Metronomic vinorelbine plus bevacizumab as salvage therapy for patients with metastatic breast cancer

PURPOSE

Continuous administration of oral vinorelbine, given 3 times a week (metronomic), is feasible and exceptionally well tolerated at doses up to 50 mg with clinical activity against refractory tumors. In this phase II study oral metronomic vinorelbine and bevacizumab were evaluated as salvage therapy in women with pretreated metastatic breast cancer (MBC).

METHODS

Patients received oral vinorelbine (50 mg 3 times a week) and bevacizumab (10 mg/kg) biweekly in cycles of 28 days. The primary endpoint was objective response rate (ORR). A preplanned analysis was performed when the first 13 patients were evaluated for tumor response.

RESULTS

One patient (7.7%) achieved partial response (PR) and 6 (46.1%) stable disease (SD). The combination was very well tolerated but, as per protocol, the study was closed prematurely due to lack of efficacy.

CONCLUSION

The combination of oral metronomic vinorelbine and bevacizumab has good tolerance but minimal activity in terms of objective responses in pretreated patients with MBC.

Efficacy and treatment tolerance in older patients with NSCLC: a meta-analysis of five phase III randomized trials conducted by the Hellenic Oncology Research Group

BACKGROUND

Approximately 50% of newly diagnosed cases of non-small-cell lung cancer (NSCLC) are observed in patients >65 years, while 30%-40% of cases occur in patients >70 years.

PATIENTS AND METHODS

The objective of the current study was to determine (i) the number of elderly (>70 years) patients with advanced/metastatic NSCLC enrolled in phase III trials of the Hellenic Oncology Research Group, (ii) the treatment-related toxicity observed in these patients compared with their younger counterparts, and (iii) the differences in terms of response rate, time to tumor progression (TTP), and overall survival (OS) between younger and older patients.

RESULTS

Pooled data from five clinical trials including 1845 patients were analyzed; 1421 (77%) and 424 (23%) were <70 years and ≥70 years, respectively. No difference was observed in terms of the overall response rate and TTP. There was an OS difference between young and older patients, with higher risk for death in older patients. However, when the analysis was carried out after omitting a trial that showed a different trend, no difference was observed. Older patients experienced higher toxicity.

CONCLUSIONS

This report supports the feasibility of chemotherapy treatment for older NSCLC patients. Optimization of treatment of older NSCLC patients requires the design of prospective older-specific phase III trials for these patients.

Folinic acid, 5-fluorouracil, irinotecan (FOLFIRI) plus chemoradiation (CRT) with 5-fluorouracil (5FU) as adjuvant treatment for patients with operable gastric cancer (OGC): A feasibility study with pharmacogenetic analysis

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Background: To evaluate the efficacy and safety of FOLFIRI plus CRT with 5FU as adjuvant treatment for patients with OGC.

Methods: Patients received treatment with FOLFIRI (irinotrecan 150 mg/m2, d1, LV 200 mg/m2, d1+2 and 5FU [400 mg/m2/d bolus and 600 mg/m2/d, 22 h infusion, d1+2]) for 2 15-day cycles followed by RT (45Gy) with 5FU continuous infusion (325 mg/m2/d in the 1st and 5th week) administration. Eight additional cycles of FOLFIRI were administered after the completion of CRT. BRCA1, ERCC1, XPD, TOPO-I, TOPO-IIA and B and TS mRNA expression was determined in the primary tumor where available.

Results: The median age of the 171 enrolled patients was 62 years, 114 (66%) were males, 136 (79%) had R0 resections and 152 (89%) had at least a D1 resection. Treatment was completed as per protocol in 107 (63%) of the patients. CRT was completed in all but 5 (3%) patients. The median rate of drug exposure was 93% for irinotecan, 87% for 5FU and 91% for LV. The most common grade 3/4 adverse events were neutropenia (32%), febrile neutropenia (3.5%) and diarrhea (7%). After a median follow-up of 45.7 months 84 had relapsed and 70 were deceased. The median disease-free survival (DFS) was 30 months (95% CI: 18-41 months), while the projected median overall survival (mOS) was 53.7 months (95% CI: 30-77 months). The recurrence free probability at 5 years was 44% while the probability of survival at 5 years was 46%. From the studied pharmacogenetic markers only TS low expression was correlated with a trend towards improved DFS and OS in patients with R0 resections.

