Abstract P4-08-13: Prognostic significance of CD8+ tumor-infiltrating lymphocytes (TILs) in patients with early breast cancer (EBC) treated with dose-dense sequential adjuvant chemotherapy (dds-CT). An observational study (ACTRN12616001043426)

Background - aim: Information on the prognostic role of cytotoxic CD8+ T cells in the era of modern adjuvant CT is limited. The primary objective of the present report is to assess the prognostic impact of CD8+ cells in patients with intermediate or high-risk EBC (T1-3N1-2M0) treated with dds-CT. Secondary endpoints are safety, disease-free survival (DFS) and overall survival (OS).

Patients and Methods: Patients (N=1,000) were treated with 4 cycles of Epirubicin, 75mg/m2, and Cyclophophamide, 600mg/m2 every 2 weeks followed by 4 cycles of Docetaxel (D), 100mg/m2 every 3 weeks with G-CSF support in all cycles. Trastuzumab was initiated concurrently with D and continued for a total of 1 year. Hormonal and radiation therapy were given post CT, as indicated. Formalin-fixed paraffin-embedded tumors were available for 642 patients (64.2%) and were centrally assessed for immunohistochemical subtypes (IHC4; N=526), stromal TILs density by morphology (N=636), as well as stromal and intratumoral cytotoxic CD8+ T cell numbers (N=554). TILs and CD8+ were assessed as continuous variables for associations and as 10% increments for outcome.

Results: In total, 901/1,000 pts (90.1%) completed 8 cycles of CT. Severe (gradeIII-IV) toxicitiesincludedneutropenia (5.6%), leucopenia (3.6%), lymphopenia (2.1%), hand-footsyndrome (2.1%), and hepatotoxicity (1.8%). Febrileneutropenia occurred in 1.6% of the patients. The 5-year DFS and OS rates were 89.5% and 93.1%, respectively. Luminal A tumors were classified in 26.2%, Luminal B in 35.2%, luminal HER2 in 9.5%; HER2-enriched in 7.2%; and, triple-negative (TNBC) in 21.9% of informative patients. Among subtypes, stromal TILs density was higher in HER2-enriched and TNBC (p<0.001); intratumoral CD8+ values were higher in TNBC (p<0.001); and, stromal CD8+ were higher in HER2-enriched (p=0.034). In all patients, TILs density and intratumoral CD8+ cell numbers were not associated with DFS and OS, while increased stromal CD8+ were marginally associated with prolonged DFS (HR=0.98, 95%CI 0.96-1.00, p=0.066).Adjusted for histological grade, menopausal, ER/PgR and nodal status, higher stromal CD8+ were associated with prolonged DFS (HR=0.98, 95% CI 0.96-1.00, p=0.043). In TNBC, higher stromal TILs density conferred prolonged DFS (HR=0.97, 95%CI 0.94-0.99, p=0.029), which retained its prognostic significance in multivariate analysis (HR=0.97, 95% CI 0.94-1.00, p=0.049).

Conclusions: In this study, dds-CT was well tolerated and active in patients with EBC. We confirm the presence of morphologically assessed higher TILs density, and of higher cytotoxic CD8+ T cell numbers in hormone receptor negative EBC, as well as the favorable prognostic impact of higher stromal TILs density in TNBC. In comparison to stromal TILs density, higher stromal CD8+ may confer favorable prognosis irrespectively of EBC subtype. Stromal CD8+ seems to be a marker worth further standardizing for reporting on immune cell infiltrates in EBC.

Citation Format: Kourea HP, Koletsa T, Kotoula V, Koliou G-A, Batistatou A, Pentheroudakis G, Arapantoni-Dadioti P, Zagouri F, Bobos M, Sotiropoulou M, Papoudou-Bai A, Chrisafi S, Efstratiou I, Aravantinos G, Nicolaou I, Gogas H, Visvikis A, Christodoulou C, Petraki C, Koutras A, Psyrri A, Pectasides D, Fountzilas G. Prognostic significance of CD8+ tumor-infiltrating lymphocytes (TILs) in patients with early breast cancer (EBC) treated with dose-dense sequential adjuvant chemotherapy (dds-CT). An observational study (ACTRN12616001043426) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-13.

Abstract P2-08-20: Prognostic impact of SRC, CDKN1B and JAK2 expression in metastatic breast cancer patients treated with trastuzumab

Background-aim: SRC, CDKN1B and JAK2 play a crucial role in the coordination and facilitation of cell-signaling pathways controlling a wide range of cellular functions. In the present study, we investigated the prognostic significance and clinical utlity of these biomarkers in metastatic breast cancer (MBC) patients treated with trastuzumab (T). Methods: We assessed SRC, CDKN1B and JAK2 mRNA expression with qRT-PCR (Taqman-MGB assays) on 197 paraffin tumors. PIK3CA mutation status was previously assessed. Relapsed (RMBC) and de novo MBC (dnMBC) patients had received T for metastatic disease only. Tumors were centrally re-assessed for HER2 status. Results: Only 133/197 patients (67.5%) were found to be truly HER2(+). CDKN1B mRNA expression strongly correlated with SRC (rho = 0.71) and JAK2 (rho = 0.54); high CDKN1B was more frequent in RMBC compared to dnMBC (p = 0.001) and in PIK3CA wild-type tumors (p = 0.005). In HER2(+) patients, low CDKN1B conferred higher risk for progression (HR 1.58, 95% CI 1.08-2.32, p = 0.018). In HER2(-) patients, low SRC was associated with longer survival (HR 0.56, 95% CI 0.32-0.99, p = 0.045) and, as a trend, with increased progression-free survival (PFS) (p = 0.067). For PFS, in RMBC, we observed trends for unfavorable low CDKN1B (p = 0.068) and JAK2 (p = 0.086); similarly, in dnMBC for unfavorable low CDKN1B (p = 0.072). Low SRC showed a trend for better survival in RMBC (p = 0.087). Upon multivariable analyses, only PIK3CA mutations strongly predicted for unfavorable PFS in HER2(+) patients (HR 3.37, 95% CI 1.98-5.73, p < 0.001). Low CDKN1B and JAK2 mRNA expression remained unfavorable factors for PFS in dnMBC and RMBC patients (HR 2.36, 95% CI 1.01-5.48, p = 0.046 and HR 1.76, 95% CI 1.01-3.06, p = 0.047, respectively). Conclusions: Low CDKN1B and JAK2 mRNA expression were unfavorable prognosticators in a cohort of T-treated MBC patients previously unexposed to this agent, with distinct impact in de novo and RMBC. Our results highlight biological and clinical differences between de novo and RMBC and suggest that CDKN1B and JAK2, if validated, may serve as prognostic factors potentially implicated in T-resistance, which seems to be associated with distinct pathways in the two MBC settings.

