Abstract PD5-09: Immune parameters associated with survival in triple negative and HER2-positive breast cancer patients with 10 years of follow-up

The clinical utility of tumor-infiltrating lymphocytes (TIL) is actively being investigated in breast cancer (BC). It is unclear whether TIL spatial location and organization in tertiary lymphoid structures (TLS) have an impact on prognosis. Additionally, the significance of PD-1 and PD-L1 expression is being debated due to conflicting data from several studies. We hypothesize that the presence, extent and spatial location of multiple immune biomarkers, reflecting ongoing immune responses, will be consistently associated with a good prognosis in highly infiltrated BC [triple-negative (TNBC) and HER2+].

The relationship between these immune biomarkers and clinical outcome was examined in the TNBC and HER2+ cohorts of node-positive BC patients enrolled in the BIG 02-98 adjuvant phase III trial with available material for immunohistochemical (IHC) labeling (N=113 and N=136, respectively). HER2+ patients did not receive trastuzumab. Dual IHC staining was performed on full-face consecutive tissue sections. Scoring was independently performed by two pathologists, blinded to the clinical data, and included: global, intratumoral and stromal TIL and TLS, assessed on CD3/CD20 slides; the percentage and location of PD-1 and PD-L1 expression, assessed on PD-1/PD-L1 slides. TIL were considered as a categorical variable with different cut-offs used for each parameter and for each cohort (TNBC and HER2+). Invasive disease-free survival (I-DFS) and overall survival (OS) were analyzed (median follow-up: 10 years). Cox proportional hazard models were used for survival analyses.

The TNBC cohort revealed an association between global TIL and outcome [adjusted hazard ratio (HR) for I-DFS: 0.27 (0.15-0.51); OS: 0.26 (0.13-0.53)]. Similar results were observed for stromal and intratumoral TIL. PD-L1 expression within TLS was an independent predictor of OS, after adjustment for tumor size and age [HR: 0.30 (0.09-0.99)]. Multivariate analysis reveals this effect was principally driven by high stromal TIL (>17.5% based on CD3/CD20 assessment) (χ2 OS: p=0.009). In contrast, no significant prognostic associations were found in the overall HER2+ cohort. However high T cell TIL were associated with improved I-DFS and OS in the ER-/HER2+ group [I-DFS: 0.34 (0.14-0.80); OS: 0.32 (0.12-0.86)] and stromal TIL were associated with improved I-DFS in the ER+/HER2+ group [HR: 0.29 (0.09-0.94)] (univariate analyses). No significant associations between the number of TLS nor the expression of PD-1 with outcomes were observed in either cohorts.

The presence of PD-L1+ TLS, driven by high baseline TIL, was associated with an excellent prognosis in node-positive TNBC. This observation might reflect specific immune activities taking place in these mini lymph node-like structures adjacent to the tumor bed where specific antitumor memory immune responses could be generated. No different prognostic impact was observed when analyzing TIL spatial location. Although the statistical power of the study might be limited, in line with previous findings our data reveal that, among the immune parameters evaluated, TIL are the strongest predictor of outcome in TNBC, while PD-L1+ TLS could be a new and important parameter that requires further investigation.

Citation Format: Solinas C, de Wind A, Van den Eynden G, Ameye L, Garaud S, De Silva P, Boisson A, Noel G, Langouo Fontsa M, Buisseret L, de Azambuja E, Francis PA, Di Leo A, Crown JP, Sotiriou C, Larsimont D, Paesmans M, Piccart-Gebhart M, Willard-Gallo K. Immune parameters associated with survival in triple negative and HER2-positive breast cancer patients with 10 years of follow-up [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD5-09.

Abstract P2-05-02: Functional genomic screening identifies ubiquitin-specific protease 11 (USP11) as a novel regulator of ER-alpha transcription in breast cancer

Approximately 70% of breast cancers overexpress the estrogen receptor α (ERα) and depend on this key transcriptional regulator for growth and differentiation. The discovery of novel mechanisms controlling ERα function represent major advances in our understanding of breast cancer progression and potentially offer attractive new therapeutic opportunities. Here, we investigated the role of deubiquitinating enzymes (DUBs), which act to remove ubiquitin moieties from proteins, in regulating transcriptional activity of ERα in breast cancer.

To identify DUBs involved in the regulation of ERα transcriptional activity, we performed an RNAi loss-of-function screen using a library of shRNA vectors targeting all human DUB genes. The DUB library consisted of pools of four non-overlapping shRNAs targeting all 108 known or putative DUBs (432 shRNAs in total). We found that suppression of a number of DUBs markedly repressed or enhanced the activity of an estrogen-response-element (ERE) luciferase reporter following estradiol (E2) stimulation. Of particular interest, suppression of the BRCA2-associated DUB, USP11, was found to down-regulate ERα transcriptional activity.

Subsequent validation using two individual siRNAs targeted to USP11 revealed a notable reduction in expression of endogenous ERα target genes in the ZR-75-1 cell line, as quantified using qRT-PCR. Further validation was carried out in a HEK293T USP11 knockout cell line, where reduced activity of an ERE-luciferase reporter was detected when compared to wild-type cells. This phenotype was rescued with a USP11 overexpression vector, both in the presence and absence of E2. Furthermore, USP11 expression was found to be upregulated in the estrogen-independent cell line LCC1 when compared to their parental MCF7 cells. Knockdown of USP11 in LCC1 cells resulted in decreased mRNA expression of a panel of ERα target genes, while RNA-seq revealed a downregulation of several putative ERα target genes and a downregulation of many cell cycle-associated proteins.

To support the prognostic relevance of USP11, immunohistochemical staining of a breast cancer tissue microarray (103 ER+ patients available for final analysis) was performed. Kaplan-Meier analysis of this cohort revealed a highly significant association between high USP11 expression and poor overall (p=0.030) and breast cancer-specific survival (p=0.041). In silico analysis of publically available breast cancer gene expression datasets further supported an association between high USP11 mRNA levels and poor prognosis. We observed a significant correlation between high expression of USP11 mRNA in ER-positive patients and poor distant metastasis-free survival (HR 2, CI 1.37-2.91, p=0.00023). This correlation was also significant in ER-positive patients who had received tamoxifen only (HR 2.9, CI 1.63-5.15, p=0.00015).

These results suggest a role for USP11 in driving cellular growth and identify USP11 as novel therapeutic target in breast cancer.

Citation Format: Dwane L, Das S, Moran B, O'Connor AE, Mulrane L, Dirac AM, Jirstrom K, Crown JP, Bernards R, Gallagher WM, Ní Chonghaile T, O'Connor DP. Functional genomic screening identifies ubiquitin-specific protease 11 (USP11) as a novel regulator of ER-alpha transcription in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-05-02.

Impact of palbociclib plus letrozole on pain severity and pain interference with daily activities in patients with estrogen receptor-positive/human epidermal growth factor receptor 2-negative advanced breast cancer as first-line treatment

Background Palbociclib is a recently approved drug for use in combination with letrozole as initial endocrine-based therapy for the treatment of postmenopausal women with advanced estrogen receptor-positive/human epidermal growth factor receptor 2-negative (ER+/HER2-) breast cancer. This report assesses the impact of palbociclib in combination with letrozole versus letrozole alone on patient-reported outcomes of pain. Methods Palbociclib was evaluated in an open-label, randomized, phase II study (PALOMA-1/TRIO-18) among postmenopausal women with advanced ER+/HER2- breast cancer who had not received prior systemic treatment for their advanced disease. Patients received continuous oral letrozole 2.5 mg daily alone or the same letrozole dose and schedule plus oral palbociclib 125 mg, given once daily for 3 weeks followed by 1 week off over repeated 28-day cycles. The primary study endpoint was investigator-assessed progression-free survival in the intent-to-treat population, and these results have recently been published (Finn et al., Lancet Oncol 2015;16:25-35). One of the key secondary endpoints was the evaluation of pain, as measured using the Brief Pain Inventory (BPI) patient-reported outcome tool. The BPI was administered at baseline and on day 1 of every cycle thereafter until disease progression and/or treatment discontinuation. Clinical trial registration This study is registered with ClinicalTrials.gov (NCT00721409). Results There were no statistically significant differences in Pain Severity or Pain Interference scores of the BPI between the two treatment groups for the overall population or among those with any bone disease at baseline. A limitation of the study is that results were not adjusted for the concomitant use of opioids or other medications used to control pain. Conclusions The addition of palbociclib to letrozole was associated with increased efficacy without negatively impacting pain severity or pain interference with daily activities.

