Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Etoposide and cisplatin versus paclitaxel and carboplatin with concurrent thoracic radiotherapy in unresectable stage III non-small cell lung cancer: a multicenter randomized phase III trial

Background

The optimal chemotherapy regimen administered currently with radiation in patients with stage III non-small cell lung cancer (NSCLC) remains unclear. A multicenter phase III trial was conducted to compare the efficacy of concurrent thoracic radiation therapy with either etoposide/cisplatin (EP) or carboplatin/paclitaxel (PC) in patients with stage III NSCLC.

Patients and methods

Patients were randomly received 60-66 Gy of thoracic radiation therapy concurrent with either etoposide 50 mg/m2 on days 1-5 and cisplatin 50 mg/m2 on days 1 and 8 every 4 weeks for two cycles (EP arm), or paclitaxel 45 mg/m2 and carboplatin (AUC 2) on day 1 weekly (PC arm). The primary end point was overall survival (OS). The study was designed with 80% power to detect a 17% superiority in 3-year OS with a type I error rate of 0.05.

Results

A total of 200 patients were randomized and 191 patients were treated (95 in the EP arm and 96 in the PC arm). With a median follow-up time of 73 months, the 3-year OS was significantly higher in the EP arm than that of the PC arm. The estimated difference was 15.0% (95% CI 2.0%-28.0%) and P value of 0.024. Median survival times were 23.3 months in the EP arm and 20.7 months in the PC arm (log-rank test P = 0.095, HR 0.76, 95%CI 0.55-1.05). The incidence of Grade ≥2 radiation pneumonitis was higher in the PC arm (33.3% versus 18.9%, P = 0.036), while the incidence of Grade ≥3 esophagitis was higher in the EP arm (20.0% versus 6.3%, P = 0.009).

Conclusion

EP might be superior to weekly PC in terms of OS in the setting of concurrent chemoradiation for unresectable stage III NSCLC.

Trial registration ID

NCT01494558.

Cerebrovascular collaterals correlate with disease severity in adult North American patients with Moyamoya disease

BACKGROUND AND PURPOSE

Cerebrovascular collaterals have been increasingly recognized as predictive of clinical outcomes in Moyamoya disease in Asia. The aim of this study was to characterize collaterals in North American adult patients with Moyamoya disease and to assess whether similar correlations are valid.

MATERIALS AND METHODS

Patients with Moyamoya disease (n = 39; mean age, 43.5 ±10.6 years) and age- and sex-matched control subjects (n = 33; mean age, 44.3 ± 12.0 years) were graded via angiography. Clinical symptoms of stroke or hemorrhage were graded separately by imaging. Correlations between collateralization and disease severity, measured by the modified Suzuki score, were evaluated in patients with Moyamoya disease by fitting a regression model with clustered ordinal multinomial responses.

RESULTS

The presence of leptomeningeal collaterals (P = .008), dilation of the anterior choroidal artery (P = .01), and the posterior communicating artery/ICA ratio (P = .004) all correlated significantly with disease severity. The presence of infarct or hemorrhage and posterior steno-occlusive disease did not correlate significantly with the modified Suzuki score (P = .1). Anterior choroidal artery changes were not specific for hemorrhage. Patients with Moyamoya disease were statistically more likely than controls to have higher posterior communicating artery/ICA ratios and a greater incidence of leptomeningeal collaterals.

CONCLUSIONS

As with Moyamoya disease in Asian patients, the presence of cerebrovascular collaterals correlated with the modified Suzuki score for disease severity in North American patients with Moyamoya disease. However, anterior choroidal artery changes, which correlated with increased rates of hemorrhage in Asian studies, were not specific to hemorrhage in North Americans.

