Abstract OT3-1-10: ASTER 70s (UNICANCER phase III trial): Is personalized adjuvant treatment for women over 70 with luminal breast cancer the way to go?

Background

The question of the additional benefit of adjuvant chemotherapy (CT) compared to hormonal therapy alone (HT) for women >70 with ER+ / HER2- breast cancer (BC) and aggressive characteristics is still unsolved. This trial compares the impact of both strategies on overall survival (OS).

Trial design

Following surgery, ∼2,000 patients will have a Genomic Grade (GG) centrally performed on FFPE specimens. Those with a high or equivocal GG will be randomized HT alone vs HT+CT. Patients with low GG will be followed as an observational cohort. The study, on-going in France since April 2012, has been recently activated in Belgium.

Eligibility criteria

Any ER+ HER2- BC after complete surgery, M0, any pT or pN. Normal organ functions. No specific BC treatment before surgery. Contralateral BC, invasive BC after ductal carcinoma in situ and isolated local invasive relapse when adjuvant systemic treatment is considered are all eligible. Multifocal or bilateral are eligible according to focus with worst GG. The G8 screening tool is used as stratification criteria for randomization.

Specific aims

OS (all deaths) is the primary endpoint. Secondary objectives include competing events, cost-effectiveness and Q-TWiST analysis, geriatric dimension, acceptability/willingness and health-related quality of life including specific ELD15. The Lee's 4-year mortality score is calculated. Translational research will focus on prognostic biomarkers and pharmacogenetic, investigating also the impact of treatments on putative ageing biomarkers as CRAMP, stathmin, EF-1α and chitinase and telomeres length.

Statistical methods

Sample size based on 4-year OS (87.5 vs 80%), bilateral test, α = 0.05, β = 0.20 and HR = 0.60.

In total, 129 events are expected, requiring 340 patients/arm. Considering those lost to follow-up, ∼700 patients in total should be included (5 extra patients/year).

Present accrual and target accrual

As of May 2013, 43 centres have included 406 Patients aged 70-88.

Only 14 GG evaluations were not performed for the following reasons: Patients consent withdrawal (n = 3), tumour block not available for the GG test (n = 5), CT not a treatment option anymore (patients or investigator's decision) (n = 2) or tumour status (ER+/HER2-) not confirmed by central review (n = 4). 8 GG evaluations are on-going.

Of 384 cases with GG report, 160 (42%), 151 (39%) and 65 (17%) were respectively GG-1 (low risk), GG-3 (high risk) and GG-EQ (equivocal); 8 (2%) tests failed for technical reasons. The proportion of high GG in the study (53%) is similar to those observed in previous studies in general BC populations (40% to 60%).

Of 216 GG-3/-EQ cases, 4 were not randomized because of distant metastases detected during extensive work-up (n = 3) and Patient refusal of CT treatment before randomization (n = 1). Five randomizations are on-going.

GG determination was obtained in 384 leading to randomization in 207, totalizing so far 30% of the projected recruitment for the primary objective. This confirms the feasibility of such multicentre strategic program with an innovative prognostic signature in the elderly BC population.

Contact information

c-orsini@unicancer.fr.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-1-10.

Abstract PD5-5: Phase 2 study of single agent MLN8237 (alisertib), an investigational aurora A kinase (AAK) inhibitor, in patients (pts) with relapsed/refractory breast cancer (BrC)

Background: AAK, a key mitotic regulator, is frequently amplified/overexpressed across a spectrum of tumors, including BrC. AAK overexpression is associated with poor prognosis. MLN8237 is an oral selective AAK inhibitor under evaluation in pts with advanced cancer as a single agent and in combination therapy. A phase 1/2 study (NCT01045421) evaluated MLN8237 in pts with different solid tumors; phase 2 data for the Brc cohort are presented.

Methods: Females aged ≥18 y with relapsed/refractory BrC including HR+, HER2+ and triple-negative histological subtype, ECOG PS 0–1, measurable disease by RECIST v1.1 and ≤4 prior cytotoxic chemotherapy regimens (not including adjuvant, neo-adjuvant; no limitation on prior hormonal or HER2 targeted, immunological or biological agents) were enrolled. Symptomatic brain metastases were excluded (treated stable metastasis allowed). A Simon's optimal 2-stage design was used; 20 pts were initially enrolled, expansion proceeded if ≥2 objective responses were observed in these response-evaluable pts. Pts received MLN8237 50 mg BID for 7 days in 21-day cycles. Primary objective: overall response rate (ORR). Secondary objectives: safety, duration of response (DOR) and progression-free survival (PFS). An exploratory study was performed to assess clinical responses in relation to candidate biomarker dysregulation (mutation, amplification, and deletion) in banked tumor specimens.