Abstract P4-13-02: Treatment patterns of post-disease progression in the PALOMA-1/TRIO-18 trial

Background

Palbociclib (P) is an oral CDK4/6 inhibitor. In PALOMA-1/TRIO-18, a randomized phase 2 trial, addition of P to letrozole (L) significantly prolonged progression-free survival (PFS) (20 mo with P+L vs 10 mo with L alone; HR = 0.488, P=0.0004; Finn et al, Lancet Oncol, 2015) in postmenopausal women with estrogen-receptor-positive (ER+), HER2-negative advanced breast cancer (ABC) in the first-line setting. At the time of final PFS analysis, overall survival (OS) was immature.

Objectives

It is clinically important to understand whether patients (pts) benefit from standard of care endocrine therapy (ET) after they progressed on P+L as first-line treatment for ABC. We report patterns of post-progression treatment in the next line of therapy immediately following participation in the PALOMA-1 trial.

Methods

Postmenopausal women with ER+ and HER2- ABC who had not received any treatment for their advanced disease were randomized to receive P+L (N = 84) or L alone (N = 81) in the first-line setting. The primary endpoint was investigator-assessed PFS. Tumor assessment was performed every 8 weeks. Post-progression treatment data was captured and analyzed.

Results

As of the data cut-off (Nov 29, 2013), 40 progression events had occurred in the P+L arm and 59 in the L alone arm. 50% of pts in the P+L arm vs. 64% in the L alone arm received ET after progression on study treatment. 60% of pts in the P+L arm vs. 66% in the L alone arm received chemotherapy (CT) after progression on study treatment. The time to 1st subsequent ET/ CT after progression on study treatment, duration of 1st subsequent ET/CT, and choice of 1st subsequent ET/ CT are shown in Table 1.

Table 1 P + LL N=84N=81Patients (pts) with Disease Progression, NN (%)a40 (47.6)59 (72.8)Pts who received subsequent Endocrine Therapy (ET) after progression on study treatment, n(%)b20 (50.0)*38 (64.4)*Time from randomization to 1st subsequent ET (days), median (range)465.5 (239-1100)368.5 (65-1102)Duration of 1st subsequent ET (days), median (range)**153 (24-592)151 (16-1135)Choice of 1st subsequent ET, n(%)bFulvestrant9 (22.5)15 (25.4)Exemestane6 (15.0)9 (15.3)Medroxyprogesterone4 (10.0)1 (1.7)Letrozole1 (2.5)5 (8.5)Tamoxifen08 (13.6)Pts who received subsequent Chemotherapy (CT) after progression on study treatment, n(%)b24 (60.0)*39 (66.1)*Time from randomization to 1st subsequent CT (days), median (range)388.5 (69-918)281 (46-1013)Duration of 1st subsequent CT (days), median (range)**92 (1-457)120 (1-1143)Choice of 1st subsequent CT, n(%)bCapecitabine1 (2.5)10 (17.0)Mitoxantrone13 (32.5)1 (1.7)Paclitaxel013 (22.0)Other10 (25)15 (25.4)apercentages are based on N as denominator; bpercentages based on NN as denominator; *some patients had both ET and CT after progression; **calculated as treatment stop date minus treatment start date +1; if treatment was ongoing at time of data cut-off, stop date was imputed as Nov 29, 2013.

Conclusions

P+L delayed the time to ET/CT as compared to L alone. Pts benefited from standard of care ET/CT after they progressed on P+L as first-line treatment for ABC as demonstrated by the length of time on subsequent therapies; no difference was observed from the L alone arm.

Clinical Trial Information: NCT00721409

Funding Source: Pfizer.

Citation Format: Finn RS, Crown JP, Ettl J, Pinter T, Thummala A, Shparyk Y, Patel R, Randolph S, Kim S, Huang X, Nadanaciva S, Huang Bartlett C, Slamon DJ. Treatment patterns of post-disease progression in the PALOMA-1/TRIO-18 trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-02.

Abstract P4-09-06: miR-187 is an independent prognostic factor in lymph node-positive breast cancer patients

Purpose: MicroRNAs (miRNAs) involved in cancer progression have now become the focus of much attention as they represent a new class of biomarkers and potential drug targets. Here, we describe an integrated bioinformatics, functional analysis and translational pathology approach for the identification of novel miRNAs involved in breast cancer progression.

Experimental Design

Differential gene expression can, in part, be attributed to the activity of specific miRNAs. Given a database of miRNA binding site motifs and gene expression levels determined by transcriptomic profiling, correspondence analysis, between group analysis and co-inertia analysis can be combined to produce a ranked list of miRNAs associated with a specific gene signature and phenotype. Here, using two independent breast cancer cohorts, this approach was employed to produce a ranked list of miRNAs associated with disease progression. Functional studies were subsequently carried out in MCF7 cells assessing for alterations in growth, tumorigenicity and agressiveness and miRNA expression was evaluated in two cohorts of breast cancer patients by locked nucleic acid in situ hybridisation on tissue microarrays.

Results: CIA identified miR-187 as a key miRNA associated with poor outcome in breast cancer.

Ectopic expression of miR-187 in MCF7 cells resulted in a more aggressive phenotype (evidenced by increased anchorage-independent growth, migratory and invasive potential).

In a test cohort (n = 117) breast cancer patients, high expression of miR-187 was associated with a trend towards reduced breast cancer-specific survival (BCSS) (p = 0.058), and a significant association with reduced BCSS in lymph node-positive patients (p = 0.036). In a validation cohort (n = 470), high miR-187 was significantly associated with reduced BCSS in the entire cohort (p = 0.021) and, again, in lymph node-positive patients (p = 0.012).

Multivariate cox regression analysis revealed that miR-187 is an independent prognostic factor in both TMA cohorts (Cohort 1 HR-7.369 (95% CI 2.048–26.509, p = 0.002); Cohort 2 HR-2.798 (95% CI 1.518–5.157, p = 0.001).

Conclusions: miR-187 expression in breast cancer leads to the formation of a more aggressive, invasive phenotype and acts as an independent predictor of outcome.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-09-06.

Abstract OT1-1-06: A phase III randomized study of Paclitaxel and Trastuzumab versus Paclitaxel, Trastuzumab and Lapatinib in first line treatment of HER2 positive metastatic breast cancer

Background: Preclinical studies have shown that dual targeting of the extracellular domain and the kinase domain of HER2 using trastuzumab (H) and lapatinib (L) produces greater growth inhibition than single agent treatment. The combination of trastuzumab and lapatinib has shown improved clinical outcome compared to lapatinib alone in the pre-treated metastatic setting (EGF104900), and compared to trastuzumab in the neo-adjuvant setting (Neo-Altto). This international phase III randomised trial will compare the efficacy of trastuzumab and paclitaxel (T) with trastuzumab, paclitaxel and lapatinib in first line treatment of HER2 positive metastatic breast cancer, and will examine potential predictive biomarkers of response to trastuzumab and/or lapatinib.