Citation Format: Economopoulou P, Kotoula V, Koliou G-A, Papadopoulou K, Christodoulou C, Pentheroudakis G, Koutras A, Bafaloukos D, Papakostas P, Pectasides D, Kotsakis A, Razis E, Samantas E, Kalogeras KT, Economopoulos T, Fountzilas G. Prognostic impact of SRC, CDKN1B and JAK2 expression in metastatic breast cancer patients treated with trastuzumab [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-20.

Mitomycin C and Vinblastine in Anthracycline-resistant Metastatic Breast Cancer: A Phase Ii Study

The purpose of this phase II study was to evaluate the clinical efficacy of mitomycin C and vinblastine in patients with anthracycline-resistant metastatic breast cancer. This single-center, non-randomized trial enrolled 39 patients. Eligible patients must have received at least three chemotherapy regimens with epirubicin or CAF and had treatment failure while on chemotherapy or within 6 months of completing therapy. Treatment consisted of mitomycin C at a starting dose of 8 mg/m2 on day 1 and vinblastine (8 mg/m2, days 1 and 28). The regimen was repeated every 6 weeks with a 20% dose escalation of both drugs after the first cycle in the absence of grade III hematologic or other toxicity. On an intent-to-treat basis, 38 patients were eligible for assessment; 9 (23.7%, 95% confidence interval 1.92-2.45%) achieved a partial response and 13 (34.2%) had stable disease. The median time to disease progression was 6.21 ±4.26 months (range, 1-15; 95% confidence interval, 4.81-7.61), and the median survival was 10.76±7.6 (range, 1-29; 95% confidence interval 8.0-13.1%). Responsive patients had a significantly better survival than those with stable and progressive disease. Treatment was well tolerated. Anemia and neutropenia (grade I-III) developed in 28.9% and 26.3% of the patients, respectively. One patient with grade III granulocytopenia developed fever and infection that required hospitalization. Moderate neurotoxicity, myalgia, constipation, diarrhea and alopecia were observed. No toxic death occurred. Mitomycin C plus vinblastine is an effective and well-tolerated regimen for anthracycline resistant cancer.

Abstract P1-07-03: Evaluation of the prognostic value of CD3, CD8 and FOXP3 mRNA expression in early breast cancer patients treated with anthracycline-based adjuvant chemotherapy

Background: Tumor-infiltrating lymphocytes (TILs) have been shown to be of prognostic value in several cancer types. In early breast cancer, TILs have a prognostic utility, as well, especially in HER2-positive and triple-negative breast cancer (TNBC). TILs presence is broadly associated with improved survival, however there is controversy regarding TILs subpopulations. In general, T cell infiltration is higher in non-luminal and more aggressive tumors, like the basal-like subtype. Among TILs subpopulations, CD8-positive T cell infiltration is associated with better outcome, whereas high numbers of FOXP3-positive T regulatory cells are associated with worse outcome in ER-positive tumors and better outcome in HER2-positive and TNBC tumors.

Patients and Methods: Early breast cancer patients, treated with anthracycline-based chemotherapy within two randomized trials (HE10/97 and HE10/00) were included in the study. We evaluated, by qRT-PCR, 826 macrodissected formalin-fixed paraffin-embedded tumor tissue samples for mRNA expression of CD3, CD8 and FOXP3for potential prognostic significance in terms of disease-free survival (DFS) and overall survival (OS). TILs were evaluated in whole sections as percent of total cells.

Results: Median age was 52.7 years, while 54.2% of the patients were postmenopausal and 79.0% ER/PgR-positive. After a median follow-up of 133.0 months, 255 patients (30.9%) had died and 314 (38.0%) had disease progression. All three mRNA markers were positively correlated with TILs (Spearman's r=0.52 for CD3, 0.41 for CD8 and 0.47 for FOXP3, all p-values <0.001), while Ki67 protein expression was greater in tumors with high mRNA expression (median cut-off) of the markers (Mann-Whitney, all p-values <0.001). Additionally, tumors of higher histological grade and negative ER/PgR status were more frequent in patients with high CD3, CD8 or FOXP3 mRNA expression, as compared to patients with low expression, (chi-square, p-values <0.010). In the univariate analysis, high CD3 and CD8 mRNA expression was found to be of favorable prognostic value for DFS (HR=0.74, 95% CI 0.59-0.92, Wald's p=0.007 and HR=0.76, 95% CI 0.61-0.95, p=0.016, respectively). In multivariate analyses, the association of high CD8 mRNA expression with increased DFS was retained (HR=0.77, 95% CI 0.60-0.99, p=0.048), whereas that of high CD3 mRNA expression was of marginal statistical significance (HR=0.77, 95% CI 0.59-1.01, p=0.059). Moreover, a significant interaction was observed between HER2 status and CD3 mRNA expression with respect to DFS (interaction p=0.032). In the HER2-positive subgroup, the hazard ratio associated with high CD3 mRNA expression was of greater magnitude (HR=0.48, 95% CI 0.30-0.76, p=0.002) compared to the hazard ratio presented above, for the entire cohort. No significant findings were observed for FOXP3 in terms of DFS, while none of the studied markers were of prognostic value for OS.

Conclusions: High CD3 and CD8 mRNA expression in early breast cancer patients is of prognostic value for decreased risk for relapse and, in the future, could potentially be of importance in deciding the most appropriate therapeutic strategy in light of the recent immune-related treatment developments.

Citation Format: Tsiatas M, Kalogeras KT, Manousou K, Wirtz RM, Gogas H, Veltrup E, Zagouri F, Lazaridis G, Koutras A, Christodoulou C, Pentheroudakis G, Petraki C, Bafaloukos D, Pectasides D, Kosmidis P, Samantas E, Karanikiotis C, Papakostas P, Dimopoulos M-A, Fountzilas G. Evaluation of the prognostic value of CD3, CD8 and FOXP3 mRNA expression in early breast cancer patients treated with anthracycline-based adjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-03.

Abstract P6-09-07: Mutation characteristics and tumor infiltrating lymphocytes in early and metastatic HER2-positive breast cancer

Background-aim: HER2-positive breast cancer (BC) features high rates of tumor infiltrating lymphocytes (TILs) and mutations (mut) in various genes, more frequently in TP53. We investigated associations between TILs and mutations in HER2-positive BC and their impact on patient outcome in early and metastatic BC (EBC and MBC, respectively), which remain largely unexplored.