PPM1A is a RelA phosphatase with tumor suppressor-like activity

Nuclear factor-κB (NF-κB) signaling contributes to human disease processes, notably inflammatory diseases and cancer. NF-κB has a role in tumorigenesis and tumor growth, as well as promotion of metastases. Mechanisms responsible for abnormal NF-κB activation are not fully elucidated; however, RelA phosphorylation, particularly at serine residues S536 and S276, is critical for RelA function. Kinases that phosphorylate RelA promote oncogenic behaviors, suggesting that phosphatases targeting RelA could have tumor-inhibiting activities; however, few RelA phosphatases have been identified. Here, we identified tumor inhibitory and RelA phosphatase activities of the protein phosphatase 2C (PP2C) phosphatase family member, PPM1A. We show that PPM1A directly dephosphorylated RelA at residues S536 and S276 and selectively inhibited NF-κB transcriptional activity, resulting in decreased expression of monocyte chemotactic protein-1/chemokine (C-C motif) ligand 2 and interleukin-6, cytokines implicated in cancer metastasis. PPM1A depletion enhanced NF-κB-dependent cell invasion, whereas PPM1A expression inhibited invasion. Analyses of human expression data revealed that metastatic prostate cancer deposits had lower PPM1A expression compared with primary tumors without distant metastases. A hematogenous metastasis mouse model revealed that PPM1A expression inhibited bony metastases of prostate cancer cells after vascular injection. In summary, our findings suggest that PPM1A is a RelA phosphatase that regulates NF-κB activity and that PPM1A has tumor suppressor-like activity. Our analyses also suggest that PPM1A inhibits prostate cancer metastases and as neither gene deletions nor inactivating mutations of PPM1A have been described, increasing PPM1A activity in tumors represents a potential therapeutic strategy to inhibit NF-κB signaling or bony metastases in human cancer.

Abstract 1947: Self-reporting dendritic nanoparticles (nanodendrons) for drug delivery targeted to the tumor microenvironment and with reduced neurotoxicity

Proteinases, including matrix metalloproteinases (MMPs), contribute to cancer progression and other pathologies. Selective MMP expression can be used to distinguish benign from malignant tumors and identify aggressive tumors associated with poor outcome. MMP9, a basement membrane-degrading type-IV collagenase/gelatinase, is associated with tumor invasion and metastasis. In this project, we describe a new class of dendritic nanoparticles, nanodendrons (NDs), with MMP molecular recognition and targeting capabilities. These NDs can be studied as individual dendrons tuned for specific functions such as enhanced imaging or targeted drug treatments. Additionally, the NDs can be coupled to facilitate multifunctional purposes such as in NDs that can self-report drug delivery to tumors. The prototypical system presented here describes NDs that are activated by MMP9: 1) ND-PB, a near infrared imaging beacon; 2) ND-PXL, a therapeutic that delivers paclitaxel (PXL) and 3) NDPB-NDPXL, a bi-functional agent. In vivo studies in two orthotopic models of breast cancer demonstrate efficacy of these NDs to image and treat breast cancer. The proteinase-activated prodrug, NDPXL, delivers PXL to breast cancer through release of the drug in the tumor microenvironment and increases therapeutic efficacy while reducing systemic toxicity (including peripheral neuropathy). The delivery of PXL using the proteolytically activated ND-PXL is effective in inhibiting tumor growth in two orthotopic models of breast cancer (PyVT-R221A and MDA-MB231). Daily treatment of MDA-MB231 tumors with 12.5 mg/kg PXL as either ND-PXL or Abraxane® (Abx), showed similar reduction in tumor growth as compared with vehicle-treated animals. Further investigation of the NDPXL in a fully immunocompetent mouse model (PyVT-R221A) with treatments given on alternate days at a dose of 12.5 mg/kg (ND-PXL or Abx) yielded similar results: an average reduction in tumor growth of 58% and 53% in ND-PXL and Abx cohorts, respectively. Peripheral nerve toxicity, a debilitating, long term side effect of Abx therapy, was assessed in both tumor and non-tumor mice through monitoring behavior indicative of peripheral nerve damage before, during and after administration of each drug. Peripheral neurotoxicity is markedly reduced in the ND-PXL-treated versus Abraxane®-treated mice as evident in a number of behavioral assessments. The development of this novel class of NDs expands upon the current capabilities of modern proteinase-based optical beacons and prodrugs and is a step forward in treatment of both primary and metastatic cancer. [Supported in part by Susan G. Komen for the Cure®]

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1947. doi:1538-7445.AM2012-1947

Identification of driver mutations in tumor specimens from 1,000 patients with lung adenocarcinoma: The NCI’s Lung Cancer Mutation Consortium (LCMC)