Study Design and Eligibility: Six hundred patients with invasive HER2 positive (3+ or FISH positive) metastatic breast cancer (measurable disease per RECIST 1.1), who have not received prior systemic therapy for metastatic disease, will be randomised to receive (A) weekly paclitaxel (80 mg/m2, for 3 weeks of a 4 week cycle) plus trastuzumab (8 mg/kg loading dose day 1 and 4mg/kg every 2 weeks) or (B) weekly paclitaxel (80 mg/m2, for 3 weeks of a 4 week cycle) plus trastuzumab (8 mg/kg loading dose day 1 and 4 mg/kg every 2 weeks) plus lapatinib (1,000 mg daily), until disease progression, unacceptable toxicity or consent withdrawal.

Objectives: The primary objective of the study is to compare the efficacy of THL versus TH in first line treatment of metastatic HER2 positive breast cancer. Secondary objectives include: (i) examining the objective tumour response rate and overall survival; (ii) assessing the safety and tolerability of lapatinib when administrated with both paclitaxel and trastuzumab; (iii) examining the effects of the TH regimen versus the THL regimen on health-related quality of life (FACT-B); (iv) examining potential biomarkers in tumour tissue and serum samples; (v) determining if prophylactic loperamide significantly reduces the number of diarrhoea-related adverse events.

Statistical Methods: The expected median progression free survival time for the control arm is 6.9 months based on the trastuzumab plus paclitaxel arm of the phase III trastuzumab plus chemotherapy trial. A total of 600 evaluable patients (and 485 observed events) would be sufficient to detect an increase to 8.9 months in median PFS time for the THL combination, with 80% power and a two sided significance level of 0.05. Progression-free survival will be analysed at nine months after enrolment ends and overall survival will be analysed at 30 months after the end of enrolment. Objective response will be defined as the proportion of patients who receive a complete or partial response as defined by RECIST 1.1.

Accrual: This study will accrue six hundred patients across forty International centres. Countries signed up to participate include Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Netherlands, Norway, Poland, Portugal, Switzerland and Spain. The study opened to accrual in Ireland Feb 12 and six patients have been accrued to date.

Funding: Trial supported by GlaxoSmithKline. Lapatinib kindly supplied by GlaxoSmithKline.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT1-1-06.

Abstract S1-6: Results of a randomized phase 2 study of PD 0332991, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with letrozole vs letrozole alone for first-line treatment of ER+/HER2− advanced breast cancer (BC)

Background: PD 0332991, a selective inhibitor of CDK 4/6, prevents cellular DNA synthesis by blocking cell cycle progression. Preclinical studies in a BC cell line panel identified the luminal ER subtype, elevated expression of cyclin D1 and Rb protein, and reduced p16 expression as being associated with sensitivity to PD 0332991 (Finn et al. 2009). Synergistic activity was also observed in vitro when combined with tamoxifen. After determination of the recommended phase 2 dose in combination with letrozole (letrozole 2.5 mg QD plus PD 0332991 125 mg QD on Schedule 3/1), a randomized phase 2 study comparing letrozole alone (L) to letrozole plus PD 0332991 (L+P) was initiated.

Methods: The phase 2 portion of the study was designed as a two-part study; Part 1 enrolled post- menopausal women with ER+/HER2− advanced BC; Part 2 in addition to ER+/HER2− as eligibility criteria, screened for CCND1 amplification and/or loss of p16 by FISH. The primary endpoint is progression-free survival (PFS); secondary endpoints include response rate, overall survival, safety, and correlative biomarker studies. In both parts, post-menopausal women with ER+/HER2− advanced BC were randomized 1:1 to receive letrozole either with or without PD 0332991. Pts continue on assigned study treatment until disease progression, unacceptable toxicity, or consent withdrawal, and are followed for tumor assessments every 2 months.

Results: 66 pts were randomized in Part 1 and 99 pts in Part 2. Preliminary results from Part 1 of this study have been previously reported (IMPAKT Breast Cancer Conference, Abstract #292, Finn et al. May 2012) demonstrating a significant improvement in median PFS in the L+P vs. L arm (HR = 0.35; 95% CI, 0.17 to 0.72; p = 0.006). With the additional 99 pts randomized in Part 2 (N = 165), the statistically significant improvement in median PFS (26.2 vs. 7.5 months, respectively) continues to be observed with a HR=0.32 (95% CI, 0.19 to 0.56) with p <0.001. The response rate for the L+P arm (n = 84) was 31% vs. 26% for the L arm (n = 81) and the clinical benefit rate was 68% vs. 44%, respectively. The most commonly reported treatment-related AEs in the combination arm were neutropenia, leukopenia, anemia, and fatigue. The updated results from the combined Part 1 and Part 2 group will be presented in December 2012.

Conclusions: The combination of PD 0332991 and letrozole is well tolerated and shows encouraging clinical benefit, confirming the sensitivity of ER+ BC to PD 0332991 observed in preclinical models. A phase 3 trial in this setting will commence in 2013.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S1-6.

P1-17-05: Preliminary Results of a Randomized Phase 2 Study of PD 0332991, a Cyclin-Dependent Kinase (CDK) 4/6 Inhibitor, in Combination with Letrozole for First-Line Treatment of Patients (pts) with Post-Menopausal, ER+, HER2−Negative (HER2–) Advanced Breast Cancer

Background: PD 0332991 is an orally bioavailable selective inhibitor of CDK 4/6 and prevents cellular DNA synthesis by prohibiting progression of the cell cycle from G1 into the S phase. Preclinical evaluations suggest that reduction in CDKN2A (p16) expression and cyclin D1 (CCND1) overexpression confer susceptibility to PD 0332991 (Finn 2009). In addition, PD 0332991 was synergistic in combination with tamoxifen in vitro in ER+ human breast cancer cell lines. Based on these observations, a phase 1/2 study in combination with letrozole as first-line therapy for advanced ER+ post-menopausal breast cancer was initiated. The phase 1 part of the study (completed) determined the recommended phase 2 dose to be PD 0332991 125 mg QD on Schedule 3/1 (3 weeks on treatment followed by 1-week off treatment) in combination with letrozole 2.5 mg QD. The combination was generally well tolerated and encouraging antitumor activity was observed. We present preliminary data from the randomized Phase 2 portion comparing letrozole alone to letrozole plus PD 0332991.

Methods: The Phase 2 portion of the study is designed as a two-part study; we present data from Part 1. In both parts, eligible patients are randomized 1:1 to letrozole 2.5 mg QD alone (control) or PD 0332991 125 mg QD on schedule 3/1 and letrozole 2.5 mg QD (treatment, tx). Part 1enrolled post-menopausal women with ER+, HER2− cancer using only ER+, HER2−as a selection criteria. Part 2 is now enrolling post-menopausal women with ER+, HER2− breast cancer with CCND1 amplification and/or loss of p16 by FISH (target N=150). The primary endpoint is progression-free survival (PFS); secondary endpoints include overall survival, response rate, safety, and correlative studies. Pts are stratified for disease site and length from prior adjuvant therapy. Pts continue assigned study treatment until disease progression, unacceptable toxicity, or consent withdrawal and are followed every 2 months to assess disease status. Tumor tissue was required for participation.

Results: 66 patients have been randomized in Part 1. At the time of data cut-off (April 2011) median duration of treatment is 20 (range 4–64) wks for control and 27 (2-59) wks for tx. Dose reductions occurred in 9 pts on the tx arm and none on the control arm. There are no complete responses. The number of partial responses for pts with measurable disease are similar between arms (4/22 control vs 5/24 in tx). The number of pts with stable disease> 24 weeks was higher in the tx arm (5 vs 8). The number of pts with best response of progressive disease is lower in the treatment arm (2 vs 6). PFS data are immature. Twelve pts remain on control vs. 21 on tx. As in the Phase I portion of the study, the most common treatment-related AEs were neutropenia and leucopenia without febrile neutropenia. Biomarker studies for CCND1 amplification, p16 loss, RB status, and Ki67 are ongoing.

