Clinical Outcomes and Immune Markers by Race in a Phase I/II Clinical Trial of Durvalumab Concomitant with Neoadjuvant Chemotherapy in Early-Stage TNBC

PURPOSE

The incidence of triple-negative breast cancer (TNBC) is higher among Black or African American (AA) women, yet they are underrepresented in clinical trials. To evaluate safety and efficacy of durvalumab concurrent with neoadjuvant chemotherapy for stage I-III TNBC by race, we enrolled additional AA patients to a Phase I/II clinical trial.

PATIENTS AND METHODS

Our study population included 67 patients. The primary efficacy endpoint was pathologic complete response (pCR; ypT0/is, N0) rate. χ2 tests were used to evaluate associations between race and baseline characteristics. Cox proportional hazards models were used to assess association between race and overall survival (OS) and event-free survival (EFS). Multivariate logistic regression analyses were used to evaluate associations between race and pCR, immune-related adverse events (irAE) and recurrence.

RESULTS

Twenty-one patients (31%) self-identified as AA. No significant associations between race and baseline tumor stage (P = 0.40), PD-L1 status (0.92), and stromal tumor-infiltrating lymphocyte (sTIL) count (P = 0.57) were observed. pCR rates were similar between AA (43%) and non-AA patients (48%; P = 0.71). Three-year EFS rates were 78.3% and 71.4% in non-AA and AA patients, respectively [HR, 1.451; 95% confidence interval (CI), 0.524-4.017; P = 0.474]; 3-year OS was 87% and 81%, respectively (HR, 1.72; 95% CI, 0.481-6.136; P = 0.405). The incidence of irAEs was similar between AA and non-AA patients and no significant associations were found between irAEs and pathologic response.

CONCLUSIONS

pCR rates, 3-year OS and EFS after neoadjuvant immunotherapy and chemotherapy were similar in AA and non-AA patients. Toxicities, including the frequency of irAEs, were also similar.

Clinical outcomes and immune markers by race in a phase I/II clinical trial of durvalumab concomitant with neoadjuvant chemotherapy in early-stage TNBC

516

Background: The incidence of triple negative breast cancer (TNBC) is higher among Black or African American (AA) women, yet AA patients (pts) are underrepresented in clinical trials, exemplifying racial disparity in oncology. We conducted a phase I/II trial to assess the safety and efficacy of durvalumab concurrent with weekly nab-paclitaxel and dose dense doxorubicin/cyclophosphamide (ddAC) neoadjuvant therapy for stage I-III TNBC. The primary efficacy endpoint was pathologic complete response (pCR; ypT0/is,N0) rate. Given the unclear efficacy and safety of immunotherapy in AA pts with breast cancer, we extended our accrual to recruit AA pts, with the goal of evaluating the association between racial groups and PD-L1 expression, stromal tumor infiltrating lymphocytes (sTILs), toxicities, treatment response and survival. Methods: Our study population included 67 pts. PD-L1 immunohistochemistry results and sTIL counts were available on 59 and 60 pts, respectively. Chi-Squared test was used to evaluate associations between race and baseline characteristics. Cox proportional hazards model was used to assess association between AA race and overall survival (OS) and event free survival (EFS), adjusting for age, comorbidities and pCR status. Multivariate logistic regression analyses were used to evaluate the association between race and pCR, development of immune-related adverse events (irAEs) and breast cancer recurrence. Results: Twenty-one pts (31%) self-identified as AA. No significant associations between AA race and baseline body mass index (BMI; p=0.075), Charlson comorbidity index (p=0.32), tumor stage (p=0.40), grade (p=0.54), PD-L1 status (0.92) and sTIL count (p=0.57) were observed. pCR rates did not significantly differ between AA and non-AA pts: 9/21 (43%) AA vs. 22/48 (48%) non-AA (p=0.71). 3-yr OS was 87% in the non-AA versus 81% in the AA cohort (HR 1.72, 95% CI 0.481-6.136; p=0.405); 3 yr EFS were 78.3% and 71.4% in non-AA and AA pts respectively. (HR 1.451, 95% CI 0.524-4.017; p=0.474). Pts with pCR were more likely to remain event-free at 3 yrs, irrespective of race (HR 0.234, 95% CI 0.066-0.829; p=0.024). In multivariate logistic regression analyses, lack of pathologic response (OR for pCR 0.17, 95% CI 0.03-0.7; p=0.02) and node positive status (OR 4.13, 95% CI 1.05-19.88; p=0.05) were associated with recurrence. The incidence of irAEs was similar between AA and non-AA pts and no significant associations were found between irAEs and pathologic response. Conclusions: pCR rates after neoadjuvant immunotherapy and chemotherapy were similar in AA and non-AA pts. Stromal TILs, PD-L1 status, 3yr OS and EFS, and the frequency of irAEs were also similar. These results suggest that when patients receive identical treatment and are monitored closely, disparities in outcomes can be mitigated or abolished. Clinical trial information: NCT02489448.

