EGFR and EML4-ALK gene mutations in NSCLC: a case report of erlotinib-resistant patient with both concomitant mutations

The fusion gene EML4-ALK (echinoderm microtubule-associated protein-like 4 gene and the anaplastic lymphoma kinase gene) was recently identified as a novel genetic alteration in non-small cell lung cancer (NSCLC). EML4-ALK translocations correlate with specific clinical and pathological features, in particular lack of EGFR and K-ras mutations, and may be associated with resistance to EGFR tyrosine-kinase inhibitors (TKIs). Here, we report a case of a patient with a concomitant EGFR mutation and ALK translocation resistant to erlotinib. Considering this report, ALK status should be investigated in unexplained cases of EGFR-TKI-resistance of EGFR mutated NSCLCs.

Abstract P2-04-01: HER2 Status as Predictor of Mammographic Screening Detection: Comparison of Interval-and Screen-Detected Breast Cancers

Background: To determine whether markers of poor prognosis are associated with risk of breast cancer diagnosis in the interval between screening examinations, we estimated the effect of the mode of detection on distribution of breast cancer molecular subtypes using population cancer registry data.

Material and Methods: Subjects (n = 641) comprised all breast cancers systematically collected by the Cancer Registry of Parma Province and diagnosed in women aged 50-69, from 2004 to 2007. These included 370 screen-detected and 271 symptomatic breast cancers (63 women with interval cancers and 208 who had not attended screening). We used logistic regression to determine whether interval cancers were associated with selected clinical and biologic characteristics. We also estimated the relative risk of cause-specific fatality and disease-free survival (DFS) by each resulting predictive factor (screen-detected compared to either symptomatic or interval cancers).

Results: Interval-detected cancers occurred more in younger women and were of more advanced tumor stage than screen-detected cancers. In unconditional logistic regression models adjusted for age and tumor stage, tumors with high histologic grade (odds ratio[OR] = 2.2; 95% CI =1.0-5.4), high proliferation rate (OR =2.7; 95% CI =1.5-4.8), or positive HER2 status (OR =2.6; 95% CI =1.3-5.1) were more likely to surface in the interval between screening examinations. After adjusting for various potential biases, women with screen-detected breast cancer had a substantial survival advantage over those with symptomatic breast cancer. In a multivariate model, positive HER2 status independently predicted poor DFS when the mode of cancer detection was included as covariate in addition to age, histologic grade, proliferation rate, and tumor stage. Conclusions: This is the first population-based cancer registry study demonstrating that HER2-positive tumors account for a substantial proportion of mammographic screening failure to detect breast cancer. Our data indicate that molecular subtype distribution of screen-detected breast cancer differs from that of interval cancers and accounts in part for the better outcome of screen-detected cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-04-01.

Abstract P2-17-01: Phase II Study of Bevacizumab in Combination with Docetaxel and Capecitabine for the First-Line Treatment of Patients with Locally Recurrent or Metastatic Breast Cancer

Background: Docetaxel (T; Taxotere) with capecitabine (X) is active against metastatic breast cancer (MBC); bevacizumab (B) has demonstrated efficacy with taxanes in the first-line setting. This study was conducted to assess the efficacy and safety of TX-B in patients (pts) with MBC. Patients and methods: In this single-arm, multicenter phase II study, pts received first-line bevacizumab 15 mg/kg and docetaxel 60 mg/m2 on day 1, plus capecitabine 900 mg/m2 twice per day on days 1-14 every 21 days. The treatment was administrated for 3 cycles and in case of objective response or stable disease at that time, pts were treated with 3 additional cycles. More courses of chemotherapy were administered at Investigator's discretion. Bevacizumab was continued until progressive disease, patient refusal, or unacceptable toxicity. Primary end point was progression-free survival (PFS) and secondary end points were tumor response rate (RR), overall survival (OS), and toxicity.

Results: We report data from the first 30 pts enrolled. Median age was 54 (37-72). Eight (27%) pts had triple-negative disease, while 18 (60%) were hormone-receptor positive. HER2 status was recognized as negative in 25 (84%) pts. TX-B was administered for a median of seven cycles. Five complete and 13 partial responses were observed (overall RR 60%). Median response duration was 12 months. Median OS and PFS were 26 and 11 months, respectively. Grade 3/4 adverse events included tromboembolism (10%), neutropenia (23%), hand-foot syndrome (13%), stomatitis (10%). The median TX doses administered per cycle were 60 mg/m2 and 660 mg/m2, respectively. Ten (33%) pts required dose reductions of docetaxel, while capecitabine dose was reduced in 15 (50%) pts. Results of all the 80 assessable pts entered in the study will be presented at the meeting.