Conclusion: The combination of PD 0332991 and letrozole is well tolerated as first-line treatment of ER+, HER2− post-menopausal breast cancer. Updated efficacy data and biomarker data will be presented.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-17-05.

The cocaine- and amphetamine-regulated transcript mediates ligand-independent activation of ERα, and is an independent prognostic factor in node-negative breast cancer

Personalized medicine requires the identification of unambiguous prognostic and predictive biomarkers to inform therapeutic decisions. Within this context, the management of lymph node-negative breast cancer is the subject of much debate with particular emphasis on the requirement for adjuvant chemotherapy. The identification of prognostic and predictive biomarkers in this group of patients is crucial. Here, we demonstrate by tissue microarray and automated image analysis that the cocaine- and amphetamine-regulated transcript (CART) is expressed in primary and metastatic breast cancer and is an independent poor prognostic factor in estrogen receptor (ER)-positive, lymph node-negative tumors in two separate breast cancer cohorts (n=690; P=0.002, 0.013). We also show that CART increases the transcriptional activity of ERα in a ligand-independent manner via the mitogen-activated protein kinase pathway and that CART stimulates an autocrine/paracrine loop within tumor cells to amplify the CART signal. Additionally, we demonstrate that CART expression in ER-positive breast cancer cell lines protects against tamoxifen-mediated cell death and that high CART expression predicts disease outcome in tamoxifen-treated patients in vivo in three independent breast cancer cohorts. We believe that CART profiling will help facilitate stratification of lymph node-negative breast cancer patients into high- and low-risk categories and allow for the personalization of therapy.

Abstract P5-10-17: Bevacizumab (Bev) in Combination with Docetaxel (T) and Cyclophosphamide (C) as Adjuvant Treatment (AdjRx) for Patients (pts) with Early Stage (ES) Breast Cancer (BrCa) and Normal HER-2 Status. A Pilot Evaluation

In random assignment trials, the combination of Bev+ chemotherapy has been shown to produce superior response rates and progression free survival compared to chemotherapy alone, providing a rationale for the study of Bev in the AdjRx of pts with ESBrCa. As a principal side effect of Bev is hypertension (HTN), anthracycline-containing (Anth) AdjRx may pose additional cardiovascular risks. The role of Anth in Her2 normal ESBC is uncertain. TC is a standard non-Anth AdjRx. We performed a single arm pilot study to evaluate the feasibility and toxicity of TC+Bev in pts with ESBC in preparation for participation in a random assignment trial. Methods: Eligibility criteria included: ESBC which was HER-2 normal, node-positive or >2 cm and receptor negative, or >3 cm and receptor positive, normal cardiac ejection fraction (EF), no active or uncontrolled cardiovascular disease, normal organ and marrow function. Treatment consisted of four 3 weekly cycles of docetaxel 75 mg/m2 together with cyclophosphamide 600 mg/m2. Patients commenced bevacizumab 15 mg/kg i.v. on day 1, and q 3 weeks to a total of 19 treatments. Pts were monitored clinically, with echocardiograms and with serial estimations of BNP and troponin.

Results: A total of 105 female pts were accrued in 9 ICORG sites between Dec 2008 and June 2010. Ages ranged from 26-86 (median 55). At June 2010, 33 have completed all phases of therapy, 54 are still on treatment. Eighteen pts have been removed from study due to: HTN -7, intestinal perforation -2, withdrew consent-4, proteinuia-1, anaphylaxis-1, infection-3. The perforations occurred at cycles 9 and 19. Neither pt. with perforation had prior abdominal surgery. The median number of cycles achieved by the discontinued pts was 9. HTN requiring Rx occurred in 25 pts. Among 12 with HTN who have completed Bev, 2 are off HTN meds, and 9 are on reducing doses. The median EF at base line was 67%, at 13 cycles (42 pts) 63%, 18 cycles (27 pts) 66%. Six pts had EF drop >10%, in 3 of these EF fell below 50% as last recorded value. There were no episodes of clinical cardiac failure. Troponin and BNP levels were normal in all 57 pts with serial measurements. Thirteen pts required treatment for neutropenia-related infection or for abscess.

Conclusions: The spectrum and frequency of bevacizumab toxicity in our population of healthy adjuvant pts is similar to that reported for pts with metastatic BC and other malignancies. Hypertension is the principal cause of treatment discontinuation, but cardiac toxicity appears to be limited, with this non-anth chemotherapy +Bev. Intestinal perforation can also occur in pts with ESBC. These toxicities can occur in the post chemotherapy phase of Bev therapy. Pts enrolled on random assignment trials of Bev containing AdjRx require careful monitoring for toxicity.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-17.

Safety and tolerability of lapatinib in combination with taxanes (T) in patients with breast cancer (BC)

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Background: Lapatinib (L) is an oral, dual ErbB1/B2 tyrosine kinase inhibitor. T are mainstay of BC treatment. The side-effects seen with T in combination with gefitinib and erlotinib include neutropenia, diarrhea and rash. Based on preclinical synergy, early clinical studies with L and paclitaxel (P) or docetaxel (D) were studied. Methods: We summarize pharmacokinetics (PK) and preliminary safety data from 192 patients. Results: PK analysis for EGF10009 (q3w), show systemic exposure was increased for both L (21%) and P (23%) at doses of 1500mg daily and 175mg/m2/q3w, respectively. PK analysis in EGF10021 , (L 1250 mg & D 75 mg/m2 with prophylactic pegfilgrastim) indicated no significant effect on systemic exposure of either agent. Toxicities across all studies include i.e., for all patients = grade 3, neutropenia (7.3%), diarrhea (18.2%), rash (3.6%). The rate of adverse events for neutropenia and rash were similar to each agent alone, however diarrhea was more common. The frequency and severity of diarrhea was increased in studies EGF10009 and EGF102580 where no proactive treatment of diarrhea was introduced, whereas in EGF105764, with proactive treatment, currently no =grade 3 diarrhea has been reported. The data show that the combination of L and P has clinical activity (>70% RR reported in EGF102580). Conclusions: T plus L combinations have a predictable and manageable safety profile and clinical activity of P plus L combination was observed. Proactive diarrhea management is essential for these combinations. Based on the PK data, no dose adjustments are required, and any dose adjustments should be toxicity-based. Ongoing clinical studies investigating the combinations of L with T, and combinations of L with T plus trastuzumab will be reported in the future.

[Table: see text]

No significant financial relationships to disclose.

Is bisphosphonate-induced osteonecrosis of the jaw (BONJ) an ischemic manifestation of pseudo-osteopetrosis?: Biochemical, densitometric, and imaging evidence

18621

Background: BONJ is an increasingly recognised but poorly understood complication of long-term B therapy. We hypothesise that the pathophysiology is ischaemic, and is due to an osteopetrosis (OP)-like lesion which causes progressive constriction of maxillo- mandibular perforating arterial foramina. Support for this comes from the observation that the osteoclast ruffled border is functionally impaired in osteopetrosis and structurally lost with B therapy. Cases of maxillomandibular osteomyelitis and avascular necrosis complicating OP exist. Additionally the blood supply of the jaw relies partly on small periosteal perforators. Methods: Bone mineral density (BMD) of 2 female patients (pt) with BONJ was investigated with dual energy x-ray absorbptiometry. Serum creatinine BB-isoenzyme (CK-BB) was determined. Serum acid phosphatase was assessed for patient 1. Bone biochemistry; (serum calcium, phosphate, parathyroid hormone, bone alkaline phosphatase, 25(OH) vitamin D, osteocalcin (intact), N. Ter.procoll1, CTX-1) was assessed. Multislice CT with orthoradial reconstruction was performed on pt 1. Results: CK-BB isoenzyme was increased at 21% and 20% in patients 1 and 2 (upper limit normal 2%). DEXA scan patient 1 results: BMD, lumbar spine; T score 4.9 (152%), Z score 5.4 (160%), femur; T score 2.2 (128%) Z score 2.5 (134%). DEXA scan patient 2 results: BMD lumbar spine; T score 0.2, Z score 1.2, femur; T score 1.2, Z score 1.8. Serum acid phosphatase in pt 1 was normal. Orthoradial reconstruction of the mandible in pt 1 showed absence of lateral lingual canals in affected hemi mandible.Mental foramen and inferior alveolar canal were not constricted. Conclusion: The increased BMD and CK BB isoenzyme seen in our pts are characteristic features of osteopetrosis. The normal acid phosphatase is explained by bisphosphonate-induced osteoclast apoptosis a phenomenon that does not occur in osteopetrosis. Orthoradial reconstruction of the mandible provided radiological correlation. The data was found to be consistent with the hypothesized disease process.

