Efficacy of trabectedin in malignant solitary fibrous tumors: a retrospective analysis from the French Sarcoma Group

Background

Advanced malignant solitary fibrous tumors (SFTs) are rare soft-tissue sarcomas with a poor prognosis. Several treatment options have been reported, but with uncertain rates of efficacy. Our aim is to describe the activity of trabectedin in a retrospective, multi-center French series of patients with SFTs.

Methods

Patients were mainly identified through the French RetrospectYon database and were treated between January 2008 and May 2013. Trabectedin was administered at an initial dose of 1.5 mg/m², q3 weeks. The best tumor response was assessed according to the Response Evaluation Criteria In Solid Tumors 1.1. The Kaplan–Meier method was used to estimate median progression-free survival (PFS) and overall survival (OS). The growth-modulation index (GMI) was defined as the ratio between the time to progression with trabectedin (TTP_n) and the TTP with the immediately prior line of treatment (TTP_n-1).

Results

Eleven patients treated with trabectedin for advanced SFT were identified. Trabectedin had been used as second-line treatment in 8 patients (72.7 %) and as at least third-line therapy in a further 3 (27.3 %). The best RECIST response was a partial response (PR) in one patient (9.1 %) and stable disease (SD) in eight patients (72.7 %). Disease-control rate (DCR = PR + SD) was 81.8 %. After a median follow-up of 29.2 months, the median PFS was 11.6 months (95 % CI = 2.0; 15.2 months) and the median OS was 22.3 months (95 % CI = 9.1 months; not reached). The median GMI was 1.49 (range: 0.11–4.12).

Conclusion

Trabectedin is a very promising treatment for advanced SFTs. Further investigations are needed.

Abstract B81: Barriers to colorectal cancer screening in Hispanic/Latino women in Connecticut

Background: Colorectal cancer is the 2nd most commonly diagnosed and the 3rd leading cause of cancer death in Hispanic/Latino (H/L) women, falling behind breast and lung cancer. Although the incidence is 16% lower in H/L women compared with non-Hispanic White women, there are geographic differences, with Hispanic rates in the US higher than those reported for Puerto Rico and Central and South America, suggesting that rates increase with increased acculturation. A factor that may contribute to worse outcomes is the relatively lower colorectal cancer screening rates reported for Hispanic/Latinos. These rates are even lower for those with low education and/or for those who lack insurance.

Purpose: Employing a mixed methods approach, the goal of this investigation is to identify barriers to colorectal cancer screening in a cohort of Hispanic/Latinas, ages 50-75, living in Connecticut. With little information on cancer screening behaviors on HLs living in the Northeast, US, this study should help inform strategies for improving colorectal cancer screening.

Methods: Qualitative: Following a structured format, we conducted 3 focus groups with urban, community-living H/Ls (21 women, ages 50 and older) recruited from a local primary care clinic. Quantitative: Building on an established cohort of 1600 community-based Hispanic/Latino women, ages 45-70 in association with the Cancer Screening in Hispanic/Latinas Living in the Northeast, US (RO1 CA134276, Beth A Jones, PI), we conducted preliminary descriptive analyses on 813 women, ages 50 and older. Information on history of colorectal cancer screening (sigmoidoscopy, colonoscopy, and fecal occult blood testing (FOBT) and extensive information on socio-demographic, medical care, psychosocial, acculturation factors, and health beliefs were collected in a one hour telephone interview (85% in Spanish language).

Results: Qualitative: 84% of focus group participants (mean age 59) were from Puerto Rico, 61% reporting household incomes of less than $10,000 and low education levels. 35% of the participants reported receipt of colonoscopy in last 10 years and 33% reported a FOBT in last 10 years. There was significant variability in the knowledge and prior experience with all colorectal cancer screening among participants. Discomfort in discussing colorectal cancer screening and embarrassment associated with undergoing colorectal cancer screening were mentioned in all focus groups. Distrust of the MDs performing the test and history of sexual abuse emerged as potential barriers for women. Logistical barriers (time needed for the prep, time away from work, transportation and escort availability) were also identified. Quantitative: 813 H/L women between the ages of 50-75 were available for this analysis; 17% were age 65 or older. Similar to qualitative findings, women were of low socioeconomic status. 340 of the 813 women (41.8%) had not received endoscopic screening in specified time period. Older women (age 65+) were slightly more likely to have received either colonoscopy or sigmoidoscopy.

Conclusions: With little published scientific literature on colorectal cancer screening in the Hispanic/Latino population in the Northeast, US, this mixed methods study has confirmed low colorectal cancer screening rates in H/L women as well as unique cultural barriers to receiving screening. Our results suggest that it will be critical to address educational and unique cultural belief and attitudinal barriers in order to improve colorectal cancer screening in this at-risk population.

Citation Format: Beth A. Jones, Juliana Quintero, Maria Rios, Margaret Doyle. Barriers to colorectal cancer screening in Hispanic/Latino women in Connecticut. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B81.