Methods:In 352 primary paraffin tumors from patients with HER2-positive disease, we examined amino acid changing mutations (<0.1% minor allele frequency) in 58 genes for type and possible clonality (>20% variant frequency). Study groups were: (A) 218 EBC, including 117 patients treated with adjuvant chemotherapy only (CT) and 101 patients treated with CT and trastuzumab (CTT); (B) 134 MBC, including 95 patients who relapsed upon adjuvant CT without trastuzumab (R-MBC) and 39 patients who were first diagnosed with metastatic disease (de novo MBC). TILs were assessed as percentage of stromal tumor area. Clinical endpoints were disease-free survival in 5 years (5yr DFS) for EBC, and time-to-progression (TTP) from 1st line CTT treatment start for MBC.

Results: 243/352 tumors (69%) carried at least one mut; 27/352 (8%) of tumors >10 up to 150 mut (hypermut); 192/352 (54%) at least one possibly clonal mut. Mean mut number and TP53 mut in particular were highest in R-MBC and lowest in EBC; mean TILs density followed the opposite pattern (all p<0.001). TILs density was lower in all settings in hypermut tumors and in tumors with multiple clonal mut (p values 0.043 – 0.050). Upon multivariate analysis in EBC, higher risk for relapse in 5yrs was noticed for CT patients compared to CTT (odds ratio [OR] 2.39, 95%CI [CI] 1.13-5.04, p=0.023) and for >3 compared to 0-3 positive nodes (OR 3.83, CI 1.76-8.34, p=0.001); lower risk for relapse was observed for higher TILs irrespectively of treatment (OR 0.93, CI 0.90-0.97, p=0.001), for TP53 mut (OR 0.39, CI 0.18-0.87, p=0.022) and for clonal TP53 mut in CTT-treated patients (OR 0.10, CI 0.02-0.58) but not in CT-treated patients (interaction p=0.084). The presence of any clonal mut (hazard ratio [HR] 2.77, CI 1.42-5.38) and of clonal TP53 mut (HR 2.24, CI 1.20-4.17) conferred worse TTP in de novo but not in R-MBC; these interactions remained significant upon multivariate analysis (interaction p=0.007 and p=0.061, respectively). Higher TILs in the absence of clonal mut conferred longer TTP (HR 0.75, CI 0.56-0.99) but no such effect was observed for tumors with clonal mut (multivariate interaction p=0.052). Classic independent predictors of unfavorable TTP in MBC were younger age (p=0.002), absence of hormone receptors (p=0.001) and poor performance status (p=0.044). PIK3CA mut did not remain significant in any of the examined settings.

Conclusions: The expected pattern of higher TILs associated with mutation number and clonality was not observed in HER2-positive BC; the favorable effect of TILs only in the absence of clonal mut in MBC may imply exhausted immune response. Clonal TP53 mut may serve as a predictor for trastuzumab benefit in EBC but as an adverse prognosticator in trastuzumab-treated de novo MBC, which, if further validated, is of potential clinical relevance.Background-aim: HER2-positive breast cancer (BC) features high rates of tumor infiltrating lymphocytes (TILs) and mutations (mut) in various genes, more frequently in TP53. We investigated associations between TILs and mutations in HER2-positive BC and their impact on patient outcome in early and metastatic BC (EBC and MBC, respectively), which remain largely unexplored.

Methods:In 352 primary paraffin tumors from patients with HER2-positive disease, we examined amino acid changing mutations (<0.1% minor allele frequency) in 58 genes for type and possible clonality (>20% variant frequency). Study groups were: (A) 218 EBC, including 117 patients treated with adjuvant chemotherapy only (CT) and 101 patients treated with CT and trastuzumab (CTT); (B) 134 MBC, including 95 patients who relapsed upon adjuvant CT without trastuzumab (R-MBC) and 39 patients who were first diagnosed with metastatic disease (de novo MBC). TILs were assessed as percentage of stromal tumor area. Clinical endpoints were disease-free survival in 5 years (5yr DFS) for EBC, and time-to-progression (TTP) from 1st line CTT treatment start for MBC.

Results: 243/352 tumors (69%) carried at least one mut; 27/352 (8%) of tumors >10 up to 150 mut (hypermut); 192/352 (54%) at least one possibly clonal mut. Mean mut number and TP53 mut in particular were highest in R-MBC and lowest in EBC; mean TILs density followed the opposite pattern (all p<0.001). TILs density was lower in all settings in hypermut tumors and in tumors with multiple clonal mut (p values 0.043 – 0.050). Upon multivariate analysis in EBC, higher risk for relapse in 5yrs was noticed for CT patients compared to CTT (odds ratio [OR] 2.39, 95%CI [CI] 1.13-5.04, p=0.023) and for >3 compared to 0-3 positive nodes (OR 3.83, CI 1.76-8.34, p=0.001); lower risk for relapse was observed for higher TILs irrespectively of treatment (OR 0.93, CI 0.90-0.97, p=0.001), for TP53 mut (OR 0.39, CI 0.18-0.87, p=0.022) and for clonal TP53 mut in CTT-treated patients (OR 0.10, CI 0.02-0.58) but not in CT-treated patients (interaction p=0.084). The presence of any clonal mut (hazard ratio [HR] 2.77, CI 1.42-5.38) and of clonal TP53 mut (HR 2.24, CI 1.20-4.17) conferred worse TTP in de novo but not in R-MBC; these interactions remained significant upon multivariate analysis (interaction p=0.007 and p=0.061, respectively). Higher TILs in the absence of clonal mut conferred longer TTP (HR 0.75, CI 0.56-0.99) but no such effect was observed for tumors with clonal mut (multivariate interaction p=0.052). Classic independent predictors of unfavorable TTP in MBC were younger age (p=0.002), absence of hormone receptors (p=0.001) and poor performance status (p=0.044). PIK3CA mut did not remain significant in any of the examined settings.

Conclusions: The expected pattern of higher TILs associated with mutation number and clonality was not observed in HER2-positive BC; the favorable effect of TILs only in the absence of clonal mut in MBC may imply exhausted immune response. Clonal TP53 mut may serve as a predictor for trastuzumab benefit in EBC but as an adverse prognosticator in trastuzumab-treated de novo MBC, which, if further validated, is of potential clinical relevance.

Citation Format: Kotoula V, Giannoulatou E, Kouvatseas G, Tikas I, Lazaridis G, Charalambous E, Efstratiou I, Bobos M, Tsolaki E, Zagouri F, Christodoulou C, Pentheroudakis G, Koutras A, Papakostas P, Kosmidis PA, Pectasides D, Fountzilas G. Mutation characteristics and tumor infiltrating lymphocytes in early and metastatic HER2-positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-07.