Conclusion: TX-B demonstrated significant activity with an acceptable toxicity profile. Maintenance therapy with B is possible for a long period of stable tumor disease.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-17-01.

PTEN status in advanced colorectal cancer treated with cetuximab

BACKGROUND

Loss of phosphatase and tensin homologue deleted in chromosome 10 (PTEN) function in advanced colorectal cancer (CRC) may represent one of the resistance mechanisms to cetuximab by interfering with the epidermal growth factor receptor signal transduction pathway.

METHODS

PTEN expression tested by indirect immunofluorescence was evaluated both on primary (n=43) and on metastatic (n=24) sites in CRC patients treated with cetuximab.

RESULTS

The loss of PTEN expression tested on metastatic sites was negatively associated with response (100% progressive disease (PD) in PTEN-negative cases vs 30% PD in PTEN-positive cases; P<0.05), PFS (0.8 vs 8.2 months; P<0.001) and OS (2.9 vs 14.2 months; P<0.001).

CONCLUSION

A potential role of PTEN in the anti-tumour activity of cetuximab could be hypothesised.

Usefulness of 18FDG-positron emission tomography (FDG-PET) for early prediction of erlotinib (Eb) treatment outcome in non-small cell lung cancer (NSCLC) patients: Results of a pilot study

7568

Background: FDG-PET could be useful for early evaluation of tumor response to tyrosine kinase inhibitors (TKI). Glucose metabolic activity seems to closely reflect response to epidermal growth factor receptor (EGFR) TKI in vivo and in vitro (Su H et al, Clin Cancer Res 2006;12:5659–67). Thus, we attempted to assess the clinical value of FDG-PET for early prediction of tumor response to Eb an EGFR-TKI. Methods: Pts with NSCLC stage IV in progression after at least one line of chemotherapy and PS 0–1 were treated with Eb (150 mg orally once daily). FDG-PET was performed on days 0 and 2, after administration of 3 daily doses. FDG uptake was evaluated as the maximum standardized uptake value in the tumor (SUVmax). SUVmax was divided by SUV of the background region (liver) to produce the tumor:nontumor ratio (TNT). FDG-PET responses were evaluated by quantitative changes on TNT and classified according to the EORTC PET study group. PET response were compared with radiographic tumor response (RECIST criteria) assessment based on CT scan at baseline and on day 45. Results: From May 2007, 27 pts were enrolled and 23 were evaluable (4 not-evaluable: 2 BAC PET negative, 2 violations). FDG-PET revealed a metabolic partial response (PR) in 8 pts; subsequent CT scan assessment evidenced 4 PR and 4 long lasting stable disease (SD), respectively. Seven pts had metabolic progressive disease (PD) at PET scan and 8 had SD, all of them presented PD at CT scan. Metabolic PR was associated with a longer median progression-free survival (152 vs 45 days, p = < 0.0001) and longer overall survival (323 vs 128 days p=0.15). For radiological PD pts who presented metabolic SD or PD, survival time was respectively 220 and 117 days. EGFR gene mutation, gene copy number and protein expression are ongoing. Conclusions: FDG-PET using changes on TNT can very early predict (already 2 days after initiation) Eb treatment outcome. Particularly, pts with early metabolic PD are unlikely to benefit from Eb. Therefore, evaluation of the early metabolic response holds promise for assessment of pts selection. The two different behavior of FDG-PET observed on refractory pts, deserve biomolecular analysis for understanding mechanism of resistance.

No significant financial relationships to disclose.

Multifactorial CNS relapse susceptibility in HER2-positive breast cancer patients: First results from a population-based registry study

