Abstract GS2-10: Nimbus: A phase 2 trial of nivolumab plus ipilimumab for patients with hypermutated her2-negative metastatic breast cancer (MBC)

Background: While high tumor mutational burden (TMB-H) has been used as a tissue-agnostic biomarker for approval of immune checkpoint inhibitors (ICI), there is a paucity of data regarding efficacy of ICI in TMB-H MBC. The aim of this study was to evaluate if patients with TMB-H HER2-negative MBC benefit from the combination of nivolumab plus ipilimumab. Methods: This is an open-label, single-arm, multicenter, phase 2 study assessing the efficacy of nivolumab 3 mg/kg intravenously (IV) every 14 days plus ipilimumab 1 mg/kg IV every 6 weeks in subjects with TMB-H HER2-negative MBC. Eligible patients were required to have measurable HER2-negative MBC, TMB ≥9 Mut/Mb assessed by a cancer-gene panel evaluating > 300 genes and performed in a CLIA-certified laboratory, and 0-3 prior lines of chemotherapy in the advanced setting. The primary objective was overall response rate (ORR) according to RECIST 1.1. Secondary objectives include safety and tolerability, progression-free survival (PFS), and overall survival (OS). The study followed a two-stage design. In the first stage, 14 patients were enrolled. The study required at least 1 objective response in order to continue to the second stage where an additional 16 patients were enrolled. At least 4 objective responses among the 30 patients would suggest the regimen is worthy of further study. If the true response rate is 25%, the chance that the regimen is declared worthy of further study is > 90%. Tumor biopsies, peripheral blood mononuclear cells, circulating tumor DNA, and stool collection were mandatory and were obtained at baseline and on treatment (end of cycle 1). Results: From February 2019 to June 2021, 31 patients were enrolled across 3 different academic institutions. Among 30 patients who initiated study treatment, the median age was 63 yo, 20 had hormone-receptor positive (HR+) breast cancer and 10 had triple-negative breast cancer (TNBC), and median number of prior lines of chemotherapy was 1.5 (0-3). Among the 10 patients with TNBC, PD-L1 status was known in 7 patients (3 positive and 4 negative). Median TMB was 10.9 Mut/Mb and 16.7% (n = 5) of patients had a TMB ≥14 mut/Mb. After a median follow-up of 9.7 (4.4 - 16.4) months, 4 (13.3%) patients achieved a confirmed objective response (all partial responses) meeting the primary endpoint of this study. The median duration of response has not been reached and 3 of these patients are still progression-free for at least 15 months. Two patients have short follow-up, and one has an unconfirmed partial response and the other has a stable disease at the time of the data cut. Median PFS and OS was respectively 1.4 (95% CI 1.3 - 9.5) months and 8.8 (95% CI 4.2 - not reached). Exploratory analysis did not show a difference in response rate according to HR status and PD-L1 status (data not shown) but tumors with TMB ≥14 mut/Mb had a response rate of 60% vs 4% in the group with TMB between ≥9 and <14 mut/Mb (p = 0.01). The treatment was associated with a favorable toxicity profile, with only three patients developing grade 3 immune-related adverse events (1 had adrenal insufficiency and cardiac troponin elevation, and two other had hepatitis). There were no reported grade 4-5 events. Data regarding TIL, PD-L1 and CD8 immunohistochemistry will be presented at the symposium. Conclusion: This study of nivolumab plus ipilimumab in TMB-H MBC achieved the primary endpoint and demonstrated a confirmed ORR of 13.3%. While patients with TMB ≥ 14 Mut/Mb were minority in this study, the 60% of ORR in this subgroup highlights the need to better evaluate the optimal TMB cutoff to predict benefit to immunotherapy in MBC.

Citation Format: Romualdo Barroso-Sousa, Tianyu Li, Sangeetha Reddy, Leisha A. Emens, Beth Overmoyer, Paulina Lange, Molly K Dilullo, Victoria Attaya, Jeffrey Kimmel, Eric P. Winer, Elizabeth A. Mittendorf, Nabihah Tayob, Sara M. Tolaney. Nimbus: A phase 2 trial of nivolumab plus ipilimumab for patients with hypermutated her2-negative metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr GS2-10.

Progression-free survival (PFS) and toxicities of palbociclib in a geriatric population

PURPOSE

Over 40% of newly diagnosed metastatic breast cancer patients are ≥ 70 years old; however, this population is less likely to be represented in clinical trials. The objective of this study was to analyze PFS, dose reductions, dose delays, and toxicity in a geriatric population receiving palbociclib in a non-trial setting.

