Response to tumor-infiltrating lymphocyte adoptive therapy is associated with preexisting CD8+ T-myeloid cell networks in melanoma

Adoptive cell therapy (ACT) using ex vivo-expanded tumor-infiltrating lymphocytes (TILs) can eliminate or shrink metastatic melanoma, but its long-term efficacy remains limited to a fraction of patients. Using longitudinal samples from 13 patients with metastatic melanoma treated with TIL-ACT in a phase 1 clinical study, we interrogated cellular states within the tumor microenvironment (TME) and their interactions. We performed bulk and single-cell RNA sequencing, whole-exome sequencing, and spatial proteomic analyses in pre- and post-ACT tumor tissues, finding that ACT responders exhibited higher basal tumor cell-intrinsic immunogenicity and mutational burden. Compared with nonresponders, CD8+ TILs exhibited increased cytotoxicity, exhaustion, and costimulation, whereas myeloid cells had increased type I interferon signaling in responders. Cell-cell interaction prediction analyses corroborated by spatial neighborhood analyses revealed that responders had rich baseline intratumoral and stromal tumor-reactive T cell networks with activated myeloid populations. Successful TIL-ACT therapy further reprogrammed the myeloid compartment and increased TIL-myeloid networks. Our systematic target discovery study identifies potential T-myeloid cell network-based biomarkers that could improve patient selection and guide the design of ACT clinical trials.

Low-Dose Radiotherapy Reverses Tumor Immune Desertification and Resistance to Immunotherapy

Developing strategies to inflame tumors is critical for increasing response to immunotherapy. Here, we report that low-dose radiotherapy (LDRT) of murine tumors promotes T-cell infiltration and enables responsiveness to combinatorial immunotherapy in an IFN-dependent manner. Treatment efficacy relied upon mobilizing both adaptive and innate immunity and depended on both cytotoxic CD4⁺ and CD8⁺ T cells. LDRT elicited predominantly CD4⁺ cells with features of exhausted effector cytotoxic cells, with a subset expressing NKG2D and exhibiting proliferative capacity, as well as a unique subset of activated dendritic cells expressing the NKG2D ligand RAE1. We translated these findings to a phase I clinical trial administering LDRT, low-dose cyclophosphamide, and immune checkpoint blockade to patients with immune-desert tumors. In responsive patients, the combinatorial treatment triggered T-cell infiltration, predominantly of CD4⁺ cells with Th1 signatures. Our data support the rational combination of LDRT with immunotherapy for effectively treating low T cell-infiltrated tumors. SIGNIFICANCE: Low-dose radiation reprogrammed the tumor microenvironment of tumors with scarce immune infiltration and together with immunotherapy induced simultaneous mobilization of innate and adaptive immunity, predominantly CD4⁺ effector T cells, to achieve tumor control dependent on NKG2D. The combination induced important responses in patients with metastatic immune-cold tumors.This article is highlighted in the In This Issue feature, p. 1.

A promising platform for predicting toxicity

Organ-on-chip approaches could help researchers to better predict the toxicity of cancer immunotherapy drugs.

Phase I prognostic online (PIPO): A web tool to improve patient selection for oncology early phase clinical trials

PURPOSE

Patient selection in phase 1 clinical trials (Ph1t) continues to be a challenge. The aim of this study was to develop a user-friendly prognostic calculator for predicting overall survival (OS) outcomes in patients to be included in Ph1t with immune checkpoint inhibitors (ICIs) or targeted agents (TAs) based on clinical parameters assessed at baseline.

METHODS

Using a training cohort with consecutive patients from the VHIO phase 1 unit, we constructed a prognostic model to predict median OS (mOS) as a primary endpoint and 3-month (3m) OS rate as a secondary endpoint. The model was validated in an internal cohort after temporal data splitting and represented as a web application.

RESULTS

We recruited 799 patients (training and validation sets, 558 and 241, respectively). Median follow-up was 21.2 months (m), mOS was 10.2 m (95% CI, 9.3-12.7) for ICIs cohort and 7.7 m (95% CI, 6.6-8.6) for TAs cohort. In the multivariable analysis, six prognostic variables were independently associated with OS - ECOG, number of metastatic sites, presence of liver metastases, derived neutrophils/(leukocytes minus neutrophils) ratio [dNLR], albumin and lactate dehydrogenase (LDH) levels. The phase 1 prognostic online (PIPO) calculator showed adequate discrimination and calibration performance for OS, with C-statistics of 0.71 (95% CI 0.64-0.78) in the validation set. The overall accuracy of the model for 3m OS prediction was 87.2% (95% CI 85%-90%).

CONCLUSIONS

PIPO is a user-friendly objective and interactive tool to calculate specific survival probabilities for each patient before enrolment in a Ph1t. The tool is available at https://pipo.vhio.net/.

OX40 Agonist BMS-986178 Alone or in Combination With Nivolumab and/or Ipilimumab in Patients With Advanced Solid Tumors

PURPOSE

This phase I/IIa study (NCT02737475) evaluated the safety and activity of BMS-986178, a fully human OX40 agonist IgG1 mAb, ± nivolumab and/or ipilimumab in patients with advanced solid tumors.

PATIENTS AND METHODS

Patients (with non-small cell lung, renal cell, bladder, other advanced cancers) received BMS-986178 (20-320 mg) ± nivolumab (240-480 mg) and/or ipilimumab (1-3 mg/kg). The primary endpoint was safety. Additional endpoints included immunogenicity, pharmacodynamics, pharmacokinetics, and antitumor activity per RECIST version 1.1.

