Adrenal Insufficiency Related to Anti-Programmed Death-1 Therapy

BACKGROUND/AIM

Adrenal insufficiency is one of the adverse events (AEs) associated with anti-programmed death-1 (PD1) therapy. Delaying diagnoses can lead to serious conditions. It is necessary to elucidate detailed clinical features of these AEs.

PATIENTS AND METHODS

Patients treated with anti-PD-1 monotherapy or in combination with anti-cytotoxic T cell lymphocyte-4 therapy at our hospital from January 2013 to December 2016 were identified. The patients' clinical characteristics and laboratory and radiologic findings were collected.

RESULTS

Adrenal insufficiency occurred in 3% of the patients. All patients were male. At the onset of symptoms, eosinophilia (>500/μl) was observed in four cases. Eosinophilia was observed more than a month before onset of symptoms in three cases. Other pituitary hormones remained relatively stable. Radiological evidence of pituitary inflammation was detected only in one case.

CONCLUSION

Most anti-PD1-related adrenal insufficiency cases involved an isolated ACTH deficiency. Eosinophilia may be an early indicator before the onset of symptoms.

Prospective exploratory study of gemcitabine and S-1 against elderly patients with advanced non-small cell lung cancer

A prospective study was conducted to investigate the efficacy of a combined regimen of gemcitabine and S-1 for the treatment of elderly patients (>70 years) with advanced non-small cell lung cancer (NSCLC) as a first-line setting based on the dosage recommended in a previous phase I study. Chemotherapy-naïve patients with advanced NSCLC received gemcitabine plus S-1. S-1 (40 mg/m²) was administered orally twice daily for 14 days while gemcitabine (1,000 mg/m²) was administered on days 1 and 15 of each cycle, and this regimen was repeated every 4 weeks. A total of 20 patients were included in the present study. Of these, 8 patients achieved an overall response rate of 40.0%, and the overall disease control rate was 65.0%. According to the histological type, the response rate in patients with NSCLC and adenocarcinoma was 38.5%, and that for non-adenocarcinoma was 42.9%. Progression-free survival and median survival times were 6.4 months and 17.8 months, respectively. Grade 3 or 4 hematological toxicities observed were leukopenia (29%) and neutropenia (24%), while febrile neutropenia was not observed in any patient. The only non-hematological adverse event observed was grade 3 skin rash (10%). Therefore, the combination of gemcitabine and S-1 may be a promising and feasible regimen in the first-line setting for elderly patients with advanced NSCLC.

Detection of EGFR mutations in NSCLC patients in clinical practice: Comparison between cobas and Scorpion ARMS method

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Background: Epidermal growth factor receptor (EGFR) mutation is the most important factor for determining the treatment strategy for non-small-cell lung cancers (NSCLCs). Currently, two methods (cobas and Scorpion ARMS) have been approved as companion diagnostics for using EGFR tyrosine kinase inhibitor (TKI). Although there are some differences in the spectrums and sensitivities for detecting EGFRmutations such as exon 19 deletions (ex19del), L858R and T790M mutations, the extent of the differences affecting clinical practice is unclear. Methods: All patients with NSCLC who underwent EGFR mutation tests and treated at our hospital from February 2014 to February 2016 were enrolled. To detect EGFR mutations, the Scorpion ARMS (S) method was used from 2014 to 2015 and thecobasEGFR Mutation Test (C) from 2015 to 2016. We retrospectively investigated the detection rate of each EGFRmutation type and compared the rates between the two methods. Results: A total of 1,287 patients were enrolled. To detect EGFR mutations, 627 patients were tested by the S method and 660 by the C method, respectively. Of 1287 patients, 910 patients underwent initial biopsy, whereas 121 patients underwent re-biopsy after EGFR-TKI failure. EGFRmutations were detected in 130 of 418 (31.1%) patients and 153 of 492 (31.1%) patients by the S and C methods, respectively in the initial biopsy (P = 0.982). However, the detection rate of ex19del was slightly lower in the S method (12.6%) than in the C method (16.3%) (P = 0.105). Conversely, the detection rate of L858R was lower in the C method (13.8%) than in the S method (16.7%), but the difference was not significant (P = 0.252). De novo T790M was detected in one (0.2%) patient by the S method and in none by the C method. In re-biopsy after EGFR-TKI failure, the detection rates of T790M were as follows: 19 of 55 patients (34.5%) by the S method and 20 of 66 (30.3%) by the C method (P = 0.619). Conclusions: The different spectrums and sensitivities of EGFR mutations between the S and C methods were observed; however, they did not significantly affect clinical practice.