METHODS

Patients with metastatic breast cancer receiving palbociclib in any line of therapy were identified from a cohort of 845 patients at a large academic institution. Dose delays, dose reductions, and toxicities were retrospectively extracted from the medical record. Data were analyzed using Fischer's exact test for categorized variables and T test/Wilcoxon rank-sum test for continuous variables. PFS and OS were analyzed using the Kaplan-Meier method.

RESULTS

605 patients who met eligibility criteria were included. 160 patients were ≥ 65 years old and 92 patients were ≥ 70 years old. Patients ≥ 70 had a significantly increased number of dose reductions (p = 0.03) and dose delays (p = 0.02) compared to the younger patients. There was no significant increase in toxicities, including neutropenic fever, infections, or hospitalizations, in the ≥ 70 cohort (p = 0.3). The ≥ 70 cohort had a significantly improved PFS as compared to the younger cohort (p = 0.02); however, age was no longer a significant variable in the multivariate analysis.

CONCLUSIONS

Palbociclib was well tolerated in the geriatric population and there was no difference in PFS between older and younger patients. These results are reassuring as palbociclib becomes the frontline standard of care therapy for patients.

Abstract P3-11-03: The impact of dose delays and reductions on toxicity and progression free survival (PFS) in patients receiving palbociclib

Background: Despite the high rates of neutropenia observed in the PALOMA studies, the incidence of neutropenic fevers remained low. The safety analysis from the PALOMA-3 trial showed no difference in PFS among pts who had dose reductions or delays secondary to neutropenia. We conducted a retrospective study to analyze the impact of dose delays and reductions on toxicity and progression free survival (PFS) in pts receiving palbociclib as standard of care.

Methods: Pts with metastatic ER positive breast cancer receiving palbociclib in any line of therapy were identified from a cohort at MD Anderson Cancer Center. Clinical, demographic, baseline labs, comorbidities and recurrence data were collected. Dose delays, dose reductions, and toxicities were recorded up to the first 6 cycles of palbociclib. Early dose delays and reductions were defined as events occurring during the first 2 cycles of palbociclib while late events were defined as cycles 3-6. Data was analyzed using Fischer's exact test for categorized variables and T test/Wilcoxon rank-sum test for continuous variables. PFS was analyzed using the Kaplan Meier method and Cox model was used to analyze factors associated with PFS.

Results: 344 pts who met eligibility criteria were included in the analysis. Pts receiving palbociclib on clinical trial were excluded. 109 (31.6%) pts received dose reductions and 153 (44.4%) experienced dose delays. The rate of neutropenic fever was low, occurring in 2.3% of all pts. There was a significant association between pts experiencing dose reductions and Hispanic race, baseline ANC, history of adjuvant endocrine therapy, adjuvant radiation therapy (XRT), and heart disease. History of adjuvant XRT, baseline ANC, and heart disease were associated with dose delays. Toxicities, including neutropenic fever, infections requiring antibiotics, and hospitalizations, were associated with dose reductions and dose delays. Median PFS for the cohort was 263.5 days. There was no significant association between early dose reductions or delays with PFS. Pts experiencing late dose delays (hazard ratio [HR], 0.4, P=0.0001) and reductions (HR, 0.4, P=0.0005) had a significantly longer PFS. Median PFS for pts without late dose delays was 228 days compared to 313.5 days for pts with late dose delays. Median PFS for pts without late dose reductions was 246 days compared to 305.5 days for pts with late dose reductions. In the multivariable analysis, liver metastasis, metastatic line, and higher tumor grade were associated with worse PFS. Pts receiving palbociclib and fulvestrant were found to have worse PFS than pts receiving palbociclib and letrozole.

Conclusions: Similar to the PALOMA trials, this study found that while the rate of toxicities such as neutropenic fever were low, dose reductions and delays were common. In pts receiving palbociclib as standard of care, pts with late dose reductions and delays had a longer PFS than those without dose reductions and delays. It is reassuring that the PFS was not negatively affected in pts with dose reductions and delays. As use of palbociclib as standard of care becomes more common, further larger retrospective studies are warranted to examine the impact of dose delays and reductions.

Citation Format: Clifton KK, Kimmel J, Yi M, Chad B, Litton J, Debu T, Meghan K. The impact of dose delays and reductions on toxicity and progression free survival (PFS) in patients receiving palbociclib [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 P3-11-03.