RESULTS

Twenty patients received BMS-986178 monotherapy, and 145 received combination therapy in various regimens (including two patients receiving nivolumab monotherapy). With a follow-up of 1.1 to 103.6 weeks, the most common (≥5%) treatment-related adverse events (TRAEs) included fatigue, pruritus, rash, pyrexia, diarrhea, and infusion-related reactions. Overall, grade 3-4 TRAEs occurred in one of 20 patients (5%) receiving BMS-986178 monotherapy, six of 79 (8%) receiving BMS-986178 plus nivolumab, zero of two receiving nivolumab monotherapy, six of 41 (15%) receiving BMS-986178 plus ipilimumab, and three of 23 (13%) receiving BMS-986178 plus nivolumab plus ipilimumab. No deaths occurred. No dose-limiting toxicities were observed with monotherapy, and the MTD was not reached in either the monotherapy or the combination escalation cohorts. No objective responses were seen with BMS-986178 alone; objective response rates ranged from 0% to 13% across combination therapy cohorts.

CONCLUSIONS

In this study, BMS-986178 ± nivolumab and/or ipilimumab appeared to have a manageable safety profile, but no clear efficacy signal was observed above that expected for nivolumab and/or ipilimumab.

PSA Kinetics as Prognostic Markers of Overall Survival in Patients with Metastatic Castration-Resistant Prostate Cancer Treated with Abiraterone Acetate

Background

Abiraterone acetate (AA) is widely used in the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC). However, a significant percentage of patients will still progress, highlighting the need to identify patients more likely to benefit from AA. Parameters linked to prostate-specific antigen (PSA) kinetics are promising prognostic markers. We have examined clinical and PSA-related factors potentially associated with overall survival (OS) in patients treated with AA.

Methods

Between 2011 and 2014, 104 patients with mCRPC treated with AA after progression to docetaxel at centers of the Catalan Institute of Oncology were included in this retrospective study. Patients were assessed monthly. Baseline characteristics and variables related to PSA kinetics were included in univariate and multivariate analyses of OS.

Results

Median OS was 16.4 months (range 12.4-20.6) for all patients. The univariate analysis identified the following baseline characteristics as significantly associated with OS: ECOG PS, location of metastases, time between starting androgen deprivation therapy and starting AA, time between stopping docetaxel treatment and starting AA, neutrophil-lymphocyte ratio (NLR), alkaline phosphatase levels, and PSA levels. Factors related to PSA kinetics associated with longer OS were PSA response >50%, early PSA response (>30% decline at four weeks), PSA decline >50% at week 12, PSA nadir <2.4ng/mL, time to PSA nadir >140 days, the combination of PSA nadir and time to PSA nadir, and low end-of-treatment PSA levels. The multivariate analysis identified ECOG PS (HR 37.46; p<0.001), NLR (HR 3.7; p<0.001), early PSA response (HR 1.22; p=0.002), and time to PSA nadir (HR 0.39; p=0.002) as independent prognostic markers.

Conclusion

Our results indicate an association between PSA kinetics, especially early PSA response, and outcome to AA after progression to docetaxel. Taken together with other factors, lack of an early PSA response could identify patients who are unlikely to benefit from AA and who could be closely monitored with a view to offering alternative therapies.

High versus low dose irradiation for tumor immune reprogramming

Local administration of ionizing radiation to tumors can promote anticancer immune responses that lead to the abscopal regression of distant metastases, especially in patients receiving systemic immune-checkpoint inhibitors. Growing preclinical evidence indicates that high-dose irradiation administered locally to destroy malignant lesions, can promote the release of danger-associated molecular patterns that lead to the recruitment of immune cells, thus inducing a systemic response against tumor antigens that protects against local disease relapse and also mediates distant antineoplastic effects. An accumulating body of preclinical evidence supports also the implementation of low-dose irradiation to induce tumor immune reprogramming. Here, we provide the rationale for a clinical research agenda to refine future clinical practice based on innovative combinations of radiation-immunotherapy.

Guillain-Barré syndrome after adoptive cell therapy with tumor-infiltrating lymphocytes

BACKGROUND

Adoptive cell therapy (ACT) using tumor-infiltrating lymphocytes (TILs) is a promising experimental immunotherapy that has shown high objective responses in patients with melanoma. Current protocols use a lymphodepletive chemotherapy before infusion of ex vivo expanded TILs, followed by high-dose interleukin-2 (IL-2). Treatment-related toxicities are mainly attributable to the chemotherapy regimen and to the high-dose IL-2 and are generally reversible. Neurological side effects have rarely been described. Nevertheless, due to improvements in cell production techniques and due to combinations with other immunomodulating molecules, side effects not previously described may be encountered.

CASE PRESENTATION

We report the case of a 53-year-old heavily pretreated patient with melanoma who developed Guillain-Barré syndrome (GBS) 19 days after ACT using autologous TILs, given in the context of a phase I trial. He presented with dorsal back pain, unsteady gait and numbness in hands and feet. Lumbar puncture showed albuminocytological dissociation, and nerve conduction studies revealed prolonged distal motor latencies in median, ulnar, tibial and peroneal nerves, compatible with a GBS. The patient was treated with intravenous immunoglobulins and intensive neurological rehabilitation, with progressive and full recovery at 21 months post-TIL-ACT. Concomitant to the onset of GBS, a cytomegalovirus reactivation on immunosuppression was detected and considered as the most plausible cause of this neurological side effect.