No significant financial relationships to disclose.

Dual targeting of EGFR and HER-2 in breast cancer cell lines

13132

Background: ErbB2 is overexpressed in approximately 25–30% of breast cancers. Recent studies have shown that overexpression of ErbB2 is also frequently associated with expression of ErbB1 and that ErbB1 expression influences response to ErbB2 inhibition. The aim of this study was to investigate the effects of dual targeting of ErbB1 and ErbB2 in ErbB2 overexpressing breast cancer cell lines. Methods: Combinations of Trastuzumab (Herceptin), Gefitinib (Iressa) and Lapatinib (GW572016) were tested in two ErbB2 and ErbB1 positive breast cancer cell lines, SKBR3 and BT474. Proliferation assays were performed using the acid phosphatase assay and apoptosis was measured using the Cell Death Detection ELISA (Roche). The average combinations index (CI) values at ED25, ED50 and ED75 were determined using CalcuSyn. Results: With regard to inhibition of proliferation, dual targeting with Trastuzumab and Gefitinib is additive (CI=0.8) in SKBR3 cells and synergistic (CI=0.6) in BT474 cells. Combined treatment with Trastuzumab and Lapatinib is synergistic (CI=0.5) in SKBR3 cells and additive (CI=1.0) in BT474 cells. Dual targeting with Gefinitib and Lapatinib is antagonistic in both cell lines. Trastuzumab (10 nM) alone and Gefitinib (5 μM) alone did not induce significant apoptosis in SKBR3 cells whereas Lapatinib (0.75 μM) alone induced apoptosis and in combination with Trastuzumab enhanced apoptosis induction. Combined treatment with Trastuzumab (10 nM) and Gefitinib (5 μM) induced apoptosis comparable to Lapatinib alone (0.75 μM). Conclusions: Our results suggest that dual targeting of ErbB1 and ErbB2 with combinations of the monoclonal antibody, Trastuzumab and tyrosine kinase inhibitors may improve response to treatment in a sub-group of patients with ErbB2 overexpressing tumours that also express ErbB1. Interestingly, the apoptosis assays suggest that inhibition of both ErbB1 and ErbB2 is required to efficiently induce apoptosis in cells which express both receptors.

[Table: see text]

Docetaxel (T) given concurrently with or sequentially to anthracycline-based (A) adjuvant therapy (adjRx) for patients (pts) with node-positive (N+) breast cancer (BrCa), in comparison with non-T adjRx: First results of the BIG 2–98 Trial at 5 years median follow-up (MFU)

LBA519

Background: The activity of T in metastatic BrCa mandated evaluation as adjRx. We compared the efficacy of T with, or after A, both followed by CMF (cyclophosphamide/ methotrexate/ 5-fluorouracil), versus non-T adjRx. Methods: Random assignment trial in resected N+ pts, 18–70 yrs, stratified by: center, 1–3 vs >3 nodes and age <50 vs ≥50. The treatment arms were (mg/m2, intravenously unless otherwise stated): Ia: A 75 q 3 weeks × 4 ⋄ CMF ×3 (oral C 100 day 1–14, F 600 + M 40 d 1+8; q 28 days). Arm Ib; AC 60/600 × 4⋄CMF × 3. Arm II: A75 × 3 ⋄T100 ×3 ⋄CMF ×3. Arm III: AT 50/75 ×4 ⋄ CMF × 3. Pts subsequently received hormono-(receptor+), and radiotherapy per local guidelines. Randomization was in the ratio (1:1:2:2). The trial was designed to have 80% power to detect a 78% hazard ratio (HR) for relapse in II+III v I, with final analysis at 1215, and interim at 405 and 810 events. The primary comparison between the II+III and I would be done at a one-tailed significance level of 0.025. Secondary comparisons of II vs Ia and III vs Ib would be done using a closed testing procedure at a one-tailed significance level of 0.025. The 95% confidence limits of the HR of III v II would be calculated. Due to a low relapse rate, the plan was amended with main analysis after 810 events or 5 years MFU. Results: 2887 pts were enrolled (6/1998–6/2001). Characteristics were well-balanced, 46% had >3N+. Grade 3/4 toxicity occurred in 22.9, 24.7, 35.3 and 28.6 % of pts in Ia, Ib, II and III respectively. At 62.2 months MFU (3/2006), 732 pts (25%) had events. Planned event-free survival (EFS) comparisons were: Conclusion: In this study, the HR for T v non-T adjRx was of borderline significance. There were possibly important differences related to schedule, sequential but not concurrent appearing superior to non-T adjRx. Overall survival analysis will require longer follow-up. Translational studies are underway.

[Table: see text] [Table: see text]

Odynorgasmia

Painful ejaculation ("odynorgasmia") is not well recognized. When it occurs it may indicate the precise site of pathology.

The platinum agents: a role in breast cancer treatment?

Metastatic breast cancer is a partially chemotherapy-sensitive neoplasm. Most chemotherapy groups have activity in this disease, and the most active single drugs are the taxanes, especially docetaxel (Taxotere; Aventis Pharmaceuticals, Inc, Parsippany, NJ), and the anthracyclines. The alkylating agents, antimetabolites, and vinca alkaloids are also widely used. The platinum coordination complexes, which are widely used in oncology, are also active in metastatic breast cancer, but the availability of other drugs that are less toxic and easier to administer has resulted in their having a strictly limited use in this setting. Cisplatin appears to be somewhat more active than carboplatin, but direct comparative studies are lacking. The identification of the prominent activity of the taxanes has led to the investigation of wholly novel non-anthracycline-containing combination regimens, and platinum/taxane doublets appear to be particularly active. More recently, reports that trastuzumab (Herceptin, Genentech, South San Francisco, CA), a novel monoclonal antibody directed against the protein product of the HER2/(neu) oncogene, has a powerful synergistic interaction with docetaxel and with platinum agents have prompted evaluation of the triplet docetaxel/platinum/trastuzumab in the therapy of metastatic breast cancer.

Expanding options in breast cancer

In metastatic breast cancer, docetaxel is the only drug to have shown superior activity to doxorubicin [objective response rates (ORRs) 48 versus 33%] by direct comparison in a randomized trial. Importantly, this greater activity was accompanied by a lower risk of cardiotoxicity. Docetaxel has also proved superior to various combination regimens in patients who had previously failed anthracyclines. In the comparison versus mitomycin C plus vinblastine, survival was significantly prolonged in the docetaxel arm. The combination of paclitaxel with doxorubicin has achieved remarkably high rates of response. However, the combination is cardiotoxic (with the highest response rates reporting an incidence of clinical congestive heart failure in the region of 18%). In comparison, the combination of docetaxel with doxorubicin, while also highly active (ORR > 70%), is relatively non-cardiotoxic (with only one case of clinical congestive heart failure in 96 patients treated). Given that docetaxel appears to be the most active single agent in metastatic breast cancer, there is a compelling case for the drug to be evaluated in the adjuvant setting and such studies are ongoing.

