (72%) and positive margin in 10 (13%). Positive re-resection specimen was detected in 31 cases (39.7%) (in 10 cases with positive RM after primary procedure, in 3 with negative margin < 2 mm and in 18 with 2-5 mm margin). The re-resection rate according to the location of the primary tumor was 77% (n=60) in the upper outer quadrant, 8% (n=6) in the lower outer quadrant, 6% (n=5) in the upper inner quadrant, 4% (n=3) in the lower inner quadrant, and 5% (n=4) in centrally located tumors. Multicentric/ multifocal tumor was diagnosed in 16 cases from which re-resection was indicated in 12 cases (75%). The number of re-resection according to tumor size was as follows: Tis 8 cases (30.7%), T1a none, T1b 14 (20.2%), T1c 34 (22.5%), T2 22 (28%). Re-resection was performed in 8 cases (31%) of ductal carcinoma in situ (DCIS), in 53 (22%) of ductal carcinoma, in 10 (37%) of lobular carcinoma, and in 7 (15%) of other histology. Five cases with local relapse were detected during follow up.

CONCLUSION

The generally recommended clear RM of 1-5 mm is not sufficient because of the high number of positive specimens in the case of clear RM of 2-5 mm. The risk factors for close or positive RM are multicentric tumors and upper outer location of the primary tumor. Longer follow up will be needed to analyze local relapse rate according to RM status.

[Good's syndrome (thymoma associated hypogammalobulinaemia) - 2 case reports]

Although tumours of the thymus are rare, they are common among neoplasms of the anterior superior mediastinum. They usually exhibit indolent behavior, but do have the capacity to invade surrouding structures. Their metastatic potential is low. Paraneoplastic complications including autoimmune disorders (frequently myastenia, cytopenia) or combined immunodeficiency are of clinical significance. Here we report two case reports of thymoma patients associated with secondary immunodeficiency known as Goods syndrom. The first case exhibited as symptomatic combinated immunodeficiency with oral lichen planus. Thymoma findings was accidental. Severity of immunodeficiency required long-term intravenous immunoglobulins supplementations, even after complete surgical resection. On the other hand, the second case manifested by signs of advanced local tumour growth. Antibiotic prophylaxis was selected as immunodeficiency treatment.

Analysis of CD40 expression in breast cancer and its relation to clinicopathological characteristics

Breast cancer is currently the most common cancer in women worldwide. For this reason, new biomarkers for better predicting response to treatment are needed. CD40, described as expressed in haematological and epithelial tumors, is linked to apoptosis and offers promise as a new predictive/ prognostic marker. We evaluated CD40 expression in formalin-fixed, paraffin-embedded samples from 181 breast carcinomas using immunohistochemical staining with CD40 antibody. Samples were divided according to hormone (oestrogen receptor /ER/, progesterone receptor /PR/) and her-2/neu status into groups: 1.Luminal A (ER+PR+her-2/neu-), 2. Luminal B (ER+PR+her-2/neu+), 3.Triple-negative (ER-PR-her-2/neu-) and 4. Her-2/neu (ER-PR-her-2/neu+). The results of CD40 staining were correlated with clinicopathological data. CD40 was found to be expressed in membrane, cytoplasm and nucleus. Normal ducts expressed cytoplasmic CD40 in 30% of cases, in breast tumor ducts in 53% of cases. CD40 was evaluated as an independent marker and significant positive correlation was found with Bcl-2 (p =0.002), early stage (p =0.016) and preoperative chemotherapy (p =0.043). There was higher overall survival for patients with cytoplasmic CD40 expression (0.05). Differences in expression of cytoplasmic CD40 between groups with different hormonal and her-2/neu status were statistically highly significant (p=0.00003). In groups with different hormonal status, a positive statistical correlation was found for the luminal A group with relapse (p=0.024) and stage (p=0.006). No correlation was found with age, disease onset, family history of cancer/ breast cancer, patient history, hormonal replacement therapy, menopausal status at onset of disease, adjuvant chemotherapeutic treatment or disease free survival. Nuclear expression of CD40 was found to be unrelated to any clinicopathological data. However, there was higher ratio of positive cases in cancer cases (83%) than in normal tissue (30%). In conclusion, cytoplasmic expression of CD40 is related to factors connected to better prognosis and suggest that CD40 may have potential as a new prognostic factor in breast cancer.