CONCLUSION

We describe for the first time a case of GBS occurring shortly after TIL-ACT for melanoma, even though we could not identify with certainty the triggering agent. The report of such rare cases is of extreme importance to build on the knowledge of immune cellular therapies and their specific spectrum of toxicities.

A first-in-human phase 1 dose escalation study of spartalizumab (PDR001), an anti-PD-1 antibody, in patients with advanced solid tumors

BACKGROUND

Spartalizumab is a humanized IgG4κ monoclonal antibody that binds programmed death-1 (PD-1) and blocks its interaction with PD-L1 and PD-L2. This phase 1/2 study was designed to assess the safety, pharmacokinetics, and preliminary efficacy of spartalizumab in patients with advanced or metastatic solid tumors.

METHODS

In the phase 1 part of the study, 58 patients received spartalizumab, intravenously, at doses of 1, 3, or 10 mg/kg, administered every 2 weeks (Q2W), or 3 or 5 mg/kg every 4 weeks (Q4W).

RESULTS

Patients had a wide range of tumor types, most commonly sarcoma (28%) and metastatic renal cell carcinoma (10%); other tumor types were reported in ≤3 patients each. Most patients (93%) had received prior antineoplastic therapy (median three prior lines) and two-thirds of the population had tumor biopsies negative for PD-L1 expression at baseline. The maximum tolerated dose was not reached. The recommended phase 2 doses were selected as 400 mg Q4W or 300 mg Q3W. No dose-limiting toxicities were observed, and adverse events included those typical of other PD-1 antibodies. The most common treatment-related adverse events of any grade were fatigue (22%), diarrhea (17%), pruritus (14%), hypothyroidism (10%), and nausea (10%). Partial responses occurred in two patients (response rate 3.4%); one with atypical carcinoid tumor of the lung and one with anal cancer. Paired tumor biopsies from patients taken at baseline and on treatment suggested an on-treatment increase in CD8+ lymphocyte infiltration in patients with clinical benefit.

CONCLUSIONS

Spartalizumab was well tolerated at all doses tested in patients with previously treated advanced solid tumors. On-treatment immune activation was seen in tumor biopsies; however, limited clinical activity was reported in this heavily pretreated, heterogeneous population. The phase 2 part of this study is ongoing in select tumor types.

TRIAL REGISTRATION NUMBER

NCT02404441.

Phase I Study of the Indoleamine 2,3-Dioxygenase 1 (IDO1) Inhibitor Navoximod (GDC-0919) Administered with PD-L1 Inhibitor (Atezolizumab) in Advanced Solid Tumors

PURPOSE

IDO1 induces immune suppression in T cells through l-tryptophan (Trp) depletion and kynurenine (Kyn) accumulation in the local tumor microenvironment, suppressing effector T cells and hyperactivating regulatory T cells (Treg). Navoximod is an investigational small-molecule inhibitor of IDO1. This phase I study evaluated safety, tolerability, pharmacokinetics, and pharmacodynamics of navoximod in combination with atezolizumab, a PD-L1 inhibitor, in patients with advanced cancer.

PATIENTS AND METHODS

The study consisted of a 3+3 dose-escalation stage (n = 66) and a tumor-specific expansion stage (n = 92). Navoximod was given orally every 12 hours continuously for 21 consecutive days of each cycle with the exception of cycle 1, where navoximod administration started on day -1 to characterize pharmacokinetics. Atezolizumab was administered by intravenous infusion 1,200 mg every 3 weeks on day 1 of each cycle.

RESULTS

Patients (n = 157) received navoximod at 6 dose levels (50-1,000 mg) in combination with atezolizumab. The maximum administered dose was 1,000 mg twice daily; the MTD was not reached. Navoximod demonstrated a linear pharmacokinetic profile, and plasma Kyn generally decreased with increasing doses of navoximod. The most common treatment-related AEs were fatigue (22%), rash (22%), and chromaturia (20%). Activity was observed at all dose levels in various tumor types (melanoma, pancreatic, prostate, ovarian, head and neck squamous cell carcinoma, cervical, neural sheath, non-small cell lung cancer, triple-negative breast cancer, renal cell carcinoma, urothelial bladder cancer): 6 (9%) dose-escalation patients achieved partial response, and 10 (11%) expansion patients achieved partial response or complete response.

CONCLUSIONS

The combination of navoximod and atezolizumab demonstrated acceptable safety, tolerability, and pharmacokinetics for patients with advanced cancer. Although activity was observed, there was no clear evidence of benefit from adding navoximod to atezolizumab.

Patient survival with immune checkpoint inhibitors and targeted agents in phase 1 trials: A propensity score weighted analysis