CRA7506

Background: The ability to detect driver mutations like EGFR and EML4-ALK in tumor specimens from patients with lung cancer and administer agents targeting those molecular lesions has revolutionized the management of adenocarcinoma of the lung. The availability of multiplexed assays to detect mutations permits the identification of multiple driver mutations from tumors at diagnosis. The number of molecular lesions and new agents to target them continues to grow. To exploit this, we created the LCMC to determine 10 driver mutations in tumors from 1,000 patients and to give the results to clinicians for care and entry onto targeted therapeutic trials based on these findings. Methods: The 14 member LCMC is prospectively enrolling patients to test tumors from patients with lung adenocarcinoma in CLIA laboratories for KRAS, EGFR, HER2, BRAF, PIK3CA, AKT1, MEK1, and NRAS using standard multiplexed assays and fluorescence in situ hybridization (FISH) for ALK rearrangements and MET amplifications. All are stage IIIB/IV, PS 0-2, have available tissue, and signed consent. Results: 830 patients have been registered with 50 enrolling monthly. We detected a driver mutation in 60% (252/422, 95% CI 55 to 65%) of tumors thus far. Mutations found: KRAS 107 (25%, 95% CI 21 to 30%), EGFR 98 (23%, 95% CI 19 to 27%), ALK rearrangements 14 (6%, 95% CI 4 to11%), BRAF 12 (3%, 95% CI 1 to 5%), PIK3CA 11 (3%, 95% CI 1 to 5%), MET amplifications 4 (2%, 95% CI 0.5 to 5%), HER2 3, (1%, 95% CI 0.1 to 2%), MEK1 2 (0.4%, 95% CI 0.1 to 2%), NRAS 1 (0.2%, 95% CI 0.01 to 1%), AKT1 0 (0%, 95% CI 0 to 1%). 95% of molecular lesions were mutually exclusive. Conclusions: We detected an actionable driver mutation in 60% of tumors from prospectively studied patients with lung adenocarcinoma. Results of EGFR mutation testing are given to treating physicians to select erlotinib as initial treatment per NCCN and ASCO guidelines. Patients with other driver mutations are offered participation in LCMC-linked trials of agents targeting the mutation identified, e.g. crizotinib with EML4-ALK. At half of LCMC sites, multiplexed testing for all mutations is now routine practice in their pathology departments. Supported by 1RC2CA148394-01.

Novel p63 target genes involved in paracrine signaling and keratinocyte differentiation

The transcription factor p63 is required for proper epidermal barrier formation and maintenance. Herein, we used chromatin immunoprecipitation coupled with DNA sequencing to identify novel p63 target genes involved in normal human epidermal keratinocyte (NHEKs) growth and differentiation. We identified over 2000 genomic sites bound by p63, of which 82 were also transcriptionally regulated by p63 in NHEKs. Through the discovery of interleukin-1-α as a p63 target gene, we identified that p63 is a regulator of epithelial–mesenchymal crosstalk. Further, three-dimensional organotypic co-cultures revealed TCF7L1, another novel p63 target gene, as a regulator of epidermal proliferation and differentiation, providing a mechanism by which p63 maintains the proliferative potential of basal epidermal cells. The discovery of new target genes links p63 to diverse signaling pathways required for epidermal development, including regulation of paracrine signaling to proliferative potential. Further mechanistic insight into p63 regulation of epidermal cell growth and differentiation is provided by the identification of a number of novel p63 target genes in this study.

Abstract S3-8: RNAi Screening Identifies the Insulin/Insulin-Like Growth Factor-I Receptor Pathway as a Mechanism of Escape from Hormone Dependence in Estrogen Receptor-Positive Breast Cancer

Estrogen receptor-positive (ER+) breast cancers are treated with strategies aimed at inducing estrogen deprivation such as aromatase inhibitors (AIs). However, many ER+ tumors adapt to hormone deprivation and acquire resistance to AIs. The purpose of this study was to identify kinases essential for the growth of endocrine-resistant ER+ breast cancer cells. To model acquired resistance to AIs, we maintained four ER+, estrogen-dependent human breast cancer cell lines (MCF-7, MDA-361, HCC-1428, and ZR75- 1) under hormone-depleted conditions for several months until hormone-independent populations emerged (termed long-term estrogen-deprived, LTED). We then performed an RNAi screen targeting 779 protein kinases to identify molecules required for growth of MCF-7/LTED cells in hormonefree conditions. Individual knockdown of 42 kinases significantly inhibited MCF-7/LTED cell growth ≥33% (p≥0.05) in at least 3/4 independent experiments. Of these 42 hits, knockdown of the insulin receptor (InsR) inhibited MCF-7/LTED growth (n=4 experiments) compared to control siRNA. Knockdown of InsR expression using independent siRNA oligonucleotides significantly inhibited growth of MCF-7/LTED, ZR75-1/LTED, and HCC-1428/LTED cells.