1117

Background: A series of retrospective studies have reported a higher incidence of central nervous system (CNS) metastases in HER-2-positive (HER-2+) metastatic breast cancer. Trastuzumab, which does not cross the blood-brain barrier, has been associated with this increased risk. Methods: The aim of this study was to evaluate incidence, survival, and risk factors of CNS metastases in the incident breast cancer population systematically collected by the Tumor Registry of Parma Province over the 4-year period, 2004–2007. Study endpoints were: any distant metastasis as first event; CNS metastasis as first event; CNS metastasis at any time. Associations between CNS metastases and HER-2 status in the entire population and between trastuzumab and CNS metastases in HER-2+ patients (pts) were estimated. A multivariate analysis was performed to test the effect of covariates. Results: We evaluated the total resident population (n = 1500) of breast cancer pts diagnosed during the period 2004–2007 in Parma Province. Two-hundred and twenty-five pts (15%) were HER-2+ (IHC 3+/FISH amplified). Of these, 100 pts were treated with adjuvant trastuzumab-based therapy. At a median follow-up of 36 months from the diagnosis, the incidence of CNS relapse was 3% (1.3% as first recurrence). The median time to death from the diagnosis of CNS metastases was 25 months. Among the HER-2+ pts, there was a significant association between trastuzumab and subsequent CNS metastases (p = 0.02). However, in multivariate analysis, HER-2 status regardless of trastuzumab therapy was found to be the only independent predictive factor for CNS metastases (either as first or as subsequent recurrences; p < 0.01). Conclusions: This is the first population-based registry study analyzing CNS metastases in breast cancer in relation to tumor biological features, systemic treatment, and clinical outcome. Based on our results, HER-2 status independently distinguishes pts with a higher risk of CNS metastases. It is however presumable that, in some cases, improvements in systemic control and overall survival associated with trastuzumab-based therapy lead to an “unmasking” of CNS relapse that would otherwise have remained clinically silent prior to a patient's death.

No significant financial relationships to disclose.

A protein microarray immunoassay for the serological evaluation of the antibody response in vertically transmitted infections

The detection of specific serum antibodies is mainly achieved by enzyme-linked immunosorbent assay (ELISA). Here, we describe the setting up of a microarray-based serological assay to screen for IgG and IgM against vertically transmitted pathogens (Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus types 1 and 2, varicella zoster virus, Chlamydia trachomatis). The test, accommodated onto a restricted area of a microscope slide, consists of: (a) the immobilization of antigens and human IgG and IgM antibody dilution curves, laid down in an orderly manner; (b) addition of serum samples; (c) detection of antigen-serum antibodies complexes by indirect immunofluorescence. The IgG and IgM curves provide an internal calibration system for the interpolation of the signals from the single antigens. The test was optimized in terms of spotting conditions and processing protocol. The detection limit was 400 fg for the IgG assay and 40 fg for the IgM assay; the analytical specificity was >98%. The clinical sensitivity returned an average value of 78%, the clinical specificity was >96%, the predictive values were >73%, and the efficiency was >88%. The results obtained make this test a promising tool, suitable for introduction in the clinical diagnostic routine of vertically transmitted infections, in parallel (and in future as an alternative) to ELISA.

Phase II study of liposomal doxorubicin (Myocet®), docetaxel and trastuzumab combination as first line treatment of patients with her-2/neu positive locally advanced or metastatic breast cancer

Abstract #3149

Objective: the aims of the study are to assess activity and safety of liposomal doxorubicin (Myocet®) in combination with Docetaxel and Trastuzumab as first-line treatment of patients with HER-2/neu positive MBC.&#x2028; Methods: forty-six (46) non treated patients with metastatic HER2-overexpressing BC were planned to receive Myocet 50 mg/m2 (d1) and Docetaxel 30 mg/m2 (d2 and d9) plus Trastuzumab (d2, 4 mg/kg followed by 2 mg/kg weekly) for at least 6 cycles (up to a maximum of 8 unless occurrence of unacceptable toxicity or PD). Cycles were repeated every 21 days. Objective response was assessed according to WHO criteria every 3 cycles. To evaluate the tolerability WHO grading toxicity events were assessed at each cycle. Cardiotoxicity was defined as signs and/or symptoms of CHF and/or a decrease in LVEF below normal limit (&lt; 50%) or a decline ≥ 15% from baseline value. To evaluate LVEF an echocardiography was done at baseline and at cycles 3, 6 and 8.&#x2028; Results: we reported preliminary results of 46 patients enrolled. 41 patients completed at least 3 cycles and at first response evaluation Complete Response was seen in 2 pts (CR=4,9%), Partial Response in 22 pts (PR=53,7%), Stable Disease in 15 pts (SD=36,6%) and Progression Disease in 2 pts (PD=4,9%). The Overall Response Rate (ORR) was 58,6%.&#x2028; 36 pts completed the planned chemotherapy (6 cycles): Complete Response was seen in 4 pts (CR=11,1%), Partial Response in 15 pts (PR=41,7%), Stable Disease in 9 (SD=25,0%) and Progression Disease in 8 pts (PD=22,2%). The Overall Response Rate (ORR) was 52,8%. 12 pts were entered in the follow up and for this subgroup median TTP was 13 months.&#x2028; All 46 enrolled patients were included in the safety analysis. Most frequent toxicity events occurred during the study were: granulocytopenia Grade 4 in 16 pts (30.4%), leukocytopenia Grade 3 in 15 pts (32.6%), increase of transaminase levels Grade 1 in 14 pts (30.4%), alopecia Grade 4 in 16 pts (34.8%) and nausea Grade 2 in 13 pts (28.3%). In 2 patients LVEF dropped &lt; 50% and other 2 pts registered a decrease of LVEF &gt;15% with respect to baseline value. In the whole population LVEF mean value changed from 62.6 ± 4.9 at baseline to 61.0 ± 5.5 at cycle 3, to 62.9 ± 6.4 (cycle 6) and to 60.0 ± 8.1 (cycle 8).&#x2028; Conclusion: these preliminary results suggest that the combination of non-pegylated liposomal doxorubicin, docetaxel and trastuzumab has shown a promising activity in first line MBC. The combination is safe with no significant change in LVEF values from baseline to the end of therapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3149.