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Background: There have been important changes in early drug development units with an unprecedented increase of immune-oncology (IO) trials. Currently at the Vall d’Hebron Institute Oncology (VHIO) close to 50% of our Phase 1 trials (Ph1t) portfolio includes IO drugs, while from 2011 to 2015 more than 80% of our trials assessed targeted agents (TA). We wanted to investigate whether this swift had a positive impact on patient (pts) outcome. Methods: We performed a retrospective analysis of the pts treated with IO and TA at VHIO Ph1t Unit from Jun’11 to May’18. Only patients treated with IO in ≥ 2nd line were included (and without an approved IO therapy as per standard-of-care) and those with TA classified as tiers II-III-IV by the ESMO scale for clinical actionability of molecular targets ESCAT (which also represents unapproved indications). The aim of this study was to compare overall survival (OS) for the two cohorts. Given the non-randomized nature of the study a propensity score weighting (PSW) was used to control for selection bias in treatment effect estimation. Results: Out of 545 eligible pts, 281 (51.5%) received TA and 264 (48.5%) IO, with unadjusted median OS (mOS) of 7.7 months (m) and 9.2m, respectively. In univariate analysis, OS was associated with tumor type, number of previous treatment lines, regimen (monotherapy vs combination), and clinical-laboratory prognostic factors (Vioscore: albumin < 3.5 g/dl; LDH > upper limit of normal; neutrophil/[leukocytes minus neutrophils] ratio (dNLR) > 3; more than 2 sites of metastasis; and presence of liver metastasis) (p < 0.05). After adjusting for these factors in a PSW model, the IO group showed statistically significant longer OS with HR = 0.75 (CI95% 0.65 – 0.86, p < 0.0001). The In a stratified analysis by tumor type we found no significant heterogeneity in the relative benefit of IO over TA. Conclusions: In real world data from our Ph1t population, treatment with IO was associated with longer OS than treatment with TA, even after adjusting for known prognostic factors and treatment selection biases. These results suggest that the likelihood of patient benefit with IO therapies in Ph1t is increasing.

A Phase 1 Trial of Oncolytic Adenovirus ICOVIR-5 Administered Intravenously to Cutaneous and Uveal Melanoma Patients

Oncolytic viruses represent a unique type of agents that combine self-amplification, lytic, and immunostimulatory properties against tumors. A local and locoregional clinical benefit has been demonstrated upon intratumoral injections of an oncolytic herpes virus in melanoma patients, leading to its approval in the United States and Europe for patients without visceral disease (up to stage IVM1a). However, in order to debulk and change the local immunosuppressive environment of tumors that cannot be injected directly, oncolyitc viruses need to be administered systemically. Among different viruses, adenovirus has been extensively used in clinical trials but with few evidences of activity upon systemic administration. Preclinical efficacy of a single intravenous administration of our oncolytic adenovirus ICOVIR5, an adenovirus type 5 responsive to the retinoblastoma pathway commonly deregulated in tumors, led us to use this virus in a dose-escalation phase 1 trial in metastatic melanoma patients. The results in 12 patients treated with a single infusion of a dose up to 1 × 10¹³ viral particles show that ICOVIR5 can reach melanoma metastases upon a single intravenous administration but fails to induce tumor regressions. These results support the systemic administration of armed oncolytic viruses to treat disseminated cancer.

Abstract A092: Phase 1 trial of RO6874813, a novel bispecific FAP-DR5 antibody, in patients with solid tumors

Introduction: FAP-DR5 (RO6874813) is a novel bispecific antibody that binds with high and low affinity to fibroblast activation protein (FAP) and death receptor 5 (DR5), respectively. FAP-driven binding of RO6874813 mediates the high levels of DR5 clustering that are required for triggering cell death. Here, we present ongoing phase 1 data in patients with advanced solid tumors who were treated with escalating doses of single agent RO6874813 and assessed for tolerability. Methods: Study endpoints are safety and tolerability (primary) and antitumor activity (secondary). The study uses a continuous reassessment method (CRM) design for dose escalation. Patients received drug (IV ≤ 90 min) weekly (QW) or every other week (Q2W), starting with a run-in dose on Cycle 0/Day 1 (C0/D1) of 0.5 mg/kg for all cohorts to characterize linear and nonlinear pharmacokinetics (PK) . Doses administered at C1/D1 ranged from 1.0 to 45 mg/kg (3 or more patients per cohort). Dosing continued until progression of disease (PD) or toxicity occurred. Plasma biomarkers (BM) of DR5 binding (TRAIL, the DR5 ligand) and apoptosis (ccCK18) were measured at multiple timepoints. Archival or fresh tumor samples collected prior to RO6874813 treatment were analyzed for target expression by IHC and mRNA (qRT-PCR), cellular infiltrates, and apoptosis. Results: As of 26 April 2017, 32 patients have been treated with RO6874813. Patients had a median of 3.5 prior regimens (range 1-11) and received a median of 4 (range 2-21) doses of RO6874813. One patient (NSCLC) remains on treatment; 31 discontinued treatment (30 for PD; 1 for subject decision). A maximum tolerated dose has not been reached. The most common treatment-related adverse events (TR-AEs) were: fatigue (21.9%); nausea (15.6%), and infusion-related reactions (9.4%). Grade (Gr) ≥3 TR-AEs occurred in 2 patients (6.25%): anemia and asthenia (both Gr 3, occurring in 1 patient each). No Gr 4/5 TR-AEs and no protocol-defined DLTs were reported. No AE led to permanent study drug withdrawal; 5 patients died from PD, one within 30 days of their last dose. Thirty-one patients were evaluated for antitumor activity: using RECIST criteria, 1 PR (NSCLC; time on treatment = 324 days, ongoing) and 6 stable diseases (SD; median duration 42 days) were observed. 28 patients were evaluated by PET, with 2 (7%) FDG partial metabolic responses (EORTC criteria) seen. No difference was found between QW (used with select doses) and Q2W schedules for safety, antitumor activity, and PK/PD parameters. RO6874813 serum concentrations increased linearly with dose and revealed saturation of TMDD at ≥ 5 mg/kg (Q2W). For the single patient with a PR (30 mg/kg; Q2W), the Cmax at C1 exceeded that of other patients and showed accumulation over time, despite two dose interruptions for Gr 2 neutropenia. Blood BM analyses revealed a significant upregulation of TRAIL and ccCK18 after dosing in this and other patients, suggesting apoptotic activity. FAP and DR5 were expressed in tumor tissue of all patients. Conclusions: RO6874813 demonstrated a favorable safety profile in patients with multiple solid tumor types, and dose escalation and regimen optimization continue. Preliminary antitumor activity was observed in a patient with heavily pretreated NSCLC. Analyses required to support the hypothesis that FAP-binding mediates sufficiently high levels of DR5 clustering for apoptosis induction are ongoing.