Collaborative study for the characterization of a chikungunya virus RNA reference reagent for use in nucleic acid testing

BACKGROUND AND OBJECTIVES

Infections with the mosquito-borne chikungunya virus (CHIKV) can cause febrile illness or be asymptomatic. Laboratory diagnosis of CHIKV is often made with laboratory-developed nucleic acid amplification technology (NAT) assays because there are no U.S. Food and Drug Administration (FDA)-approved diagnostic or blood screening assays. We aimed to produce a well-characterized CHIKV RNA reference reagent (CHIKV-RR) for use in NAT assays.

MATERIALS AND METHODS

A CHIKV RNA-RR consisting of cell culture-grown, heat-inactivated CHIKV diluted in human plasma was assessed by 8 laboratories in a collaborative study. The participants were asked to test the CHIKV-RR using their NAT assay(s) by qualitative testing (determination of RNA end-point by testing log and half-log dilutions followed by calculation of estimated NAT-detectable units/ml, after adjustment for the sample volume used for testing), and by quantitative testing, when available.

RESULTS

Results from the testing showed that the CHIKV-RR had an estimated overall mean of 7.56 log10 detectable units/ml, ranging from 6.2 log10 to 8.6 log10.

CONCLUSIONS

The Center for Biologics for Evaluation and Research/FDA CHIKV RNA-RR for NAT was established with a concentration of 7.56 log10 detectable units/ml.

Abstract P3-06-07: Alterations of intratumoral signalling in breast cancer patients receiving pre-operative trastuzumab alone or combined with everolimus

Background: PI3K/AKT/mTOR and MAP kinase pathways are major signaling pathways involved in mammary tumorigenesis and are investigated as putative targets for therapy. Multiple cross-talks exists between these two pathways, allowing the regulation of one another by and inversely, depending on the cell conditions. It has been reported that trastuzumab acted differently when used pre-operatively or in neo-adjuvant setting with a lower implication of signaling blockade and a higher induction of ADCC when used alone in chemotherapy naive patients. Additionally, mTOR blockade has been experimentally reported to activate MAPK pathway through a feed-back loop effect. The purpose of this study was to retrospectively investigate the effect on MAPK signaling of adding everolimus to trastuzumab as preoperative therapy of HER-2 positive primary breast cancer amenable to surgery (Unicancer RADHER Phase II trial).

Patients and methods: Formalin-fixed paraffin embedded and frozen tumor samples of primary breast cancer (n=80), were obtained from 82 patients with infiltrating breast carcinoma randomized from July 2008 to April 2012 to receive ttrastuzumab alone (T arm) (loading dose 4mg/kg, then 2mg/kg/week), or combined with everolimus (T+E arm) (10 mg/day) for a 6 week pre-operative treatment. The median patient age at diagnosis (at the randomization) was 52.7 years. All patients had baseline biopsies taken before initiation of the treatment, at cycle 4 as an option and at surgery. FFPE samples were used for immunohistochemistry (pAKT, pS6K, eIF4E, LKB1), frozen samples were used for multiplex immunoanalysis of phosphorylated PI3K/AKT/mTOR and MAPKinase signaling proteins analysis (p-AKT, p-GSK3, p-P70S6K, p-MEK1, p-ERK1/2, p-P90RSK). Before being submitted to total protein extraction, all biopsies were controlled to ensure a tumor content >50%. 40 pairs associating baseline + surgery tumor specimens or baseline + cycle 4 biopsies were eligible for protein extraction.

Results: No statistically significant relationship was observed between the expression level of any of the phosphoproteins in the initial biopsies and neither the clinical nor the pathological response, overall. After treatment, as compared to the level of expression measured in the initial biopsies, no significant variation of expression of either PI3 kinase or MAP kinase related phosphoprotein was observed in T arm. In T+E arm, significant inhibition of PI3 kinase/mTOR pathway was only observed downstream mTOR protein with decreased expression of p-P70S6 kinase and p-4EBP1 together with a significant activation of MAPK pathway was detected with increased expression of p-MEK1, p-ERK1/2 was observed in T+E arm.

Conclusion: These results confirm that when used alone in chemotherapy naive patients, trastuzumab could not mainly act through the blockade of signaling and therefore when combined with mTOR inhibitors could lead to the suppression of negative feedback regulation of MAP kinase pathway.

Citation Format: Jean-Louis Merlin, Maeva Lion, Jennifer Wong, Thomas Bachelot, Fabrice Andre, Isabelle Treilleux, Delphine Loussouarn, Jacques Bonneterre, Maria Rios, Véronique Dieras, Marta Jimenez, Agnès Leroux, Mario Campone. Alterations of intratumoral signalling in breast cancer patients receiving pre-operative trastuzumab alone or combined with everolimus [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-06-07.

Trabectedin in patients with advanced soft tissue sarcoma: a retrospective national analysis of the French Sarcoma Group

AIM

The French Sarcoma Group performed this retrospective analysis of the 'RetrospectYon' database with data of patients with recurrent advanced soft tissue sarcoma (STS) treated with trabectedin 1.5 mg/m(2) as a 24-h infusion every three weeks.