Conclusions: These results show that the administration of FOLFIRI plus CRT with 5FU as adjuvant treatment in OGC is a feasible approach with acceptable toxicity and challenging efficacy which merits further evaluation in a randomized trial.

No significant financial relationships to disclose.

PKM2 as a biomarker for sensitivity to oxaliplatin-based chemotherapy in metastatic colorectal cancer (mCRC)

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Background: Tumour cells have been shown to express exclusively the embryonic M2 isoform of pyruvate kinase (PKM2), which is a key enzyme that regulates aerobic glycolysis in tumor cells. Use of RNA interfering (RNAi) targeting PKM2 significantly inhibits tumor growth when combined with cisplatin in xenograft models. We evaluated the predictive significance of PKM2 in patients with mCRC treated with oxaliplatin- based chemotherapy in the first-line setting.

Methods: FFPE primary tumors from 140 mCRC patients were analyzed for PKM2 mRNA expression by RT-qPCR. The analysis was performed with a set of primers and probes which amplify only the M2 isoform.

Results: The patients' characteristics were all typical for mCRC (median age 65 years, 61% males, 75% colon cancer 25% rectal cancer, 41% undifferentiated tumors, 21% mucinous features). PKM2 was successfully amplified in all specimens. Time to tumor progression (TTP) was significantly lower in patients with overexpression of PKM2 (6.7 vs. 9.1 months for high and low expression, respectively, p=0.004). Similarly, median overall survival (mOS) was significantly decreased in patients with upregulation of PKM2 (21.9 vs. 30.2 months for high and low expression, respectively, p=0.004). Multivariate analysis revealed PKM2 high mRNA expression (HR: 1.7, p=0.005) and the presence of undifferantited tumors (HR: 2.2, p<0.0001) as independent prognostic factors for decreased TTP. Similarly, PKM2 high mRNA expression (HR: 1.8, p=0.005) and the presence of undifferantited tumors (HR: 2.5, p<0.0001) were revealed as independent prognostic factors for decreased mOS.

Conclusions: These results provide evidence that the PKM2 mRNA expression could be used as a predictive factor for sensitivity to oxaliplatin-based chemotherapy. The results should be validated prospectively in an independent patient cohort.

No significant financial relationships to disclose.

Impact of KRAS, BRAF, and PIK3CA mutations, PTEN, AREG, and EREG expression, and skin rash in metastatic colorectal cancer patients treated with cetuximab-containing salvage treatment

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Background: To investigate the predictive significance of KRAS exon 2, BRAF V600E, PIK3CA exon 9 and 20 mutational status, AREG- EREG mRNA expression, PTEN protein expression and skin rash in patients with metastatic colorectal cancer (mCRC) treated with cetuximab containing salvage chemotherapy.

Methods: Primary tumors from 112 mCRC patients were analyzed. The worst skin toxicity during treatment was recorded.

Results: KRAS, BRAF and PIK3CA mutations were present in 37 (33%), 8 (7.2%) and 11 (9.8%) cases, respectively, PTEN was lost in 21 (19.8%) cases, AREG and EREG were overexpressed in 48 (45%) and 51 (49%) cases. In the whole study population, time to tumor progression (TTP) and overall survival (OS) was significantly lower in patients with KRAS (p=0.001 and p=0.026, respectively) or BRAF (p=0.001 and p<0.0001, respectively) mutant tumors, downregulation of AREG (p=0.018 and p=0.013, respectively) or EREG (p=0.002 and p=0.004, respectively) and in those with grade 0-1 skin rash (p<0.0001 and p<0.0001, respectively). In KRAS wt patients TTP and OS was significantly lower in patients with BRAF (p=0.0001 and p<0.0001, respectively) mutant tumors, downregulation of AREG (p=0.021 and p=0.004, respectively) or EREG (p=0.0001 and p<0.0001, respectively) and grade 0-1 skin rash (p<0.0001 and p<0.0001, respectively). TTP was significantly lower in patients with PIK3CA mutations (p=0.01) or lost PTEN (p=0.002). Multivariate analysis revealed KRAS (hazard ratio [HR] 4.3, p<0.0001), BRAF mutation (HR: 5.1, p<0.0001), EREG low mRNA expression (HR: 1.6, p=0.021) and absence of severe/moderate skin rash (HR: 4.0, p<0.0001) as independent prognostic factors for decreased TTP. Similarly, KRAS (HR 2.9, p=0.01), BRAF mutation (HR: 3.0, p=0.001), EREG low mRNA expression (HR: 1.7, p=0.021), absecence of severe/moderate skin rash (HR: 3.7, p<0.0001) and the presence of undifferantited tumours (HR: 2.2, p=0.001) were revealed as independent prognostic factors for decreased OS.