Advantages of multidetector-row CT with multiplanar reformation in guiding percutaneous lung biopsies

PURPOSE

This study aimed to assess the usefulness of multiplanar reformations (MPR) during multidetector-row computed tomography (MDCT)-guided percutaneous needle biopsy of lung lesions difficult to access with the guidance of the native axial images alone owing to overlying bony structures, large vessels or pleural fissures.

MATERIALS AND METHODS

MDCT-guided transthoracic needle biopsy (TNB) was performed on 84 patients (55 men and 29 women; mean age 65 years) with suspected lung neoplasm by using a spiral MDCT scanner with the simultaneous acquisition of six slices per rotation. We determined the site of entry of the 22-gauge Chiba needle on native axial images and coronal or sagittal MPR images. We took care to ensure the shortest needle path without overlying large vessels, main bronchi, pleural fissures or bony structures; access to the lung parenchyma as perpendicular as possible to the pleural plane; and sampling of highly attenuating areas of noncalcified tissue within the lesion.

RESULTS

Diagnostic samples were obtained in 96% of cases. In 73 patients, lesions appeared as a solid noncalcified nodule <2 cm; 11 lesions were mass-like. In 22, the biopsy required MPR guidance owing to overlying ribs (18), fissures (2) or hilar-mediastinal location (2).

CONCLUSIONS

MDCT MPR images allowed sampling of pulmonary lesions until now considered unreachable with axial MDCT guidance because of overlying bony structures (ribs, sternum and scapulae) or critical location (hilar-mediastinal, proximity to the heart or large vessels). Compared with the conventional procedure, the use of MPR images does not increase the rate of pneumothorax or the procedure time.

A combination of gefitinib and FOLFOX-4 as first-line treatment in advanced colorectal cancer patients. A GISCAD multicentre phase II study including a biological analysis of EGFR overexpression, amplification and NF-kB activation

Interesting activity has been reported by combining chemotherapy with cetuximab. An alternative approach for blocking EGFR function has been the development of small-molecule inhibitors of tyrosine kinase domain such as gefitinib. We designed a multicentre phase II study in advanced colorectal cancer combining gefitinib+FOLFOX in order to determine the activity and to relate EGFR expression and gene amplification and NF-kB activation to therapeutic results. Patients received FOLFOX-4 regimen plus gefitinib as first-line treatment. Tumour samples were analysed for EGFR protein expression by immunohistochemical analysis and for EGFR gene amplification by fluorescence in situ hybridisation (FISH), chromogenic in situ hybridisation (CISH) and NF-kB activation. Forty-three patients were enrolled into this study; 15 patients experienced a partial response (response rate=34.9%), whereas other 12 (27.9%) had a stable disease. Median progression-free survival (PFS) was 7.8 months and median overall survival (OS) was 13.9 months. We did not find any relationship with EGFR overexpression, gene amplification, while NF-kB activation was associated with a resistance to therapy. Gefitinib does not seem to increase the activity of FOLFOX in advanced colorectal cancer even in patients overexpressing EGFR or with EGFR amplification. Furthermore, while NF-kB activation seems to predict resistance to chemotherapy as demonstrated ‘in vitro’ models, gefitinib does not overcome this mechanism of resistance, as reported for cetuximab.