Monitoring of peripheral lymphocyte and neutrophil counts to predict efficacy of nivolumab (nivo)

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Background: Programmed death-1 (PD-1) antibody is a key drug for treating non-small cell lung cancer (NSCLC), but the response rate is about 20% in non-selected populations and efficacy is difficult to predict. We examined correlations between peripheral blood tests, including counts of lymphocytes (Lym), neutrophils (Neu), and C-reactive protein (CRP), and the efficacy of nivolumab (nivo) monotherapy. Methods: Eighty NSCLC patients treated with nivo (3mg/kg every 2 weeks) in our hospital between December 2015 and September 2016 were evaluated. Peripheral blood tests on day (d) 0 (the day before 1st nivo), d15 (the day of 2nd nivo), d29 (the day of 3rdnivo) were evaluated. Absolute counts and the change ratio (%) of Lym, Neu and CRP from baseline (d0) were calculated. Response to nivo was evaluated according to RECIST v1.1. Results: Response to nivo was partial response in 23 cases, stable disease in 13 and progressive disease (PD) in 44 patients (overall response rate, 28%; disease control rate, 45%). Absolute counts of Lym, Neu and CRP at baseline did not differ significantly between non-PD and PD (Lym, 1323/µl vs. 1376/µl; Neu, 4830/µl vs. 5189/µl; CRP, 3.48 mg/dl vs. 3.38 mg/dl). Neu was significantly increased from baseline to d15 and d29 in the PD population compared with the non-PD population (δNeu (d15): 25.2% vs. -6.3%, P= 0.008; δNeu (d29): 16.7% vs. -8.6%, P= 0.006). CRP was also significantly increased from baseline to d29 in the PD population compared with the non-PD population (δCRP: 60.1% vs. -21.2%, P= 0.010). In contrast, Lym was significantly increased from baseline to d29 in the non-PD population compared with the PD population (δLym: 9.6% vs. –6.7%, P= 0.010). Conclusions: Changes in peripheral blood test results after nivo differed between non-PD and PD populations. Monitoring of Neu and Lym and CRP may allow prediction of the efficacy of nivo.

Clinical and radiological features of advanced RET-rearranged lung cancer

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Background: RET fusion gene was found in 1–2% of non-small cell lung cancer (NSCLC). Most of the reports published so far investigated only surgical specimens, and details of advanced tumors were unknown. This study explored the clinical and radiological characteristics of RET-rearranged lung cancers in advanced stages. Methods: Among 1,074 advanced NSCLC patients who were treated at The Cancer Institute Hospital, Tokyo, from 2012 to 2016, 14 cases (14/1,074 = 1.3%) were treated as RET- rearranged lung cancer. The cases were identified by FISH and / or by RT-PCR (FISH 3, RT-PCR 2, FISH and RT-PCR 8, unknown 1). The fusion partner genes included KIF5B (n = 10), CCDC6 (n = 1). Three were unknown. The tumor size, location, and shape/margins of the primary tumor as well as lymphadenopathy and site of metastasis were recorded based on computed tomography (CT) images taken right before the initial chemotherapy. Results: The median age of the 14 patients was 64 years (range, 34–79), with 10 patients (71%) over 60 years old. Nine patients (64%) were women, whereas 10 patients (71%) were never smokers. Eight patients were classified as stage IV and 6 underwent recurrence after surgery. We successfully evaluated CT images at the initial chemotherapy of 12 patients. Of the 7 patients whose primary lesions were detectable, all were located peripherally and were of a solid tumor type without ground-glass, air bronchograms, or cavitation. The median size of the primary lesion was 3.0 cm (range, 1.2–6.8), and 3 lesions were less than 3.0 cm. Only 5 patients had lymphadenopathy (4 were of Stage IV, 1 was a recurrence), most of which were isolated with a median size of 1.5 cm (range, 1.2–3.5). The sites of distant metastases included 8 pleural disseminations, 5 lungs, 5 bones, 3 livers, 2 brains, and 0 adrenals. Conclusions: Advanced RET-rearranged lung cancer manifested as a relatively small and peripherally located solid primary lesion with isolated lymphadenopathy. Pleural dissemination was frequently observed, whereas brain metastasis was less frequent. These features differ from EGFR-mutated or ALK-fused lung cancers.