Abstract P2-07-02: Tumor infiltrating lymphocytes density and coding mutations effects on the outcome of operable triple negative breast cancer patients

Background-Aim: Neoantigens are considered to trigger host immune responses against tumors, which may be reflected by tumor infiltrating lymphocytes (TILs) density within the tumor stroma. High TILs levels have been associated with favorable triple-negative breast cancer (TNBC) patient outcome. Herein we evaluated the presence of coding mutations and TILs density with regard to outcome in a cohort of TNBC patients treated with anthracycline-based adjuvant chemotherapy.

Patients and Methods: Paraffin TNBC tissues from 242 patients treated in the context of four prospective clinical trials were histologically reviewed and submitted to massively parallel semiconductor sequencing with a custom panel targeting 57 breast cancer (BC)-related genes. Mutations (mut) were evaluated in 210 informative samples as missense/nonsense amino acid changing variants, with minor allele frequency <1% in the case of single nucleotide polymorphisms. TILs density was morphologically evaluated as percent of the stromal area in 197 tumors; lymphocyte predominant (LP) BC tumors were called for TILs >50%. Disease-free survival (DFS) was used as the endpoint for the present analysis.

Results: 426 Mut were observed for 40 genes in 147 TNBC patients (70%). Among mutated genes, ranging from 1 in 97 tumors up to >10 in 8 tumors, the most frequently affected were TP53 (102 tumors, 69%) and PIK3CA (40 tumors, 27%). Intriguingly, mut rate (p=0.042) and number of mut genes (p=0.018) per tumor were inversely associated with TILs density. Nineteen tumors (10%) were LP-TNBC, carrying TP53 and PIK3CA mut as the only coding alterations in 10 and 3 cases, respectively. LP-TNBC patients did not experience any relapses during a follow-up period of 46-152 months (mean 66 months). For the 90% of non-LP-TNBC, the previously reported outcome benefit for 10% increments of TILs density was only demonstrated for tumors with 31-50% TILs. In non-LP-TNBC, upon adjustment for standard clinicopathological parameters, PIK3CA mut, TP53 mut and TILs density as a continuous variable, TP53 mut and nodal status independently conferred unfavorable DFS (HR=1.89, 95% CI 1.03-3.47, p=0.040 and HR=2.89, 95% CI 1.59-5.24, p=0.001, respectively). When continuous TILs density was added in the multivariate models in the entire cohort, 10% increments significantly predicted favorable DFS (HR=0.73, 95% CI 0.59-0.91, p=0.006), while high nodal status predicted unfavorable DFS (HR=2.75, 95% CI 1.51-4.99, p<0.0001).

Conclusions: In the present study, tumors with higher TILs density, including LP-TNBC, were not characterized by multiple mutations or mutated genes with the panel tested. In TNBC, increasing TILs density is a strong favorable and high nodal status a strong unfavorable prognosticator. Importantly, LP-TNBC may be regarded as a distinct subgroup with excellent prognosis concerning 10% of TNBC. In non-LP-TNBC, TP53 mut and nodal status were significant unfavorable prognosticators. These data may suggest that the level of morphologically assessed TILs density does not necessarily correspond to the tumoral mutational load and merit validation in larger cohorts.

Citation Format: Kotoula V, Fountzilas E, Chatzopoulos K, Alexopoulou Z, Timotheadou E, Xanthakis I, Gogas H, Skondra M, Christodoulou C, Papadopoulou K, Chrisafi S, Koutras A, Xepapadakis G, Venizelos V, Efstratiou I, Patsea H, Kalogeras KT, Lakis S, Fountzilas G. Tumor infiltrating lymphocytes density and coding mutations effects on the outcome of operable triple negative breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-07-02.

Abstract P4-14-05: Genomic parameters affecting the outcome of patients with advanced breast cancer treated with trastuzumab

Background-Aim: There is an unmet need for de-selecting HER2-positive patients with advanced breast cancer (ABC), since only some of those patients benefit from the addition of anti-HER2 agents to chemotherapy. The aim of this study was to investigate candidate biomarkers, including MYC and MET, in parallel with an extended array of biomarkers previously associated with trastuzumab (T) resistance.

Patients and Methods: Two hundred and twenty-nine ABC patients treated with T and chemotherapy over a period of 13 years were included in the study. Paraffin tumors were retrospectively centrally assessed with immunohistochemistry (IHC) for breast cancer subtypes; fluorescence in situ hybridization (FISH) for HER2, TOP2A and centromere (CEN) 17, MYC and CEN8, MET and CEN7; qPCR for MYC and MET copy number (CN); and, for PI3K activation (PIK3CA mutations, PTEN and phospho-mTOR IHC). Patterns of CEN CN aberrations corresponding to chromosome "polysomy" were also evaluated, with cut-offs based on normal tissue. Time to progression (TTP) and survival were evaluated from the initiation of T as first-line treatment.

Results: Median follow-up was 70 months. Of the 229 patients treated with T as HER2-positive, central analysis identified 90 cases being HER2-negative, as per current guidelines (39.3% of the total cohort). HER2-positive patients showed a trend for survival benefit over HER2-negative patients (median 50.7 vs. 38.1 months, respectively, p=0.118). HER2-positive tumors were subtyped as Luminal-HER2 (n=77) and HER2-enriched (n=53); 156 patients presented with ABC and 65 with disease initially diagnosed at stage IV (de novo ABC). MET and MYC CN gains (≥2.5 copies) were found in 40 (25%) and 15 (9%) cases with qPCR, while MET and MYC amplification with FISH was present in 4 (2.5%) and 31 (18%) cases, respectively. Concordance between FISH and qPCR was low for MYC (kappa value 0.46) and absent for MET. Polysomy was collectively observed in 70 cases, in 54 of them (32% of all tumors) concerning any 1 of the 3 examined chromosomes. This condition, called restricted polysomy, interacted with ABC presentation, conferring decreased survival to patients with ABC (HR=2.32, 95% CI 1.43-3.76, Wald's p=0.001) but not to those with de novo ABC (interaction p=0.077). MYC CN gain was the only marker significantly associated with increased risk for progression (HR=3.22, 95% CI 1.66-6.24, p<0.001) and death (HR=5.45, 95% CI 2.89-10.28, p<0.001) at univariate analysis. Adjustment of all tested markers with standard clinicopathological parameters revealed that along with poor patient performance status that was associated with poor prognosis, MYC CN gain was an independent adverse prognosticator for both TTP and survival (all p-values <0.001). The HER2-enriched subtype was independently associated with T benefit for TTP (p=0.001) and survival (p=0.051). The interaction between restricted polysomy and disease presentation was also independently significant for survival (p=0.041).