Results: As of April, 2013, 53 pts were enrolled: median age was 60 y (range 33–81), median of 4 cycles (range 1–21). 49 pts (92%) were response-evaluable (HR+, n = 26; HER2+, n = 9; triple negative, n = 14). 33% of pts received treatment for ≥6 months (HR+, n = 11 [69%]; HER2+, n = 3 [19%]; triple negative, n = 2 [12%]). ORR (all pts) was 18% and median PFS was 5.42 months. Efficacy data per subgroup are shown in the table. All 53 pts were included in the safety population; drug-related adverse events (AEs) were reported in 51 pts (96%), most frequent were neutropenia (55%), alopecia (49%) and diarrhea (45%). 38 pts (72%) had grade ≥3 drug-related AEs, including neutropenia (49%), leukopenia (21%) and febrile neutropenia (4%). G-CSF use was 32%. 2 pts (4%) discontinued due to AEs (sepsis [grade 4], n = 1; neutropenia [grade 3], n = 1); no on-study deaths were reported. Treatment is ongoing in 3 HR+ pts. Whole-exome sequencing of selected tumor samples was completed. Correlative analysis is ongoing to identify potential genetic markers/mutated pathways associated with clinical response. Preliminary results will be presented.

Conclusions: MLN8237 appears to have a generally manageable toxicity profile and shows signs of single agent antitumor activity in pts with heavily pretreated (different molecular subgroups) of relapsed/refractory BrC supporting further evaluation of MLN8237 in this tumor type in different combination strategies.

Efficacy HR+ (n = 26)HER2+ (n = 9)Triple-negative (n = 14)Best response,%ORR (PR)23227Stable disease653336Progressive disease124457Median DOR, months4.2-*-**Median PFS, months7.94.11.5*2 events, **1 event

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD5-5.

Lapatinib in metastatic breast cancer

Lapatinib is an oral, small-molecule, dual kinase inhibitor that targets both HER2 and the EGF receptor. Lapatinib was approved in June 2008 in Europe for the treatment of advanced HER2-positive breast cancer. Promising results in trastuzumab-refractory metastatic breast cancer were obtained from Phase I, II and III studies in combination with chemotherapy. Diarrhea and rash are the most common side-effects and are mostly moderate and treatable. Cardiac toxicity occurs rarely and mostly as an asymptomatic and reversible decrease of left ventricular ejection fraction. Unlike trastuzumab, some data show that lapatinib could cross the blood-brain barrier, with some evidence of activity in treating or preventing brain metastases. Its evaluation is actively ongoing, in combination with trastuzumab and in the adjuvant setting.

A multicenter phase II trial of weekly paclitaxel (wPC) and epirubicin (E) in first line metastatic breast cancer (MBC) and pronostic impact of VEGF level

Abstract #6122

Background : wPC and E are effective in the treatment of MBC. The main objective was to determine the efficacy of combined induction with wPC and E followed by consolidation with wPC. Secondary objective were to determine tolerance survivals and characterize antiangiogenic PC activity and predictive values of plasmatic neurotrophic and endothelial factors, in terms of neurotoxicity and efficacy.
 Methods : patients (pts) with RECIST measurable metastasis were recruited from april 2004 to may 2006 : ages (18-75 y) PS≤2, prior neoadjuvant adjuvant chemotherapy (NA-A CT) was permited if >6 month. 3 cycles [wPC 80 mg/m² (D1, D8, D15, reinduction D28) and epirubicine 100 mg/m² D15], were followed by wPC (no week rest). VEGF, IL6, IL6SR, BDNF were measured in plasma at baseline and C2. Evaluation was performed after 3 induction cycles and every 3 month. A Simon optimal two-stage design was performed with 13 objective responses, allowing to accrue 25 more patients (28 responses expected).
 Results : 54 patients: median age 58.5 (30-75); 81% had surgery, 53.7% radiotherapy and 40.7% had NA-A CT, 46.3% hormonotherapy. Metastatic sites were nodes (36) lung (36) liver (28) bone (23). 100% PC and 90% E dose were administered at C2 and C3. 49 patients were evaluable for response; 3 patients withdrawn for taxol hypersensitivity, 1 early death (GIII asthenia and dyspnea), 1 investigator's decision. ITT analysis was performed: 33 responses (ORR: 61 %) Median OS was 30 months. During induction, 16 grade III, 27 grade IV and 3 febrile neutropenia were reported. There were 13 serious adverse events.
 Consolidation was mainly associated with neurotoxicity n=28 (20pts), GIII (n=1; 3.6%) GIV (n=1; 3.6%), astenia n=26 (18pts) ), GIII n=1; 3.8% GIV n=1; 3.8%and onycholysis n=15 (13pts) ), GIII n=2 ; 13.4% GIV n=1; 6.7%.
 High initial VEGF plasma levels were correlated with poor survival s (PFS, OS) with an univariate cox model (OR=1.954, 95%CI 0.944-4.043, p=0.071 ; HR 4.437, 95%CI 1.731-11.371, p=0.0019). Thresholds were determined. No correlation were observed between neurotoxicity and IL6, IL6SR and BDNF plasma levels.
 Conclusion : Despite the significant but manageable haematologic toxicity, PC + E showed a high efficacy. VEGF plasma levels are predictive of the outcome and should be tested as antiangiogenic drugs targeting factors.This work was supported in part by BMS.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6122.

