Aberrations in the epidermal growth factor receptor gene in 958 patients with diverse advanced tumors: implications for therapy

BACKGROUND

Epidermal growth factor receptor (EGFR) mutations are associated with the response to EGFR inhibitors in patients with non-small-cell lung cancer (NSCLC). We sought to investigate EGFR aberrations in patients with diverse advanced cancers.

PATIENTS AND METHODS

Patients referred to the phase I clinic were evaluated for the presence of EGFR mutations and response to therapy.

RESULTS

EGFR aberrations were detected in 34 of 958 patients (3.5%). Though EGFR mutations were most frequent in NSCLC (21 of 131, 16%), they were also present in a variety of other solid tumors (13 of 827 patients, 1.6%) including adrenocortical (1/10 patients), skin (1/24), breast (1/55), carcinoid (1/8), cholangiocarcinoma (1/20), head and neck (1/61), ovarian (1/84), parathyroid (1/1), salivary gland (1/20), renal (1/17), sarcoma (2/38), and thymic carcinomas (1/7). Of the 13 EGFR aberration-positive non-NSCLC patients (median number of prior systemic therapies = 3), 6 had treatment with an EGFR inhibitor. Two patients (diagnosis = parathyroid tumor and basal cell carcinoma) achieved stable disease (SD), lasting 6 and 7 months, respectively.

CONCLUSION

We found EGFR aberrations in 1.6% of a large group of patients with diverse tumors other than NSCLC, and treatment with an EGFR inhibitor could be associated with prolonged SD.

Dose-finding study of hepatic arterial infusion of oxaliplatin-based treatment in patients with advanced solid tumors metastatic to the liver

BACKGROUND

Liver metastases in patients with cancer are associated with poor survival. We hypothesized that hepatic arterial infusion (HAI) of oxaliplatin combination therapy would have antitumor activity in these patients.

PATIENTS AND METHODS

Patients with advanced cancer and predominant liver metastases were treated on a phase I study of HAI oxaliplatin in combination with systemic bevacizumab, with or without HAI or systemic fluorouracil and/or leucovorin and/or cetuximab. Patients were divided into two treatment arms according to KRAS mutational status and physician choice. A "3 + 3" design was used.

RESULTS

Among 76 patients (median age 61 years; 34 women; median number of prior therapies 4), the most common cancer was colorectal (CRC) (n = 58). Overall, the only dose-limiting toxicity was Grade 3 diarrhea (n = 2). The most common treatment-related toxicities were hypertension (n = 40), nausea (n = 29), fatigue (n = 28), and transaminitis (n = 26). Of 76 patients, one (1 %) had a complete response (CR), 12 (16 %) had a partial response (PR), and 12 (16 %) had SD for ≥ 6 months (total CR/PR/SD ≥ 6 months 25/76 = 33 %). In CRC (n = 58), total CR/PR/SD ≥ 6 months was 31 % (n = 18). Both patients with pancreatic neuroendocrine tumors achieved a PR (24+ months) and a CR (6+ months). Time to treatment failure (TTF) on the current regimen was 3.5 versus 2.8 months on patients' prior systemic treatment (p = 0.37).

CONCLUSIONS

HAI oxaliplatin combination therapy with 5-fluorouracil, leucovorin, bevacizumab, and/or cetuximab was well tolerated and had antitumor activity in selected heavily pretreated patients with predominant liver disease.

Antibody-independent isolation of circulating tumor cells by continuous-flow dielectrophoresis

Circulating tumor cells (CTCs) are prognostic markers for the recurrence of cancer and may carry molecular information relevant to cancer diagnosis. Dielectrophoresis (DEP) has been proposed as a molecular marker-independent approach for isolating CTCs from blood and has been shown to be broadly applicable to different types of cancers. However, existing batch-mode microfluidic DEP methods have been unable to process 10 ml clinical blood specimens rapidly enough. To achieve the required processing rates of 10(6) nucleated cells/min, we describe a continuous flow microfluidic processing chamber into which the peripheral blood mononuclear cell fraction of a clinical specimen is slowly injected, deionized by diffusion, and then subjected to a balance of DEP, sedimentation and hydrodynamic lift forces. These forces cause tumor cells to be transported close to the floor of the chamber, while blood cells are carried about three cell diameters above them. The tumor cells are isolated by skimming them from the bottom of the chamber while the blood cells flow to waste. The principles, design, and modeling of the continuous-flow system are presented. To illustrate operation of the technology, we demonstrate the isolation of circulating colon tumor cells from clinical specimens and verify the tumor origin of these cells by molecular analysis.

Targeted therapy of advanced gallbladder cancer and cholangiocarcinoma with aggressive biology: eliciting early response signals from phase 1 trials

PURPOSE

Patients with advanced cholangiocarcinoma (CC) and gallbladder carcinoma (GC) have few therapeutic options for relapsed disease. methods: Given the overall poor prognosis in this population and the availability of novel targeted therapies, we systematically analyzed the characteristics and outcomes for GC and CC patients treated on phase I trials with an emphasis on targeted agents and locoregional therapies.