The efficacy and toxicity of osimertinib in T790M-positive NSCLC with acquired resistance to EGFR-TKI in clinical practice

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Background: A Phase III study (AURA3) demonstrated that osimertinib prolonged PFS compared to platinum doublet in patients with T790M-positive non-small-cell lung cancer (NSCLC) exhibiting acquired resistance to epidermal growth factor receptor- tyrosine kinase inhibitor (EGFR-TKI). Although the patients in the study had good PS and only one prior EGFR-TKI treatment, most practical patients had multiple prior EGFR-TKI and poor PS. Moreover, several patients exhibited symptomatic central nervous system (CNS) metastasis in clinical practice. In this study, we evaluated the efficacy and toxicity of osimertinib in clinical practice. Methods: We retrospectively analyzed 30 patients who were treated with osimertinib at our hospital from April 11th 2016 to September 30th 2016. The efficacy and toxicity was compared between the patients with matched and unmatched AURA3 eligibility criteria. Efficacy was evaluated according to RECIST ver.1.1 and toxicity was evaluated using CTCAE ver.4.0. Results: A total of 9 out of 30 patients matched the AURA3 eligibility criteria (PS ≤ 1 and one prior EGFT-TKI) and 21 patients were unmatched (PS ≥ 2 or two or more EGFR-TKI or symptomatic CNS metastasis). The overall response rate(ORR) of osimertinib was 78% and 67% for the matched and unmatched patients, respectively. The disease control rate (DCR) was 100% and 90% for the matched and unmatched patients, respectively. In addition, the response rate of symptomatic CNS metastasis was 67%. Regarding toxicity, grade 3/4 toxicities were observed in 22% of the matched patients and 33% of the unmatched patients. In the matched patients, the most frequent AE was a rash (89%) and the frequent grade 3/4 toxicities were a rash (22%) and pneumonitis (11%). In unmatched patients, the most frequent AE was also a rash (57%), but the frequent grade 3/4 toxicities were pneumonitis (14%), rash (10%), and neutropenia (10%). Conclusions: Both the ORR and DCR in the unmatched patients were slightly lower than the matched patients; however, osimertinib was still found to be beneficial in clinical practice.

Preexistence of CT findings with usual interstitial pneumonia (UIP) pattern correlates to radiation pneumonitis (RP) in non-small cell lung cancer (NSCLC) patients receiving chemoradiotherapy (CRT)

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Background: RP is a major toxicity commonly observed in NSCLC patients who receive CRT; RP prediction is a critical issue. Although preexisting interstitial pneumonia (IP) is considered as one of the risk factors of RP, the correlation between interstitial lung shadows (ILSs) in the pretreatment CT scan and RP is not well examined. Methods: We reviewed patients with stage III NSCLC who received CRT at our hospital from January 2011 until December 2014. The pretreatment CT scans were retrospectively evaluated, and preexisting ILSs were classified according to the ATS/ERS/JRS/ALAT statement for idiopathic pulmonary fibrosis (IPF) as follows: UIP pattern, possible UIP pattern, and others (not UIP pattern). The incidence, severity, and features of RP were compared between ILS patterns. Results: In total, 105 patients with stage III NSCLC had received CRT. ILSs in pretreatment CT scans were identified in 16 (15.2%) of 105 patients. Of all the identified patterns, one (0.9%) was UIP pattern, six (5.7%) were possible UIP pattern, and nine (8.6%) were not UIP pattern. Grade 3 or higher RP was observed in 2 of 7 (28.6%) patients with UIP pattern or possible UIP pattern and 1 of 9 (11.1%) patients with not UIP pattern ( P = 0.55). RP that extended outside the irradiation field like an acute exacerbation of IP was observed in 4 of 7 (57.1%) patients with UIP pattern or possible UIP pattern and 1 of 9 (11.1%) patients with not UIP pattern ( P = 0.106). Conclusions: Preexistence of ILSs classified as UIP pattern or possible UIP pattern should be considered as a risk factor for severe or extensive RP after CRT.