Sequential dose-dense doxorubicin, paclitaxel, and cyclophosphamide for resectable high-risk breast cancer: feasibility and efficacy

PURPOSE

Dose-dense chemotherapy is predicted to be a superior treatment plan. Therefore, we studied dose-dense doxorubicin, paclitaxel, and cyclophosphamide (A-->T-->C) as adjuvant therapy.

METHODS

Patients with resected breast cancer involving four or more ipsilateral axillary lymph nodes were treated with nine cycles of chemotherapy, using 14-day intertreatment intervals. Doses were as follows: doxorubicin 90 mg/m2 x 3, then paclitaxel 250 mg/m2/24 hours x 3, and then cyclophosphamide 3.0 g/m2 x 3; all doses were given with subcutaneous injections of 5 microg/kg granulocyte colony-stimulating factor on days 3 through 10. Amenorrheic patients with hormone receptor-positive tumors received tamoxifen 20 mg/day for 5 years. Patients treated with breast conservation, those with 10 or more positive nodes, and those with tumors larger than 5 cm received radiotherapy.

RESULTS

Between March 1993 and June 1994, we enrolled 42 patients. The median age was 46 years (range, 29 to 63 years), the median number of positive lymph nodes was eight (range, four to 25), and the median tumor size was 3.0 cm (range, 0 to 11.0 cm). The median intertreatment interval was 14 days (range, 13 to 36 days), and the median delivered dose-intensity exceeded 92% of the planned dose-intensity for all three drugs. Hospital admission was required for 29 patients (69%), and 28 patients (67%) required blood product transfusion. No treatment-related deaths or cardiac toxicities occurred. Doxorubicin was dose-reduced in four patients (10%) and paclitaxel was reduced in eight (20%). At a median follow-up from surgery of 48 months (range, 3 to 57 months), nine patients (19%) had relapsed, the actuarial disease-free survival rate was 78% (95% confidence interval, 66% to 92%), and four patients (10%) had died of metastatic disease.

CONCLUSION

Dose-dense sequential adjuvant chemotherapy with doxorubicin, paclitaxel, and cyclophosphamide (A-->T-->C) is feasible and promising. Several ongoing phase III trials are evaluating this approach.

The development of docetaxel (Taxotere) in non-small cell lung cancer--docetaxel in new combinations and new schedules: an overview of ongoing and future developments

Non-small cell lung cancer is the most common cause of cancer death in the western world. Non-small cell lung cancer is modestly sensitive to chemotherapy with a small survival benefit in locally advanced and metastatic disease. Newer agents such as docetaxel are yielding encouraging response rates both as single agents and in combination. A phase I/II study is in progress in our institution to determine the maximum tolerated dose and noncomparative efficacy of the combination of docetaxel (Taxotere; Rhône-Poulenc Rorer, Antony, France), ifosfamide, and cisplatin, with mesna and lenograstim support, in the treatment of patients with advanced non-small cell lung cancer. To date, nine patients have received 37 cycles of treatment at increasing dose levels (no intrapatient dose escalation). Treatment was administered to patients on an inpatient basis every 3 weeks, with lenograstim on days 3 to 10. Dose-limiting toxicity has not occurred at levels I to III (dose level III: docetaxel 75 mg/m2, cisplatin 75 mg/m2, and ifosfamide 3 g/m2). These preliminary results suggest that the combination of docetaxel, ifosfamide, and cisplatin, with lenograstim support, is well tolerated in the doses evaluated. Preliminary efficacy results show a response rate of 67% (six of nine patients). The study continues to determine the maximum tolerated dose of this regimen in preparation for a phase II evaluation.

Resolution of paraneoplastic bile duct paucity following successful treatment of Hodgkin's disease

We report the case of a 21-year-old woman who developed severe adult onset ductopenia in association with Hodgkin's lymphoma. Chemotherapy resulted in a remission of her Hodgkin's disease (HD) and significant improvement in liver function with resolution of the hepatic and biliary duct histological abnormalities, a therapeutic success not previously described in the literature.

Dose escalation of paclitaxel with high-dose carboplatin using peripheral blood progenitor cell support in patients with advanced ovarian cancer

A phase I study of escalating doses of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) given in combination with high-dose carboplatin was conducted to identify the antitumor efficacy and maximum tolerated dose of paclitaxel in patients who had received sequential cycles of paclitaxel/cyclophosphamide as prior treatment for ovarian carcinoma. Eighteen patients with advanced ovarian cancer were treated in this study. Induction therapy consisted of two cycles of cyclophosphamide 3.0 g/m2 plus high-dose paclitaxel 300 mg/m2 plus filgrastim and leukapheresis to harvest peripheral blood progenitor cells, followed by four courses of rapidly cycled high-dose carboplatin with planned dose escalation of paclitaxel (150, 200, 250, and 300 mg/m2) rescued with peripheral blood progenitor cells. The study was amended after accrual of 11 patients, and the remaining seven patients received a single cycle of induction therapy with paclitaxel/cyclophosphamide, followed by four courses of rapidly cycled high-dose carboplatin with planned dose escalation of paclitaxel through levels 200 and 250 mg/m2. All 18 patients have completed therapy. Of the 15 who are evaluable for response, the pathologic complete response was 33% (five of 15 patients). The administration of escalating doses of paclitaxel in combination with high-dose carboplatin following sequential cycles of paclitaxel/cyclophosphamide induction resulted in significant nonhematopoietic toxicity. Induction with a single cycle of paclitaxel/cyclophosphamide resulted in excellent progenitor cell mobilization, and significantly ameliorated the toxicity of this approach. The response rates thus far obtained are promising and warrant further evaluation.

Phase II and pharmacologic study of docetaxel as initial chemotherapy for metastatic breast cancer

PURPOSE

Because docetaxel (Taxotere, RP 56976; Rhone-Poulenc Rorer, Antony, France) appeared to be active against breast cancer in phase I trials, we performed this phase II study.

PATIENTS AND METHODS

Thirty-seven patients with measurable disease were enrolled. Only prior hormone therapy was allowed, as was adjuvant chemotherapy completed > or = 12 months earlier. Docetaxel 100 mg/m2 was administered over 1 hour every 21 days. Diphenhydramine hydrochloride and/or corticosteroid premedication was added after hypersensitivity-like reactions (HSRs) were seen in two of the first six patients. Pharmacokinetic studies were performed during cycle 1 for correlation with toxicity.

RESULTS

Thirty-seven patients were assessable. Nineteen (51%) required dose reductions, usually for neutropenic fever. The median nadir WBC count was 1.4 x 10(3)/microL. HSRs were noted in 20 patients (54%). At a median cumulative dose of 297 mg/m2 (range, 99.6 to 424.5 mg/m2), 30 patients (81%) developed fluid retention, for which 11 (30%) subsequently stopped treatment. The first-cycle plasma area under the concentration-time curve (AUC) did not correlate with toxicity, although an ineligible patient with hepatic metastases (pretreatment bilirubin level 1.8 mg/dL) had an elevated AUC and died of toxicity. Responses were seen at all sites. On an intent-to-treat basis, there were two (5%) complete responses (CRs) and 18 (49%) partial responses (PRs). The overall response proportion (CRs plus PRs) was 54% (95% confidence interval, 37% to 71%). The median time to response was 12 weeks (range, 3 to 15) and the median duration was 26 weeks (range, 10 to 58+).

CONCLUSION

Docetaxel is active for metastatic breast cancer. Neutropenia and fluid retention are dose-limiting. The AUC did not predict toxicity, but caution is warranted when treating patients with liver dysfunction. An understanding of the pathophysiology of the fluid retention may facilitate prevention. Frequent HSR may warrant prophylactic premedication.

Paclitaxel as second and subsequent therapy for metastatic breast cancer: activity independent of prior anthracycline response

PURPOSE

Two phase II clinical trials were performed to determine efficacy and tolerability of paclitaxel (Taxol; Bristol-Myers Squibb Co, Wallingford, CT) and granulocyte colony-stimulating factor ([G-CSF] Neupogen; Amgen, Inc, Thousand Oaks, CA) as second or subsequent therapy for metastatic breast cancer.