Erlotinib in non-small cell lung cancer (NSCLC): Interim safety analysis of the TRUST study

7645

Background: In patients (pts) with relapsed NSCLC, erlotinib 150 mg/d significantly prolonged survival, delayed symptom progression, and improved quality of life versus placebo (Shepherd et al, N Engl J Med 2005;353:123–32). TRUST is an open label, non- randomized trial initiated to provide erlotinib access to pts with advanced NSCLC. Methods: Eligible pts had stage IIIb/IV NSCLC, and had failed or were unsuitable for chemotherapy. Erlotinib (150 mg/d p.o.) was given until disease progression or unacceptable toxicity. Pts were monitored monthly. Results: In November 2006, data were available for 5,015 pts (ITT population) from 51 countries. Median age was 63y (range 19–95). Pt characteristics (%) were: male/female 62/38; Caucasian/Oriental/other 76/19/5; non-smoker/ex- or current-smoker 28/71 (no data 1); ECOG PS 0/1/2/3 21/53/20/6; adenocarcinoma/squamous cell/other 53/25/21; stage IIIb/IV 22/78; erlotinib 1st/2nd/3rd-line/other 14/48/37/1. Safety data were available for 4,423 pts, 55% of whom had at least one adverse event (AE). Only 5% had one or more erlotinib- related serious AEs, the most common being gastrointestinal (GI) disorders (86 pts; 63 grade [gr] 3/4). 6% of pts discontinued treatment due to erlotinib-related AEs: GI disorders in 96 pts (54 gr 3/4), skin disorders in 92 (50 gr 3/4). Unexpected erlotinib-related AEs occurred in 10% of pts (4% gr 1, 3% gr 2, 3% gr 3/4). As expected, rash was observed in 70% of pts, with the majority (84%) being of gr 1/2. 80% pts received >4 weeks of erlotinib. Among 4,405 pts, only 14% had dose reductions, mainly due to rash (83%) and diarrhea (21%). Similar safety results were seen for 2nd-line pts only. Efficacy for all and 2nd-line pts will be presented. Conclusions: These results, achieved through routine clinical use of erlotinib in unselected pts with advanced NSCLC, confirm the favorable tolerability profile seen with erlotinib in selected patients in the clinical trial setting.

[Table: see text]

Tumor response to chemotherapy as a surrogate endpoint of survival in advanced non-small cell lung cancer (NSCLC): Results of an individual patients data meta-analysis

7548

Background: In order to assess the validity of objective response to chemotherapy (CT) as a surrogate endpoint of survival in advanced non-small cell lung cancer (NSCLC), we applied the four Prentice criteria to the data collected in the CISCA meta-analysis, comparing the efficacy of carboplatin and cisplatin in the first-line treatment of advanced NSCLC. Methods: Nine trials including 2,968 patients (pts) were analyzed in the CISCA meta-analysis. The prognostic effect of tumor response on survival was analyzed setting a landmark at two months after randomization (time of response recording), in order to eliminate early death from the analysis. After this landmark correction, pts included in the validation analysis were 2,525 with complete data on tumor response and survival. Results: Cisplatin-based CT was associated with a significantly higher tumor response rate compared with carboplatin-based CT (OR = 1.39; 95% CI: 1.18–1.64; p < 0.001). Carboplatin regimens also led to a numerically higher risk of death as compared to cisplatin (HR = 1.06; 95% CI: 0.98–1.16; p = 0.15). Tumor response was a highly significant predictor of survival (HR = 0.50; 95% CI: 0.46–0.55; p < 0.001). When tumor response was introduced in the Cox model (as a four level variable), the hazard ratio in favour of cisplatin treatment changed from 1.06 to 1.004 (95% CI: 0.922–1.093; p = 0.94), indicating that no residual effect of the cisplatin treatment on survival was present once tumor response was adjusted for. This suggests that the overall survival benefit of cisplatin CT was a result of the increase in response rate. The median survival time of patients with complete and partial response was 19.5 months (95% CI: 11.5–27.5 months) and 14.0 months (95% CI: 13.1–14.9 months), respectively; whereas, the median survival time of patients with no response was 7.8 months (95% CI: 7.5–8.1 months). Conclusions: These results support the hypothesis that the achievement of an objective response to CT in advanced NSCLC is associated with a survival benefit. The potential role of objective response as a surrogate endpoint for survival in CT trials of advanced NSCLC warrants further investigation.

No significant financial relationships to disclose.