Conclusions: These results underscore the potential of advanced CRCs genetic profiling in order to identify patients with different treatment response.

No significant financial relationships to disclose.

Abstract PD04-04: Cytokeratin-19 mRNA Positive Circulating Tumor Cells during Follow-Up of Patients with Early Breast Cancer: Prognostic Relevance for Late Relapse

PURPOSE: We reported previously that the detection of CK-19 mRNA-positive circulating tumor cells (CTCs) after adjuvant chemotherapy in patients with early breast cancer is associated with poor clinical outcome. Reliable prognostic markers for late disease relapse are not available. In this study we investigated the prognostic value of CTCs’ detection during the first 5 years of follow-up in predicting late disease relapse. PATIENTS AND METHODS: Blood was obtained from 281 patients with early breast cancer who had not experienced disease relapse during the first two years of follow up. CTCs were detected using a real-time reverse transcriptase polymerase chain reaction for CK 19 mRNA after the completion of adjuvant chemotherapy and every six months thereafter for a 5-year follow up period. Patients were classified into four groups based on the CTCs’ status during the first two years and the subsequent three years of follow up (persistently negative, persistently positive, negative turned to positive and the opposite).

RESULTS: The vast majority of patients (92.9%) received some kind of hormonal therapy in addition to chemotherapy. Sixty-nine (24.6%) patients remained CTCs-free throughout the 5-year period. A change in CK-19 mRNA status was observed in 126 (44.9%) patients; 60 (21.4%) patients with initially CK-19 mRNA-positive CTCs during the first 24 months turned CTC-negative afterwards while 66 (23.5%) patients who were initially CTC-negative became CTC-positive. Eighty-six (30.6%) patients remained persistently CK-19 mRNA-positive for the entire 5 years. After 94 months of median follow up (range: 51-147), the relapse rate for each of the above groups of patients is illustrated in the following table.

Table 1: CTCs’ detection status and risk of late disease repapse.

Compared to the persistently negative, only the group of CK-19 mRNA-persistently positive patients had a statistically significant higher risk of relapse (38.4% versus 7.2%, p&lt; 0.001), shorter progression-free survival (not reached vs 135 months, P&lt;0.001) and significant difference in overall survival (not reached vs 146 months, p=0.045).

CONCLUSION: Persistent detection of CK-19 mRNA-positive CTCs in the blood during the first 5 years of follow up after adjuvant chemotherapy is associated with an increased risk of late disease relapse indicating the presence of chemotherapy-and hormonetherapy-resistant residual disease. This prognostic evaluation may be useful when deciding on subsequent adjuvant systemic therapy.

Correlation of BRCA1, TXR1 and TSP1 mRNA expression with treatment outcome to docetaxel-based first-line chemotherapy in patients with advanced/metastatic non-small-cell lung cancer

BACKGROUND

We explored the predictive significance of BRCA1, TXR1 and TSP1 expression in non-small-cell lung cancer (NSCLC) patients treated with docetaxel in association with cisplatin or gemcitabine.

METHODS

To analyse BRCA1, TXR1 and TSP1 mRNA expression from microdissected primary tumours of 131 patients with stage IIIB (wet) and IV NSCLC, RT-qPCR was used.

RESULTS

The mRNA levels of TXR1/TSP1 were inversely correlated (Spearman's test: -0.37; P=0.001). Low TXR1 mRNA levels were associated with higher response rate (RR; P=0.018), longer median progression-free survival (PFS; P=0.029) and median overall survival (mOS P=0.003), whereas high TSP1 expression was correlated with higher RR (P=0.035), longer PFS (P<0.001) and mOS (P<0.001). Higher BRCA1 mRNA expression was associated with higher RR (P=0.028) and increased PFS (P=0.021), but not mOS (P=0.4). Multivariate analysis demonstrated that low TXR1/high TSP1 expression was an independent factor for increased PFS (HR 0.49; 95% CI 0.32-0.76; P<0.001) and mOS (HR 0.37; 95% CI 0.2-0.58; P<0.001), whereas high BRCA1 expression was correlated with increased PFS (HR 0.53; 95% CI 0.37-0.78; P=0.001).