RESULTS

Of 40 treated patients (GC=6; CC=34; median age, 60 years), 8 (20%) had stable disease (SD) > 6 months, 3 (8%) partial response (PR), on protocols with hepatic arterial drug infusion and anti-angiogenic, anti-HER-2/neu or novel MAPK/ERK kinase (MEK) inhibitors. Median progression-free survival (PFS) on phase I trials was 2.0 months (95% CI 1.7, 2.8) versus 3.0 months (95% CI 2.4, 5.0), 3.0 months (95% CI 2.3, 4.6), and 3.0 months (95% CI 2.4, 3.9) for their first-, second-, and last-line FDA-approved therapy. In univariate analysis, >3 metastatic sites, elevated alanine aminotransferase (ALT) (>56IU/L), serum creatinine (>1.6mg/dL), and CA19-9 (>35U/mL) were associated with a shorter PFS. Mutational analysis revealed mutation in the KRAS oncogene in 2 of 11 patients (18%). The SD >6 months/PR rate of 28% was seen with hepatic arterial infusion of oxaliplatin, and inhibitors of angiogenesis, HER-2/neu or MEK.

CONCLUSIONS

The PFS in phase I trials was similar to that of the first, second, and last-line therapy (P=0.95, 0.98, 0.76, respectively) with FDA-approved agents given in the advanced setting, emphasizing a role for targeted agents in a clinical trials setting as potentially valuable therapeutic options for these patients.

Electrocardiograms (ECGs) in phase I anticancer drug development: the MD Anderson Cancer Center experience with 8518 ECGs

BACKGROUND

Cardiac sequelae from oncologic drugs are important in early cancer drug development. Prolongation of the corrected QT interval (QTc) by noncardiac drugs is the most common cause of drug development delays, nonapprovals and postmarketing withdrawals by the US Food and Drug Administration.

PATIENTS AND METHODS

We analyzed 8518 electrocardiograms (ECGs) in 525 consecutive cancer patients enrolled in 22 industry-sponsored phase I clinical trials, starting 1 January 2006.

RESULTS

Seventy-four patients [14%, 95% confidence interval (CI) 11% to 17%] with normal QTc at baseline had QTc intervals above upper limit of normal after treatment initiation; 33 (6%, 95% CI 4% to 9%) had prolonged QTc intervals at baseline, and only one (3%, 95% CI 0% to 16%) worsened after dosing. Seven of 33 patients (21%, 95% CI 9% to 39%) with prolonged baseline QTc had normalization of QTc intervals after dosing. All QTc prolongations were clinically insignificant; study drugs were continued uneventfully. Two of 525 patients (0.4%, 95% CI 0% to 1%) experienced cardiac serious adverse events (myocardial infarction possibly related to drug and unstable atrial flutter related to metastatic disease). Both cardiac events were detected by clinical assessment, not surveillance ECGs.

CONCLUSION

Frequent ECG monitoring provided no clinically significant information in 525 patients in early phase trials.

PIK3CA mutation H1047R is associated with response to PI3K/AKT/mTOR signaling pathway inhibitors in early-phase clinical trials

PIK3CA mutations may predict response to PI3K/AKT/mTOR inhibitors in patients with advanced cancers, but the relevance of mutation subtype has not been investigated. Patients with diverse cancers referred to the Clinical Center for Targeted Therapy were analyzed for PIK3CA and, if possible, KRAS mutations. Patients with PIK3CA mutations were treated, whenever possible, with agents targeting the PI3K/AKT/mTOR pathway. Overall, 105 (10%) of 1,012 patients tested harbored PIK3CA mutations. Sixty-six (median 3 prior therapies) of the 105 PIK3CA-mutant patients, including 16 individuals (of 55 PIK3CA-mutant patients tested) with simultaneous KRAS mutations, were treated on a protocol that included a PI3K/AKT/mTOR pathway inhibitor; 17% (11/66) achieved a partial response (PR). Patients with a PIK3CA H1047R mutation compared with patients who had other PIK3CA mutations or patients with wild-type PIK3CA treated on the same protocols had a higher PR rate (6/16, 38% vs. 5/50; 10% vs. 23/174, 13%, respectively; all P ≤ 0.02). None of the 16 patients with coexisting PIK3CA and KRAS mutations in codon 12 or 13 attained a PR (0/16, 0%). Patients treated with combination therapy versus single-agent therapies had a higher PR rate (11/38, 29% vs. 0/28, 0%; P = 0.002). Multivariate analysis showed that H1047R was the only independent factor predicting response [OR 6.6, 95% confidence interval (CI), 1.02-43.0, P = 0.047). Our data suggest that interaction between PIK3CA mutation H1047R versus other aberrations and response to PI3K/AKT/mTOR axis inhibitors warrants further exploration.

Risk of serious toxicity in 1181 patients treated in phase I clinical trials of predominantly targeted anticancer drugs: the M. D. Anderson Cancer Center experience

BACKGROUND

This study assessed toxicity in advanced cancer patients treated in a phase I clinic that focuses on targeted agents.

PATIENTS AND METHODS

An analysis of database records of 1181 consecutive patients with advanced cancer who were treated in the phase I program starting 1 January 2006 was carried out.

RESULTS

All patients were treated on at least 1 of the 82 phase I clinical trials. Overall, 56 trials (68.3%) had only targeted agents, 13 (15.9%) only cytotoxics, and 13 (15.9%) targeted and cytotoxic agents. Rates of grade 3 and 4 toxicity that were at least possibly drug related were 7.1% and 3.2%, respectively, and 5 of the 1181 patients (0.4%) died from toxicity that was at least possibly drug related. The most common grade 3 or more toxic effects were neutropenia, thrombocytopenia, anemia, dehydration, infection, altered mental status, bleeding, vomiting, nausea, and diarrhea. Eastern Cooperative Oncology Group (ECOG) performance status greater than zero and use of a cytotoxic agent were selected as independent factors associated with serious toxicity.