Conclusions: MYC CN gain is a strong unfavorable prognosticator in T-treated ABC patients. Distinguishing between HER2-positive subtypes seems important for identifing T benefit in ABC. Chromosomal polysomy may distinctly affect T benefit in patients with pre-treated and de novo ABC.

Citation Format: Gogas H, Kotoula V, Alexopoulou Z, Christodoulou C, Kostopoulos I, Bobos M, Raptou G, Charalambous E, Tsolaki E, Xanthakis I, Pentheroudakis G, Koutras A, Bafaloukos D, Papakostas P, Aravantinos G, Psyrri A, Petraki K, Kalogeras KT, Fountzilas G, Pectasides D. Genomic parameters affecting the outcome of patients with advanced breast cancer treated with trastuzumab. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-05.

Abstract P5-08-50: Associations of MYC protein expression and gene status with breast cancer subtypes and outcome in patients treated with anthracycline-based adjuvant chemotherapy

Background-Aim: Breast cancer is a heterogeneous disease and despite recent scientific progress there is still need for the identification of biomarkers associated with risk for relapse, as well as for markers identifying patients who will benefit from specific treatments. The aim of the present study was to investigate the role of MYC, as a clinically meaningful biomarker, in the outcome of breast cancer subtypes.

Patients and Methods: We have pooled the patients and the respective breast carcinomas from two randomized anthracycline-based adjuvant phase III trials, consecutively conducted by the Hellenic Cooperative Oncology Group (HE10/97 and HE10/00). The HE10/97 trial included a non-paclitaxel arm. Tissue microarrays were constructed from 1,060 formalin-fixed paraffin-embedded tumor tissue samples that were collected retrospectively in the first and prospectively in the second trial. MYC was evaluated by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) in 986 cases.

Results: In total 61.0% of the cases showed positive cytoplasmic MYC immunostaining, while 26.5% showed positive nuclear staining. 65-80% of the patients were characterized as non-amplified or loss/normal-low gain in all FISH cut-offs examined. A weak association was observed between FISH and nuclear protein expression of MYC. High histological grade was associated with MYC protein overexpression and gene amplification. In terms of disease-free survival (DFS), low (2.5-5 copies) and high (≥5 copies) gain of MYC was of adverse prognostic value compared to loss/normal (<2.5 copies) MYC (HR=1.50, 95% CI 1.13-1.98, Wald's p=0.004 and HR=1.45, 95% CI 1.07-1.97, p=0.016, respectively). Comparable results were observed for overall survival (OS) (HR=1.51, 95% CI 1.09-2.08, p=0.013 and HR=1.65, 95% CI 1.17-2.33, p=0.005, respectively). The comparison of neoplasms with CEP8 ratio ≥1.3 and polysomy 8 for MYC versus all others resulted in worse survival prognosis (HR=1.44, 95% CI 1.13-1.83, p=0.004), while tumors with nuclear protein overexpression were associated with better DFS (HR=0.77, 95% CI 0.60-0.99, p=0.039) and OS (HR=0.73, 95% CI 0.55-0.98, p=0.034). In HER2-enriched patients, MYC amplification was found to be an adverse prognostic factor for DFS (HR=2.11, 95% CI 1.09-4.07, p=0.026) and OS (HR=2.41, 95% CI 1.12-5.15, p=0.024).

Treatment with paclitaxel was found to differentiate the effect of MYC: CEP8 ratio ≥1.3 and polysomy 8 in terms of DFS and OS in our total cohort. Among patients with CEP8 ratio ≥1.3 and polysomy 8, those treated with paclitaxel performed significantly better than those not treated, while among patients not treated with paclitaxel, those with CEP8 ratio ≥1.3 and polysomy 8 performed much worse than those with CEP8 ratio <1.3 or no polysomy 8.

Conclusions: Our data suggest that MYC has prognostic and predictive value in patients with breast cancer. MYC amplification and MYC protein overexpression are detected in breast cancer patients and are of adverse prognostic value for DFS and OS. Polysomy 8 is also associated with worse prognosis. Treatment with paclitaxel in the adjuvant setting benefits breast cancer patients with MYC:CEP8 ratio ≥1.3 and polysomy 8.

Citation Format: Batistatou A, Razis E, Bobos M, Tsolaki E, Timotheadou E, Alexopoulou Z, Goussia A, Gogas H, Koutras A, Karina M, Pentheroudakis G, Efstratiou I, Petraki K, Sotiropoulou M, Pavlakis K, Koletsa T, Kotoula V, Fountzilas G. Associations of MYC protein expression and gene status with breast cancer subtypes and outcome in patients treated with anthracycline-based adjuvant chemotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-50.

The inhibition of aromatase alters the mechanical and rheological properties of non-small-cell lung cancer cell lines affecting cell migration

Tumor invasion and metastasis are key aspects of non-small cell lung cancer (NSCLC). During migration, cells undergo mechanical alterations. The mechanical phenotype of breast cancer cells is correlated with aromatase gene expression. We have previously shown that targeting aromatase is a promising strategy for NSCLC. The aim of this study was to examine morphological and mechanical changes of NSCLC cells, upon treatment with aromatase inhibitor and correlate their ability to migrate and invade. In vitro experiments were performed using H23 and A549 NSCLC cell lines and exemestane was used for aromatase inhibition. We demonstrated that exemestane reduced H23 cell migration and invasion and caused changes in cell morphology including increased vacuolar structures and greater pleomorphism. In addition, exemestane changed the distribution of α-tubulin in H23 and A549 cells in a way that might destabilize microtubules polymerization. These effects were associated with increased cell viscosity and decreased elastic shear modulus. Although exemestane caused similar effects in A549 cells regarding viscosity and elastic shear modulus, it did not affect A549 cell migration and caused an increase in invasion. The increased invasion was in line with vimentin perinuclear localization. Our data show that the treatment of NSCLC cells with an aromatase inhibitor not only affects cell migration and invasion but also alters the mechanical properties of the cells. It suggests that the different origin of cancer cells is associated with different morphological characteristics and mechanical behavior.

Abstract P6-05-27: p53, c-Myc and EGFR protein interactions confer worse prognosis in patients with triple negative breast cancer (TNBC)

Background - aim: TNBC is a heterogeneous disease comprising different molecular subtypes that are mostly defined by gene expression profiling and are related to patient outcome. Herein, we investigated the prognostic significance of molecular subtype-related, surrogate protein markers.

Methods: Immunohistochemistry was applied on tissue microarrays containing a series of 330 centrally assessed TNBC from early high-risk breast cancer patients treated with anthracyclines and/or taxanes. The following markers were examined (in parentheses: cut-offs for low/high and negative/positive): Ki67 (14%); p53 (10%); c-Myc (10%); P-cadherin (10%); E-cadherin (10%); Claudin-7 (H-score median: 105); CK5 (1%); EGFR (1%); androgen receptor (AR [1%]).