The InsR can heterodimerize with the highly homologous insulin-like growth factor-I receptor (IGF-IR) to potently activate the phosphatidylinositol-3 kinase (PI3K)/AKT signaling pathway. Immunoblot analysis revealed that siRNA knockdown of InsR or IGF-IR caused a compensatory upregulation of IGF-IR and InsR expression, respectively. Knockdown of InsR or IGF-IR inhibited growth of 3/4 LTED lines, but knockdown of both InsR and IGF-IR was required for maximal inhibition of PI3K/AKT. Inhibition of these receptors by treatment with the InsR/IGF-IR tyrosine kinase inhibitor (TKI) OSI-906 decreased PI3K signaling and disrupted the basal association between p85 and the IGF-IR/InsR effectors IRS-1 and IRS-2 in MCF-7/LTED cells. Further, OSI-906 inhibited the hormone-independent growth of all four LTED lines and prevented the emergence of hormone-independent ER+ parental cells following estrogen deprivation. Treatment with the TKI or the neutralizing IGF-IR monoclonal antibody MK-0646 induced feedback upregulation and phosphorylation of the ErbB3/HER3 receptor tyrosine kinase (RTK). Induction of P-HER3 was blocked by the EGFR/HER2 TKI lapatinib. Combined treatment of lapatinib and OSI-906 prevented the emergence of hormone-independent (HER2+/ER+) MDA-361 cells more effectively than either drug alone. Finally, treatment of ovariectomized nude female mice with OSI-906 suppressed the growth of established MCF-7 xenografts. In addition, treatment with OSI-906 decreased PI3K signaling as measured by immunoblot analysis of tumor extracts using P-AKT antibodies. These results suggest that 1) InsR/IGF-IR signaling is required for PI3K/AKT signaling and hormone-independent growth of ER+ breast cancer cells; 2) these cells compensate for the inhibition of InsR/IGF-IR by upregulating alternative RTK pathways such as HER3; 3) combined targeting of InsR/IGF-IR and ER signaling may be effective for the treatment of endocrine-resistant breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S3-8.

DNA copy number aberrations in small-cell lung cancer reveal activation of the focal adhesion pathway

Small-cell lung cancer (SCLC) is the most aggressive subtype of lung cancer in its clinical behavior, with a 5-year overall survival as low as 5%. Despite years of research in the field, molecular determinants of SCLC behavior are still poorly understood, and this deficiency has translated into an absence of specific diagnostics and targeted therapeutics. We hypothesized that tumor DNA copy number alterations would allow the identification of molecular pathways involved in SCLC progression. Array comparative genomic hybridization was performed on DNA extracted from 46 formalin-fixed paraffin-embedded SCLC tissue specimens. Genomic profiling of tumor and sex-matched control DNA allowed the identification of 70 regions of copy number gain and 55 regions of copy number loss. Using molecular pathway analysis, we found a strong enrichment in these regions of copy number alterations for 11 genes associated with the focal adhesion pathway. We verified these findings at the genomic, gene expression and protein level. Focal Adhesion Kinase (FAK), one of the central genes represented in this pathway, was commonly expressed in SCLC tumors and constitutively phosphorylated in SCLC cell lines. Those were poorly adherent to most substrates but not to laminin-322. Inhibition of FAK phosphorylation at Tyr(397) by a small-molecule inhibitor, PF-573,228, induced a dose-dependent decrease of adhesion and an increase of spreading in SCLC cell lines on laminin-322. Cells that tended to spread also showed a decrease in focal adhesions, as demonstrated by a decreased vinculin expression. These results support the concept that pathway analysis of genes in regions of copy number alterations may uncover molecular mechanisms of disease progression and demonstrate a new role of FAK and associated adhesion pathways in SCLC. Further investigations of FAK at the functional level may lead to a better understanding of SCLC progression and may have therapeutic implications.