Sunitinib followed by sorafenib or vice versa for metastatic renal cell carcinoma--data from the Czech registry

BACKGROUND

Sequential therapy with tyrosine kinase inhibitors (TKIs), sunitinib and sorafenib, is a common treatment choice for patients with advanced/metastatic renal cell carcinoma (mRCC) despite lack of randomised trials. The aim of this retrospective registry-based study was to analyse the outcomes of RCC patients treated with sunitinib-sorafenib or sorafenib-sunitinib sequence.

PATIENTS AND METHODS

The Czech database containing information on patients treated for mRCC using targeted agents was used as a source of data for retrospective analysis. There were 138 patients treated with sunitinib-sorafenib sequence and 122 patients treated with sorafenib-sunitinib sequence.

RESULTS

Progression-free survival (PFS) was 17.7 months for patients treated with sunitinib-sorafenib sequence and 18.8 months for those receiving sorafenib followed by sunitinib (P = 0.47). Overall survival (OS) at 1 year was 83% [95% confidence interval (CI) 77% to 90%] for patients treated with sunitinib-sorafenib and 84% (95% CI 77% to 91%) for sorafenib-sunitinib patients (P = 0.99). Treatment toxic effects were predictable but a significant proportion of patients (up to 14%-25% for different lines of therapy and used TKI) switched between TKIs or discontinued TKI therapy because of toxicity.

CONCLUSIONS

In contrast to most of the previously published reports, we have not observed improved PFS or OS for mRCC patients treated with the sorafenib-sunitinib sequence as compared to the sunitinib-sorafenib sequence.

Pazopanib: a new multiple tyrosine kinase inhibitor in the therapy of metastatic renal cell carcinoma and other solid tumors

Angiogenesis plays a crucial role in tumor progression. Tumor angiogenesis is driven by host-derived circulating factors. Prominent among these factors is vascular endothelial growth factor (VEGF). Two basic approaches have been pursued in therapies targeting VEGF: neutralization of VEGF by antibodies or inhibition of VEGF receptor (VEGFR). VEGFR inhibition has relied on the use of small-molecular inhibitors. These drugs inhibit the tyrosine kinase activity of VEGFRs as well as other tyrosine kinases, and the term tyrosine kinase inhibitor (TKI) is used to describe this class of drugs. Pazopanib (GW786034), N(4)-(2,3-dimethyl-2H-indazol-6-yl]-N(4) - methyl-N(2)-(4-methyl-3-sulfnonamidophenyl)-2,4-pyrimidinediamine, is a novel orally bioavailable TKI that targets VEGFR1, VEGFR3, platelet-derived growth factor receptor (PDGFR)-alpha, PDGFR-beta and c-kit. Activity was observed in early clinical testing, specifically in patients with metastatic renal cell carcinoma (RCC). In subsequent phase II and phase III trials, the activity of pazopanib was comparable to other targeted agents used in the first-line therapy of metastatic RCC. Promising activity was reported in a number of other tumors, including metastatic carcinoma of the uterine cervix and differentiated carcinomas of the thyroid.

Prognostic significance of increased urinary neopterin concentrations in patients with breast carcinoma

Increased serum or urinary concentrations of neopterin have been described in patients with tumors of different primary locations, but reports on neopterin in patients with breast carcinoma are relatively innumerous. We have evaluated urinary neopterin in 456 patients with breast carcinoma. Urinary neopterin was determined using high-performance liquid chromatography. Neopterin in patients was increased only in a minority of patients with breast carcinoma. Increased urinary neopterin was associated with inferior overall survival. Prognostic significance of increased urinary neopterin was evident in patients with tumors expressing hormone receptors or/and human epidermal growth factor receptor (HER)-2, but not in patients with triple negative tumors. Among other parameters determined, C-reactive protein, hemoglobin, peripheral blood neutrophil count and platelet count were significant prognostic factors. On multivariate analysis, age, expression of hormone receptors, neutrophils, stage and hemoglobin concentration were independent prognostic indicators. In conclusion, serum neopterin is increased only in a minority of patients with breast carcinoma. Increased urinary neopterin was predictive of poor survival in univariate, but not multivariate analysis. Age, expression of hormone receptors, neutrophils, stage and hemoglobin concentration were independent prognostic indicators.