Results: The majority of tumors (269/327, 81.5%) were grade-III ductal carcinomas of no special type. Tumors were frequently positive for Ki67 (239/314, 76.1%), E-cadherin (193/271, 71.2%), P-cadherin (249/302, 82.5%) and expressed markers of the basal phenotype (CK5+ and/or EGFR+, 268/316, 84.8%). Grade-III, Ki67-high carcinomas and tumours positive for E- and P-cadherin were more prevalent among those of basal phenotype (Fisher's exact p<0.001). Tumors expressing low levels of Claudin-7 were infrequently positive for AR and EGFR proteins (p = 0.015 and p = 0.003, respectively). AR positivity was more frequent among CK5 negative, grade I-II, and Ki67-low tumors (p = 0.021, p = 0.05 and p = 0.011 respectively). When examined individually, none of these markers was related to patient outcome. An interaction was noticed between p53 and c-Myc immunopositivity (Wald's p = 0.028 for disease-free [DFS] and p = 0.005 for overall survival [OS]). Among patients with c-Myc negative tumors, patients with p53 positive tumors (n = 63) had shorter median DFS (46.8 months) and OS (56 months) (HR 1.9; 95%CI 1.0-3.9; p = 0.049 and HR 2.28; 95%CI 1.0-4.8; p = 0.031, respectively) as compared to those with p53 negative tumors (n = 56; median DFS 69 months, OS 70 months). Similarly, in the absence of p53, c-Myc expression correlated with shorter median OS (44.5 months) (HR 2.1; 95%CI 1.0-4.5; p = 0.038) but showed only a trend for shorter DFS as compared to c-Myc negative tumors. p53 protein status was a discriminating factor for EGFR negative tumors (Wald's p = 0.052), whereby p53 positive tumors (n = 54) were associated with reduced DFS as compared to p53 negative tumors (n = 68; median DFS: 47 vs. 68.8 months; HR 2.1; 95%CI 1.1-4.0; p = 0.025). Accordingly, EGFR immunopositivity conferred a trend for shorter DFS within p53 negative cases.

Conclusions: In the current study, it was not possible to assign prognostic significance to individual proteins that have been introduced as surrogate markers for gene expression-based molecular subtypes in TNBC. By contrast, significant interactions involving the status of p53 and c-Myc or EGFR were observed. It seems that aberrant p53 adversely influences tumor behaviour in the absence of c-Myc and EGFR, while the opposite is also effective but to a lesser extent. These findings are hypothesis generating and need to be pursued in sufficiently powered studies for validating the apparently mutually exclusive adverse effects of p53, c-Myc and EGFR on tumor behaviour.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-27.

PD05-02: Effect of HER2/Topoisomerase II alpha (TOP2A) Gene Status or Protein Expression and Chromosome 17 (CEP17) Polysomy on the Outcome of Breast Cancer Patients Treated with Anthracycline-Containing Dose-Dense Sequential Adjuvant Chemotherapy with or without Paclitaxel – A Pooled Analysis of Two Hellenic Cooperative Oncology Group (HeCOG) Phase III Trials

Background: The HER2 gene has been established as a valid biomarker in the treatment of breast cancer patients with trastuzumab and probably with other agents, such as paclitaxel or anthracyclines. The TOP2A gene has been associated with response to anthracyclines. The relationship of HER2/TOP2A gene status in the presence of CEP17 polysomy with patients’ outcome following adjuvant treatment with anthracyclines with or without paclitaxel is not established.

Patients and methods: Formalin-fixed paraffin-embedded (FFPE) tumor tissue blocks from 1,033 patients (61.5% of 1,681 randomized patients) with high-risk operable breast cancer enrolled in two sequential phase III trials1,2 were assessed in a central laboratory for HER2/TOP2A gene amplification and CEP17 polysomy by fluorescence in situ hybridization (FISH) and tumors were categorized according to the 2007 American Society of Clinical Oncology/College of American Pathologists guidelines. HER2 and TOP2A amplification was defined as a gene/CEP17 ratio of >=2.2 and >=2.0, respectively or a gene copy number of >6. Additionally HER2, TOP2A, ER/PgR, Ki67, CK5 and EGFR protein expression were assessed by immunohistochemistry (IHC) and all patients were classified according to their IHC phenotype. Treatment consisted of epirubicin-based dose-dense sequential adjuvant chemotherapy followed by hormonal therapy and radiation, as indicated.

Results: Disease-free survival (DFS) and overall survival (OS) did not differ significantly between treatment groups. Median follow-up was 92 months, while 5-year DFS (OS) rates were 74% (88%), 69% (81%) and 75% (86%) for the E-T-CMF, E-CMF and ET-CMF groups, respectively. HER2 amplification was found in 24.1% of the patients and TOP2A amplification in 10.3%. In total, 46.7% of HER2 amplified tumors demonstrated TOP2A co-amplification. The median (range) of HER2, TOP2A and CEP17 copy numbers was 2.55 (0.70−45.15), 2.2 (0.50−26.15) and 2.05 (0.45−26.55), respectively. 21% of the tumors were considered to be polysomic (32.5% of those with HER2 amplification). Adjusting for treatment groups in the Cox model, TOP2A amplification, CEP17 polysomy and HER2/TOP2A co-amplification were not associated with either relapse or death. Treatment with paclitaxel was associated with improved survival in the HER2−amplified subgroup (HR=0.493, interaction p=0.036; adjusting for clinicopathological prognostic factors: HR=0.553, interaction p=0.054), an association that was not apparent for DFS. Conclusions: HER2 amplification was predictive for OS benefit from adjuvant treatment with paclitaxel in patients treated with epirubicin-based dose-dense sequential adjuvant chemotherapy, but not for DFS. TOP2A amplification, CEP17 polysomy and HER2/TOP2A co-amplification were not associated with outcome.