Citation Format: Johanna Bendell, Jean-Yves Blay, Philippe Cassier, Todd Bauer, Catherine Terret, Claudia Mueller, Anthony Morel, Evelyne Chesne, Zhi-xin Xu, Jean Tessier, Maurizio Ceppi, Ian James, Sabine Wilson, Elizabeth Quackenbush, Maria Ochoa de Olza, Josep Tabernero, Maria De Miguel, Emiliano Calvo. Phase 1 trial of RO6874813, a novel bispecific FAP-DR5 antibody, in patients with solid tumors [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A092.

Immuno-Oncology: The Third Paradigm in Early Drug Development

Clinical researchers in oncology face the difficulty of developing new drugs for treating cancer patients. This challenge nowadays extends towards new horizons since a high number of drugs are developed in each of the three paradigms: classical cytotoxics, new targeted agents, and emergent immunotherapeutic approaches. Over the last decade, there has been an unstoppable progress in this third paradigm, to the extent that in 2013 immunotherapy was granted the scientific breakthrough of the year. However, the novel mechanisms of action of these immunotherapeutic agents entail a whole new series of concepts, resulting in a number of unresolved questions to which clarification is crucial for their success: establishment of accurate preclinical models able to predict human toxicities, better selection of candidate populations, finding and validation of predictive biomarkers, definition of suitable endpoints, improvements in first-in-human study designs, proposal of more accurate radiological response criteria, management of novel immune-related toxicities and development of combinations based on a biological rationale. In this article, we review the major challenges to overcome in forthcoming years. The final role of immunotherapy in cancer will be determined by our capacity to shed some light on some of these key points.

Molecular markers to predict response to selective fibroblast growth factor receptor inhibitors (FGFRinh) in patients (pts) with FGFR-amplified (amp) or mutated (mut) tumors

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Background: Several FGFR and ligand (11q) alterations have been described in cancer. While FGFR fusions are recognized biomarkers of response to FGFRinh, it is still unclear to what extent FGFRamp, FGFR mRNA high expression (mRNAh) or FGFRmut predict sensitivity in the clinic. Methods: Retrospective analysis of pts with molecularly-selected FGFRamp/mRNAh/mut tumors treated with FGFRinh in phase 1 trials at our institution. Mut were detected with IlluminaÒ or Foundation OneÒ. FGFR1-2amp were analyzed by in situ hybridization and mRNA levels by qRT-PCR or nCounterÒ. Clinical benefit (ClinBen) was defined as any tumor shrinkage plus disease control for ³ 4 months (m). Time to progression (TTP) was defined as time between start of FGFRinh and end for any cause. Results: From 2011 to 2016, 36 pts with FGFRamp(25)/mRNAh(5)/mut(6) received an FGFRinh (irreversible- [11 cases (c)] or reversible-FGFR1-4inh [23 c], isoform-specific FGFRinh [3 c] or combo with PI3Kinh [1 c]). Median age 55 yrs (34-76); median prior palliative lines was 3 (0-8); tumor types: breast (17), colorectal (3), esophagus (3), liver (3), lung (3), others (7). Median TTP was 1.67 m (CI 95%; 1.40-2.87). In the FGFRamp/mRNAh population (30), 7 pts achieved ClinBen (23%). 4 out of these seven pts had mRNAh (1 FGFR2amp breast with FGFR2 mRNAh, 1 bladder FGFR3 mRNAh and 2 liver FGFR4 mRNAh without known amp), and 2 pts harboured 11q co-amplification (1 FGFR2amp breast, 1 FGFR2amp head and neck). There was no correlation between ClinBen and level of FGFRamp in the overall population (p = 0.51) or in the breast cancer group (p = 0.29). Of 6 FGFRmut pts, one with bladder cancer had ClinBen (clonal oncogenic FGFR3 S249C). The remaining 5 unresponsive FGFRmut pts had subclonal events, some of these FGFRmut were of unknown functional significance, and had coexisting oncogene mut in MAPK or PI3K pathways. Conclusions: Our results suggest that ClinBen with FGFRinh in the FGFRamp setting is enriched in pts with high mRNA expression and/or ligand co-amplification, and in the FGFRmut population may be dependent on clonality and functionality of the event and co-existence of driver mut.

Association of Survival Benefit With Docetaxel in Prostate Cancer and Total Number of Cycles Administered: A Post Hoc Analysis of the Mainsail Study

Importance

The optimal total number of docetaxel cycles in patients with metastatic castration resistant prostate cancer (mCPRC) has not been investigated yet. It is unknown whether it is beneficial for patients to continue treatment upon 6 cycles.

Objective

To investigate whether the number of docetaxel cycles administered to patients deriving clinical benefit was an independent prognostic factor for overall survival (OS) in a post hoc analysis of the Mainsail trial.