Safety and pharmacokinetics of paclitaxel and the oral mTOR inhibitor everolimus in advanced solid tumours

Everolimus displays antiproliferative effects on cancer cells, yields antiangiogenic activity in established tumours, and shows synergistic activity with paclitaxel in preclinical models. This study assessed the safety and the pharmacokinetic interactions of everolimus and paclitaxel in patients with advanced malignancies. Everolimus was dose escalated from 15 to 30 mg and administered with paclitaxel 80 mg m⁻² on days 1, 8, and 15 every 28 days. Safety was assessed weekly, and dose-limiting toxicity (DLT) was evaluated in cycle 1. A total of 16 patients (median age 54.5 years, range 33–69) were entered; 11 had prior taxane therapy for breast (n=5), ovarian (n=3), and vaginal cancer (n=1) or angiosarcoma (n=2). Grade 3 neutropenia in six patients met the criteria for DLT in two patients receiving everolimus 30 mg weekly. Other drug-related grade 3 toxicities were leucopenia, anaemia, thrombocytopenia, stomatitis, asthenia, and increased liver enzymes. Tumour stabilisation reported in 11 patients exceeded 6 months in 2 patients with breast cancer. Everolimus showed an acceptable safety profile at the dose of 30 mg when combined with weekly paclitaxel 80 mg m⁻², warranting further clinical investigation.

A rare gynecological case of paraneoplastic cerebellar degeneration discovered by FDG-PET

BACKGROUND

PET/CT may be particularly useful to detect the primary cancer in paraneoplastic cerebellar degeneration (PCD) with anti-Yo which is most commonly associated with breast, ovarian and other gynecological cancers.

CASE

A 60-year-old woman developed a PCD associated with anti-Yo antibodies in serum and cerebrospinal fluid. Conventional imaging was negative. FDG-PET showed an abnormal hot spot in the right ovarian area associated with lombo aortic lymph nodes. The diagnosis was confirmed by surgery as an ovarian adenocarcinoma.

CONCLUSION

In this case report, FDG-PET played a crucial role in detecting the unknown primary tumor in a patient with PCD.

Vinflunine: a new active drug for second-line treatment of advanced breast cancer. Results of a phase II and pharmacokinetic study in patients progressing after first-line anthracycline/taxane-based chemotherapy

To evaluate the single agent activity, pharmacokinetics and tolerability of the novel tubulin targeted agent vinflunine (VFL) (320 mg m⁻² q 21 days) as second-line chemotherapy in patients with metastatic breast carcinoma (MBC). All patients had disease progression after anthracycline/taxane (A/T) therapy. They could have received a nonanthracycline adjuvant treatment and subsequently received a first-line A/T combination for advanced/metastatic disease; or relapsed >6 months after completion of adjuvant A/T therapy and were subsequently treated with the alternative agent; or relapsed within 6 months from an adjuvant A/T combination. Objective response was documented in 18 of 60 patients enrolled (RR: 30% (95% confidence interval (CI): 18.9–43.2%)). Among the responders, seven patients had relapsed during a period of <3 months from taxane-based regimen yielding a RR of 33.3%. The median duration of response was 4.8 months (95% CI: 4.2–7.2), median progression-free survival was 3.7 months (95% CI: 2.8–4.2) and median overall survival was 14.3 months (95% CI: 9.2–19.6). The most frequent adverse event was neutropenia (grade 3 in 28.3% and grade 4 in 36.7% of patients). No febrile neutropenia was observed. Fatigue (grade 3 in 16.7% of patients) and constipation (grade 3 in 11.7% of patients) were also common; these were non-cumulative and manageable permitting achievement of a good relative dose intensity of 93.5%. Vinflunine is an active agent with acceptable tolerance in the management of MBC patients previously treated with (A/T)-based regimens. These encouraging phase II results warrant further investigation of this novel agent in combination with other active agents in this setting or in earlier stages of disease.