CONCLUSION

Phase I trials of primarily targeted agents showed low rates of toxicity, with 10.3% of patients experiencing grade 3 or 4 toxicity and a 0.4% rate of death, at least possibly drug related.

Intraperitoneal and intravenous chemotherapy in peritoneal carcinomatosis

BACKGROUND/AIMS

We conducted a phase I trial of IP oxaliplatin and paclitaxel with IV paclitaxel and bevacizumab in patients with peritoneal carcinomatosis.

METHODOLOGY

Patients received IV bevacizumab (2.5mg/kg) over 1 hour (day 1), then IV paclitaxel (110 mg/m2) 24-hr-infusion (day 1) and IP oxaliplatin (25-40 mg/m2) (day 2), and IP paclitaxel (30-60 mg/m2) (day 8 from cycle 2 onwards). A '3+3' design was used.

RESULTS

Nineteen patients were treated (median age 60 years; 10 women, 9 men; median number of prior therapies 3). Primary tumors were colorectal (n=9), signet ring carcinoma (n=2), gastric (n=2), ovarian (n=2) and others (n=4). The maximum tolerated doses (MTD) of IP oxaliplatin and IP paclitaxel were 25mg/m2 and 60 mg/ m2, respectively. Nine (47%) patients reported no toxicities >grade 2. Two patients receiving IP oxaliplatin 40 mg/m2 and IP paclitaxel 60 mg/m2 had dose limiting toxicities (DLT) of grade 3 diarrhea/dehydration and febrile neutropenia. Toxicities included abdominal pain (n=14), nausea (n=10) and constipation (n=7). Of 12 patients restaged at 2 months, 7 (58%) had stable disease (SD) including 2 (17%) who had SD for >4 months.

CONCLUSIONS

IP paclitaxel and IP oxaliplatin can be given safely at 60 mg/m2 and 25mg/m2, respectively.

Outcomes in 144 patients with colorectal cancer treated in a phase I clinic: the MD Anderson Cancer Center experience

BACKGROUND

Patients with advanced colorectal cancer have a poor prognosis once standard therapies fail. This retrospective study presents the characteristics and outcomes in 144 patients treated in phase I clinical trials.

METHODS

We retrospectively reviewed the clinical outcomes in 144 consecutive patients with colorectal cancer referred to the phase I clinic at MD Anderson.

RESULTS

Median age was 60 years (range, 35-86 years). The median number of previous systemic therapies was 4 (range, 1-7). The median PFS with the last line of conventional systemic treatment was 12.3 weeks (95% confidence interval [CI], 11.0-14.4); the median PFS of the best phase I treatment was shorter at 8.1 weeks (95% CI, 7.9-8.7 weeks; log-rank test, P < .0001). In the multivariate analysis that included the RMH score, sex (male vs. female, P = .02; hazard ratio [HR], 1.57), hemoglobin (< 10.5 vs. ≥ 10.5 g/dL; P = .03; HR 1.79), and the RMH score (2-3 vs. 0-1; P < .003; HR, 1.85) were significant predictors of poor survival.

CONCLUSION

The PFS of patients with colorectal cancer in phase I treatment was shorter than it was on their last line of conventional systemic treatment. Multivariate analysis confirmed the value of the RMH score for predicting overall survival in patients with colorectal cancer enrolled in phase I studies.

Abstract LB-446: Target-based therapeutic matching in patients with PIK3CA mutations and PTEN aberrations

Background: Activating mutations of PIK3CA or loss of PTEN function result in increased PI3K/AKT/mTOR signaling and may predict sensitivity to drugs targeting the PI3K/AKT/mTOR pathway, while simultaneous KRAS mutations may mediate resistance. Methods: From 10/2008, available tumor samples from advanced cancer patients referred to the Phase I Clinical Trials Program were screened for PIK3CA mutations and PTEN aberrations (loss of expression on immunohistochemistry or mutation) in a CLIA-certified laboratory. Patients with tumors carrying PIK3CA mutations and/or PTEN aberrations were treated, whenever possible, with agents targeting the PI3K/AKT/mTOR pathway. Results: Overall, 1,540 patients were tested, and 285 (19%) had PIK3CA mutations (n=141), PTEN aberrations (n=130), or a simultaneous PIK3CA mutation and PTEN aberration (n=14). Of these 285 patients, 131 (46%) were treated in clinical trials containing a PI3K/AKT/mTOR inhibitor (median age, 56; median number of prior therapies, 3). Of these 131 patients, 26 (20%, 95% CI 0.14-0.27) achieved a partial response (PR) (4/21 breast cancers; 4/19 endometrial cancers; 3/13 ovarian cancers; 4/9 head and neck cancers; 4/10 cervical cancers; 2/9 renal cancers; 2/4 salivary gland cancers; 1/4 sarcomas; 1/3 non-small cell lung cancers; 1/2 melanomas). Patients without known PIK3CA mutations and/or PTEN aberrations treated on the same protocols had a PR rate of 6% (26/458; 95% CI 0.04-0.08, p=0.0001). Treated patients with wild-type KRAS had a higher PR rate of 20% compared to 8% in patients with simultaneous KRAS mutations (p=0.05). Conclusion: Heavily pretreated patients with PIK3CA mutations and/or PTEN aberrations had higher PR rates on protocols with PI3K/AKT/mTOR inhibitors than patients without these aberrations (20% vs 6%; p = 0.0001). Simultaneous KRAS mutations were associated with a lower PR rate. Screening for PIK3CA mutations and PTEN aberrations merits further evaluation in making treatment decisions.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-446. doi:1538-7445.AM2012-LB-446