PATIENTS AND METHODS

Paclitaxel plus G-CSF was administered as a second stage IV regimen to 25 patients with metastatic breast cancer at a dose of 250 mg/m2 intravenously over 24 hours. Fifty-two patients received paclitoxel plus G-CSF at 200 mg/m2 as a third or subsequent regimen (no restriction on number of prior regimens or on prior high-dose chemotherapy). All patients had received prior anthracycline treatment, and ultimately had progressive bidimensionally measurable disease.

RESULTS

Twenty-five of 76 patients (32.8%) had a major objective response (95% confidence interval [CI], 14% to 37%). The median duration of response was 7 months (range, 1 to 20+). Responses were as likely in patients with disease demonstrated to be unresponsive to anthracycline, ie, de novo resistance (11 of 37, or 30%) as in those with disease that once exhibited anthracycline sensitivity, ie, acquired resistance, (10 of 31, or 32%). G-CSF administration was associated with febrile neutropenic episodes in 36 of 402 cycles (9%) in 16 of 76 patients (21%).

CONCLUSION

Paclitaxel's clinically significant activity against metastatic breast cancer extends to patients with many prior chemotherapy regimens. The lack of impact of prior doxorubicin therapy on the likelihood of subsequent response to paclitaxel suggests an important role for this agent in the treatment of refractory metastatic breast cancer.

High-dose chemotherapy with peripheral blood progenitor autografting

Mobilized PBPs are an acceptable alternative to ABMT for hematopoietic rescue following high-dose therapy (table 10-3). Platelet recovery appears to be faster following PBPs than ABMT. In most series, leukocyte recovery is also accelerated, but this may be particularly due to the use of colony-stimulating factor. Morbidity and mortality also appear to be reduced. The optimal mobilization methodology is not defined, but larger numbers of PBPs are mobilized by chemotherapy plus colony-stimulating factors compared to CSFs alone, at the cost of enhanced toxicity. The use of PBPs has also facilitated the study of very-high-intensity regimens in which multiple courses of high-dose chemotherapy are given at very short intervals. Following completion of feasibility studies, prospective random assignment trials will be necessary to determine the benefit, if any, of this approach.

Factors affecting the mobilization of primitive and committed hematopoietic progenitors into the peripheral blood of cancer patients

Rapid hematopoietic reconstitution following peripheral blood progenitor cell (PBPC) autotransplantation is thought to result from reinfusion of committed progenitor cells. This has raised concern that PBPC autografts might be rich in committed hematopoietic progentors responsible for early engraftment, but deficient in more primitive progenitors required for long-term hematopoietic reconstitution. The granulomonocytic colony-forming unit (CFU-GM) assay measures committed progenitors responsive to a single species of colony-stimulating activity such as granulocyte-macrophage colony-stimulating factor (GM-CSF), whereas the pre-CFU assay identifies more primitive progenitors by measuring interleukin-3 (IL-3) and kit ligand (KL) induced generation of secondary CFU-GM from CD34+, 4-hydroperoxycyclophosphamide resistant progenitors that require multiple cytokine stimuli. Paired bone marrow (BM) and PBPC samples from 17 breast and ovarian cancer patients participating in four separate clinical trials were compared in these assay systems. In seven of nine patients, PBPC autografts mobilized with cyclophosphamide rebound and G-CSF compared favorably with paired BM autografts in both committed and primitive progenitor capacity. Failure to mobilize substantial primitive progenitor cell numbers occurred in two of nine patients undergoing this mobilization regimen and could not have been predicted by either circulating CFU-GM or CD34+ cell number. Prior myelosuppressive treatment experiences reduced peripheral progenitor yields somewhat, but still allowed for the collection of PBPC autografts which compared favorably with BM autografts in total CFU-GM and Pre-CFU. Mobilization of PBPC with G-CSF or GM-CSF alone in patients who had received prior myelosuppressive therapies produced autografts which were relatively deficient in committed progenitors, but absolutely deficient in primitive progenitors. We conclude that optimization of patient characteristics and mobilization parameters can achieve PBPC autografts rich in both the primitive and committed hematopoietic progenitor cells.

Taxol (paclitaxel) plus recombinant human granulocyte colony-stimulating factor in the treatment of metastatic breast cancer

We treated 28 patients who had no prior chemotherapy for stage IV breast cancer and 51 patients with extensive prior exposure to other chemotherapeutic agents with a 24-hour infusion of Taxol (paclitaxel) as a single agent. Prophylactic recombinant human granulocyte colony-stimulating factor was administered routinely to ameliorate the anticipated dose-limiting toxicity of neutropenia. Nonhematologic toxicity was mild to moderate in most cases. Taxol was more active in patients with chemotherapy-naive stage IV disease, but activity was also observed in extensively treated patients as well. There is a strong clinical suggestion of at least partial noncross-resistance with doxorubicin. Taxol is a very promising agent for the treatment of metastatic breast cancer; its optimal application in this disease will be the subject of future trials.

Excretion of Ascaris lumbricoides during total body irradiation

We describe the excretion of Ascaris lumbicoides, an intestinal roundworm, in the emesis of an asymptomatic patient undergoing total body irradiation. This suggests that Ascaris is sensitive to irradiation.

Paclitaxel and recombinant human granulocyte colony-stimulating factor as initial chemotherapy for metastatic breast cancer

PURPOSE

A phase II study of Taxol (paclitaxel; Bristol-Myers Squibb Co, Princeton, NJ) as initial chemotherapy for metastatic breast cancer was conducted. Recombinant human granulocyte colony-stimulating factor (rhG-CSF) was used to ameliorate myelosuppression, the anticipated dose-limiting toxicity.

PATIENTS AND METHODS

Twenty-eight patients with bidimensionally measurable breast cancer who had not received prior chemotherapy for metastatic disease were treated. Taxol was administered at 250 mg/m2 as a continuous 24-hour intravenous (i.v.) infusion every 21 days. rhG-CSF was administered at 5 micrograms/kg/d subcutaneously on days 3 through 10.

RESULTS

Objective responses were observed in 16 of 26 assessable patients (62%; 95% confidence interval, 41% to 80%). There were three (12%) complete responses (CRs) and 13 (50%) partial responses (PRs). Ten of 16 patients (63%) who had received prior adjuvant chemotherapy responded, which included one CR and four PRs among eight patients who had received prior doxorubicin-containing therapy. Responses were observed in all sites of metastatic disease. The median time to first objective response was 5 weeks (range, 1 to 14). Administration of rhG-CSF was associated with a short duration of neutropenia (median, 2 days with absolute neutrophil count < 500 cells/microL). Eight of 26 patients (31%) who received more than one course received subsequent therapy without dose reduction. One hundred seventy-eight cycles of treatment were administered, with a median of six cycles per patient (range, one to 19). Eight courses (4.5%) were associated with admissions for neutropenic fever. Twenty-two patients (79%) did not require admission for neutropenic fever. Treatment was well tolerated. Adverse effects included generalized alopecia in all patients. Myalgias, arthralgias, and peripheral neuropathy were mild. No hypersensitivity reactions and no cardiac toxicity were observed.

CONCLUSION

Taxol is highly active as initial chemotherapy for metastatic breast cancer. Administration of rhG-CSF reduced the incidence, depth, and duration of neutropenia, compared with published prior experience. Further studies of Taxol in breast cancer, including combinations with other active agents, are clearly warranted.