Phase I dose-escalation study of a novel antitumor agent, SR271425, administered intravenously in split doses (d1–d2–d3) in patients with refractory solid tumors

BACKGROUND

SR271425 is a novel DNA-binding cytotoxic agent with a broad spectrum of antitumor activity in preclinical models,across a variety of the schedule of administration. In toxicological studies, it has been reported to prolong QTc proportionally to C (max). In order to circumvent this C (max)-related QTc prolongation, 5 phase I studies were initiated to investigate 1-h, 24-h, weekly, and split iv infusions. This phase I study assessed a split-dose regimen (a 1-h infusion on each of Days 1 to 3, repeated every 3 weeks) to establish the dose limiting toxicities (DLT), to recommended a phase II dose, and to characterize PK/PD.

METHODS

Patient with advanced solid tumors, adequate bone marrow, hepatic, renal function and on specific cardiac criteria were eligible and "3 + 3" design was used for dose escalation. That dose escalation was guided by PK data, toxicities observed and information from other ongoing phase I studies with SR271425. SR271425 plasma levels (PK samples) were measured using a validated LC-MS/MS method. Careful monitoring of ECGs was done, and ECGs were read centrally.

RESULTS

Three centers enrolled 19 heavily pretreated patients to six dose levels, from 75 to 450 mg/m(2)/day (i.e., 225-1,350 mg/m(2)/cycle): 12 males and 7 females. Median age 56. Median ECOG, PS = 1. Main tumor types were brain, breast, gynecological, and urological. Patients received a median of 2 cycles (range: 1-6). NCI-CTC Grade 1-2 toxicities included nausea, vomiting, asthenia, rash, and yellow skin discoloration. No DLTs were reported, and there were no dose-limiting prolongations of QTc. Both C (end) and AUC increased in a dose-related manner, with no evidence of accumulation between Day 1 and Day 3, consistent with the mean (+/-SD) terminal elimination half-life of 5.11 +/- 1.21 h. Stable disease was observed in five cases.

CONCLUSION

Split doses allow high cumulative exposure to SR271425 without significant toxicity, especially without QTc prolongation. MTD was not reached due to the early termination of the SR271425 program by the sponsor.

Evaluation of the safety of C-1311 administered in a phase I dose-escalation trial as a weekly infusion for 3 consecutive weeks in patients with advanced solid tumors

2069

Background: C-1311 is the most active member of a new series of anti-cancer agents, the imidazoacridinones, specially designed compounds developed from research on the structure-activity relationships of other cancer therapies such as the anthracenediones (e.g. mitoxantrone) and the anthracyclines (e.g. doxorubicin). This first-in-man clinical trial was designed to assess the safety profile of C-1311 and determine the recommended dose upon weekly administration for 3 consecutive weeks, within a 28-day cycle. Methods: Patients with advanced solid tumors refractory to conventional therapy were enrolled. The dose escalation scheme was divided into 2 phases: an initial accelerated phase of cohorts of 1 patient at doubling doses and a modified Fibonacci phase of cohorts of 3 pts at 25–33% dose increments. The maximum tolerated dose (MTD) was defined as the dose at which 2/3 or 2/6 pts experienced a dose-limiting toxicity (DLT). The recommended dose (RD) was defined as the dose level below the MTD, confirmed by expansion of the cohort to 9 pts. Results: 16 pts received doses of 15, 30, 60, 120, 240, 480 and 640 mg/m2/wk. The 2 pts treated at 640 mg/m2 experienced a DLT (grade 3 neutropenia preventing the administration of the 2nd and 3rd dose of the first cycle respectively). The RD was defined as 480 mg/m2/wk (cohort of 9 pts). Six additional pts were treated at the RD in an extension study in which one of the first 2 doses was given orally. Overall, 2 serious adverse events have been reported as possibly drug-related, both consisting of post-infusion fever without evidence of infection, resolving within 24 hours. Transient neutropenia was the only recurring grade 3 or 4 drug-related adverse event (AE). Grade 1 or 2 AEs most commonly reported as drug-related were nausea, asthenia, vomiting and diarrhea. Stable disease was observed in 3 patients with advanced malignancy. One pt had a stable course over > 8 cycles, and two had stable courses over 4 cycles. Plasma drug concentrations were linear and proportional to dose. Conclusions: The recommended phase 2 dose of 480 mg/m2, weekly × 3 q 28 days, offers a predictable safety profile and excellent tolerability.