1. Ann Oncol 16:1762–71, 2005; 2. Ann Oncol 19:853–60, 2008.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD05-02.

Evaluation of the Predictive Value of IGF-IRa, IGF-IRb, UPA, and PAI-1 in Patients with Advanced Breast Cancer (ABC) Treated with Trastuzumab

Background: It has been shown that the HER2 and uPA/PAI-1 pathways independently affect the aggressive behavior of breast tumors. While HER2 positive patients have been shown to respond to trastuzumab, the role of uPA and PAI-1 in patients with advanced breast cancer (ABC) treated with trastuzumab is unclear, while the IGF-IR pathway appears to mediate resistance to trastuzumab.Material and Methods: Formalin-fixed paraffin-embedded tumor tissue samples were retrospectively collected from 138 patients with ABC treated with trastuzumab in the first-line. Clinical information was retrieved from medical records. The median age of the patients was 55 years, with 31% being premenopausal. HER2, IGF-IRa, IGF-IRb, uPA, PAI-1, Ki-67, ER, and PgR were assessed centrally by immunohistochemistry (IHC), while HER2 was also assessed centrally by FISH. All stains were examined by 2 independent pathologists, using the Allred 8-unit system for IGF-IRa and IGF-IRb, a combination of a proportion score from 0 to 5 and an intensity score on a scale of 0 to 3 (none, weak, moderate, strong). uPA protein expression was considered positive if >75% of the cells showed intense staining, with PAI-1 deemed positive when >6% of the cells showed mild staining. PFS and survival from the initiation of trastuzumab were estimated by the Kaplan-Meier method and compared using the log-rank test.Results: Trastuzumab alone or in combination with chemotherapy and/or hormonal therapy was given as first-line treatment in all patients. HER2 gene amplification was confirmed in 89 cases, while in 49 patients HER2 was found to be non-amplified (HER2 negative patients). As expected, survival of HER2 positive patients was found to be significantly longer (50.7 months vs. 30.5 months, p<0.0001), with no significant differences found in PFS (14.0 months vs. 9.2 months, p=0.124). IGF-IRa, IGF-IRb, uPA, or PAI-1 positive patients were not found to have significantly different PFS or survival in either HER2 positive or negative patients.Discussion: Protein expression of IGF-IRa, IGF-IRb, uPA, or PAI-1 assessed by IHC was not found to be associated with significantly different survival in patients with advanced breast cancer treated with trastuzumab in the current analysis. Studies are ongoing to include patients receiving second-line treatment with trastuzumab and evaluation of PI3K mutations.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2036.

Paclitaxel/gemcitabine versus paclitaxel/vinorelbine in advanced non-small cell lung cancer (NSCLC): A phase III randomized study

8038

Background: Paclitaxel and vinorelbine (PV) have shown synergism of cytotoxic effect in vitro (Cancer Invert, 2000, 18(8): 804-5). This combination was compared prospectively to the paclitaxel/gemcitabine (PG) regimen in non-operable NSCLC. Methods: 415 stage IIIb wet and IV chemotherapy-naïve for metastatic disease patients with PS 0–1 were randomized to paclitaxel 200mg/m2 on day 1 plus either gemcitabine 1gm/m2 (Group A) or vinorelbine 25mg/m2 (Group B) on days 1 and 8 every 3 wks as first line chemotherapy. Results: A total of 398 out of 415 patients were eligible for analysis on the intent to treat basis (group A: 196, group B: 202). All patient and disease characteristics were well balanced. Overall response rate (RR) was 27% for group A and 24% for group B (P=0.57). Median progression free survival (PFS) was 5.2 months (m) (95% CI, 4.4 - 5.9) and 4.7m (95% CI, 4.1 - 5.3) for groups A and B respectively (P=0.51). Median survival (OS) was 11.5m (95% CI, 9.5 - 12.6) and 9.3m (95% CI, 7.7 - 10.9) for groups A and B respectively (P=0.25). Grade 3/4 neutropenia was worse (P<0.001) in group B. Febrile neutropenia and severe infections were more prominent (P<0.001, P=0.005 respectively) in group B. Conclusions: Although RR, PFS, OS are similar in both groups, toxicity is significantly worse in group B and therefore further investigation of PV is of no value.

No significant financial relationships to disclose.

Dual inhibition of aromatase and epidermal growth factor receptor in non-small cell lung cancer

e22189

Background: Recent evidence suggests that estrogen signaling is important in the progression of cancers expressing estrogen receptors (ERs) and may also be involved in the pathogenesis of non-small cell lung cancer (NSCLC). Aromatase is an enzyme complex that catalyses the final step in estrogen synthesis and is present in several tissues, including the lung. In view of a possible functional interaction between the ER and the epidermal growth factor receptor (EGFR) pathways in NSCLC, we investigated the dual inhibition of aromatase and EGFR in NSCLC cell lines. Methods: In the current study we used exemestane, an irreversible steroidal aromatase inactivator, and erlotinib, an EGFR tyrosine kinase inhibitor. The in vitroexperiments were performed using H23 and A549, two NSCLC cell lines with low and high levels of aromatase, respectively. Cell proliferation was measured by MTT assay. Metalloproteinase (MMP) levels were detected by zymography and cell migration was determined by boyden chamber assay. EGFR protein levels detection was performed by immunofluorescense assay. Results: Exemestane and erlotinib inhibited H23 and A549 cell proliferation either alone or in combination, 48 hours after their application. However, the combination of exemestane and erlotinib was more effective than each agent alone, in H23 cells. Furthermore, exemestane decreased MMP-2 and MMP- 9 levels in H23 cells, whereas erlotinib did not. The combination of exemestane and erlotinib had the same effect on MMPs, as exemestane alone. The effect on cell migration was in line with the results in MMPs levels. In A549 cells, no changes in MMPs levels or cell migration were demonstrated. In addition, exemestane altered the location of EGFR protein in H23 cells, but not in A549 cells. Conclusions: Our findings suggest an antiproliferative effect of exemestane and erlotinib in both cell lines, as well as synergy for the combination in H23 cells. The activity of the combination in these cells with low levels of aromatase might involve an additional effect of exemestane on EGFR protein location. Erlotinib did not enhance the effect of exemestane on MMPs secretion and migration in H23 cells.

No significant financial relationships to disclose.

Effects of epoetin-alpha on quality of life of cancer patients with solid tumors receiving chemotherapy

BACKGROUND

Erythropoietin corrects and prevents anemia and decreases the need for red blood cell (RBC) transfusions; its impact on quality of life (QOL) of cancer patients receiving chemotherapy is not clear.

PATIENTS AND METHODS

399 patients with solid tumors and Hb level of < or = 12 g/dl receiving chemotherapy were randomized to receive or not 10,000 IU epoetin-alpha thrice weekly. QOL was measured by the Functional Assessment of Cancer Therapy-Anemia (FACT-An) scale and various subscales at baseline, at two months and at the end of the study.

RESULTS

Changes in the average QOL scores were similar in the two groups. The improvement in Hb levels was significantly higher for the epoetin-alpha group, with a decrease in transfusion requirements compared to the control group.

CONCLUSION

Epoetin-alpha does not improve QOL of patients with solid tumors receiving chemotherapy as assessed using FACT-An scale and various subscales, despite improving Hb levels and reducing transfusion requirements.