First-in-human phase I study of an oral HSP90 inhibitor, TAS-116, in advanced solid tumors

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Background: TAS-116 is an oral non-ansamycin, non-purine, and non-resorcinol highly selective inhibitor of HSP90α/β. The objective of this FIH study was to determine the MTD and investigate the safety, tolerability, PK, PD (HSP70 protein levels in PBMCs), and antitumor activity of TAS-116. Methods: The study is being conducted in Japan and the UK. Patients with advanced solid tumors received escalating doses of TAS-116 once daily (QD) with an accelerated titration design. After the MTD was determined, safety and tolerability of 5 days on / 2 days off per week administration (QDx5) at the MTD in QD was explored. In parallel, the MTD with every other day administration (QOD) was evaluated by using a 3 + 3 design. Results: As of 20 September 2016, 52 patients were enrolled. TAS-116 was evaluated at doses of 4.8 to 150.5 mg/m2/day in the QD schedule and doses of 107.5 to 295.0 mg/m2/day in the QOD schedule. The MTD was 107.5 mg/m2/day with QD and 210.7 mg/m2/day with QOD. QDx5 at the MTD in QD using a flat dose of 160 mg was evaluated. The most common adverse events in all regimens were gastrointestinal disorders and increased creatinine. DLTs were observed in 4 patients in QD (night blindness, visual disorder, AST/ ALT/gamma-GTP elevations, and anorexia) and in 2 patients in QOD (platelet count decreased, febrile neutropenia, pneumonia, respiratory failure, and septic shock). Reversible eye disorders were observed in all schedules, but those observed in QDx5 were limited to grade 1. The PK level demonstrated dose proportionality without unexpected accumulation under repeated administration. Dose-related HSP70 induction of PBMCs was observed. As of 20 September 2016, three confirmed durable PRs by RECIST were observed (239 days in GIST and 173 days in NSCLC with QD; 293 + days in NSCLC with QOD). PR and SD ≥ 12 weeks were observed in 15 out of 47 patients. Conclusions: TAS-116 had an acceptable safety profile under all schedules, especially QDx5. Preliminary antitumor activity was demonstrated with evidence of target engagement. Dose expansion at the MTD in this phase 1 study and the phase 2 study in patients with GIST are ongoing. Parts of this study will be expanded to the US with an amended study protocol. Clinical trial information: NCT02965885.

The reasons why re-biopsies were not performed after failure with EGFR-TKI

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Background: Repeat biopsy becomes important to determine subsequent treatment after failure of EGFR-TKI. However, some patients did not receive re-biopsy in real world. Here we retrospectively analyzed the reasons why the patients did not receive re-biopsy. Methods: We reviewed medical records of 235 patients treated with EGFR-TKI at our institution between January 2014 and September 2016 and analyzed the treatment, the progression site after failure of EGFR-TKI and the reasons why they did not receive re-biopsy. Results: 127 of 235 (54%) patients had tumor progression after treatment with EGFR-TKI and 93 (73.2%) of 127 patients received re-biopsy and 34 (26.8%) patients didn’t. The characteristics of 34 patients who did not received re-biopsy were; the median age, 67 years (29-83), male/ female: 12/22, PS0-1/2 ≥:27/7, stage IV/recurrence/other:20/10/4, smoking history never/ex/current: 15/17/2, histology : adeno/other 34/0, EGFR mutation type; 19del/L858R/Other = 13/15/6, prior EGFR-TKI; Gefitinib/Erlotinib/Afatinib/other: 22/9/2/1. The commonest reason why they did not receive re-biopsy was no target lesion to get biopsy (n = 13,38%). CT scans of these patients were retrospectively evaluated and it was confirmed that there were no lesions that could be accessed safely at that time. Central nervous system lesions, multiple small pulmonary lesions and bone metastasis were unaccessible lesions. Although 21 patients had accessible lesions including lung, superficial lymph nodes, pleural effusion, liver, they did not receive re-biopsy because of patient refusal (n = 9), worsening of general condition (n = 3), need for other therapy immediately (ex: chemotherapy, radiotherapy) (n = 3), old age (n = 2), existence of de novo T790M (n = 2), complications (n = 1) and physician’s choice (n = 1). Conclusions: Some patients who did not recieve re-biopsy had some target lesions and it could be increase the re-biopsy rate.

Correlation of low CT attenuation and necrotic features of tumor in contrast-enhanced CT with nivolumab response