A Phase Ib Trial of Erlotinib, an EGFR Inhibitor, and Everolimus (RAD001), an mTOR Inhibitor, in Patients with Metastatic Breast Cancer

Background: The EGFR and the PI3K pathways have been implicated in breast cancer's prognosis and mechanisms of resistance to conventional therapies. Preclinical data have shown synergy between EGFR and PI3K/Akt pathway blockade. Therefore, we conducted a phase Ib trial to determine the maximum tolerated dose (MTD) and antitumor activity of Erlotinib, an oral EGFR tyrosine kinase inhibitor, and Everolimus (RAD001), an oral mTOR inhibitor, given daily to patients with metastatic breast cancer.Materials and Methods: This was an open-label, phase I dose-escalation study. Everolimus was started at 2.5 mg/d and Erlotinib was started at 100 mg/d on a 28-day treatment cycle. Doses were escalated over 6 levels (Everolimus 2.5, 5 or 10 mg daily with Erlotinib 100 or 150 mg daily). Treatment was continued until consistent dose-limiting toxicity (DLT) was observed or until progression of disease. All toxicities were documented using the NCI CTC v.3. Disease assessment was done every 2 months after initiation of therapy.Results: A total of 14 patients were enrolled on the first 2 dose levels (Erlotinib 100 mg with Everolimus 2.5 mg [level I] and 5 mg [level II] daily). Eight patients were enrolled on level I and 6 patients were enrolled on level II. The median age of all patients enrolled was 55 years of age, and 92% of them had visceral disease. Half of the patients had ER+ disease, 35% had HER2 + disease, and 15% had triple-negative disease. The median number of previous chemotherapy regimens in the metastatic setting was 4. Two patients on the level II cohort discontinued trial due to grade 3 stomatitis prior to their first disease assessment. Of the remaining 13 patients, 11 progressed at the time of their first disease assessment, and 1 patient on the dose level I cohort had a partial response that lasted for 7 months. The most common toxicities were rash (16%), transaminase elevation (15%), stomatitis (13%), fatigue (7%) and diarrhea (5%). Grade 3 and 4 toxicities were overall uncommon (3.5%), and mostly consisted of stomatitis, transaminase elevation and rash. Stomatitis was the only DLT, and was seen at dose level II. The MTD was determined to be Erlotinib 100 mg and Everolimus 2.5 mg daily.Discussion: In patients with metastatic HER2-negative breast cancer the combination of Erlotinib and Everolimus was overall well tolerated, but clinically ineffective from a tumor activity point of view in this heavily pre-treated patient population. Stomatitis was one of the most common toxicities and also the DLT in the cohort treated with dose level II. In view of the plethora of novel active agents currently in clinical trials in breast cancer, we do not believe the above combination warrants further testing in this disease.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3094.

Nuclear factor-kappa B pathway and response in a phase II trial of bortezomib and docetaxel in patients with recurrent and/or metastatic head and neck squamous cell carcinoma

BACKGROUND

Our previous study has shown that nuclear factor-kappa B (NF-kappaB)-signaling pathway was associated with a higher rate of recurrence in head and neck squamous cell carcinoma (HNSCC). The combination of bortezomib, an NF-kappaB inhibitor by inhibition of proteasomes, plus docetaxel was assessed for efficacy and toxicity.

MATERIALS AND METHODS

Patients with recurrent and/or metastatic HNSCC were enrolled on a phase II bortezomib/docetaxel trial (bortezomib 1.6 mg/m(2) and docetaxel 40 mg/m(2) on days 1 and 8 of a 21-day cycle). Response was assessed using RECIST. Tissue specimens were evaluated for the presence of human papillomavirus (HPV) and expression of NF-kappaB-associated genes.

RESULTS

Twenty-one of 25 enrolled patients were assessable for response; one partial response (PR, 5%), 10 stable disease (SD, 48%) and 10 progressive disease (PD, 48%). Patients with PR/SD had significantly longer survival compared with patients with PD and the regimen was well tolerated. Only one of 20 tumors was positive for HPV. Patients with PD had higher expression of NF-kappaB and epidermal growth factor receptor-associated genes in their tumors by gene expression analysis.

CONCLUSION

Further understanding of treatment resistance and interactions between bortezomib and docetaxel may provide novel approaches in managing HNSCC.