Abstract 2669: Early-phase trials in patients with advanced gallbladder cancer and cholangiocarcinoma: The MD Anderson Clinical Center for Targeted Therapy experience

BACKGROUND: Patients with cholangiocarcinoma (CC) and gallbladder carcinoma (GC) have few effective therapeutic options in the relapsed and/or metastatic setting. With that purpose, we analyzed the characteristics and outcomes of patients with advanced CC and GC treated on early-phase clinical trials in the Clinical Center for Targeted Therapy at MD Anderson Cancer Center. METHODS: We searched an electronic database of consecutive pts with GC and CC referred to the Clinical Center for Targeted Therapy starting in November 2004. We assessed the relationship between types of clinical trial and pts’ tumor types, progression-free survival, and mutations. RESULTS: Of the 72 patients with CC and GC referred to the clinic, 32 (44%) were not enrolled in a clinical trials mainly due to deterioration of performance status (n=25), decision to pursue alternate therapies (n=6), and insurance denial (n=1). Forty pts (5 w GC; 35 w CC) who received treatment on early clinical trials are included in this analysis. The median age was 60.2 yrs (range, 41.4-73.6 yrs). ECOG performance status (PS) was 0-1 in 36 pts (90%) and 2 in 4 (10%). Median number of prior therapies was 3 (range 0-17). Six pts were not restaged due to early disease progression. Of the 40 pts evaluable for response, 8 (20%) had stable disease (SD) &gt; 6 months and 3 (8%) had a partial response (PR) (total SD &gt; 6 mos/PR = 28%). Highest rates of SD &gt; 6 mos/PR were observed in patients treated with protocols that included hepatic arterial infusion drug administration (7/17 = 41%) or anti-angiogenic agents (9/24 = 38%) (with 6 of these pts receiving treatment that included hepatic arterial infusion chemotherapy combined with a systemic anti-angiogenic agent). SD lasting 9 months was also seen in 1 pt treated with a MEK inhibitor. Median progression-free survival for the 40 pts was 2.0 months 9 (95% CI 1.7, 2.8) on early-phase clinical trials versus 3.0 months on their last FDA-approved treatment before Phase I referral (95% CI 2.3, 3.7). CONCLUSIONS: About one-third of patients with CC and GC referred for early-phase trials cannot be enrolled because of poor performance status. Twenty-eight percent of patients who met eligibility criteria achieved SD &gt; 6 mos/PR, with responses predominantly observed in regimens that contained locoregional treatment, anti-angiogenic agents, or a targeted MEK inhibitor.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2669. doi:1538-7445.AM2012-2669

Abstract 1751: A phase I study of lenalidomide in combination with bevacizumab, sorafenib, temsirolimus, or 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX) in patients with advanced cancers

Introduction: Patients with advanced cancer have limited therapeutic options. We conducted an investigator-initiated 4-arm phase I study of lenalidomide (len) combined with bevacizumab (bev), sorafenib (soraf), temsirolimus (tem), or 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX) in patients with advanced cancers. Patients and Methods: Patients were treated with escalating doses of len (5, 10, 20 mg daily) combined with bev (5, 7.5, 10 mg/m2 on days 1, 15); soraf (200, 400mg daily); tem (15, 20, 25mg on days 1, 8, 15, 22); or FOLFOX (oxaliplatin 65, 85 mg/m2 on day 1). The escalation phase (“3+3”) was followed by an expansion phase per arm. Response was assessed by RECIST v.1. Patients were to receive enoxaparin prophylaxis. Results: Overall, 101 patients were enrolled; and 59 were treated in the dose escalation phase (4 arms) and are included in this analysis (169 cycles to date). Diagnoses were colorectal cancer (n=19), sarcoma (n=5), ovarian (n=4), lung (n=3), hepatocellular carcinoma (n=3), melanoma (n=4), neuroendocrine (n=2), prostate (n=2) and other (n=17). The median number of cycles/patient was 2 (range, 1-10). Pretreatment characteristics and outcomes are shown in Table. Two DLTs were noted: Grade 3 transient ischemic attack (TIA) while on enoxaparin in the len + FOLFOX arm and Grade 3 acute renal failure (ARF) in the len + tem arm. Three pts (two on enoxaparin prophylaxis and one not) had venous thrombosis while on study. Fifteen of 59 (25%) pts had prolonged stable disease (SD) for &gt; 4 months, including 7 (12%) for &gt; 6 mos. The len+soraf and len+tem arms have reached the maximum dose level tested; currently, expansion phase). The lev+bev and len+FOLFOX arms are in the dose escalation phase. Conclusion: Lenalidomide combined with bev, soraf, tem or FOLFOX is well tolerated and it is associatd with antitumor activity in patients with advanced solid tumors. Anticoagulation phophylaxis is needed.

Survival of 1,181 patients in a phase I clinic: the MD Anderson Clinical Center for targeted therapy experience

PURPOSE

To determine whether the Royal Marsden Hospital (RMH; London, UK) prognostic score for phase I patients can be validated in a large group of individuals seen in a different center and whether other prognostic variables are also relevant, we present an analysis of 1,181 patients treated in the MD Anderson Cancer Center (MDACC; Houston, TX) phase I clinic.