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Background: Anti-PD1/PD-L1 antibodies, including nivolumab, produce durable responses in non-small cell lung cancer (NSCLC), but the response rate is about 20% in unselected NSCLC. Identifying predictive markers of response is necessary. Although PD-L1 expression may be a potential biomarker, evaluating whole tumors based on a small sample is difficult. Identifying radiographic features of responders can be very useful. We hypothesized that low attenuation on computed tomography (CT), considered to represent necrosis, correlates with nivolumab response. Methods: We retrospectively evaluated contrast-enhanced CT images before treatment and tumor response in 60 patients receiving nivolumab. The largest tumor lesion was characterized in each patient. CT attenuation (CTA) of whole tumor areas was measured; the presence of radiological findings of necrosis (necrotic features), presenting cavitation or ring- or patchy-enhancement in tumors, were assessed. We evaluated the association between CT imaging characteristics and nivolumab response and that between CT imaging characteristics and PD-L1 expression in tumors. Results: Thirty-nine target lesions in lung, 12 in lymph node, and 9 in other organs were chosen. The mean CTA was 58.5 ± 15.3 HU. Necrotic feature were observed in 24 (40%) of 60 lesions.Twenty of 60 lesions (33%) shrank to > 30% with nivolumab treatment. Mean CTA in responding lesions was 48.6 HU, significantly lower than that in nonresponding lesions (63.4 HU) (p < 0.001). The response rate of lesions with/without necrotic features was 45% and 28%, respectively (p = 0.246).Systemic tumor response, assessed by RECIST v1.1, was confirmed in 20 (33%) patients. Mean CTA of target lesions was lower in responders than patients with stable disease or progressive disease (51.4 vs. 62.0 HU, p = 0.011). The systemic response rate of lesions with/without necrotic features was 50% and 25%, respectively (p = 0.081).Mean CTA of target lesions was lower in tumors with high PD-L1 expression than in tumors with low PD-L1 expression (54.8 vs. 64.4 HU, p = 0.045). Conclusions: Low CTA and necrotic features in CT may correlate with nivolumab response. Tumors with low CTA may have high PD-L1 expression.

Phase Ia/Ib study of the pan-class I PI3K inhibitor pictilisib (GDC-0941) administered as a single agent in Japanese patients with solid tumors and in combination in Japanese patients with non-squamous non-small cell lung cancer

Pictilisib (GDC-0941) is an oral class I phosphatidylinositol-3-phosphate kinase inhibitor. This phase Ia/Ib study investigated the safety, tolerability, pharmacokinetics, and pharmacodynamics of pictilisib in monotherapy or in combination with carboplatin-paclitaxel and bevacizumab (CP + BEV) in Japanese patients with advanced solid tumors or non-squamous non-small cell lung cancer. A standard 3 + 3 dose escalation design was applied. In stage 1, 140, 260, or 340 mg/day of pictilisib was administered once daily to 12 patients with advanced solid tumors. In stage 2, 260 or 340 mg/day of pictilisib was administered in combination with CP + BEV to 7 patients with advanced non-squamous non-small cell lung cancer. In stage 1, 1 of 6 patients in the 340 mg/day cohort exhibited dose limiting toxicity (DLT) of grade 3 maculopapular rash. The maximum plasma concentration and area under the curve of pictilisib were dose-dependent. A reduction in phosphorylated AKT in platelet rich plasma was observed. No patient had an objective anti-tumor response. In stage 2, DLT was observed in 1 of 3 patients in the 260 mg/day cohort (grade 3 febrile neutropenia), and 2 of 4 patients in the 340 mg/day cohort (1 each of grade 3 febrile neutropenia and grade 3 febrile neutropenia/erythema multiforme). Partial responses were observed in 3 out of 7 patients. In conclusion, pictilisib was shown to have good safety and tolerability in Japanese patients with advanced solid tumors. A recommended dose of pictilisib in monotherapy was determined to be 340 mg once daily. For combination with CP + BEV, tolerability up to 260 mg/day was confirmed.

P-glycoprotein Mediates Ceritinib Resistance in Anaplastic Lymphoma Kinase-rearranged Non-small Cell Lung Cancer

The anaplastic lymphoma kinase (ALK) fusion oncogene is observed in 3%–5% of non-small cell lung cancer (NSCLC). Crizotinib and ceritinib, a next-generation ALK tyrosine kinase inhibitor (TKI) active against crizotinib-refractory patients, are clinically available for the treatment of ALK-rearranged NSCLC patients, and multiple next-generation ALK-TKIs are currently under clinical evaluation. These ALK-TKIs exhibit robust clinical activity in ALK-rearranged NSCLC patients; however, the emergence of ALK-TKI resistance restricts the therapeutic effect. To date, various secondary mutations or bypass pathway activation-mediated resistance have been identified, but large parts of the resistance mechanism are yet to be identified. Here, we report the discovery of p-glycoprotein (P-gp/ABCB1) overexpression as a ceritinib resistance mechanism in ALK-rearranged NSCLC patients. P-gp exported ceritinib and its overexpression conferred ceritinib and crizotinib resistance, but not to PF-06463922 or alectinib, which are next-generation ALK inhibitors. Knockdown of ABCB1 or P-gp inhibitors sensitizes the patient-derived cancer cells to ceritinib, in vitro and in vivo. P-gp overexpression was identified in three out of 11 cases with in ALK-rearranged crizotinib or ceritinib resistant NSCLC patients. Our study suggests that alectinib, PF-06463922, or P-gp inhibitor with ceritinib could overcome the ceritinib or crizotinib resistance mediated by P-gp overexpression.