Urine PGE-M to assess prostaglandin E2 (PGE2) levels in non-small cell lung cancer (NSCLC)

e19026

Background: COX-2 is often overexpressed in NSCLC leading to high systemic PGE2 levels that in turn play a role in NSCLC pathogenesis. Changes in urine PGE-M (the major PGE2 metabolite) reflect changes in systemic & intratumoral PGE2 [Csiki et al. Clin Cancer Res 11:6634, 2005]. A ≥70% decline in PGE-M in NSCLC patients (pts) treated with celecoxib (C) (400 mg bid) + docetaxel (D) was associated with an apparent survival benefit [Ibid]. To effect maximum COX-2 inhibition we tested a higher C dose in a subsequent phase II trial. Methods: Eligibility: previously treated NSCLC, PS 0–2, evaluable/measurable disease, adequate marrow, renal & hepatic function, no current NSAID or sulfa allergy. Urine PGE-M measured prior to & 5–10 days after C 600 mg PO bid. Pts with ≥70% decline in PGE-M continued on C + D 75 mg/m2 or pemetrexed 500 mg/m2 q3wk x 4 cycles followed by maintenance C 400 mg PO bid until PD or drug intolerance. Results: 21 pts enrolled; F=7, M=14; 2 ineligible (1 carcinoid; 1 elevated LFT); 2 stopped C early (1 ARF; 1 pruritus). Mean PGE-M levels decreased from 38.9 to 7.8 ng/mg Cr pre- & post-C (mean change = 80%; P=0.002). The mean decline was greater in current & former smokers (81%; P=0.002) compared to never smokers (46%; P=0.19). Males had higher pre- treatment PGE-M (44 vs. 28.8 ng/mg Cr; P=0.21). Males had a significant decrease in mean PGE-M levels after C (78%; P=0.011); a similar albeit not significant change occurred in females (P=0.12). 12 screened pts (57%) had a ≥70% decline in PGE-M & received treatment with C + chemotherapy; 8 pts are evaluable for response; SD = 6; PD = 2. Treatment was well tolerated with no cardiac toxicities noted. Conclusions: These preliminary data indicate C 600 mg bid effectively inhibits intratumoral COX-2 in >50% NSCLC pts, a higher percentage than our previous trial using C 400 mg bid. The effect is greatest in former & current smokers & males compared to never smokers & females. Toxicities are acceptable. Accrual is ongoing. [Funding: VICC Lung Cancer SPORE CA90949].

No significant financial relationships to disclose.

Loss of PTEN engages ErbB3 and IGF-I receptor signaling to promote antiestrogen resistance in breast cancer

Abstract #73

We sought to determine whether loss of the lipid phosphatase PTEN confers resistance to antiestrogens in estrogen receptor (ER)-positive breast cancer cells and primary tumors. Stable knockdown of PTEN expression (PTEN-kd) with shRNA in MCF-7, T47D, and MDA-361 ER+ human breast cancer cells resulted in upregulation of PI3K and P-Akt, resistance to tamoxifen and faslodex, and estrogen-independent growth. Upon PTEN-kd, ER levels were maintained in MCF-7 cells but markedly reduced in T47D and MDA-361 cells. While PTEN-kd upregulated ER transcriptional reporter activity in MCF-7 cells, opposite effects were seen in T47D and MDA-361 cells.
 We evaluated mechanisms of PI3K activation in PTEN-kd cells by immunoprecipitating the p85 regulatory subunit of PI3K and examining p85-bound tyrosine-phosphorylated adaptors or receptors. PTEN-kd increased the binding of p85 to IRS-1 (MCF-7) and ErbB3 (T47D). PTEN-kd increased PI3K pathway sensitivity to IGF-I (MCF-7) and endogenous ligand (T47D, MDA-361). PTEN-kd cells had increased and prolonged activation of IGF-IR and ErbB3, thus implicating PTEN in the regulation of signaling upstream of PI3K. Further, PTEN-kd increased non-genomic, estrogen-induced signaling via IGF-IR by increasing p85-IRS-1 binding and activation of PI3K/Akt in MCF-7 cells. Inhibition of PI3K and mTOR with the small molecule BEZ235, of IGF-IR with the small molecule AEW541, and/or of ErbB2-mediated activation of ErbB3 with lapatinib restored the growth inhibitory effect of antiestrogens.
 We generated gene expression signatures of PTEN loss in each cell line by microarray analyses. Comparison of these signatures to the Connectivity Map (Science 313:1929, 2006) suggested activation of PI3K, as signatures of PTEN loss negatively connected with those induced by the PI3K inhibitors wortmannin and LY294002 (all p<0.06). We found a 24-gene signature of PTEN loss common to all 3 lines, which we used to score the gene expression profiles of tumors from a cohort of 268 patients with ER+ breast cancer treated with adjuvant tamoxifen for 5 yrs and a median follow-up of 9.1 years (BMC Genomics 9:239, 2008). Patients with tumors exhibiting a signature of PTEN loss had shorter relapse-free survival (p<0.0001; log rank test). Eleven genes in the PTEN signature were individually predictive of disease outcome (p<0.05). In a separate, smaller cohort of patients with ER+ cancers treated with adjuvant tamoxifen (n=34), undetectable PTEN in tumor cells (measured by IHC) correlated with shorter relapse-free survival vs. tumors with detectable PTEN (p=0.06). These data suggest that 1) PTEN loss confers antiestrogen resistance to ER+ breast cancer by genomic and non-genomic mechanisms; 2) PTEN loss is permissive for activation of IGF-IR and ErbB3 signaling; 3) inhibition of IGF-IR and/or ErbB signaling pathways overcomes the resistance to antiestrogens conferred by PTEN loss; and 4) a gene expression signature reflective of loss of PTEN and/or absence of PTEN protein can predict poor patient outcome after adjuvant hormonal therapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 73.