METHODS

Patients who achieved non-progressive disease after six initial cycles could receive long-term trabectedin treatment until disease progression.

RESULTS

Overall, 885 patients from 25 French centres were included. Patients received a median of four trabectedin cycles (range: 1-28). The objective response rate was 17% (six complete/127 partial responses) and 50% (n = 403) of patients had stable disease for a disease control rate of 67%. After a median follow-up of 22.0 months, median progression-free survival (PFS) and overall survival (OS) were 4.4 and 12.2 months, respectively. After six cycles, 227/304 patients with non-progressive disease received trabectedin until disease progression and obtained a significantly superior median PFS (11.7 versus 7.6 months, P<0.003) and OS (24.9 versus 16.9 months, P < 0.001) compared with those who stopped trabectedin treatment. Deaths and unscheduled hospitalisation attributed to drug-related events occurred in 0.5% and 9.4% of patients, respectively.

CONCLUSION

The results of this real-life study demonstrate that treatment with trabectedin of patients with STS yielded comparable or improved efficacy outcomes versus those observed in clinical trials. A long-term treatment with trabectedin given until disease progression is associated with significantly improved PFS and OS.

Rapid detection of hepatitis B virus in blood plasma by a specific and sensitive loop-mediated isothermal amplification assay

BACKGROUND

Hepatitis B virus (HBV) is an important blood-borne pathogen that causes hepatic inflammation and can lead to liver cirrhosis and hepatocellular carcinoma. Conventional methods of HBV detection are time consuming and require highly trained personnel and elaborate equipment. This report describes the development of a rapid, simple, specific, and sensitive loop-mediated isothermal amplification assay (LAMP) for detection of HBV genotypes A, B, C, D, E, and F in blood samples.

METHODS

HBV standard plasma panels and clinical donor plasma specimens were used for the development and validation of the LAMP assay. Amplification was performed at 60°C for 60 minutes using extracted DNA or heat-treated plasma specimens without DNA extraction. The assay was evaluated for its ability to detect various HBV genotypes and for its sensitivity, specificity, and time-point of detection.

RESULTS

The LAMP assay detected HBV genotypes A-F and demonstrated a sensitivity of 10-100 IU per reaction of HBV DNA. The assay also detected 69 of 75 (92%) HBV-positive donor plasma specimens tested and demonstrated a specificity of 100%.

CONCLUSIONS

These results demonstrate that our HBV-LAMP assay is rapid, sensitive and specific, and capable of detecting the major HBV genotypes. This assay could be used in clinical point-of-care settings, mainly in endemic and resource-limited environments for HBV diagnostics, donor screening, epidemiological studies, and therapeutic monitoring of patients undergoing antiviral treatment.

Force-time course parameters and force fatigue model during an intermittent fatigue protocol in motorcycle race riders

Fatigue in forearm muscles may be critical for motorcycle riders in relation to performance and forearm disorders. Force-time course parameters were examined to better characterize the reduction in the maximal force generating capacity (MVC) during an intermittent fatigue protocol (IFP) specifically designed for motorcycle riders. Also, a mathematical force fatigue model is proposed. Forty motorcyclists (aged 27.6 ± 6.8 years) performed an IFP that simulated the braking gesture and posture of a rider. Fatigue was confirmed by a 40% decrement of the normalized MVC in comparison with basal value. Contraction time increased in comparison with basal condition (P ≤ 0.034). Relaxation kinetics presented two phases: (a) a pre-fatigue phase where half relaxation time (HRTraw ) and normalized (HRTnor ) decreased (P ≤ 0.013) while relaxation rate (RRraw ) remained unchanged; and (b) a fatiguing phase where HRTraw , HRTnor increased and RRraw decreased (P ≤ 0.047). Normalized RRraw (RRnor ) declined progressively (P ≤ 0.016). The proposed nonlinear force fatigue model confirmed a satisfactory adjustment (R(2)  = 0.977 ± 0.018). This mathematical expression derived three patterns of force fatigue: three-phase, exponential and linear, representing 70%, 13%, and 17% of the participants, respectively. Overall, these results provided further support to force fatigue theoretical and applied proposals.

Primary localized rectal/pararectal gastrointestinal stromal tumors: results of surgical and multimodal therapy from the French Sarcoma group

BACKGROUND

Rectal and pararectal gastrointestinal stromal tumors (GISTs) are rare. The optimal management strategy for primary localized GISTs remains poorly defined.

METHODS

We conducted a retrospective analysis of 41 patients with localized rectal or pararectal GISTs treated between 1991 and 2011 in 13 French Sarcoma Group centers.