Neoadjuvant durvalumab plus weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide in triple-negative breast cancer

The goal of this Phase I/II trial is to assess the safety and efficacy of administering durvalumab concurrent with weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide (ddAC) neoadjuvant therapy for stages I-III triple-negative breast cancer. The primary endpoint is pathologic complete response (pCR:ypT0/is, ypN0). The response was correlated with PDL1 expression and stromal tumor-infiltrating lymphocytes (sTILs). Two dose levels of durvalumab (3 and 10 mg/kg) were assessed. PD-L1 was assessed using the SP263 antibody; ≥1% immune and tumor cell staining was considered positive; sTILs were calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area. 59 patients were evaluable for toxicity and 55 for efficacy in the Phase II study (10 mg/kg dose). No dose-limiting toxicities were observed in Phase I. In Phase II, pCR rate was 44% (95% CI: 30-57%); 18 patients (31%) experienced grade 3/4 treatment-related adverse events (AE), most frequently neutropenia (n = 4) and anemia (n = 4). Immune-related grade 3/4 AEs included Guillain-Barre syndrome (n = 1), colitis (n = 2), and hyperglycemia (n = 2). Of the 50 evaluable patients for PD-L1, 31 (62%) were PD-L1 positive. pCR rates were 55% (95% CI: 0.38-0.71) and 32% (95% CI: 0.12-0.56) in the PD-L1 positive and negative groups (p = 0.15), respectively. sTIL counts were available on 52 patients and were significantly higher in the pCR group (p = 0.0167). Concomitant administration of durvalumab with sequential weekly nab-paclitaxel and ddAC neoadjuvant chemotherapy resulted in a pCR rate of 44%; pCR rates were higher in sTIL-high cancers.

Abstract PD1-01: Durvalumab (MEDI4736) concurrent with nab-paclitaxel and dose dense doxorubicin cyclophosphamide (ddAC) as neoadjuvant therapy for triple negative breast cancer (TNBC)

Background: The goal of this Phase I/II trial (NCT02489448) was to assess the safety and efficacy of concurrent durvalumab with weekly nab-paclitaxel (100 mg/m2) x 12 followed by ddAC x 4 as neoadjuvant therapy for stage I-III TNBC and to identify biomarkers of response. The primary efficacy endpoint was pathologic complete response (pCR: ypT0,is/N0). Methods: The Phase I portion of the trial assessed two dose levels of durvalumab 3 and 10 mg/kg q 2 weeks. The trial followed Simon’s two step design, with early stopping for futility if < 7 of the first 20 patients achieve pCR. PD-L1 expression on pretreatment biopsies was assessed with chromogenic immunohistochemistry using the SP263 antibody. PD-L1 positivity was determined by consensus review of 2 pathologists (E.R., D.R.) and staining >1 % on immune and tumor cells was considered positive. Tumor infiltrating lymphocyte (TIL) count was assessed on H&E stained slides using QuPath v0.2.0 open source digital image analysis software platform and a breast cancer specific scoring algorithm (CL11NN). TIL count was expressed as TIL:TIL+Tumor cells x 100. Results: 57 patients were enrolled and evaluable (n=4 at 3 mg/kg, n=53 at 10 mg/kg dose). No dose limiting toxicities were observed during the Phase I portion, the final pCR rate is 44% (95% CI:30%-57%). 18 patients (31%) experienced grade 3/4 adverse events (AE), most frequently neutropenia (n=5). Possibly immune related grade 3 or 4 AEs included Guillain-Barre syndrome (n=1), hypothyroidism (n=1), colitis (n=1), hyperglycemia (n=1). 14 (24%) patients received < 9 of the planned 12 cycles of durvalumab. No perioperative adverse events were seen. Fifty patients had baseline PD-L1 IHC results available (n=7 QC failure), 19 (38%) were PD-L1 positive. The pCR rates were 55% (95% CI: 36%-73%) versus 21% (95% CI: 6%-45%) in the PDL-1 positive and negative groups, respectively (p=0.03). Digital stromal TIL counts were available on 52 patients, there was no significant difference in TIL count between the response groups. Conclusion: Concomitant administration of durvalumab with weekly nab-paclitaxel and sequential ddAC neoadjuvant chemotherapy resulted in a pCR rate of 44%. pCR rate was higher in PD-L1 positive patients (55%) than PD-L1 negative (21%) cancers.