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Ceritinib resistant patient-derived cancer cells overexpress P-gp without having mutation in ALK and other major oncogenes.

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P-gp overexpression conferred the resistance to ceritinib and crizotinib but not to alectinib and PF-06463922.

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Ceritinib is a substrate of P-gp, and P-gp-inhibitors or knockdown of P-gp reversed ceritinib resistance.

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P-gp overexpression was observed in 3 out of 11 crizotinib- or ceritinib-resistant ALK-rearranged NSCLC patients.

For treatment of ALK-rearranged NSCLC, two ALK-TKIs, crizotinib and ceritinib are currently in use, but the emergence of acquired resistance limits the efficacy of ALK-TKIs. Except for the resistance-associated mutations in ALK, ALK-TKIs resistance mechanisms are still largely unknown. Here we identified P-gp overexpression mediating resistance in three ceritinib-resistant ALK-rearranged NSCLC patients. P-gp overexpression conferred ceritinib and crizotinib resistance but did not confer alectinib and PF-06463922 resistance, and treatment using P-gp inhibitor with ceritinib, or alectinib- or PF-06463922- monotherapy overcame the resistance, suggesting that P-gp expression could be an important determinant in the future treatment strategies.

Abstract B87: First-in-human phase I dose escalation study of TAS-116, a novel, orally active HSP90α and HSP90β selective inhibitor, in patients with advanced solid tumors

Purpose: TAS-116 is a potent non-ansamycin, non-purine, and non-resorcinol orally available highly selective inhibitor of HSP90α and HSP90β. The primary objective of this phase I first-in-human study was to determine maximum-tolerated dose (MTD) of two TAS-116 dosing regimens and estimate recommended phase 2 dose (RP2D) in patients with advanced solid tumors. Secondary objective was to investigate safety, pharmacokinetic and pharmacodynamic profiles.

Methods: Eligible patients included those 20 years or older of age with advanced solid tumor that was refractory to conventional treatment or for which no standard therapy existed and ECOG performance status of 0 or 1. TAS-116 was administered orally once daily (Step1) and then subsequently every other day (Step 2) of a 21-day cycle in an accelerated titration dose escalation and a standard 3+3 dose escalation, respectively. Pharmacokinetics was measured after single and multiple dose. Pharmacodymanics was assessed by HSP70 induction in peripheral blood mononuclear cells (PBMCs).

Results: As of 17 Jun 2015, 16 patients were enrolled in Step 1 followed by 3 in Step 2. (57% male, median age of 56, 70% PS 0). The numbers of types of tumors were 13 with non-small cell lung cancer (NSCLC), 2 with gastrointestinal stromal tumor (GIST), 2 with thymic carcinoma, and 2 with others. In Step 1, TAS-116 was evaluated at 7 dose levels of 4.8 to 150.5 mg/m2. The most common treatment related adverse events were increased creatinine, diarrhea, increased alkaline phosphatase, night blindness, nausea, anorexia and skin rash. Dose limiting toxicities (DLTs) occurred in 4 patients at 107.5 mg/m2 and 150.5 mg/m2, with grade 3 night blindness and visual disorder, grade 3 AST/ ALT/ gamma-GTP elevations, and grade 3 anorexia. Night blindness and visual disorder including grade 3 were reversible when study drug was interrupted. 107.5 mg/m2 was determined as the once daily MTD and additional patients are being investigated at this dose to confirm tolerability. TAS-116 exposure was increased dose-dependently without unexpected accumulation after repeated administrations. HSP70 induction in PBMC was observed, indicative of target engagement. Of 16 evaluable patients on once daily dosing, there was two confirmed partial response (GIST and NSCLC). Five patients had stable disease more than 12 weeks.

Conclusions: TAS-116 administered once daily has an acceptable toxicity profile and the MTD was determined as 107.5 mg/m2. Preliminary antitumor activity was demonstrated with evidence of target engagement. The dose escalation study administered every other day is ongoing and the MTD will be determined.

Clinical trial information: JapicCTI-142444.