RESULTS

Of 12 patients who received preoperative imatinib therapy for a median duration of 7 (2-12) months, 8 experienced a partial response, 3 had stable disease, and 1 had a complete response. Thirty and 11 patients underwent function-sparing conservative surgery and abdominoperineal resection, respectively. Tumor resections were mostly R0 and R1 in 35 patients. Tumor rupture occurred in 12 patients. Eleven patients received postoperative imatinib with a median follow-up of 59 (2.4-186) months. The median time to disease relapse was 36 (9.8-62) months. The 5-year overall survival rate was 86.5%. Twenty patients developed local recurrence after surgery alone, two developed recurrence after resection combined with preoperative and/or postoperative imatinib, and eight developed metastases. In univariate analysis, the mitotic index (≤5) and tumor size (≤5 cm) were associated with a significantly decreased risk of local relapse. Perioperative imatinib was associated with a significantly reduced risk of overall relapse and local relapse.

CONCLUSIONS

Perioperative imatinib therapy was associated with improved disease-free survival. Preoperative imatinib was effective. Tumor shrinkage has a clear benefit for local excision in terms of feasibility and function preservation. Given the complexity of rectal GISTs, referral of patients with this rare disease to expert centers to undergo a multidisciplinary approach is recommended.

Neurotrophins and the regulation of energy balance and body weight

Complex interactions between the brain and peripheral tissues mediate the effective control of energy balance and body weight. Hypothalamic and hindbrain neural circuits integrate peripheral signals informing the nutritional status of the animal and in response regulate nutrient intake and energy utilization. Obesity and its many medical complications emerge from the dysregulation of energy homeostasis. Excessive weight gain might also arise from alterations in reward systems of the brain that drive consumption of calorie dense, palatable foods in the absence of an energy requirement. Several neurotrophins, most notably brain-derived neurotrophic factor, have been implicated in the molecular and cellular processes underlying body weight regulation. Here, we review investigations interrogating their roles in energy balance and reward centers of the brain impacting feeding behavior and energy expenditure.

Abstract P1-08-27: Quantitative analysis of tumor expression of phosphoproteins from PI3-kinase and MAP-kinase signaling pathways as biomarkers of the biological and clinical activity of trastuzumab and everolimus in breast cancer: Unicancer RADHER phase II trial results

Background: PI3-kinase (PI3K) and MAP kinase (MAPK) are the main signaling pathways implicated in molecular oncogenesis. In breast cancer, inhibition of these signaling pathways has been largely envisaged by means of targeted therapy. Unicancer RADHER study aimed at evaluating the efficacy of adding everolimus (E) to trastuzumab (T) as preoperative therapy for primary HER2+ operable breast cancer patients and to evaluate molecular response biomarkers. We report here the investigation of the expression of phosphoproteins from PI3K and MAPK signaling pathways as predictive biomarkers of clinical and pathological response as well as pharmacodynamic markers of treatment activity.

Methods: 82 eligible patients were randomized to receive T alone (loading dose 4 mg/kg, then 2 mg/kg/week), or T+E (10 mg/day) for a 6-week pre-operative treatment. Clinical response rate (cRR) was determined from OMS criteria with complete and partial responses being considered as “ responders “ and stable and progressive diseases as “ non responders “. Pathological response rate was evaluated according to Sataloff classification, with Ta and Tb being considered as “ responders “ and, Tc and Td as “ non responders “. The expression levels of phosphorylated-AKT (p-AKT), p-GSK3b, p-S6 kinase, p-MEK1, p-ERK1/2, p-P90RSK, p-IGF1R as well as p-P38MAPK were quantitatively assessed using multiplex bead immuno-assay. All patients had baseline needle frozen biopsies taken before initiation of the treatment, at cycle 4 as an option and at surgery. Before being submitted to total protein extraction, all biopsies were validated by a senior pathologist after HE slide examination to ensure a tumor content &gt;50%. 36 pairs associating baseline + surgery tumor specimens and 4 pairs of baseline + cycle 4 biopsies were eligible for protein extraction. Results: No statistically significant relationship was observed between the expression level of any of the phosphoproteins in the initial biopsies and neither the clinical nor the pathological response, overall. After treatment, as compared to the level of expression measured in the initial biopsies, a significant increase of p-GSK3β, p-MEK1, p-ERK1/2, p-P38MAPK was observed in T+E arm and a significant decrease in p-S6 kinase expression in the global patient population. No significant variation was observed in T arm. Additional analysis with immunohistochemistry data is planned and will be presented.

Conclusion: In the present study, measuring phosphoproteins expression showed that combining E with T, altered the regulation of signaling proteins from PI3-Kinase and MAP-kinase pathways. No response predictive biomarker could be identified among the phosphoproteins analyzed tending to show that the clinical and pathological response to T and T+E should be driven by additional mechanisms. As a whole, these results validate the use of multiplex bead immuno-analysis for determination of phosphorylated signaling proteins in clinical needle biopsies from breast cancer specimens and its prospective evaluation as biomarker for the activity of targeted therapies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-27.

Primary cardiac sarcomas: a retrospective study of the French Sarcoma Group

INTRODUCTION

Primary cardiac sarcomas (PCS) are rare tumours of dismal prognosis.