Comparison between epidermal growth factor receptor (EGFR) gene in primary non-small cell lung cancer (NSCLC) and in fine needle aspirates from metastatic sites

21081

Background: Epidermal growth factor receptor (EGFR) gene copy number obtained by fluorescence in situ hybridization (FISH) has been recently proposed to predict which non-small cell lung cancer patients (NSCLC) are expected to benefit from EGFR tyrosine kinase inhibitors. However, it is still unknown whether EGFR status differs in metastases compared to primary NSCLC. In all studies, FISH have been performed on histological material. The possibility to perform FISH analysis on cytological material obtained by fine-needle aspiration from superficial and deep metastases would allow to know the real EGFR status when the metastatic site is not accessible for biopsy. Methods: EGFR gene copy number was analyzed by FISH on fine-needle aspirates (FNAs) obtained from 18 patients with metastatic NSCLC (11 lymphnod, 2 liver, 1 abdomen, 2 skin, 2 pleural effusion) and results were compared with those obtained on corresponding paraffin histological sections from the primary tumor. Results: The feasibility of EGFR-FISH on cytology was 89%; 2/18 samples were not evaluable because of lack of hybridization. EGFR-FISH was positive (= 4 EGFR copy number; Cappuzzo F. et al, JNCI 2005) in 69% (11/16) of the metastases and in 38% (6/16) of the primary tumors. Five of the 16 cases were EGFR positive on both primary tumor and metastatic site and 4 were negative on both primary tumor and metastasis. Seven cases (44%) showed primary tumor vs. metastasis discordance: in 6 cases EGFR was positive in the metastatic site but not in the primary tumor, while in one sample EGFR was positive in the primary tumor but not in the metastasis. Conclusions: EGFR-FISH can be reliably assessed on FNAs obtained from NSCLC metastases. Possible changes in EGFR status during the metastatic progression as well as cancer heterogeneity may account for discrepancies observed between primary tumor and metastatic sites. These findings should be considered in future studies which will be design to better elucidate the predictive role of EGFR-FISH in NSCLC.

No significant financial relationships to disclose.

Intracranial hematopoiesis in a patient with aids-related central nervous system lymphoma and severe pancytopenia

The case here reported reflects the difficulty in diagnosing meningeal extramedullary hematopoiesis (EMH), which clinically appeared concomitantly with primary cerebral lymphoma and occurred in a patient with HIV infection and severe pancytopenia. Pancytopenia secondary to HIV infection could be hypothesized as a predisposing factor for the ectopic development of hematopoietic tissue outside the bone marrow. Although rare, intracranial EMH should always be considered in the differential diagnosis of headache and other endocranial hypertension symptoms in patients with chronic bone marrow dysfunction.

A Transmissible Cytotoxic Activity Isolated from a Patient with Brain Ischemia Causes Microglial Cell Activation and Dysfunction

1. Microglial cell activation occurs during brain injury, ischemia, and in several neurologic disorders. Recently, we isolated a transmissible cytotoxic activity (TCA) from the cerebrospinal fluid of a patient with brain ischemia. Such a TCA, associated with one or more protein(s) that supposedly had undergone in vivo misfolding, causes apoptosis in vitro in different cell lines, including microglial cells. The TCA producing cells and the potential in vivo role of such cytotoxic activity remains to be elucidated. Here, we investigated the in vitro effects of TCA on microglial cell immune functions.2. The murine microglial cell line RR4 was exposed to TCA, and then its response was evaluated as: (a) phagocytosis and antifungal activity against Candida albicans; (b) secretory pattern; and (c) levels of p38 phosphorylation.3. Unlike mock-treated controls, microglial cells exposed to TCA showed an increase in phagocytic activity. Unexpectedly, their capability to kill the ingested fungi significantly diminished. Moreover, TCA-treated cells produced amounts of macrophage inflammatory protein 1-alpha, tumor necrosis factor-alpha, and nitric oxide significantly higher than mock-treated cells. Finally, phosphorylation of p38 mitogen-activated protein kinase (MAPK) was detected in TCA-treated but not in mock-treated controls as early as 30 min after treatment.4. Overall, these results indicate that TCA causes a rapid molecular response in microglial cells, by the time, leading to an intriguing effector and secretory dysfunction.