Design, Setting, and Participants

The Mainsail trial was a multinational randomized phase 3 study of 1059 patients with mCRPC receiving docetaxel, prednisone, and lenalidomide (DPL) or docetaxel, prednisone, and a placebo (DP). Study patients were treated until progressive disease or unacceptable adverse effects occurred. Median OS was found to be inferior in the DPL arm compared with the DP arm. As a result of increased toxic effects with the DPL combination, patients on DPL received fewer docetaxel cycles (median, 6) vs 8 cycles in the control group. As the dose intensity was comparable in both treatment arms, we investigated whether the number of docetaxel cycles administered to patients deriving clinical benefit on Mainsail was an independent prognostic factor for OS. We conducted primary univariate and multivariate analyses for the intention-to-treat population. Additional sensitivity analyses were done, excluding patients who stopped treatment for reasons of disease progression and those who received 4 or fewer cycles of docetaxel for other reasons, minimizing the effect of confounding factors.

Main Outcomes and Measures

Total number of docetaxel cycles delivered as an independent factor for OS.

Results

Overall, all 1059 patients from the Mainsail trial were included (mean [SD] age, 68.7 [7.89] years). Treatment with 8 or more cycles of docetaxel was associated with superior OS (hazard ratio [HR], 1.909; 95% CI, 1.660-2.194; P < .001), irrespective of lenalidomide treatment (HR, 1.060; 95% CI, 0.924-1.215; P = .41). Likewise, in the sensitivity analysis, patients who received a greater number of docetaxel cycles had superior OS; patients who received more than 10 cycles had a median OS of 33.0 months compared with 26.9 months in patients treated with 8 to 10 cycles; and patients who received 5 to 7 cycles had a median OS of 22.8 months (P < .001).

Conclusions and Relevance

These findings suggest that continuation of docetaxel chemotherapy contributes to the survival benefit. Prospective validation is warranted.

Frequency and characteristics of familial melanoma in Spain: the FAM-GEM-1 Study

INTRODUCTION

Familial history of melanoma is a well-known risk factor for the disease, and 7% melanoma patients were reported to have a family history of melanoma. Data relating to the frequency and clinical and pathological characteristics of both familial and non-familial melanoma in Spain have been published, but these only include patients from specific areas of Spain and do not represent the data for the whole of Spain.

PATIENTS AND METHODS

An observational study conducted by the Spanish Group of Melanoma (GEM) analyzed the family history of patients diagnosed with melanoma between 2011 and 2013 in the dermatology and oncology departments.

RESULTS

In all, 1047 patients were analyzed, and 69 (6.6%) fulfilled criteria for classical familial melanoma (two or more first-degree relatives diagnosed with melanoma). Taking into account other risk factors for familial melanoma, such as multiple melanoma, pancreatic cancer in the family or second-degree relatives with melanoma, the number of patients fulfilling the criteria increased to 165 (15.8%). Using a univariate analysis, we determined that a Breslow index of less than 1 mm, negative mitosis, multiple melanoma, and a history of sunburns in childhood were more frequent in familial melanoma patients, but a multivariate analysis revealed no differences in any pathological or clinical factor between the two groups.

CONCLUSIONS

Similar to that observed in other countries, familial melanoma accounts for 6.6% of melanoma diagnoses in Spain. Although no differences in the multivariate analysis were found, some better prognosis factors, such as Breslow index, seem more frequent in familial melanoma, which reflect a better early detection marker and/or a different biological behavior.

Docetaxel and prednisone with or without lenalidomide in chemotherapy-naive patients with metastatic castration-resistant prostate cancer (MAINSAIL): a randomised, double-blind, placebo-controlled phase 3 trial

BACKGROUND

Patients with metastatic castration-resistant prostate cancer have few treatment options. We investigated the safety and efficacy of lenalidomide, an immunomodulatory agent with anti-angiogenic properties, in combination with docetaxel and prednisone in chemotherapy-naive patients with metastatic castration-resistant prostate cancer.

METHODS

In this randomised, double-blind, placebo-controlled, phase 3 study, we randomly assigned chemotherapy-naive patients with progressive metastatic castration-resistant prostate cancer in a 1:1 ratio to receive docetaxel (75 mg/m(2)) on day 1 and prednisone (5 mg twice daily) on days 1-21 and either lenalidomide (25 mg) or placebo once daily on days 1-14 of each 21 day treatment cycle. Permuted block randomisation was done with an interactive voice response system and stratified by Eastern Cooperative Oncology Group performance status, geographic region, and type of disease progression. Clinicians, patients, and investigators were masked to treatment allocation. The primary endpoint was overall survival. Efficacy analysis was by intention to treat. Patients who received at least one dose of study drug were included in the safety analyses. This study is registered with ClinicalTrials.gov, number NCT00988208.

FINDINGS

1059 patients were enrolled and randomly assigned between Nov 11, 2009, and Nov 23, 2011 (533 to the lenalidomide group and 526 to the control group), and 1046 patients received study treatment (525 in the lenalidomide group and 521 in the placebo group). At data cutoff (Jan 13, 2012) after a median follow-up of 8 months (IQR 5-12), 221 patients had died: 129 in the lenalidomide group and 92 in the placebo group. Median overall survival was 17·7 months (95% CI 14·8-18·8) in the lenalidomide group and not reached in the placebo group (hazard ratio [HR] 1·53, 95% CI 1·17-2·00, p=0·0017). The trial was subsequently closed early due to futility. The number of deaths that occurred during treatment or less than 28 days since the last dose were similar in both groups (18 [3%] of 525 patients in the lenalidomide group vs 13 [2%] of 521 patients). 109 (21%) patients in the lenalidomide group and 78 (15%) in the placebo group died more than 28 days from last dose, mainly due to disease progression. At least one grade 3 or higher adverse event was reported in 381 (73%) of 525 patients receiving lenalidomide and 303 (58%) of 521 patients receiving placebo. Grade 3-4 neutropenia (114 [22%] for lenalidomide vs 85 [16%] for placebo), febrile neutropenia (62 [12%] vs 23 [4%]), diarrhoea (37 [7%] vs 12 [2%]), pneumonia (24 [5%] vs five [1%]), dyspnoea (22 [4%] vs nine [2%]), asthenia (27 [5%] vs 17 [3%]), and pulmonary embolism (32 [6%] vs seven [1%]) occurred more frequently in the lenalidomide group than in the placebo group.