METHODS

Data of 124 patients with PCS referred to institutions of the French Sarcoma Group (FSG) from 1977 and 2010 were reviewed.

RESULTS

Median age was 48.8years. PCS were poorly-differentiated sarcomas (N=45, 36.3%), angiosarcomas (N=40, 32.3%), leiomyosarcomas (N=16, 12.9%) and others (N=23, 18.6%). At diagnosis, 100 patients (80.6%) were localised and 24 (19.4%) metastatic. Tumours were located in the right (N=47, 38.8%), left atrial cavities (N=45, 37.2%) or encompassed several locations in nine cases (7.4%). Surgery was performed in 81 cases (65.3%). Heart transplant was performed in five patients. Radiotherapy adjuvant (N=18, 14.5%) or alone (N=6, 4.8%) was performed in non-metastatic patients only (N=24, 19.4%). With a median follow-up of 51.2months, median overall survival (OS) was 17.2months for the entire cohort, 38.8months after complete resection versus 18.2 after incomplete resection and 11.2months in non-resected patients. Radiotherapy was associated with improved progression-free survival (PFS) on multivariate analysis. Chemotherapy was significantly associated with better OS only in non-operated patients but not in operated patients. In non-metastatic patients, surgery (hazard ratio [HR]=0.42, p<0.001), male gender (HR=0.56, p=.032) was associated with better OS and surgery (HR=0.61; p=.076), radiotherapy (HR=0.43; p=.004) and chemotherapy (HR=0.30, p=.003) improved PFS.

CONCLUSION

Only surgical resection is associated with a perspective of prolonged survival. Chemotherapy is associated with a better outcome in non-resected patients.

Determining the length of posttherapeutic follow-up for cancer patients using competing risks modeling

BACKGROUND/OBJECTIVE

After a curative treatment for cancer, patients enter into a posttherapeutic surveillance phase. This phase aims to detect relapses as soon as possible to improve the outcome. Mould and others predicted with a simple formula, using a parametric mixture cure model, how long early-stage breast cancer patients should be followed after treatment. However, patients in posttherapeutic surveillance phase are at risk of different events types with different responses according to their prognostic factors and different probabilities to be cured. This paper presents an adaptation of the method proposed by Mould and others, taking into account competing risks. Our loss function estimates, when follow-up is stopped at a given time, the proportion of patients who will fail after this time and who could have been treated successfully.

METHOD

We use the direct approach for cumulative incidence modeling in the presence of competing risks with an improper Gompertz probability distribution as proposed by Jeong and Fine. Prognostic factors can be taken into account, leading to a proportional hazards model. In a second step, the estimates of the Gompertz model are combined with the probability for a patient to be treated successfully in case of relapse for each event type. The method is applied to 2 examples, a numeric fictive example and a real data set on soft tissue sarcoma.

RESULTS

and

CONCLUSION

The model presented is a good tool for decision making to determine the total length of posttherapeutic surveillance. It can be applied to all cancers regardless of the localizations.

6 months versus 12 months of adjuvant trastuzumab for patients with HER2-positive early breast cancer (PHARE): a randomised phase 3 trial

BACKGROUND

Since 2005, 12 months of adjuvant trastuzumab has been the standard treatment for patients with HER2-positive early-stage breast cancer. However, the optimum duration of treatment has been debated. We did a non-inferiority trial of a shorter exposure of 6 months versus the standard 12 months of trastuzumab for patients with early breast cancer.

METHODS

We did an open-label, randomised, phase 3 trial in 156 centres in France. Patients with HER2-positive early breast cancer who had received at least four cycles of chemotherapy, had breast-axillary surgery, and had received up to 6 months of trastuzumab (administered by intravenous infusions over 30-90 min every 3 weeks; initial loading dose 8 mg/kg; 6 mg/kg thereafter) before randomisation were eligible. Patients were randomly assigned via central randomisation procedure with web-based software to continue trastuzumab for another 6 months (12 months total duration; control group) or to discontinue trastuzumab at 6 months (6 months total duration; experimental group). Randomisation was stratified by concomitant or sequential administration of trastuzumab with chemotherapy, oestrogen-receptor status, and centre using a minimisation algorithm. The primary endpoint was disease-free survival, with a prespecified non-inferiority margin of 1·15. Analyses were done in the intention-to-treat population. This study is registered at ClinicalTrials.gov, number NCT00381901.

FINDINGS

1691 patients were randomly assigned to receive 12 months of trastuzumab and 1693 to receive 6 months of trastuzumab; 1690 patients in each group were included in the intention-to-treat analyses. After a median follow-up of 42·5 months (IQR 30·1-51·6), 175 disease-free survival events were noted in the 12-month group and 219 in the 6-month group. 2-year disease-free survival was 93·8% (95% CI 92·6-94·9) in the 12-month group and 91·1% (89·7-92·4) in the 6-month group (hazard ratio 1·28, 95% CI 1·05-1·56; p=0·29). 119 (93%) of the 128 cardiac events (clinical or based on assessment of left ventricular ejection fraction) occurred while patients were receiving trastuzumab. Significantly more patients in the 12-month group experienced a cardiac event than did those in the 6-month group (96 [5·7%] of 1690 patients vs 32 [1·9%] of 1690 patients, p<0·0001).