EXPERIMENTAL DESIGN

Medical records of 1,181 consecutive patients who were treated on at least one trial in the phase I clinic were reviewed.

RESULTS

The median age was 58 years and 50% were women. The median number of prior therapies was four and median survival 10 months [95% confidence interval (CI), 9.1-10.9 months]. Independent factors that predicted shorter survival in a multivariate Cox model and could be internally validated included RMH score of >1 (P < 0.0001; albumin <3.5 g/dL; lactate dehydrogenase >upper limit of normal, and >two sites of metastases), gastrointestinal tumor type (P < 0.0001), and Eastern Cooperative Oncology Group performance status ≥ 1 (P = 0.0004). The median survival was 24.0, 15.2, 8.4, 6.2, and 4.1 months for patients with 0, 1, 2, 3, and 4 or 5 of the above risk factors, respectively.

CONCLUSION

The RMH score was validated in a large group of patients at MDACC. Internal validation of the independent prognostic factors for survival led to the development of the MDACC prognostic score, a modification of the RMH score that strengthens it.

PI3K/AKT/mTOR inhibitors in patients with breast and gynecologic malignancies harboring PIK3CA mutations

PURPOSE

Mutations of the PIK3CA gene may predict response to phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) inhibitors. Concomitant mutations in the mitogen-activated protein kinase (MAPK) pathway may mediate resistance.

PATIENTS AND METHODS

Tumors from patients with breast, cervical, endometrial, and ovarian cancer referred to the Clinical Center for Targeted Therapy (Phase I Program) were analyzed for PIK3CA, KRAS, NRAS, and BRAF mutations. Patients with PIK3CA mutations were treated, whenever feasible, with agents targeting the PI3K/AKT/mTOR pathway.

RESULTS

Of 140 patients analyzed, 25 (18%) had PIK3CA mutations, including five of 14 patients with squamous cell cervical, seven of 29 patients with endometrial, six of 29 patients with breast, and seven of 60 patients with ovarian cancers. Of the 25 patients with PIK3CA mutations, 23 (median of two prior therapies) were treated on a protocol that included a PI3K/AKT/mTOR pathway inhibitor. Two (9%) of 23 patients had stable disease for more than 6 months, and seven patients (30%) had a partial response. In comparison, only seven (10%) of 70 patients with the same disease types but with wild-type PIK3CA treated on the same protocols responded (P = .04). Seven patients (30%) with PIK3CA mutations had coexisting MAPK pathway (KRAS, NRAS, BRAF) mutations (ovarian cancer, n = 5; endometrial cancer, n = 2), and two of these patients (ovarian cancer) achieved a response.

CONCLUSION

PIK3CA mutations were detected in 18% of tested patients. Patients with PIK3CA mutations treated with PI3K/AKT/mTOR inhibitors demonstrated a higher response rate than patients without mutations. A subset of patients with ovarian cancer with simultaneous PIK3CA and MAPK mutations responded to PI3K/AKT/mTOR inhibitors, suggesting that not all patients demonstrate resistance when the MAPK pathway is concomitantly activated.

Evaluation of the clinical relevance of body composition parameters in patients with cancer metastatic to the liver treated with hepatic arterial infusion chemotherapy

The association between body composition parameters and toxicity from hepatic arterial infusion (HAI) chemotherapy regimens has not been analyzed. We assessed data from patients with advanced cancer and liver metastases treated on a clinical trial of a regimen of HAI oxaliplatin combined with systemic 5-fluorouracil/leucovorin and bevacizumab. Correlations between patient characteristics, response, and toxicity and body composition data taken from CT images were analyzed. Forty-eight of 57 patients (mean age 56 yr; 60% women) had available CT scans. The most common diagnosis was colorectal cancer (22/48, 46%); 30/48 patients (63%) had body mass index (BMI) ≥25 kg/m(2). Twenty (42%) of 48 patients were sarcopenic. Grade 3-4 adverse events did not differ among patients with and without sarcopenia or according to BMI. The median survival (95% C]) was 167 (128-206) days for sarcopenic and 280 (214-346) days for nonsarcopenic patients (P = 0.271). Among patients treated at the maximum tolerated dose, the median survival was 103 days for sarcopenic and 312 days for nonsarcopenic patients (P = 0.173). Sarcopenia was present in 30% (6/20) of patients with reduction in tumor size posttreatment, and in 52% (14/27) of patients with increased tumor size (P = 0.171). In conclusion, body composition was not significantly associated with toxicities or survival in our small sample.

PD09-01: Target-Based Therapeutic Matching in Early-Phase Clinical Trials in Patients with Advanced Breast Cancer and PIK3CA Mutations

Background: Therapeutic matching based on underlying molecular abnormalities showed promising results in early-phase clinical trials. PIK3CA mutations may predict response to therapies with PI3K/AKT/mTOR inhibitors.

Methods: Tumors from patients with breast cancer referred to the Clinical Center for Targeted Therapy (Phase I Program) were analyzed for PIK3CA mutations. Patients with PIK3CA mutations were treated, whenever feasible, with agents targeting the PI3K/AKT/mTOR pathway.