INTERPRETATION

Overall survival with the combination of lenalidomide, docetaxel, and prednisone was significantly worse than with docetaxel and prednisone for chemotherapy-naive men with metastatic, castration-resistant prostate cancer. Further research with this treatment combination is not warranted.

FUNDING

Celgene Corporation.

Weekly cabazitaxel in "unfit" metastatic castration-resistant prostate cancer patients (mCRPC) progressing after docetaxel (D) treatment: Preliminary results of CABASEM-SOGUG phase II trial

167

Background: Cabazitaxel (C), a novel taxane developed to overcome D resistance, showed an overall survival improvement after D in metastatic castration-resistant prostate cancer (mCRPC) in a three-weekly schedule. Its main toxicity is hematological, especially in unfit patients. We aimed to evaluate efficacy and safety of weekly C/prednisone (P) schedule in "unfit" mCRPC previously treated with D. Methods: Unfit pts defined as ECOG 2, dose reduction due to febrile neutropenia during D treatment or radiation therapy affecting more than 25% of bone marrow reserve, with mCRPC progressing after D treatment with adequate bone marrow, liver and kidney functions were included. C 10 mg/m2 was administered on days 1, 8, 15 and 22 of 5-week cycles with P (5 mg b.i.d.). Radiological and PSA response were evaluated according to the PCWG2 (Scher H, 2008) criteria and toxicity according NCI-CTC AE. Results: To date 70 pts have been enrolled and data are available for 66. Median age was 73 y (range 54-84), 67% pts had ECOG 2, 87% had bone, 14% liver and 11% lung metastases. Half of pts had Gleason >7. Treatment: 271 cycles (median: 3; range: 1-12); 1002 weekly infusions (median 11; range 1-48). Median dose intensity was 93%. Eighteen of 55 pts (32.7%) achieve ≥50% PSA response and 5 (9.1%) ≥80% PSA response. Radiological response was evaluable in 56 pts. PR was observed in 4 pt (7.1%) and SD in 29 pts (51.8%). Median PFS was 3.9 months. Median OS was 14.2 months. Most frequent toxicities of all grades as % of pts were: anemia (71.2%), asthenia (43.9%), thrombocytopenia (15.1%), leukopenia (24.2%), diarrhea (27.3%), nauseas (18.2%), neutropenia (12.1%), peripheral neuropathy (7.6%), and anorexia (18.2%). Grade 3-4: thrombocytopenia (4.5%), anemia (6%), neutropenia (3.0%), asthenia (10.6%), diarrhea (1.5%), anorexia (1.5%), No grade IV diarrhea nor febrile neutropenia were observed. Conclusions: Weekly cabazitaxel (10 mg/m2) plus prednisone administered to unfit pts seems a highly effective treatment and safe, with no grade 4 neutropenia, diarrhea or febrile neutropenia reported. Clinical trial information: NCT01518283.

Active surveillance in asymptomatic or minimally symptomatic renal cell carcinoma: Retrospective analyses of a cohort of three oncological centers from Spain

441

Background: Some patients (pt) with metastatic renal cell carcinoma (mRCC) have an indolent course. Treatment toxicities can worsen quality of life. Active surveillance (AS) in paucisymptomatic pts is an option often used but few data is available. Our aim is to analyze the impact of initial AS in a sequential therapy strategy in terms of overall survival (OS). Methods: Data frompt diagnosed with mRCC from January 2005 to December 2013 in 3 centres of Spain were retrospectively analyzed. AS subgroup was defined as pt with ≥6 months (m) between diagnosis and first-line (L) treatment (tto) start. A descriptive analysis and median OS (mOS) were performed comparing pt with or without AS (AS vs. tto <6m). OS curve and medians were estimated using Kaplan Meier Method. A multivariate cox regression analyses with different prognostic factors was also realized. Results: From a cohort of 277 pt with mRCC, 69 pt (25%) were on initial AS and 208 pts on tto <6m (75%). Median time on observation until systemic tto was started on pt on AS was 14 m 95%CI (17.6-26.02). Pt characteristics of AS vs tto <6 m were: median age 63/60; males 70/72%; histology: 94/76% clear cell, 3/12% papillar, 0/4% chromophob; M1 at diagnosis: 22/48%; prognosis (Heng risk criteria): 0/17.% poor, 38.5/57% intermediate, 61.5/25% good; prior nephrectomy: 93/73%; number of metastatic locations (loc): 87/68% ≤2 loc, 12.5/32.5% ≥3 loc; lines of treatment: first L 46/53%, second L 38/23%, and third L 16/24%. When comparing exposure in months to each tto L, pt on AS had longer period of tto in second L (10.06/4.14 m, p=0.014). mOS were: 62 m 95%CI (52.97-71.03) vs. 22 m 95% CI (19.87-24.12) for AS/tto <6 m respectively (p<0.001) with statistical significance after multivariate analysis (Cox regression, HR=0.39; 95% CI, 0.25-0.63). Factors that independently influence on OS were: ≥2 M1 sites and papillar histology, negatively, and prior nephrectomy and >1 year from diagnosis to M1, positively. Conclusions: Our results suggest that AS before starting first L of tto is not a detrimental action in a selected population of mRCC pt with good risk characteristics allowing them to remain free of therapy’s toxicity during a long time period.