Immunoglobulin G fragment C receptor polymorphisms and response to trastuzumab-based treatment in patients with HER-2/neu-positive metastatic breast cancer

13090

Background: A potential mechanism of action of the humanized anti-HER-2/neu monoclonal antibody Trastuzumab involves antibody-dependent cellular cytotoxicity (ADCC) with the activation of immune effector cells via their immunoglobulin G fragment C receptors (FcγRs). Trastuzumab has been shown to engage both activation (FcγRIIIa; FcγRIIa) and inhibitory (FcγRIIb) antibody receptors on myeloid cells and several FcγR polymorphisms have been identified that may affect the antibody-dependent cytotoxicity of natural killer cells and macrophages. Methods: Forty consecutive HER-2/neu-positive (FISH+) metastatic breast cancer patients receiving a trastuzumab-based treatment (combined with paclitaxel for the majority) were examined for the FcγRIIIa 158 valine (V)/phenylalanine (F), FcγRIIa 131 histidine (H)/arginine (R), and FcγRIIb 232 isoleucine (I)/threonine (T) polymorphisms. A PCR-RFLP based assay using genomic DNA was performed for FcγRIIIa and FcγRIIa genotyping, while PCR-SSCP methods using complementary DNA were utilized for FcγRIIb. Patients’ peripheral blood mononuclear cells were drawn before treatment initiation and their trastuzumab-mediated killing function was measured by 51Cr release using a HER-2/neu-expressing human breast cancer cell line as a target. The results were then correlated with clinical outcome of these patients. Results: Median age was 60 years (range 26–83 years). Thirty-six (90%) patients received a trastuzumab-based treatment as first-line therapy. The overall clinical benefit rate (CR+PR+SD) was 65% (95% Confidence Interval: 62–71%), including 8 (20%) complete and 11 (27.5%) partial responses. Median survival was 22.3 mo with a median PFS of 7 mo. Trastuzumab-based treatment was well tolerated and no changes in cardiac function were observed. Conclusions: This study evaluates for the first time the potential role of FcγR polymorphisms in predicting response to trastuzumab-based treatment. Results according to this study purpose will be presented at the meeting.

No significant financial relationships to disclose.

Second line chemotherapy with topotecan and gemcitabine in small cell lung cancer (SCLC) patients: An Alpe-Adria Thoracic Oncology Multidisciplinary group phase II study (ATOM 012)

17014

Background: Topotecan is the only single agent currently approved for the treatment of relapsed or recurrent SCLC, showing activity both in chemotherapy-refractory (RR 2–14%) and in chemotherapy-sensitive patients (RR 14–38%). The role of topotecan in combination with other active agents is still under investigation. Methods: Aim of this phase II study is to assess the activity and safety of topotecan (1mg/sqm iv d1–5) plus gemcitabine (1250 mg/sqm iv d1) in relapsed or recurrent SCLC patients. Treatment is repeated every 4 weeks, up to a maximum of 6 cycles. Eligibility criteria: histologically or cytologically confirmed SCLC; documented progressive disease after ≥ 1 chemotherapy regimen; age ≥ 18 yrs; ECOG PS 0–2; measurable disease (RECIST); no prior treatment with topotecan or gemcitabine; adequate hematologic, hepatic and renal function; brain metastases are allowed. Results: A total of 44 patients have been enrolled. Patient characteristics are as follows: median age, 64 yrs (range 35–77); male/female, 35/9; ECOG PS 0/1/2, 12/21/11 patients; 68% patients had sensitive disease (recurrence > 3 months after first-line chemotherapy) and 32% patients had refractory disease (failure ≤3 months after first-line chemotherapy). One-hundred and seventeen chemotherapy courses have been administered (median 2, range 1–6). The following preliminary results refer to 37 patients. Grade 3–4 toxicities: 54% neutropenia, 16% anemia, 46% thrombocytopenia, 13% neutropenic fever, 27% fatigue. One toxic death was observed. Objective responses have been documented in 9 patients, for an overall response rate of 24% (3% CR, 21% PR); SD was observed in 7 patients (19%), PD in 17 patients (46%). Four early deaths were reported. Median time to progression is 8.9 weeks. Median survival time is 16.3 weeks, and 1-year survival rate is 14%. Conclusions: Based on these preliminary results, the combination of topotecan plus gemcitabine shows moderate activity and an acceptable toxicity profile in previously treated SCLC patients. However, it is unlikely that the addition of gemcitabine improves the outcome compared to single agent topotecan.

No significant financial relationships to disclose.