[Pancreatic cancer surgery at Ist Surgical Clinic of the Olomouc Faculty Hospital (FN Olomouc)]

INTRODUCTION

Surgical treatment plays a key role in the efforts to improve prognosis of patients with pancreatic cancer. The pancreatic cancer incidence rates are on increase and so does the number of patients undergoing potentially curative resection procedures. However, despite all diagnostic advancements and treatments adjusted to specific patient's needs, the outcomes are not satisfactory enough. The aim of the surgical procedure is to radically remove the tumor, including the regional lymph nodes, to promote early and uncomplicated healing and to facilitate early initiation of oncological treatment.

AIM

The aim of the study was to assess current potential of diagnostic and surgical treatment in pancreatic cancer when all currently available diagnostic methods are emloyed and to present the university clinic's outcomes. METHODS AND PATIENT GROUP: From 2006 to IX 2010, a total of 177 pancreatic resections and 123 right-sided pancreatoduodenectomies for malignant disorders were performed at the authors' clinic. 76 pancreatoduodenectomies were performed for ductal carcinoma of the pancreatic head. The study group included 51 males and 25 females, the mean age of 62.9 years. Based on the TNM classification (UICC), 11% of the subjects presented with stage I, 78% with stage II and 3% with stage III diseases. The procedures radicality was the following: R0 in 59 subjects, R1 in 5 subjects while in 12 subjects, the radicality was undetected by the authors. Histopatological grading in this patient group was as follows: G1 in 20%, G2 in 34% and G3 in 46% of the subjects. Perineural invasion, invasion into lymphatic vessels or other vessels was not detected in 21 subjects (27.6%). The authors assessed complication rates based on the DeOliveira classification and survival rates in individual disease stages.

OUTCOMES

Complications occurred in 44.7% of the operated subjects. Serious complications requiring reintervention were reported in 13 subjects (17.1%), including reinterventions in general anesthesia in 10 subjects (13.1%). Two patients died: a 79-year old female died from multiorgan failure as a result of aspiration, and a 76-year old male died from multiorgan failure following completion of pancreatectomy due to pancreaticojejunal anastomosis insufficiency. The thirty- and sixty-day mortality rate was 2.6%, however, it was null over the past three years. The mean survival time was 17.1 months, with the median of 13.5 months. The patient group's overall 3-, 6-, 9-, 12, 15- and 18- month survival following radical resections was 95.6%, 90.3%, 76.3%, 62.7%, 52.3% and 45%, respectively. 82%, 52%, 35% and 35% of the operated stage I patients survived 1, 2, 3 and 4 years, respectively. The mean hospitalization duration was 16.8 days (10-45).

CONCLUSION

Although the procedures are extremely demanding, especially in the reconstruction phase, the outcomes have improved significantly due to ongoing experience, improvements in the surgical technique and in the complex postoperative care. At specialized clinics, the mortality rate has dropped below 5%, the morbidity rate below 40% and the postoperative dehiscence rates below 10%. During the past three years, the authors' clinic has reached null 30- and 60-day mortality rate following the pancreatic head resections, the complication rate following pancreaticoduodenal anastomosis is slightly above 5% (6.5%) and the morbidity rate is slightly above 40% (44.7%). The authors consider the procedure safe at their clinic and all indicated patients are expected to benefit from it.

Repeated chemosensitivity testing in patients with epithelial ovarian carcinoma

Epithelial ovarian carcinoma (EOC) is a highly chemosensitive tumor, but most patients with advanced EOC initially responding to first-line chemotherapy will eventually relapse. Chemosensitivity testing may offer an opportunity for the optimal selection of chemotherapeutic agents for individual patients. In the present retrospective analysis we have examined the changes in chemosensitivity profiles during the course of the disease. Chemosensitivity was determined using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) test. Two or more samples at least 14 days apart were obtained from 34 patients with ovarian cancer. Chemoresistance increased significantly at the second measurement only for paclitaxel and carboplatin, the most frequently used cytotoxic drugs. No significant difference compared to baseline was observed at subsequent measurements for any other cytotoxic agent studied, although a non-significant trend for increased chemoresistance was observed. In conclusion, in the present cohort only paclitaxel and carboplatin chemosensitivity changed significantly, although to a limited extent, during the course of the disease. In contrast to a limited increase of paclitaxel and carboplatin chemoresistance, no significant changes were observed for other cytotoxic agents examined. The present data indicate that chemoresistance increases, to a modest extent, against the drug most frequently used, but remains relatively stable during the course of disease, especially for agents that are not used in the therapeutic regimen.