Phase II study of weekly cabazitaxel for "unfit" metastatic castration resistant prostate cancer patients progressing after docetaxel treatment: Preliminary toxicity analysis (SOGUG-CABASEM trial)

190

Background: Docetaxel (D) is standard first-line chemotherapy in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC). Cabazitaxel (C), a novel taxane developed to overcome D resistance, showed an overall survival improvement in second line CRPC in a three-weekly dose schedule. Its main toxicity is hematological, especially in unfit patients. We aimed to evaluate efficacy and safety of weekly C/pred. in "unfit" mCRPC previously treated with D. Methods: Unfit pts (ECOG 2, dose reduction due to febrile neutropenia during treatment with D or radiation therapy affecting more than 25% of bone marrow reserve) with advanced CRPC progressing after D treatment with ECOG <=2 and adequate bone marrow, liver and kidney functions were included. C 10 mg/m2 was administered on days 1, 8, 15, and 22 of 5-week cycles with daily pred. 5 mg b.i.d. Radiological and prostate-specific antigen response was evaluated according to the PCCTWG II criteria and toxicity according NCI-CTC AE. Results: To date 47 pts have been enrolled and data are available for 38. Median age was 72 (range 56 to 83), 20 (53%) pts had ECOG 2, 29 (83%) had bone metastases. Cycles administered: 124 (median: 3; range: 1 to 9) and 446 weekly administrations (median 11; range 1 to 35). Mean dose intensity was 94%. Most frequent toxicities of all grades as % of cycles were: asthenia (20%), anemia (50%), leukopenia (13%), thrombocytopenia (14%), diarrhea (9%), rash (6%), nauseas (5%), dysgeusia (7%), xerostomia (6%), anorexia (5%), hand-foot syndrome (5%), and neuropathy (2%). Grade 3: thrombocytopenia (10%), anemia (6%), neutropenia (1%), asthenia (3%), anorexia (1%), mucositis (1%), nausea (1%), and vomiting (1%). No grade 4 toxicities were reported. Three patients discontinued the study due to asthenia G3 (2) and mucositis G3 (1). No grade III/IV diarrhea or febrile neutropenia were observed. Conclusions: Administration of weekly C (10 mg/m2) to unfit pts seems to be safe with no grade 3 or greater neutropenia, diarrhea, or febrile neutropenia reported. If activity is confirmed, weekly C may represent an attractive option for unfit pts with mCRPC progressing after D treatment. Clinical trial information: NCT01518283.

Phase I study of sirolimus plus gemcitabine in patients with advanced solid tumors: A Spanish Group for Research on Sarcomas (GEIS) study

3096

Background: In preclinical studies, combination of sirolimus with gemcitabine enhances apoptosis in vitro and increases anti-tumor efficacy in vivo. Methods: Patients with advanced solid tumors, age 18-70 years, no prior mTOR inhibitor or gemcitabine, ECOG PS 0-1, and adequate hematological, renal and hepatic function, were enrolled in this phase I study to assess safety, tolerability, pharmacokinetics (PK), and to identify the dose limiting toxicity (DLT), maximum tolerated dose (MTD) and recommended dose (RD) of the combination of sirolimus and gemcitabine. A 3+3 dose escalation design with cohorts of 3-6 patients was used. Sirolimus was given po continuously. Gemcitabine was given iv 10mg/m2/minute on days 1 and 8 every 3 weeks. Dose levels 1, 2 and 3 corresponded to sirolimus 2, 2 and 5mg/24h plus gemcitabine 800, 1000 and 1000mg/m2 respectively. After observing DLTs at higher dose level and poorer mTOR signaling inhibition at lower doses, a new cohort of sirolimus 5mg/24h plus gemcitabine 800 mg/m2 was added. Skin biopsies pre and post treatment were performed to assess the inhibition of mTOR pathway. Results: 19 patients were enrolled: median age 51 years (36-70); gender 12M, 7F. Median number of cycles was 4. Patients were treated at 4 dose levels, the MTD was reached at level 3 and the RD was: sirolimus 5mg/24h and gemcitabine 800mg/m2. 3 DLTs were observed, 1 at dose level 2 and 2 at dose level 3: transaminitis grade 3, thrombocytopenia grade 3 and thrombocytopenia grade 4. Other toxicities grade 1-2 included anemia, neutropenia, asthenia, mucositis and high cholesterol levels. 2 patients achieved partial response (1 uterine cervix cancer and 1 colon cancer). Immunohistochemistry of pS6 in skin biopsies showed significative inhibition of mTOR pathway at RD. PK parameters estimated were in agreement with those previously reported in the literature. No influence of sirolimus administration on gemcitabine clearance was found. Conclusions: Combination of sirolimus and gemcitabine is feasible and safe, allowing administration of active doses of both agents and achieving mTOR signaling inhibition. A phase II study to assess the activity of this combination in sarcomas is ongoing.