Results: Of 54 patients analyzed, 15 (28%) had PIK3CA mutations. PIK3CA mutations were found in 5/9 (56%) metaplastic, 3/8 (38%) HER2−positive, 7/29 (24%) hormone receptor-positive, and 0/8 (0%) triple negative (excluding metaplastic) breast cancers (P=0.07). Of the 15 patients with PIK3CA mutations, 12 (80%) were treated in clinical trials containing a PI3K/AKT/mTOR pathway inhibitor (median age, 54; median number of prior therapies, 3). Of these 12 patients, 3 (25%, 95% CI 0.09−0.53) had stable disease for more than 6 months (SD≥6 months; n=1) or a partial response (PR; n=2). Breast cancer patients without PIK3CA mutations treated on the same protocols had a rate of SD≥6 months/PR of 8% (1/12; 95% CI 0.01−0.35, p=0.6). Of the 4 patients with a H1047R mutation treated with agents targeting the PI3K/AKT/mTOR pathway, 3 (75%) had SD≥6 months (n=1) or a PR (n=2) compared to 0 of 8 patients (0%) with other PIK3CA mutations (P=0.045). Patients with H1047R mutations had a median progression-free survival (PFS) of 8.5 months compared to 2 months in patients with other PIK3CA mutations (p=0.13).

Conclusion: Heavily pretreated patients with PIK3CA-mutant advanced breast cancer had a SD≥6 months/PR rate of 25% on protocols incorporating PI3K/AKT/mTOR. Patients with mutation H1047R had significantly longer SD≥6 months/PR rate compared to those with other PIK3CA mutations. Our observations suggest that screening for PIK3CA mutations is warranted in larger numbers of patients with advanced breast cancer when treatment with PI3K/AKT/mTOR pathway inhibitors is planned.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD09-01.

Abstract B161: PIK3CA mutations H1047R are associated with response to PI3K/AKT/mTOR signaling pathway inhibitors in early-phase clinical trials

Background: Activating mutations in the PIK3CA gene have been identified in many malignancies. Preclinical and early clinical data suggest that these mutations predict response to PI3K/AKT/mTOR inhibitors in subsets of patients. Sensitivity and resistance mutation have not been reported to date.

Methods: Patients with diverse cancers referred to the Phase I Clinical Trials Program for targeted therapy starting from October 2008 were analyzed for PIK3CA, and if, possible for KRAS mutations using PCR-based DNA sequencing. Patients with any tumor type and any PIK3CA mutation were treated whenever possible with agents targeting the PI3K/AKT/mTOR signaling pathway. Treatment outcomes with respect to mutation types were analyzed.

Results: Overall, 1012 patients were tested and 105 (10%) had PIK3CA mutations. Of the 105 patients with PIK3CA mutations, 66 (median number of prior therapies, 3) were treated on a protocol that included a PI3K/AKT/mTOR pathway inhibitor. Of these 66 patients, 11 (17%) achieved a partial response (PR) and 4 (6%) stable disease ≥ 6 months (SD≥6). The total of SD≥6/PR was 15 (23%). Patients with PIK3CA H1047R mutation (n=16) compared to patients with other PIK3CA mutations (n=50) had higher PR rate (6/16, 37.5% vs. 5/50, 10%; p=0.018), higher rate of SD≥6/PR (7/16, 44% vs. 8/50, 16%; p=0.037), and trend toward longer median progression-free survival (PFS) (5.7 months, 95%CI 0.4–11.0 vs. 2.0 months, 95%CI 1.8–2.2; p=0.064). Patients with a PIK3CA E542K mutation (n=11) compared to others (n=55) trended toward a worse median PFS (1.8 months, 95%CI 1.4–2.2 vs. 2.6 months, 95%CI 1.4–3.8; p=0.058). Of the 66 treated patients with PIK3CA mutations, 55 (83%) had enough tissue for KRAS testing. None of the 16 patients with PIK3CA and simultaneous KRAS mutations in codon 12 or 13 had a PR (0/16, 0% vs. 9/39, 23%; p=0.046) or SD≥6/PR (0/16, 0% vs. 13/39, 33.3%; p=0.011) as compared to patients with PIK3CA, but not KRAS codon 12 or 13 mutations, whereas 2 of 2 (100%) patients with PIK3CA and Q61H KRAS mutation in codon 61 had SD≥6 (n=1) and PR (n=1).

Conclusion: Despite the small number of patients, our data suggest that PIK3CA mutations H1047R are associated with response to PI3K/AKT/mTOR inhibitors, whereas codon 12 and 13, but not codon 61 KRAS mutations are associated with resistance.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr B161.

Outcomes of research biopsies in phase I clinical trials: the MD anderson cancer center experience

BACKGROUND

Research biopsies are crucial for exploring the impact of novel agents on putative targets. The current study assesses the safety and success rate associated with performing such biopsies.

METHODS

We reviewed the medical records of 155 consecutive patients who had one or more research biopsies as part of a phase I trial from September 2004 to October 2009.

RESULTS

Of 281 research biopsies performed, 118 were paired before and after treatment biopsies (total = 236 biopsies). The most common sites of biopsy were superficial lymph node (19.9%), followed by liver (16.4%), and then soft tissue (15.7%). Ultrasound-guided biopsies were the most frequent type (53.7%). Among 142 patients who consented for mandatory biopsy, 86.6% had the biopsy performed, compared with 4.4% of 911 patients offered a biopsy on an optional basis (p < .0001). Biopsy was obtained most frequently on industry-sponsored trials; lack of funding on nonindustry trials was the most common reason that biopsies were not obtained. Of 281 single biopsies, only 4 (1.4%) had complications: pneumothorax requiring chest tube placement (n = 2), infection requiring admission (n = 1), and arrhythmia with hypotension (n = 1). All but one biopsy was successful in obtaining tissue. No deaths were attributable to biopsy.