CONCLUSIONS

These data indicate that TXR1/TSP1 and BRCA1 expression could be used for the prediction of taxanes' resistance in the treatment of NSCLC.

Baseline nutritional evaluation in metastatic lung cancer patients: Mini Nutritional Assessment versus weight loss history

BACKGROUND

Cancer cachexia adversely affects survival and quality of life but its timely recognition is problematic. Nutritional questionnaires, like the Mini Nutritional Assessment (MNA), could identify early those patients at risk. The aim of the study was to compare MNA with 5% weight loss, a common criterion used in oncologic evaluation.

PATIENTS AND METHODS

The nutritional status of 171 chemotherapy-naive patients with metastatic lung cancer was evaluated by both methods. The results were compared and correlated with clinical and laboratory values and with clinical outcome.

RESULTS

The incidence of malnourished or patients at risk was higher according to the MNA (P<0.001). Both methods correlated with the performance status (P<0.001) but MNA was further correlated with the number of metastatic sites (P=0.007) and the presence of brain metastasis (P=0.022). Of 14 laboratory values studied, 9 were correlated with MNA and 5 with the weight loss history. Both methods were correlated with response to first-line therapy, time to progression and survival but MNA had a better predictive (P<0.001) and prognostic (P < 0.001) value.

CONCLUSIONS

MNA outperforms weight loss history as a baseline nutritional screening method in patients with metastatic lung cancer and could further refine prognostication.

Abstract 1142: Development and validation of a multiplexed PCR-coupled liquid bead array for gene expression in circulating tumor cells

INTRODUCTION: The aim of our study was to develop and validate a multiplexed PCR-coupled liquid bead array to detect the expression of multiple genes in Circulating Tumor Cells (CTCs), and application of this assay in peripheral blood samples of breast cancer patients.

PATIENTS AND METHODS: We designed a novel multiplexed PCR-coupled liquid bead array that consist of the following steps: a) in silico designed gene-specific primers and capture probes for CK-19, HER-2, Mammaglobin (hMAM), MAGE-A3, TWIST-1 and PBGD (as a control gene), b) RNA isolation from immunomagnetically enriched CTCs, c) multiplex PCR, d) sequence hybridization array, e) detection in the Luminex platform. We performed extensive optimization experiments using the SKBR3 and MDA-MB-231 cell lines as positive controls, to maximize analytical sensitivity and specificity and we further validated the performance of this array in respect to cross reactivity and intra and inter-precision. Finally, we applied the developed methodology in peripheral blood samples of 37 patients with operable breast cancer, 25 patients with verified metastasis and 17 healthy individuals.

RESULTS: The analytical performance of the developed array was evaluated in tumor cell lines in respect to analytical sensitivity and specificity. Cross reaction studies were performed for each gene target in the presence of all other targets. The assay is highly specific for each gene in complex multiplexed formats, since the discriminatory power of fluorescent bead sets is unique to specifically detect by sequence hybridization the presence of individual gene specific PCR products. The developed liquid bead-based array is highly sensitive, since it can detect the expression of each individual gene at one SKBR3 cell level. The validation of the array included within day and between-days precision studies. None of the genes tested was detected in the CTC fraction of healthy donors while in patients with verified metastasis, CK-19 was detected in 45%, HER-2 in 20%, MAGE-A3 in 30%, hMAM in 15% and TWIST-1 in 20%. In operable breast cancer patients, CK-19 was detected in 13.5%, HER-2 in 5%, TWIST-1 in 16.2%, MAGE-A3 in 37.8% while hMAM was not detected in any sample.

CONCLUSIONS: Our results show that individual gene expression can be readily measured in CTCs using a bead-based platform. This may form an efficient basis for a multiplex approach to measure multiple genes (up to 100) in the same sample, thus saving sample volume and reducing the total cost and time of analysis. This is the first time that the Luminex technology is used for gene expression studies in CTCs.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 1142.