Inhibition of glycosyl-phosphatidylinositol biosynthesis in Plasmodium falciparum by C-2 substituted mannose analogues

Mannose analogues (2-deoxy-D-glucose, 2-deoxy-2-fluoro-D-glucose and 2-amino-2-deoxy-D-mannose) have been used to study glycosylphosphatidylinositol (GPtdIns) biosynthesis and GPtdIns protein anchoring in protozoal and mammalian systems. The effects of these analogues on GPtdIns biosynthesis and GPtdIns-protein anchoring of the human malaria parasite Plasmodium falciparum were evaluated in this study. At lower concentrations of 2-deoxy-D-glucose and 2-deoxy-2-fluoro-D glucose (0.2 and 0.1 mm, respectively), GPtdIns biosynthesis is inhibited without significant effects on total protein biosynthesis. At higher concentrations of 2-deoxy-D-glucose and 2-deoxy-2-fluoro-D-glucose (1.5 and 0.8 mm, respectively), the incorporation of [3H]glucosamine into glycolipids was inhibited by 90%, and the attachment of GPtdIns anchor to merozoite surface protein-1 (MSP-1) was prevented. However, at these concentrations, both sugar analogues inhibit MSP-1 synthesis and total protein biosynthesis. In contrast to 2-deoxy-2-fluoro-D-glucose and 2-amino-2-deoxy-D-mannose (mannosamine), the formation of new glycolipids was observed only in the presence of tritiated or nonradiolabelled 2-deoxy-D-glucose. Mannosamine inhibits GPtdIns biosynthesis at a concentration of 5 mm, but neither an accumulation of aberrant intermediates nor significant inhibition of total protein biosynthesis was observed in the presence of this analogue. Furthermore, the [3H]mannosamine-labelled glycolipid spectrum resembled the one described for [3H]glucosamine labelling. Total hydrolysis of mannosamine labelled glycolipids showed that half of the tritiated mannosamine incorporated into glycolipids was converted to glucosamine. This high rate of conversion led us to suggest that no actual inhibition from GPtdIns biosynthesis is achieved with the treatment with mannosamine, which is different to what has been observed for mammalian cells and other parasitic protozoa.

Glycosyl-phosphatidylinositols in protozoa structure, biosynthesis and intracellular localisation

We are investigating the structure and biosynthesis of glycosyl-phosphatidylinositols (GPI) in the protozoa Toxoplasma gondii, Plasmodium falciparum, Plasmodium yoelii and Paramecium primaurelia. This comparison of structural and biosynthesis data should lead us to common and individual features of the GPI-biosynthesis and transport in different organisms.

Repair of rotator cuff tears in tennis players

Twenty-three tennis players with a symptomatic full-thickness rotator cuff tear underwent anterior acromioplasty and rotator cuff repair. There were 8 small tears (less than 1 cm), 5 moderate tears (1 to 3 cm), 2 large tears (3 to 5 cm), and 8 massive tears (greater than 5 cm). The dominant shoulder was involved in all patients and all were unable to play tennis before surgery. Eleven patients experienced a traumatic event that caused an injury, 6 while playing tennis, and 12 patients had a gradual onset of symptoms. At average follow-up of 42 months, 19 patients (83%) achieved a good result, were pain-free, and were able to play tennis at their presymptomatic competitive level. Three patients (13%), all with massive tears, had a satisfactory result and were able to play tennis, although at a lower competitive level secondary to weakness. One patient (4%), who also had a massive tear, had an unsatisfactory result and was unable to play tennis.

Conservative management of small bowel obstruction

Intestinal Cantor tubes were used in the management of 69 gynecologic patients with pelvic malignancies who presented with small bowel obstruction. Small bowel obstruction was secondary to radiation injury, persistent or recurrent carcinoma, or postoperative adhesions. Thirty-one patients (45%) in this series had successful resolution of their small bowel obstruction with a Cantor tube, including 12 of 14 patients (86%) with postoperative adhesions. Complete obstruction of the small bowel was the only prognostic factor definitely associated with tube failure. Seventy percent of all patients had successful passage of the tube on one attempt, and no major complications were encountered. The Cantor tube has proved to be safe, effective, and easy to use, and guidelines for the management of it are included. Cantor tube decompression should be considered in the initial management of small bowel obstruction, since a significant percentage of the patients with this condition will not require surgical intervention.

Computed tomography in the management of acetabular fractures

Twenty-four patients who sustained major hip trauma received computed tomography (CT) scans as well as conventional radiographs. A comparison of plain films with the CT scans showed that CT aided the diagnosis in 23 patients (96%): that CT altered the diagnosis in 14 patients (58%) and that the CT findings altered the management in eight patients (33%). It is our conclusion that CT scanning plays an essential role in the work-up and management of patients with major hip trauma.