INTERPRETATION

After 3·5 years follow-up, we failed to show that 6 months of treatment with trastuzumab was non-inferior to 12 months of trastuzumab. Despite the higher rates of cardiac events, 12 months of adjuvant trastuzmab should remain the standard of care.

FUNDING

French National Cancer Institute.

Evolutionary dynamics of West Nile virus in the United States, 1999-2011: phylogeny, selection pressure and evolutionary time-scale analysis

West Nile virus (WNV), an arbovirus maintained in a bird-mosquito enzootic cycle, can infect other vertebrates including humans. WNV was first reported in the US in 1999 where, to date, three genotypes belonging to WNV lineage I have been described (NY99, WN02, SW/WN03). We report here the WNV sequences obtained from two birds, one mosquito, and 29 selected human samples acquired during the US epidemics from 2006–2011 and our examination of the evolutionary dynamics in the open-reading frame of WNV isolates reported from 1999–2011. Maximum-likelihood and Bayesian methods were used to perform the phylogenetic analyses and selection pressure analyses were conducted with the HyPhy package. Phylogenetic analysis identified human WNV isolates within the main WNV genotypes that have circulated in the US. Within genotype SW/WN03, we have identified a cluster with strains derived from blood donors and birds from Idaho and North Dakota collected during 2006–2007, termed here MW/WN06. Using different codon-based and branch-site selection models, we detected a number of codons subjected to positive pressure in WNV genes. The mean nucleotide substitution rate for WNV isolates obtained from humans was calculated to be 5.06×10⁻⁴ substitutions/site/year (s/s/y). The Bayesian skyline plot shows that after a period of high genetic variability following the introduction of WNV into the US, the WNV population appears to have reached genetic stability. The establishment of WNV in the US represents a unique opportunity to understand how an arbovirus adapts and evolves in a naïve environment. We describe a novel, well-supported cluster of WNV formed by strains collected from humans and birds from Idaho and North Dakota. Adequate genetic surveillance is essential to public health since new mutants could potentially affect viral pathogenesis, decrease performance of diagnostic assays, and negatively impact the efficacy of vaccines and the development of specific therapies.

West Nile Virus (WNV) is a mosquito-borne virus of African origin that is widespread around the world. The WNV life-cycle involves mosquitoes and birds, but humans and other animals can be infected, although they are not considered to be important players in the transmission cycle. Clinically, most WNV infections are unapparent, but the virus can disseminate to the central nervous system causing a potentially fatal neurological disease, especially in susceptible populations including elderly and immunocompromised individuals. West Nile virus can also be transmitted by organ transplant and by transfusion of blood and blood components. Like other arboviruses, WNV has the extraordinary capacity of growing in the different microenvironments represented by the invertebrate vector and the vertebrate hosts. From an evolutionary standpoint, the arrival of WNV in the US in 1999 represents a unique opportunity to explore the processes involved in the adaptation and dissemination of an arbovirus in a naïve environment. From the study of WNV sequences, we can not only learn about the evolutionary mechanisms that govern arboviruses, but also update diagnostic tests that rely on the detection of the viral genome upon the occurrence of mutations and study the existence of genetic markers that may be responsible for increases in clinical cases and their severity.

Impact of mutational status and other prognostic factors on survival in patients with advanced GIST treated with standard-dose imatinib (IM): Results from the BFR14 phase III trial of the French Sarcoma Group

10548

Background: Factors predicting progression free survival (PFS) and overall survival (OS) of patients (pts) with advanced GIST treated with 400 mg daily dose IM were investigated. As mutational status was a secondary objective of the BFR14 study, we wanted to evaluate the added value of these genomic profiles to conventional clinical prognostic factors. Methods: 434 pts were included in this prospective multicenter trial from June 2002 to July 2009. Prognostic factors for survival were investigated in the cohort where the mutational status was available. A multivariate Cox model including baseline characteristics statistically significant in univariate were included in a backward procedure to identify independent prognostic factors for PFS then OS. Results: Mutational analysis were available in 322 pts. Material was insufficient in 55 cases (12.5%), incomplete results were obtained in 39 pts (9%). There were 196 KIT genetic alterations (exon 11: 173 pts, exon 9: 22 pts, exon 17: 1 pt), 6 GIST with a PDGFRA mutations and 26 GIST WT. The analysis of prognostic factors was performed in all mutated and non-mutated GIST (221 pts) except for pts with a KIT exon 17 and PDGFRa mutation. As of January 2013, median follow-up was 73 months (m) (CI95%:63; 86), 147 progressions (67%) were notified and 84 deaths (38%) occurred. The median PFS and OS were 12.3 m (CI95%: 2.1;32.7) and 54.9 m (CI95%:16.5;83.8) for WT GIST, 12.6m (CI95%: 6.1;30.8) and 55m (CI95%:33.5;83.0) for KIT exon 9 and 39.4m (CI95%: 31.4;54.4) and not reached for KIT exon 11, respectively. An initial low tumour volume, gender (female), and CD34 positivity were the three independent prognostic factors of a higher PFS. A higher OS was independently predicted by PS, low neutrophil counts, KIT exon 11 alterations, normal lymphocyte count, lower tumor size and female’s gender. Conclusions: GIST pts harboring a KIT exon 11 mutations have the better outcome but the mutational status is not the only prognostic factor influencing the outcome of pts. The clinical (gender, PS, tumor size) and biological characteristics (lymphocytes and neutrophil counts) remain critical for OS.