Preliminary experience with paclitaxel (Taxol) plus recombinant human granulocyte colony-stimulating factor in the treatment of breast cancer

Single-agent paclitaxel (TAXOL) was administered to 79 patients with stage IV breast cancer. Twenty-eight patients had no prior chemotherapy (for metastatic disease), and 51 patients had extensive exposure to other chemotherapeutic agents before beginning the 24-hour paclitaxel infusion. Routine use of recombinant human granulocyte colony-stimulating factor helped to ameliorate neutropenia, the dose-limiting toxicity, in some cases. Other toxicity was generally mild to moderate. Paclitaxel was more active in patients whose stage IV disease had not yet been exposed to chemotherapy, but activity was seen in the patients previously treated extensively as well. There is a strong clinical suggestion of non-cross-resistance with doxorubicin. In one case, an excellent response in previously irradiated skin was seen. Paclitaxel is a very promising agent for the treatment of metastatic breast cancer.

Beneficial impact of peripheral blood progenitor cells in patients with metastatic breast cancer treated with high-dose chemotherapy plus granulocyte-macrophage colony-stimulating factor. A randomized trial

BACKGROUND

This study compared the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) alone or in combination with peripheral blood-derived hematopoietic progenitor cells (PBP) as support for patients receiving high-dose chemotherapy and assessed the adequacy of these strategies as alternatives to autologous bone marrow rescue.

METHODS

The authors studied patients with metastatic breast carcinoma who had a major response to conventional chemotherapy or had achieved a complete remission by surgical resection of all known metastases. They were treated with carboplatin 1500 mg/m2, etoposide 1200 mg/m2, and cyclophosphamide 5.0 g/m2. Before this high-dose chemotherapy, the patients had been randomly assigned to one of two hematopoietic support strategies: GM-CSF alone (Group 1) or GM-CSF-primed PBP and GM-CSF (Group 2). Autologous bone marrow was harvested from all patients for use only in the event of persistent pancytopenia with marrow aplasia on day 15.

RESULTS

A total of 18 patients were treated. Randomization was halted after the initial 10 patients because of the significant advantages for patients in Group 2 in comparison with those in Group 1 in regard to (1) the median number of days to absolute neutrophil count 0.5 x 10(9)/l (12 versus 21) and platelet count to 50 x 10(9)/l (13 versus 23), (2) platelet transfusions (3 versus 15.5), and (3) episodes of neutropenic sepsis (0 versus 4, respectively). One patient in Group 1 died from treatment-related complications. All patients in Group 1 required bone marrow reinfusion. No patient in Group 2 required bone marrow reinfusion, and no early mortality was observed in this group. Eight subsequent patients were treated with PBP and GM-CSF (Group 3). This group was more heavily pretreated than Groups 1 or 2 and had a slower hematologic recovery than Group 2. However, none of these patients required bone marrow reinfusion. The four patients in Group 1 that did not have early bone marrow rescue all had neutrophil counts of 0.0 on day 15. For Groups 2 and 3, the neutrophil counts on day 15 ranged from 0.3-2.1 x 10(9)/l (median, 1.9) and from 0.2-2.1 x 10(9)/l (median 0.6), respectively.

CONCLUSIONS

The use of PBP plus GM-CSF accelerated hematologic recovery after this chemotherapeutic regimen compared with GM-CSF alone; there were reduced morbidity and platelet transfusion requirements. Recovery was sufficiently rapid that PBP were an acceptable alternative to autologous bone marrow transplantation in patients receiving high-dose carboplatin, etoposide, and cyclophosphamide.

An experimental analysis of classically conditioned nausea during cancer chemotherapy

This study investigated classical conditioning in women undergoing outpatient adjuvant chemotherapy for breast cancer. Breast cancer chemotherapy outpatients were randomly assigned either to an Experimental Group (exposed to a distinctive stimulus before each infusion of chemotherapy) or to a Control Group. After repeated infusions of chemotherapy, patients' responses to the experimental stimulus were assessed in a location not associated with chemotherapy. Experimental Group patients had increased nausea (self-reported on a visual analog scale) following the presentation of the experimental stimulus at this test trial, whereas Control Group patients did not. Two other measures of nausea corroborated these results. Post hoc statistical analyses confirmed predictions based on conditioning theory. This conditioning model of anticipatory nausea bears witness to the relevance of classical conditioning in clinical medicine.

High-dose chemotherapy and autologous bone marrow rescue for patients with refractory germ cell tumors. Early intervention is better tolerated

Therapy with high-dose carboplatin plus etoposide-based chemotherapy plus autologous bone marrow rescue (AUBMR) was administered to 29 patients with advanced germ cell tumors (GCT) refractory to cisplatin-based chemotherapy. Two groups of patients with refractory disease were treated. Sixteen patients had been identified as "poor risk" at diagnosis and had an inappropriately slow decline of serum tumor markers after two cycles of induction cisplatin-based therapy (Group A). In addition, 13 patients were treated who had never had a complete response (CR) or had relapses after ifosfamide-based salvage chemotherapy (Group B). Patients in Group A were treated with high-dose carboplatin etoposide, and patients in Group B received high-dose carboplatin, etoposide, and cyclophosphamide. Fifteen of 29 (52%) patients had a CR (9, Group A; 6, Group B). The patients in Group A had fewer hematologic toxic effects, and the median number of days from day 0 to a granulocyte count greater than 0.5/microliters was 16 and to a platelet count of more than 50/microliters was 15, compared with 22 days and 23 days in Group B, respectively. There were fewer episodes of culture-positive sepsis in Group A (12%) compared with Group B (26%), and the only treatment-related death occurred in Group B. Therapy with high-dose carboplatin plus etoposide-based chemotherapy plus AUBMR is effective for patients with GCT refractory to regimens of cisplatin with or without ifosfamide. Early use of high-dose chemotherapy reduces hematologic toxic effects and allows patients to start treatment in a more predictable fashion after cytoreduction, rather than when the disease is progressing rapidly.

Mitoxantrone, etoposide, mitoguazone and vinblastine chemotherapy (MV2) in relapsed and refractory lymphomas

As part of a program to develop less leukemogenic chemotherapy regimens for the treatment of favorable prognosis Hodgkin's disease, a phase I-II trial of mitoxantrone, etoposide, mitoguazone, and vinblastine was used to treat patients with relapsed and refractory malignant lymphoma and Hodgkin's disease. An overall partial response rate of 41% was observed. Although useful responses were seen, the absence of complete remissions is disappointing.

Acquired cyclic haematopoiesis associated with a radiation-induced chromosomal abnormality with clonal, morphologically normal circulating leucocytes

A 62-year-old male with a history of vesical carcinoma treated with pelvic radiotherapy and cystectomy developed intermittent fevers associated with oral ulcers and neutropenia. Serial blood counts revealed cyclic haematopoiesis, with periodic neutropenia, lymphocytopenia, monocytopenia and thrombocytopenia. Bone marrow examination revealed intermittent hypoplasia without myelodysplasia or leukaemia. Marrow karyotype revealed a clonal chromosomal abnormality which included trisomy 8 and absence of the Y chromosome. We also provide evidence of spontaneous differentiation of the clonal marrow cells to mature leucocytes.

Predictors of 5-year survival and curability in small cell lung cancer

A retrospective analysis of various characteristics in 81 small cell lung cancer patients treated at the Mount Sinai Medical Center, New York, from 1974 to 1982 was carried out to identify factors which had prognostic significance for long-term survival, defined as actual disease-free survival for at least 5 years from initiation of therapy. Six patients, five female patients (16.7%) and one male patient (2%), including four limited disease (9.7%) and two extensive disease patients (5%) were long-term survivors (73 to 96+ months from onset of therapy), and among them three remain alive and disease-free at 84, 84, and 96 months from first treatment, respectively. Although several factors, including sex, stage of disease (limited versus extensive), and occurrence of herpes zoster predicted overall survival duration, female sex and an occurrence of herpes zoster were the only variables which were statistically significantly related to 5-year survival. Herpes zoster was a relatively late occurrence whereas female sex was an independent positive prognostic factor.