Effect of comorbidity on urinary neopterin in patients with breast carcinoma

Urinary neopterin is increased in less than 20% of patients with breast carcinoma. Moderately increased neopterin concentrations are also known to accompany comorbid conditions commonly observed in patients with breast carcinoma, for example, diabetes mellitus or complications of atherosclerosis. In the present study, we evaluated the effect of the presence of comorbid conditions on urinary neopterin. A trend for higher neopterin concentrations was observed in patients with most of the comorbid conditions, but significantly higher neopterin was observed only in patients aged 70 years or older and in a heterogeneous group of patients with comorbidity other than diabetes mellitus, thyroid disorder, hyperlipidaemia, cardiac disorder or other malignancy. Significantly higher neopterin levels were noted in patients with two or more comorbid conditions. In conclusion, present data demonstrate an association between systemic immune activation reflected in increased urinary neopterin concentrations and age or presence of comorbid diseases in patients with breast carcinoma. A cumulative effect was observed with the presence of two or more comorbid conditions resulting in significantly increased urinary neopterin. These observations should be taken into account when interpreting the changes of parameters of systemic immune and inflammatory response in patients with breast carcinoma.

Final results of the phase III, randomized, double-blind AVOREN trial of first-line bevacizumab (BEV) + interferon-α2a (IFN) in metastatic renal cell carcinoma (mRCC)

5020

Background: In the AVOREN trial, BEV (Avastin) + IFN significantly improved PFS and ORR compared with placebo + IFN in pts with mRCC [Escudier, Lancet. 2007]. The study was unblinded after interim analysis due to significant superiority of BEV + IFN and the DSMB recommended crossover of pts from placebo to BEV (n = 13). We report here the results of the final analysis. Methods: Eligible pts had predominantly clear-cell mRCC, prior nephrectomy, no prior systemic therapy for metastatic disease, KPS ≥70%, no CNS metastases and adequate organ function. Pts were randomised to IFN (9MIU tiw) + BEV (10 mg/kg q2w) or placebo until disease progression. Primary endpoint was OS, with pre-planned stratified and unstratified analyses according to regional regulatory requirements. Results: 649 pts were randomised to BEV + IFN (n = 327) or placebo + IFN (n = 322). An independent radiological review confirmed previous investigator assessments, showing PFS of 10.4 vs 5.5 months (HR 0.57) and a response rate of 31% vs 12% in the two arms, verifying the robustness of the investigator analysis. At the time of final OS analysis (444 events), median follow-up was 22.9 months in the BEV arm and 20.6 months in the placebo arm. Final median OS stratified for region and Motzer score was 23.3 months in the BEV + IFN arm and 21.3 months in the IFN + placebo arm (HR 0.86 [95% CI: 0.72–1.04], p = 0.1291). No new or unexpected AEs were observed. More pts in the IFN + placebo arm than the BEV + IFN arm received post-protocol therapy, including TKIs, mTOR inhibitors, cytokines and chemotherapy: 180 (55%) in the BEV + IFN arm and 202 (63%) in the IFN + placebo arm. Exploratory analysis showed that median OS in pts receiving second-line TKI therapy (BEV + IFN, n = 96; IFN + placebo, n = 81) was 38.6 months vs 33.2 months (HR = 0.77 [95% CI: 0.51–1.15], p = 0.1948). Further subgroup analyses will be presented. Conclusions: BEV + IFN is a first-line standard of care for pts with mRCC, improving PFS and ORR, with a trend toward improved OS, compared with IFN. The observed OS results may have been influenced by subsequent anti-neoplastic therapy, which was not prespecified in the protocol and represents an uncontrolled element of the OS analysis.

[Table: see text]