Single Agent Irinotecan for the Treatment of Metastatic or Recurrent Squamous Carcinoma of the Head and Neck (SCCHN)

Background

Patients with recurrent or metastatic head and neck cancer (HNC) have a poor response and survival with currently available chemotherapy agents. Thus new agents are needed. We report the results of a phase II trial of irinotecan in patients with metastatic or recurrent HNC.

Patients and Methods

Chemonaive patients were treated with irinotecan 125 mg/m2 on a weekly schedule for four weeks, followed by a two week rest. However, due to excessive toxicity, the dose and schedule of irinotecan was changed to 75 mg/m2 on days 1 and 8 of a 21 day cycle. All previously treated patients received 75 mg/m2 on days 1 and 8 of a 21 day cycle.

Results

Forty-nine patients were enrolled on study. The response rate was 20% in the chemonaive patients treated at the 125 mg/m2 dose. The response rate decreased to 12.5% at the 75 mg/m2 dose. In the previously treated cohort, the response rate was 20%. Median survival for the chemonaive and previously treated cohorts were 6.7 months and 5.0 months, respectively.

Conclusions

Irinotecan has modest activity in chemonaive and previously treated HNC, thus it merits further study in this advanced disease population.

Proteomic analysis of lung cancer tumors

7028

Background: In this study we assess the utility of direct tumor tissue MALDI-MS in a large prospective collection of surgically resected lung cancers to distinguish cancer from non-cancer, histology, occult lymph node involvement, and survival. Methods: 175 non-small cell lung cancer specimens and 62 histologically normal lung tissues obtained at the time of surgery were used in this analysis. Twelve micron thick frozen sections were placed on conductive glass slides. Sections were stained with Cresyl Violet and matrix applied to areas identified by a pathologist under microscopic guidance as containing greater than 80% tumor before three separate areas involved with tumor was analyzed by MALDI MS. Relative intensities of selected peaks were used for class comparison. A class prediction model was built based on the weighted flexible compound covariate method of analysis (WFCCM). Results: We created a prediction model from a training cohort consisting 81 tumors and 19 histologically normal tissue samples. A total of 221 peaks were used for statistical analysis. In tumor/normal discrimination, 46 peaks were used for the prediction model (p<0.0001), while, 22 were used (p<0.005) to predict histology, 11 (p<0.05) to predict nodal involvement, and 14 (p<0.005) in survival prediction. Using these prediction models, classification accuracy was 90% in normal/tumor discrimination, 81.8% in histology and 61.7% in nodal involvement prediction. In the survival prediction model, patients with longer than median survival could be distinguished from those with shorter than median survival (p<0.0001, Log-rank test). We then validated the same features in a blind test set from the remaining 93 tumors and 43 normals. For tumor/normal discrimination, prediction accuracy in test cohort was 94.3%. Histology prediction accuracy was 93.9% in predicting squamous cell carcinoma. Nodal involvement prediction accuracy was 49.3%. Longer or shorter median survival was also predicted in this set with statistical significance p<0.08. (Log rank test). Conclusion: We report the analysis of a large set of tumor and normal samples by MALDI MS and confirm similar accuracy in tumor/normal, histology and survival discrimination to previous our report. This project was supported by the Lung SPORE P50 CA90949 (DPC) and NCI 5R33CA86243 (RMC).

No significant financial relationships to disclose.