A large retrospective analysis of trabectedin in 885 patients with advanced soft tissue sarcoma

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Background: Trabectedin (Yondelis) is the first marine-derived antineoplastic drug approved in Europe for the treatment of patients with recurrent ASTS or for patients unsuited to receive anthracyclines and ifosfamide. We retrospectively analyzed the RetrospectYon database with patients’ data treated with trabectedin between Jan 2008 - Dec 2011. Methods: Trabectedin was given at the approved dose of 1.5 mg/m2 as a 24-h infusion every 3 weeks. Patients who achieved partial response (PR) or stable disease (SD) after 6 cycles could receive maintaining trabectedin treatment. Uni- and multivariate analyses of prognostic factors were performed. Results: 885 patients (486 women) from 26 centers in France with ASTS with a median age of 54 years (range 12-84) were included. Most had leiomyosarcoma (36%), liposarcoma (18%) or synovial STS (11%). At baseline, performance status (PS) was 0 in 26%, 1 in 47% and >1 in 27% of patients. A median of 4 trabectedin cycles (range 1-28) was given as a 2nd (41%), 3rd (39%) or ≥4th (20% of patients) treatment line. Toxic death and unscheduled re-hospitalization occurred in 0.5% and 8% of patients, respectively.The objective response rate was 15% (6 complete and 127 PR), and SD rate was 45.5% (n=403). After a median follow-up of 22.6 months (range 0.03-51.2), the patients who received trabectedin as 2nd, 3rd or ≥4th line had the median PFS of 4.3, 4.2 and 3.4 months, respectively, and the median OS of 12.9, 12.3 and 9.5 months. Multivariate analysis identified liposarcoma, leiomyosarcoma, angiosarcoma, undifferentiated pleomorphic sarcoma (UPS) and trabectedin line as independent prognostic factors for PFS, and UPS, angiosarcoma, rhabdomyosarcoma, gender, PS and trabectedin line for OS. After 6 cycles, 205 of the 273 patients with non-progressive disease received trabectedin as maintenance treatment and obtained a superior PFS (median 11 vs. 7.2 months, p=0.0001) and OS (median 25.1 vs. 16.9 months, p<0.0001) that those who stopped trabectedin after 6 cycles. Conclusions: Patients with ASTS treated with trabectedin had PFS and OS comparable or better to those observed in phase II/III trials. Trabectedin maintenance beyond 6 cycles is associated with improved OS and warrants further exploration.

Clinical experience with sunitinib (SU) in patients over age 65 with metastatic gastrointestinal stromal tumors (GIST): A retrospective study from the French Sarcoma Group (FSG)

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Background: Elderly GIST patients (pts) represent a consistent portion of all GIST pts, but are under-represented in clinical trials. Data on benefits, tolerance of SU in elderly GIST pts and their specific outcome are very limited. Methods: Charts of elderly pts (≥ 65 yrs)treated with SU in routine clinical practice from 11 Centres of the FSG were reviewed to evaluate the efficacy and safety of SU. Results: 71 elderly GIST pts were reviewed, with a median age of 74, [distributed as 65-74, n=36; 75-84, n=30; ≥ 85, n=5], 41 (57%) men, with median ECOG-PS= 1 (0-2), and median active comorbities of 1 (0-4). SU was administered after progression on first-line Imatinib (400 mg/d for 21 pts, 400 then 800 mg/d for 45 pts) or masitinib (5 pts). SU was started at 50 mg/d 4-wks-on/2 wks-off in 37 pts (52%), at 37.5 mg daily in 32 pts (45%), and at 25 mg daily in 2 pts. All but 2 pts experienced at least one adverse event (AE). Drug related AE were mainly of grade 1 or 2 (298/388, 76%), and medically manageable. Most frequent AE were fatigue (20%), diarrhea (11%), mucositis (7%), abdominal pain (7%), hand-foot syndrome (6%), neutropenia (6%), and hypertension (5%). Permanent dose reduction was reported in 33 pts (46%). In 17 pts (24%) SU was permanently stopped due to grade 3 or 4 AE. ; this occurred within 3 months after starting SU in 10 pts. At a median 36 months follow-up, 53 pts progressed, and 28 pts were alive. The median PFS and OS were 10.2 (0.2-54) and 21 (0.5-77) months, respectively. Univariate analysis showed that age (≤ 80), PS (<1), WBC (≤ 4 Giga/l), Hb and Albumin have a positive impact on OS (all p < 0.04) and PFS (all p < 0.05). In multivariate analysis, Albumin and Hb had an impact on OS and PFS, PS had an impact only on OS, and WBC only on PFS. A correlation was found between comorbidities and Grade 3/4 toxicities, but no correlation between any toxicities and outcome. Conclusions: Compared to data from clinical trials, SU yields similar rates of GIST control and OS in elderly pts despite frequent dose reductions or interruptions. Since comorbidities may increase the risks of AEs, careful follow-up to assess tolerance is particularly indicated in elderly GIST pts.