CISCA (cisplatin vs. carboplatin) meta-analysis: An individual patient data meta-analysis comparing cisplatin versus carboplatin-based chemotherapy in first-line treatment of advanced non-small cell lung cancer (NSCLC)

7011

Background: The issue of the equivalence between carboplatin and cisplatin in the treatment of advanced NSCLC is still controversial. To answer this question, we conducted an individual patient (pt) data meta-analysis of randomized trials comparing cisplatin- and carboplatin-based chemotherapy (CT) in first-line treatment of advanced NSCLC. Methods: A literature search was performed to identify randomized trials investigating the substitution of carboplatin for cisplatin, combined with the same agent/s, in the first-line CT of advanced NSCLC. The primary end-point was overall survival (OS) and the secondary end-points were response rate (RR) and toxicity. For each end-point the analysis was based on a fixed-effects model. For the study of the effect on OS, Cox proportional hazards model was used. The probability to have an objective response or an adverse event was studied using a logistic regression model. Results: Nine trials were identified and the relative databases obtained. In total, 2,968 pts were randomized to receive CT with cisplatin (1,489) or with carboplatin (1,479), respectively. The RR was 30% and 24% for cisplatin- and carboplatin-based CT, respectively, with an OR of 1.37 (95% C.I.: 1.16–1.62; p < 0.001). Concerning the OS, carboplatin was associated with a relative risk of death 7% higher compared with cisplatin, even if this difference was not statistically significant (HR = 1.07; 95% C.I.: 0.99–1.15; p = 0.101). Patients on cisplatin-based CT had more nausea-vomiting and nephro-toxicity while thrombocytopenia was more frequent during carboplatin-based CT. Subgroup analyses revealed that cisplatin-based CT led to statistically significant advantage in survival in the subgroups of pts with non-squamous tumours and in those treated with third generation CT. Conclusions: CISCA is the first individual pt data meta-analysis on this subject. We found that cisplatin-based is superior to carboplatin-based CT in terms of RR; however, the increased RR does not translate into an OS benefit. Nevertheless, selected pts with advanced NSCLC may obtain slightly more benefit from cisplatin-based third generation CT.

No significant financial relationships to disclose.

Adjuvant chemotherapy for non-small cell lung cancer: Ready for clinical practice?

Radical surgery remains the only treatment with curative potential for patients with operable non-small cell lung cancer (NSCLC). However, despite complete surgical resection, long-term survival is still disappointing with an average 5-year survival rate lower than 60%. Thoracic post-operative radiotherapy trials demonstrated a possible impact in reducing loco-regional recurrence but not overall survival. Moreover, the majority of post-surgical failures are represented by distant metastases, indicating a possible role for adjuvant systemic therapies. The role of adjuvant chemotherapy has now been clearly established in many solid tumors and the role of last generation platinum-based chemotherapy has now being considered as standard of care in advanced NSCLC. However, the role of adjuvant chemotherapy for completely resected NSCLC remains highly controversial. After the meta-analysis published in 1995, which showed a non-statistically significant 5% improvement in 5-year survival with second generation platinum-based adjuvant chemotherapy, several randomized clinical trials addressing the role of last generation adjuvant chemotherapy in patients with completely resected stage I, II and IIIA NSCLC have been completed with conflicting results. The available scientific evidence is reviewed and strengths/weaknesses of each trial are discussed in this article. Although most of the available evidence points to a possible survival benefit in long-term survival improvement ranging from 4% to 15%, the introduction of adjuvant chemotherapy as standard of care in the treatment of resected NSCLC is still a matter of debate. Practical issues and clinical aspects which may help clinicians in the decision making process about prescription of adjuvant treatment are also discussed.

Malignant mesothelioma in 2004: How advanced technology and new drugs are changing the perspectives of mesothelioma patients. Highlights from the VIIth Meeting of the International Mesothelioma Interest Group

Malignant mesothelioma (MMe) is a seemingly uncommon tumour whose incidence has in fact increased steadily and progressively over the last 30 years. Indeed, an actual "epidemic" is expected in the next 20 years, with over 1300 new cases a year till 2020 at least. Despite unquestionable improvement in the diagnostic methods at our disposal and the availability of new treatment strategies, the prognosis of MMe patients remains dramatically poor. For all the above reasons, translational research is the key to success; indeed, ever increasing knowledge of the molecular mechanisms underlying MMe pathogenesis could lead (and is actually leading) to new, hopefully more active, treatment options. To foster discussion among investigators working in this field, and to exchange different viewpoints concerning the newest advances in MMe pathogenesis and treatment, the VII International Mesothelioma Interest Group (IMIG) meeting was held in Brescia (Italy) between 24 and 26 June 2004 in cooperation with the Italian Group for the Study and Therapy of MMe (GIMe). The aim of this report is to summarize the most significant advances in the different disciplines applied to MMe presented and discussed during the IMIG meeting and how these advances will be changing the perspective of patients with MMe.