NADPH-diaphorase: a selective histochemical marker for striatal neurons containing both somatostatin- and avian pancreatic polypeptide (APP)-like immunoreactivities

Certain neurons in the brain are specifically and intensely stained by a histochemical method which demonstrates nicotinamide adenine dinucleotide phosphate NADPH-diaphorase activity. The cell types containing this enzyme in certain areas of the rat forebrain were examined by combining NADPH-diaphorase histochemistry with the indirect immunofluorescence technique. Neurons containing somatostatin- or avian pancreatic polypeptide (APP)-like immunoreactivities were found throughout the forebrain including the striatum and neocortex. These two neuropeptides were also found to coexist in many telencephalic neurons. After photography, the sections processed for immunohistochemistry were stained for NADPH-diaphorase activity by a histochemical method. It was found that within the striatum all of the neurons that were selectively stained by this technique also contained both somatostatin- and APP-like immunoreactivities. Also in the neocortex NADPH-diaphorase was found only in those neurons displaying somatostatin- or APP-like immunoreactivity. In other brain regions such as the nucleus laterodorsalis tegmenti, NADPH-diaphorase-containing cells did not contain these neuropeptides. The results indicate that NADPH-diaphorase histochemistry provides a simple, reliable, histochemical method to demonstrate those striatal neurons in which somatostatin- and APP-like immunoreactivities coexist. The selective occurrence of this enzyme within these neurons may provide a useful target for pharmacological studies of these neuropeptide-containing cells.

Coexistence of somatostatin- and avian pancreatic polypeptide (APP)-like immunoreactivity in some forebrain neurons

The indirect immunofluorescence technique was used to demonstrate the coexistence of somatostatin together with avian pancreatic polypeptide-like immunoreactivity within certain neurons of the rat forebrain. Numerous neurons containing these peptides were observed in the neocortex, hippocampus, olfactory tubercle, striatum, nucleus accumbens and lateral septum. In studies of serial sections stained alternately for these two peptides, and in restaining experiments, It could be determined that in many neurons in these areas these two peptides coexisted. In other brain areas such as the anterior periventricular hypothalamus, somatostatin cells were never found to contain avian pancreatic polypeptide-like immunoreactivity. Also, within the pancreas these two peptides were never found to coexist in the same cells. The findings represent a further example of the coexistence of more than one neuropeptide within a single neuron.

Organizational principles in the peripheral sympathetic nervous system: subdivision by coexisting peptides (somatostatin-, avian pancreatic polypeptide-, and vasoactive intestinal polypeptide-like immunoreactive materials)

Sympathetic ganglia and some peripheral tissues of adult guinea pig and cat were analyzed by the indirect immunofluorescence technique with antisera to catecholamine-synthesizing enzymes and some peptides. In the guinea pig, noradrenergic neurons could be subdivided into three populations containing respectively (i) somatostatin-like immunoreactive material, (ii) avian pancreatic polypeptide (APP)-like immunoreactive material, and (iii) apparently only noradrenaline (NA; norepinephrine). A fourth population of sympathetic neurons was nonadrenergic and contained vasoactive intestinal polypeptide (VIP)-immunoreactive material. In the cat many noradrenergic neurons with APP and some without this peptide were seen, but no somatostatin-immunoreactive neurons were observed. Also a population of non-adrenergic, presumably cholinergic, neurons containing a VIP-like peptide was observed. These neuron populations seemed to innervate different tissues with some target specificity. For example, in the nasal mucosa of the cat, nerves containing NA/APP-like immunoreactive material (called NA/APP nerves) were found around small arteries and arterioles, whereas venules and sinusoids were surrounded by nerves containing only NA (called NA nerves). Also in the submandibular salivary gland of the cat, the NA/APP nerves surrounded arteries and arterioles, whereas NA nerves were seen in relation to acini and ducts. The sympathetic (cholinergic) VIP-containing neurons innervated blood vessels and exocrine tissue in the cat sweat glands. In the coeliac-superior mesenteric ganglion complex of the guinea pig and cat, a dense network of VIP-immunoreactive fibers was seen preferentially around noradrenergic ganglionic cell bodies lacking APP-immunoreactive material. Thus, adult peripheral sympathetic neurons can be subdivided into several categories on the basis of specific peptides. These subdivisions may innervate specific targets and may receive peptide-specific neuronal inputs.

Avian pancreatic polypeptide (APP) immunoreactive neurons in the spinal cord and spinal trigeminal nucleus

Using indirect immunofluorescence technique, avian pancreatic polypeptide (APP) immunoreactive cell bodies and fibres have been observed in the superficial laminae of the dorsal horn of the spinal cord and of the spinal trigeminal nucleus. Fibres were also seen in the ventral horns, in low numbers at the cervical and thoracic levels and in high numbers at the lower lumbar and upper sacral levels. Neither total cord transection, nor dorsal rhizotomy, nor capsaicin treatment seemed to affect the APP systems described above. The present findings suggest that an APP-like peptide may be involved in processing of sensory information at the level of the first relay station.