CONCLUSIONS

Our experience demonstrates that research biopsies in early phase clinical trials are safe (1.4% risk of serious complications), and a higher percentage of patients underwent mandatory biopsies (86.6%) compared with that of the patients with optional biopsies (4.4%).

PIK3CA mutations frequently coexist with RAS and BRAF mutations in patients with advanced cancers

BACKGROUND

Oncogenic mutations of PIK3CA, RAS (KRAS, NRAS), and BRAF have been identified in various malignancies, and activate the PI3K/AKT/mTOR and RAS/RAF/MEK pathways, respectively. Both pathways are critical drivers of tumorigenesis.

METHODS

Tumor tissues from 504 patients with diverse cancers referred to the Clinical Center for Targeted Therapy at MD Anderson Cancer Center starting in October 2008 were analyzed for PIK3CA, RAS (KRAS, NRAS), and BRAF mutations using polymerase chain reaction-based DNA sequencing.

RESULTS

PIK3CA mutations were found in 54 (11%) of 504 patients tested; KRAS in 69 (19%) of 367; NRAS in 19 (8%) of 225; and BRAF in 31 (9%) of 361 patients. PIK3CA mutations were most frequent in squamous cervical (5/14, 36%), uterine (7/28, 25%), breast (6/29, 21%), and colorectal cancers (18/105, 17%); KRAS in pancreatic (5/9, 56%), colorectal (49/97, 51%), and uterine cancers (3/20, 15%); NRAS in melanoma (12/40, 30%), and uterine cancer (2/11, 18%); BRAF in melanoma (23/52, 44%), and colorectal cancer (5/88, 6%). Regardless of histology, KRAS mutations were found in 38% of patients with PIK3CA mutations compared to 16% of patients with wild-type (wt)PIK3CA (p = 0.001). In total, RAS (KRAS, NRAS) or BRAF mutations were found in 47% of patients with PIK3CA mutations vs. 24% of patients wtPIK3CA (p = 0.001). PIK3CA mutations were found in 28% of patients with KRAS mutations compared to 10% with wtKRAS (p = 0.001) and in 20% of patients with RAS (KRAS, NRAS) or BRAF mutations compared to 8% with wtRAS (KRAS, NRAS) or wtBRAF (p = 0.001).

CONCLUSIONS

PIK3CA, RAS (KRAS, NRAS), and BRAF mutations are frequent in diverse tumors. In a wide variety of tumors, PIK3CA mutations coexist with RAS (KRAS, NRAS) and BRAF mutations.

Cardiovascular toxicity profiles of vascular-disrupting agents

BACKGROUND

Vascular-disrupting agents (VDAs) represent a new class of chemotherapeutic agent that targets the existing vasculature in solid tumors. Preclinical and early-phase trials have demonstrated the promising therapeutic benefits of VDAs but have also uncovered a distinctive toxicity profile highlighted by cardiovascular events.

METHODS

We reviewed all preclinical and prospective phase I-III clinical trials published up to August 2010 in MEDLINE and the American Association of Cancer Research and American Society of Clinical Oncology meeting abstracts of small-molecule VDAs, including combretastatin A4 phosphate (CA4P), combretastatin A1 phosphate (CA1P), MPC-6827, ZD6126, AVE8062, and ASA404.

RESULTS

Phase I and II studies of CA1P, ASA404, MPC-6827, and CA4P all reported cardiovascular toxicities, with the most common cardiac events being National Cancer Institute Common Toxicity Criteria (version 3) grade 1-3 hypertension, tachyarrhythmias and bradyarrhythmias, atrial fibrillation, and myocardial infarction. Cardiac events were dose-limiting toxicities in phase I trials with VDA monotherapy and combination therapy.

CONCLUSIONS

Early-phase trials of VDAs have revealed a cardiovascular toxicity profile similar to that of their vascular-targeting counterparts, the angiogenesis inhibitors. As these agents are added to the mainstream chemotherapeutic arsenal, careful identification of baseline cardiovascular risk factors would seem to be a prudent strategy. Close collaboration with cardiology colleagues for early indicators of serious cardiac adverse events will likely minimize toxicity while optimizing the therapeutic potential of VDAs and ultimately enhancing patient outcomes.

Abstract 1279: Loss of PTEN expression in patients treated with PI3K/AKT/mTOR signaling pathway inhibitors

Background: Loss of PTEN function results in increased PI3K/AKT/mTOR signaling and may predict sensitivity to drugs targeting the PI3K/AKT/mTOR pathway.

Methods: Archival tumor samples from patients (N = 202) with diverse cancers referred to the Clinical Center for Targeted Therapy from October 2009 were tested for cytoplasmatic expression of PTEN on immunohistochemistry. Whenever possible, tumor tissue was also analyzed for PIK3CA, RAS (K-, N-), and BRAF mutations using PCR-based DNA sequencing. Consecutive patients with loss of PTEN expression and any tumor type were treated whenever possible with agents targeting the PI3K/AKT/mTOR signaling pathway.