Different molecular weight hyaluronic acid effects on human macrophage interleukin 1β production

This study examined the effect of hyaluronan (HA) molecular weight on immune response. HA with molecular weights ranging from the unitary disaccharide unit (400 Da) up to 1.7 × 10(6) Da and with very low endotoxin contamination level (less than 0.03 EU/mg) was used. Primary human monocyte/macrophage cultures were assayed for IL-1β production under a variety of inflammatory conditions with or without HA. Under the highest inflammatory states, production of interleukin 1β (IL-1β) was suppressed in the presence of high molecular weight hyaluronan (HMW-HA) and in the presence of low molecular weight hyaluronan (LMW-HA) at mg/mL concentrations. There was variability in the sensitivity of the response to HA fragments with MW below 5000 Da at micromolar concentrations. There was variability in IL-1β cytokine productions from donor to donor in unstimulated human cell cultures. This study supplements our previous published study that investigated the immunogenic effect of HA molecular weights using murine cell line RAW264.6, rat splenocytes, and rat adherent differentiated primary macrophages. These data support the hypothesis that if the amount of endotoxin is reduced to an extremely low level, LMW-HA may not directly provoke normal tissue macrophage-mediated inflammatory reactions.

Long-term outcome and effect of maintenance therapy in patients with advanced sarcoma treated with trabectedin: an analysis of 181 patients of the French ATU compassionate use program

BACKGROUND

The long term outcome of advanced sarcoma patients treated with trabectedin outside of clinical trials and the utility of maintenance treatment has not been reported.

METHODS

Between 2003 and 2008, patients with advanced sarcoma failing doxorubicin could be treated within a compassionate use program (ATU, Temporary Use Authorization) of trabectedin in France using the standard 3-weekly regimen. Data from 181 patients (55%) were collected from 11 centres and analyzed.

RESULTS

Trabectedin was given in first, second, third or fourth line in metastatic phase in 6%, 37%, 33% and 23% of patients respectively. With a median follow-up of 6 years, median PFS and OS were 3.6 months and 16.1 months respectively. The median number of cycles was 3 (range 1-19). Best response were partial response (PR, n = 18, 10%), stable disease (SD, n = 69, 39%) and progressive disease (PD, n = 83, 46%), non evaluable (NE, n = 9, 5%). Thirty patients (17%) had to be hospitalized for treatment- related side effects. Independent prognostic factors in multivariate analysis (Cox model) were myxoid LPS and line of trabectedin for PFS, and myxoid LPS and retroperitoneal sarcomas for OS. Patients in PR or SD after 6 cycles continuing treatment had a better PFS (median 5.3 vs 10.5 months, p = 0.001) and OS (median 13.9 vs 33.4 months, p = 0.009) as compared to patients who stopped after 6 cycles.

CONCLUSIONS

In this compassionate use program, trabectedin yielded similar or better PFS and OS than in clinical trials. Maintenance treatment beyond 6 cycles was associated with an improved survival.

Tumours and pseudotumours of the soft tissue in adults: perspectives and current role of sonography

Soft tissue tumours of the musculoskeletal system are reported relatively frequently. The quality of the information gained from different imaging modalities (Doppler sonography, multislice CT, MRI spectroscopy, and diffusion MRI) means that in a growing number of situations, we can envisage determining with great accuracy not only the usual information of tumour size and topography, but often the exact nature of the tissue, almost always identifying whether a lesion is aggressive or not. Of all these techniques, Doppler sonography has become the most widely used due to the striking improvements in its sensors, especially for superficial applications. Some other recent developments are: panoramic imaging, elastography (although its current contribution is still to be determined but it seems to offer promising potential), and, most importantly, specific contrast agents. These techniques have considerably refined the quality of the information obtained, and have particularly enhanced the degree of sensitivity with which lesion progression can be assessed. Ultrasonography is the very first investigation in our protocol. It is also very often used to close investigations, as it accurately guides core needle biopsy from these generally accessible lesions. The purpose of this article is to bring together updated information on the various collections of sonographic features seen in soft tissue tumours and pseudotumours and to emphasise the considerable contributions of these new technological developments, in particular contrast-enhanced sonography. The discussion will follow the World Health Organisation's anatomical pathology classifications of soft tissue tumours. We will close with a synthesis that summarises the main steps in our diagnostic process.