Nuclear survivin as a biomarker for non-small-cell lung cancer

Survivin inhibits apoptosis and promotes mitosis. We determined whether nuclear or cytoplasmic localisation of survivin predicts survival of 48 patients with resected non-small-cell lung cancer (NSCLC). Patients with nuclear staining of survivin had significantly worse survival (relative risk: 3.9, P=0.02). Therefore, survivin may be a biomarker for NSCLC.

Docetaxel Combined With Trastuzumab Is an Active Regimen in HER-2 3+ Overexpressing and Fluorescent In Situ Hybridization–Positive Metastatic Breast Cancer: A Multi-Institutional Phase II Trial

Purpose

To determine the efficacy and safety of weekly docetaxel and trastuzumab as first- or second-line therapy in women with HER-2–overexpressing metastatic breast cancer and to correlate the efficacy of trastuzumab with HER-2 status as determined by immunohistochemistry assay and fluorescent in situ hybridization (FISH).

Patients and Methods

Twenty-six women with HER-2–positive (HercepTest [Dako Corp, Carpenteria, CA]2 to 3+) metastatic breast cancer were enrolled onto this study of trastuzumab (4 mg/kg load; 2 mg/kg/wk administered intravenously) and docetaxel (35 mg/m2/wk for 6 weeks).

Results

Using an intent-to-treat analysis, the overall response rate was 50% (13 of 26 patients). Eight patients (31%) had a period of stable disease posttherapy. Among HER-2 3+ patients, the overall response rate was 63% (12 of 19 patients) compared with a 14% response rate (one of seven patients) for HER-2 2+ patients (P = .07). Patients with FISH-positive tumors experienced an overall response rate of 64%. Median time to progression was 12.4 months for the entire cohort (HER-2 3+ tumors, 12.3 months; HER-2 2+ lesions, 9.5 months) and median survival was 22.1 months. All HER-2 3+ patients were FISH-positive; the only HER-2 2+ patient responding to treatment was also FISH-positive. Grade 4 toxicities occurred in four patients; most toxicities were mild.

Conclusion

Trastuzumab plus docetaxel is an active and well-tolerated regimen in women with HER-2 3+ overexpressing or FISH-positive metastatic breast cancer.

Plasma F2-isoprostane levels are elevated in chronic hemodialysis patients

AIMS

Cardiovascular mortality has been reported to be 10- to 20-fold higher in chronic dialysis patients than in the age-matched general population. It has been suggested that increased oxidant stress and resulting vascular wall injury due to uremia and the hemodialysis procedure may be one of the mechanisms predisposing to these cardiovascular complications. Further, hemodialysis membrane bioincompatibility can contribute to increased oxidative stress and prevalence of inflammation.

MATERIALS

We studied 18 chronic hemodialysis (CHD) patients (age 62.8 +/- 14.7 years, 39% male, 61% African-American, 44% insulin-dependent diabetic, 61% smokers, 61% with documented coronary artery disease) during hemodialysis with 2 membranes with different flux and complement activating properties.

METHODS

We have measured free and phospholipid-bound F2-isoprostane (F2-IsoP) levels, a sensitive marker of oxidative stress, in CHD patients and compared them to levels in healthy subjects. We have also examined the acute effects of the hemodialysis procedure using both biocompatible and bioincompatible membranes on F2-IsoP levels.

RESULTS

The results indicated that, compared to controls, both free (96.2 +/- 48.8 pg/ml versus 37.6 +/- 17.2 pg/ml) and bound F2-IsoP (220.4 +/- 154.8 pg/ml versus 146.8 +/- 58.4 pg/ml) levels were significantly higher (p < 0.05 for both). There was a statistically significant decrease in free F2-IsoP concentrations at 15 and 30 minutes of HD, which rebounded to baseline levels at the completion of the procedure. There were no significant differences in F2-IsoP concentrations between the 2 study dialyzers at any time point. Age, smoking status, diabetes mellitus and presence of cardiovascular disease were also not correlated with F2-IsoP levels in this patient population. There was a significant association between predialysis F2-IsoP and C-reactive protein concentrations.

CONCLUSION

Using a sensitive and specific assay for the measurement of F2-IsoP, we demonstrated that CHD patients are under increased oxidative stress. During a single hemodialysis treatment, the hemodialysis membrane appears to have no discernable effect on oxidative stress status. Measurement of F2-isoprostanes may be a useful biomarker of oxidative stress status as well as in developing new therapeutic strategies to ameliorate inflammatory and oxidative injury in this patient population.