[Table: see text]

Phase I study of intravenous (IV) milataxel in adult patients with advanced malignant tumors

2037

Background: M (TL139, MAC-321) is a novel taxane with activity in human xenograft models against tumors resistant to paclitaxel. The maximum tolerated dose (MTD) when given IV every 3 weeks was 35 mg/m2. The current study was designed to determine if the dose intensity of M could be increased by a weekly IV schedule. Methods: The primary objective of the study was to determine the maximum tolerated dose (MTD), the dose limiting toxicity (DLT) and the recommended dose (RD) for phase II. Secondary objectives were pharmacokinetic (PK)/pharmacodynamic (PD) parameters of M given IV weekly and a preliminary estimate of efficacy in an expanded cohort at the RD. Key pt eligibility criteria included in adult pts with refractory malignant tumors, ECOG PS <3 and adequate hematologic, hepatic and renal function. Patients were not allowed concurrent strong inhibitors of cytochrome p450 3A4. Dose escalation was based on Fibonacci method. At the RD, additional pts with tumors that typically respond to taxane treatment were added. PK data were obtained on day 1 and 15. Results: A total of 32 pts were treated, 15 (6 females, 9 males) in the dose escalation part and 17 (15 females, 2 males) in the MTD confirmation part. The median number of doses was 11 (range 1–18). In the dose escalation phase, 3, 4, and 3 pts were treated at 8, 12, and 16 mg/m2 IV weekly without DLT. At 20 mg/m2, 2 of 5 pts developed DLT (1 pt - myalgia and neuropathy, 1 pt grade 4 neutropenia > 5 days in duration). The RD was 16 mg/m2 weekly. 17 more pts were treated at the RD. The most frequent grade 3 or 4 adverse events were asthenia (19%), nausea (9%), parethesia (9%) and neuropathy (9%). Of the 10 pts with breast cancer who were evaluable for response, one had a PR. Another breast cancer pt with a PR was a protocol violation and was not evaluable. In 20 pts at the MTD, the Tmax was 4 hr, the Cmax was 51.97 ng/mL, AUC 2711 ng*hr/mL, and the Vss was 1496 L/m2. Conclusions: Milataxel had an RD of 16 mg/m2 IV per week. Objective responses were observed in pts with metastatic breast cancer.

No significant financial relationships to disclose.

Brown fat in breast cancer patients: analysis of serial 18F-FDG PET/CT scans

PURPOSE

It has recently been suggested that FDG accumulation in the brown adipose tissue varies as a function of age, sex and outdoor temperature. The aim of this study was to assess changes in FDG uptake in brown fat in patients based on serial PET/CT scans and to compare our results with previous findings.

METHODS

Early response to neoadjuvant chemotherapy in 33 female breast cancer patients was assessed by FDG PET. Five PET/CT scans were performed for each patient. PET/CT images were analysed retrospectively. PET scans were considered positive when diffuse, symmetrical, abnormal "USA" (uptake in supraclavicular area) fat was detected.

RESULTS

A total of 163 PET images were analysed. Seventy-four PET scans (45%) revealed abnormal FDG uptake in the supraclavicular area. These foci were present on uncorrected and attenuation-corrected images. FDG uptake was identical on all five scans in only five patients. No significant relationship was found between abnormal FDG uptake and outdoor temperature, age or time interval between chemotherapy and PET. Abnormal FDG uptake in the neck seemed to predominantly occur in patients with a low body mass index (p<0.05). Most significant changes in the PET/CT scan results were observed during chemotherapy with docetaxel (p<0.05). When observed, bilateral uptake in the neck was more intense than background uptake (p<0.00001).

CONCLUSION

This study shows that FDG uptake in the neck varies as a function of time, that it is unrelated to age or outdoor temperature, and that bilateral uptake is generally intense.