Citation Format: Akihiko Shimomura, Atsushi Horiike, Yuichi Tambo, Fumiyoshi Ohyanagi, Noriko Yanagitani, Satoru Kitazono, Yutaka Fujiwara, Yuko Tanabe, Shuichi Ohkubo, Noboru Yamamoto, Makoto Nishio. First-in-human phase I dose escalation study of TAS-116, a novel, orally active HSP90α and HSP90β selective inhibitor, in patients with advanced solid tumors. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr B87.

Prognostic value of (18) F-fluoroazomycin arabinoside PET/CT in patients with advanced non-small-cell lung cancer

This study evaluated the prognostic value of positron emission tomography/computed tomography (PET/CT) using ¹⁸F‐fluoroazomycin arabinoside (FAZA) in patients with advanced non‐small‐cell lung cancer (NSCLC) compared with ¹⁸F‐fluorodeoxyglucose (FDG). Thirty‐eight patients with advanced NSCLC (stage III, 23 patients; stage IV, 15 patients) underwent FAZA and FDG PET/CT before treatment. The PET parameters (tumor‐to‐muscle ratio [T/M] at 1 and 2 h for FAZA, maximum standardized uptake value for FDG) in the primary lesion and lymph node (LN) metastasis and clinical parameters were compared concerning their effects on progression‐free survival (PFS) and overall survival (OS). In our univariate analysis of all patients, clinical stage and FAZA T/M in LNs at 1 and 2 h were predictive of PFS (P = 0.021, 0.028, and 0.002, respectively). Multivariate analysis also indicated that clinical stage and FAZA T/M in LNs at 1 and 2 h were independent predictors of PFS. Subgroup analysis of chemoradiotherapy‐treated stage III patients revealed that only FAZA T/M in LNs at 2 h was predictive of PFS (P = 0.025). The FDG PET/CT parameters were not predictive of PFS. No parameter was a significant predictor of OS. In patients with advanced NSCLC, FAZA uptake in LNs, but not in primary lesions, was predictive of treatment outcome. These results suggest the importance of characterization of LN metastases in advanced NSCLC patients.

Abstract 3590: Resistance mechanisms to ALK inhibitors

Purpose: ALK-rearranged non-small cell lung cancer (NSCLC) was first reported in 2007. Approximately 3-5% of NSCLCs harbor an ALK gene rearrangement. The first-generation ALK tyrosine kinase inhibitor (TKI) crizotinib is a standard therapy for patients with advanced ALK-rearranged NSCLC. Several next-generation ALK-TKIs have entered the clinic and have shown promising antitumor activity in crizotinib-resistant patients. As patients still relapse even on these next-generation ALK-TKIs, we examined mechanisms of resistance to one next-generation ALK-TKI - alectinib - and potential strategies to overcome this resistance.

Experimental Procedure: We established a cell line model of alectinib resistance, and analyzed resistant tumor specimens from patients who had relapsed on alectinib. Cell lines were also established under an IRB-approved protocol when there was sufficient fresh tumor tissue. We established Ba/F3 cells expressing EML4-ALK and performed ENU mutagenesis to compare potential crizotinib or alectinib-resistance mutations. In addition, we developed Ba/F3 models harboring ALK resistance mutations and evaluated the potency of multiple next-generation ALK-TKIs including 3rd generation ALK inhibitor in these models and in vivo. To elucidate structure-activity-relationships of ALK resistance mutations, we performed computational thermodynamic simulation with MP-CAFEE.

Results: We identified multiple resistance mutations, including ALK I1171N, I1171S, and V1180L, from the ENU mutagenesis screen and the cell line model. In addition we found secondary mutations at the I1171 residue from the Japanese patients who developed resistance to alectinib or crizotinib. Both ALK mutations (V1180L and I1171 mutations) conferred resistance to alectinib as well as to crizotinib, but were sensitive to ceritinib and other next-generation ALK-TKIs. Based on thermodynamics simulation, each resistance mutation is predicted to lead to distinct structural alterations that decrease the binding affinity of ALK-TKIs for ALK.

Conclusions: We have identified multiple alectinib-resistance mutations from the cell line model, patient derived cell lines, and tumor tissues, and ENU mutagenesis. ALK secondary mutations arising after alectinib exposure are sensitive to other next generation ALK-TKIs. These findings suggest a potential role for sequential therapy with multiple next-generation ALK-TKIs in patients with advanced, ALK-rearranged cancers.