Citation Format: Lajos Pusztai, Emily Reisenbichler, Yailai Bai, Neal Fischbach, Justin Persico, Kerin Adelson, Anamika Katoch, Nina Horowitz, Donald Lannin, Brigid Killelea, Anees Chagpar, Courtney Frederick, Trisha Burello, Kim Blenman, David Rimm, Andrea Silber. Durvalumab (MEDI4736) concurrent with nab-paclitaxel and dose dense doxorubicin cyclophosphamide (ddAC) as neoadjuvant therapy for triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD1-01.

Continuous low-irradiance photodynamic therapy (CLIPT) as a novel treatment for cutaneous recurrences of breast cancer

e11548

Background: Photodynamic therapy (PDT) has been used for the treatment of many malignancies. This binary therapy involves the administration of a photosensitizer followed by exposure to light. Treatment toxicity has historically limited the use of PDT. Our study aimed to assess whether a novel approach, termed continuous low irradiance photodynamic therapy (CLIPT), would result in enhanced efficacy with reduced toxicity. Preclinical data suggest decreased toxicity and increased cell death by apoptosis with CLIPT. Methods: Breast cancer patients with chest wall progression were eligible for our study. No systemic anti-cancer therapy within 30 days and no radiation to the target site within 60 days of enrollment was allowed. All patients received porfirmer sodium intravenous 0.8mg/kg at time 0 and returned at time 48 hours for light exposure. A wavelength of 630nm was delivered continuously over 24 hours by a Diomed laser via a flexible light patch. An area of uninvolved normal skin was used as a control. Post-treatment biopsy was performed to assess for apoptosis by TUNEL assay. Results: Eight breast cancer patients were enrolled in our study. The initial dose of light was 100J/cm2 and was given to subjects 1 and 2 but resulted in partial-thickness ulceration of the epidermis. Subjects 3-8 received light at 50J/cm2 and experienced erythema at the intervention site, with no ulceration observed. All patients reported mild pain at the treatment site and 6 required short-term narcotic analgesia. Five of the 8 patients showed evidence of response, and no patients had progression of treated lesions. Four of 7 biopsy specimens showed evidence of apoptosis on TUNEL assay. Conclusions: CLIPT may prove to be a valuable option for treatment of breast cancer chest wall recurrence. The dose-limiting toxicity was skin ulceration and the maximum tolerated dose (MTD) was determined to be 50J/cm2/24h. A 50% response rate was seen in patients treated at the MTD, with apoptosis seen on post-treatment biopsy specimens. Further investigation of CLIPT as a therapeutic modality is warranted.

[Aneurysm of the gastroduodenal artery ruptured into the peritoneum. Treatment by embolization]

Aneurysms rarely occur in the gastroduodenal artery. We encountered such an aneurysm which bled into the peritoneum leading to a difficult diagnostic situation. A 58-year-old man was hospitalized for acute abdominal pain. Past history included alcohol intake (wine, 3/4 litre per day) and moderate increase in serum gamma-glutamyl transferase levels (100 IU/L). At admission there was abdominal contracture, vomiting and shock (blood pressure 70 mmHg). Based on the clinical picture and laboratory tests the diagnosis of acute pancreatitis was entertained, but after the haemodynamic situation was reestablished by intravenous fluids, echography and computed tomography of the abdomen failed to give confirmation. An effusion however was seen in the peritoneum together with a large mass in the head of the pancreas compatible with a haematoma. Arteriography rapidly demonstrated an aneurysm of the gastroduodenal artery. Embolization was preferred over surgery due to the precarious haemodynamic situation. Outcome was quite favourable and no complications have been observed with a follow-up of 6 months. Reports of true aneurysms of the gastroduodenal artery are rare but clinical manifestations are usually latent or absent. Reported complications include massive digestive haemorrhage and rarely jaundice, haemobilia or wirsungorrhagia due to compression. Excepting recognized trauma, few aetiological factors have been determined. Fragile arterial walls due to atheroma, isolated dysplasia or connective tissue disease appear to be damaged by successive systolic distension leading to rupture of certain elements of the arterial wall and finally aneurysm. Embolization carries less risk than surgical repair but must be indicated only after precise characterization including localization, size and local involvement.