Results: Overall, 49 (24%) of 202 patients had loss of PTEN expression. In specific tumor types with a minimum of five patients tested, the loss of PTEN expression was most frequent in squamous cell cervical (60%, 3/5 patients), non-small-cell lung (50%, 4/8), renal (50%, 3/6), uterine (41%, 7/17), gastroesophageal junction/gastric (38%, 3/8), breast cancers (25%, 2/8), melanomas (22%, 6/27), and colorectal cancers (20%, 6/30). Tumors with PTEN loss had frequencies of simultaneous mutations in PIK3CA, RAS (K-, N-), BRAF that were similar to patients with PTEN expression. Of the 49 patients with PTEN loss, 29 (median number of prior therapies, 3) were treated on a protocol that included a PI3K/AKT/mTOR pathway inhibitor. Six of these 29 patients (20.5%) achieved a partial response (PR) (2 uterine cancers, 1 squamous cell cervical cancer; 1 squamous cell head and neck cancer; 1 melanoma; 1 renal cancer) and 8 (27.5%) had stable disease (SD) for &gt;/ = 4 months (total SD&gt;/ = 4 months + PR = 48%). These 29 treated patients had a median progression-free survival of 4.3 months (95% CI, 3.4-5.2).

Conclusion: Loss of PTEN expression was found in 24% of patients with various solid tumors. Fourteen of 29 heavily-pretreated patients (48%) had a PR or SD &gt;/ = 4 months, when treated with a PI3K/AKT/mTOR axis inhibitor, suggesting that matching patients with these inhibitors based on PTEN loss merits further exploration.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1279. doi:10.1158/1538-7445.AM2011-1279

Abstract 4410: Initiative for Molecular Profile and Advanced Cancer Therapy (IMPACT): A personalized medicine Phase I clinical trials program at MD Anderson Cancer Center

Introduction: Ongoing clinical trials are based on targeting specific pathways in addition to the tumor histology. We examined the results of mutational analyses performed in patients with advanced cancer seen in the Phase I clinic at The University of Texas MD Anderson Cancer Center.

Methods: Mutational analysis was mostly performed in the Clinical Laboratory Improvement Amendments (CLIA)-certified pathology laboratory of MD Anderson. DNA was extracted from microdissected paraffin-embedded tumor samples, and analysis was performed on specific exons, depending on the test ordered, for the following genes: PIK3CA (exon 9: codons 532-554; exon 20: codons 1011-1062); BRAF (exon 15: codons 595 to 600); KRAS and NRAS (codons 12, 13, and 61); EGFR (exons 18 to 21 of the kinase domain); KIT (exons 9, 11, 13, and 17); and RET (exon 10: codons 609, 611, 618, and 620; codon 634 of exon 11; codon 918 of exon 16). The loss of the tumor suppressor nuclear protein, PTEN, was determined using immunohistochemical staining.

Results. Tumor mutational analysis was ordered for 952 patients. Overall, 103 patients did not have adequate tissue. Of the remaining 849 patients, 354 (41.69%) had ≥ 1 mutation and 495 did not have a mutation. More women (45%) than men (38%) had a mutation (p = 0.02), but age was not associated with the presence of mutations (p=0.76). Of the patients with mutations, 313 had 1 mutation, 38 had 2 mutations, and 3 had 3 mutations. The distribution of mutations by diagnosis is shown in the Table. The total distribution of mutations in our patient population was as follows: BRAF, 19.01%; KRAS, 18.74%; PIK3CA, 9.85%; NRAS, 8.17%; EGFR, 3.38%; KIT, 2.13%; and PTEN loss, 21.20%.

Conclusion: Testing for PIK3CA, KRAS, NRAS, BRAF, EGFR, KIT, and RET mutations and PTEN loss in 849 patients with available tissue demonstrated that molecular driver aberrations are common in advanced cancer.

Inhibition of the Ras/Raf/MEK/ERK and RET kinase pathways with the combination of the multikinase inhibitor sorafenib and the farnesyltransferase inhibitor tipifarnib in medullary and differentiated thyroid malignancies

PURPOSE

Ras/Raf/MAPK kinase/ERK and rearranged in transformation (RET) kinase pathways are important in thyroid cancer. We tested sorafenib, a B-Raf, RET, and vascular endothelial growth factor receptor kinase inhibitor, combined with tipifarnib, a farnesyltransferase inhibitor that inactivates Ras and other farnesylated proteins.

PATIENTS AND METHODS

We treated 35 patients with differentiated thyroid cancer (DTC) and medullary thyroid cancer (MTC) in a phase I trial. Sorafenib and tipifarnib were given for 21 d with 7 d rest in each 28-d cycle.

RESULTS

We enrolled 22 patients with metastatic DTC (16 papillary, five follicular, and one poorly differentiated) and 13 patients with MTC, of whom 15 with DTC and 10 with MTC reached first restaging. When tissue was available, eight of 15 DTC patients (53%) had B-Raf mutations; eight of 13 MTC (61.5%) patients had RET mutations. MTC partial response rate was 38% (five of 13) (duration = 9+, 12, 13, 16+, and 34+ months), stable disease of at least 6 months was 31% (four of 13). The DTC partial response rate was 4.5% (one of 22), and stable disease of at least 6 months was 36% (eight of 22). Median progression-free survival for all 35 patients was 18 months (95% confidence interval, 14.6 to not reached months). Median overall survival has not been reached, with a median follow-up of 24 months with 80% overall survival. Grade 1-2 toxicities were mainly rash, fatigue, and diarrhea. The most common grade 3-4 toxicities were rash, rise in amylase/lipase, and fatigue.

CONCLUSIONS

Inhibiting the Ras/Raf/MAPK kinase/ERK and RET kinase pathways with sorafenib and tipifarnib is well tolerated and active against thyroid cancer.