Citation Format: Ryohei Katayama, Noriko Yanagitani, Sumie Koike, Takuya Sakashita, Satoru Kitazono, Makoto Nishio, Yasushi Okuno, Jeffrey A. Engelman, Alice T. Shaw, Naoya Fujita. Resistance mechanisms to ALK inhibitors. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3590. doi:10.1158/1538-7445.AM2015-3590

Abstract 957: The ALK inhibitor LDK378 overcomes crizotinib resistance in non-small cell lung cancer

Non-small cell lung cancers (NSCLC) harboring anaplastic lymphoma kinase (ALK) gene rearrangements are sensitive to the ALK tyrosine kinase inhibitor (TKI) crizotinib. However, these cancers invariably relapse due to the development of resistance, and approximately 1/3 of such cancers develop resistance mutations within the ALK tyrosine kinase domain. Here we report the preclinical evaluation of the next-generation ALK TKI, LDK378 in the setting of crizotinib resistance. Using EML4-ALK mutant Ba/F3 cellular models, in vivo models of acquired resistance to crizotinib, and novel cell lines established from biopsies of crizotinib-resistant NSCLC patients, we have examined the efficacy of LDK378 in crizotinib-naïve and -resistant ALK-positive cancers. These studies reveal that LDK378 is more potent than crizotinib and effectively overcomes resistance in vitro and in vivo. In particular, LDK378 inhibits ALK harboring crizotinib resistance mutations, including L1196M, G1269A, I1171T and S1206Y. Cell lines derived from crizotinib-resistant biopsies were sensitive to LDK378, including one that did not harbor an ALK resistance mutation and was also sensitive to crizotinib, suggesting that some crizotinib-resistant cancers with wildtype ALK are still sensitive to complete ALK inhibition. We observed that LDK378 did not effectively overcome two crizotinib-resistant ALK mutations, G1202R and F1174C

ALK, and mutations in one of these residues was identified in 5 out of 11 biopsies from patients with acquired resistance to LDK378. Altogether our results demonstrate that LDK378 can overcome many mechanisms of crizotinib resistance, consistent with emerging clinical data showing marked efficacy of LDK378 in patients with crizotinib-resistant disease.

Citation Format: Luc Friboulet, Nanxin Li, Ryohei Katayama, Christian C. Lee, Justin F. Gainor, Adam S. Crystal, Pierre-Yves Michellys, Mark M. Awad, Noriko Yanagitani, Sungjoon Kim, AnneMarie Pferdekamper, Jie Li, Shailaja Kasibhatla, Frank Sun, Xiuying Sun, Su Hua, Peter McNamara, Sidra Mahmood, Elizabeth L. Lockerman, Naoya Fujita, Makoto Nishio, Jennifer L. Harris, Alice T. Shaw, Jeffrey A. Engelman. The ALK inhibitor LDK378 overcomes crizotinib resistance in non-small cell lung cancer. [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 957. doi:10.1158/1538-7445.AM2014-957

Phase II study of docetaxel-plus-bevacizumab combination therapy in patients previously treated for advanced non-squamous non-small cell lung cancer

AIM

This phase II study was conducted to evaluate the efficacy and safety of docetaxel and bevacizumab combination therapy in patients with previously-treated non-squamous non-small cell lung cancer (Nsq NSCLC).

PATIENTS AND METHODS

Patients with histologically- or cytologically-confirmed Nsq NSCLC, 20-74 years of age, who had performance status 0-2, and had undergone at least one prior chemotherapy course were eligible for the study. Patients were treated with docetaxel (60 mg/m(2)) and bevacizumab (15 mg/kg) on day 1, which was repeated every three weeks until progressive disease or unacceptable toxicity occurred. The primary end-point was the response rate (RR) and the planned sample size was 28 patients.

RESULTS

Between May 2010 and July 2011, 28 patients were enrolled (16 males, 12 females; median age=65 years; performance status 0/1: 19/9; adenocarcinoma/other: 22/6; number of prior chemotherapy courses 1/2/3 or more: 16/5/7). Twenty-eight patients were included in the toxicity analysis, out of whom 27 were evaluable for response. Objective response was observed in 18 patients (partial response in 18, stable disease in 8, progressive disease in 1); the RR and disease control rates were 66.7% and 96.0%, respectively. The median follow-up was 23.9 months, median progression-free survival was 7.2 months, and median overall survival was 21.6 months. The main toxicity associated with this regimen was myelosuppression (grade 3/4 neutropenia: 82.1%; febrile neutropenia: 21%). Mild non-hematological toxicity was observed but there was no severe bleeding.

CONCLUSION

The combination regimen of docetaxel-plus-bevacizumab is very active in patients with previously-treated Nsq NSCLC and warrants further research.