Effect of epoetin alpha therapy on cognitive function in anaemic patients with solid tumours undergoing chemotherapy

The primary aim of this study was to assess whether epoetin alpha (Ea) would improve cognitive performance in a group of anaemic cancer patients receiving chemotherapy. The secondary aim was to confirm the positive impact of Ea on haematological parameters, and quality of life (QOL). Fifty patients with solid tumours and haemoglobin (Hb) <11.0 g/dL received Ea 40,000 units once weekly for 12 weeks and were administered the Mini-Mental State Examination and the European Organization for Research and Treatment of Cancer (QLQ-C30) questionnaire prior to Ea therapy and at study completion. No clinically significant alterations were observed on cognitive function during Ea treatment. Changes in cognitive function were unrelated to Hb change and there were no significant differences in cognitive performance between Ea responders and non-responders. The analyses revealed clinically significant improvements in Hb levels, physical and role function, and clinically meaningful reductions in fatigue. Hb changes were significantly associated with the magnitude of improvement in QOL parameters. The lack of a clinical benefit in cognition observed in this study during Ea treatment may redirect the focus of research from enhancing to maintaining cognitive function, since stability in cognitive performance through time may be as well clinically important.

A randomised phase III trial of adjuvant radio-chemotherapy comparing Irinotecan, 5FU and Leucovorin to 5FU and Leucovorin in patients with rectal cancer: a Hellenic Cooperative Oncology Group Study

The primary objective was to compare the 3-year survival of rectal cancer patients randomised postoperatively to irinotecan (IRI), Leucovorin (LV) and bolus 5-fluorouracil (5FU) or LV-bolus 5FU with radiotherapy. Secondary objectives included disease-free survival, local relapse and toxicity. The study included 321 eligible patients. The treatment consisted of weekly administration of IRI 80 mg/m(2) intravenously (IV), LV 200 mg/m(2) and 5FU 450 mg/m(2) bolus (arm A) versus LV 200 mg/m(2) and 5FU 450 mg/m(2) IV bolus (arm B). One cycle included four infusions and treatment was continued for a total of six cycles. The first cycle was followed by pelvic irradiation plus 5FU. There were no differences between the arms in 3-year overall, disease-free and local relapse-free survival. Grades 3 and 4 toxicity was similar in both the arms with the exception of leucopaenia, neutropaenia and alopecia, which were higher in the IRI arm. IRI added to adjuvant radiochemotherapy with LV and bolus 5FU was not shown to improve survival, whereas the incidence of severe leucopaenia was significantly higher in the IRI arm.

Exploring the variability of single trials in somatosensory evoked responses using constrained source extraction and RMT

This paper describes the theoretical background of a new data-driven approach to encephalographic single-trial (ST) data analysis. Temporal constrained source extraction using sparse decomposition identifies signal topographies that closely match the shape characteristics of a reference signal, one response for each ST. The correlations between these ST topographies are computed for formal Correlation Matrix Analysis (CMA) based on Random Matrix Theory (RMT). The RMT-CMA provides clusters of similar ST topologies in a completely unsupervised manner. These patterns are then classified into deterministic set and noise using well established RMT results. The efficacy of the method is applied to EEG and MEG data of somatosensory evoked responses (SERs). The results demonstrate that the method can recover brain signals with time course resembling the reference signal and follow changes in strength and/or topography in time by simply stepping the reference signal through time.

Mitoxantrone plus vinorelbine in pretreated patients with metastatic breast cancer

Vinorelbine and mitoxantrone have both been demonstrated to have significant antitumor activity in patients with breast cancer. The aim of this study was to evaluate the efficacy and safety of the combination as second or third line treatment in patients with metastatic breast cancer (MBC). Fifty-one previously treated patients with MBC were enrolled from October 2001 to May 2004 and 48 were eligible for evaluation. Median age was 59 years (range 33-82) and ECOG performance status was < or =2. Distant sites of metastasis were as follows: liver 64%, bone 49%, lung 36%, lymph nodes 6%, skin 4%, brain 2% and other sites 6%. All patients received vinorelbine 20 mg/m(2), D1+8 and mitoxantrone 10 mg/m(2) D8 every 21 days for 6 cycles. All eligible patients were analyzed for toxicity and response. Two patients (4%) achieved complete response and 12 (25.5%) partial response. The objective overall response rate was 29.5% (95% confidence interval [CI] 17 - 45), 9 (19%) patients had stable disease, 17 (36%) had progressive disease and 7 (15%) were non-evaluable. After a median follow up of 18 months, overall survival was 13 months (range 0.8 - 38+) and median time to disease progression was 5 months (range 1 - 32). A total of 280 cycles was delivered. The relative dose intensities of mitoxantrone and vinorelbine were 79% and 77%, respectively. Toxicities (grade III-IV) were as follows: leukopenia 18 (38%), neutropenia 21 (45%), thrombocytopenia 1 (2%), anemia 4 (8.5%), alopecia 2 (4%) and constipation 1 (2%). Febrile neutropenia was recorded in one patient. There were no treatment related deaths. The combination of mitoxantrone and vinorelbine is an effective regimen with manageable toxicity in pretreated patients with advanced breast cancer.

A simplified technique for translaryngeal tracheostomy (TLT). A preliminary report

OBJECTIVE

In this prospective observational study we present preliminary results of a modification of the translaryngeal tracheostomy technique that was introduced by Fantoni in 1997. The study was conducted in a five-bed surgical intensive care unit of a university teaching hospital.

PATIENTS AND METHODS

The study included 14 consecutive surgical patients (8 men, 6 women) who underwent a modified translaryngeal tracheostomy in a 6-month period. In our modification of the technique, we keep the basic principle of the inside-to-outside approach of the Fantoni technique, and combine it with a blind needle insertion, as reported in the classic subcricoid retrograde intubation technique. The technique that we use involves two medical doctors and a nurse.

RESULTS

Mean patient age was 68.9 years (range: 31-85 years) and mean APACHE II score was 15.8 (range: 6-31). Mean operative time for the procedure was 15.2 min (range: 11.5-22 min). Eight of the patients died during the postoperative course in the ICU from causes relevant to their surgical pathology. One patient survived to be discharged from the ICU but died of an acute myocardial infraction later in the same hospital stay. Five patients survived to be discharged from the hospital.

CONCLUSIONS

The modified translaryngeal tracheostomy seems to be as reliable and safe as the original technique. In addition, the modified technique is faster and can be performed without the use of an endoscope.

Phase II study of irinotecan plus leucovorin and bolus 5 fluorouracil as first or second line chemotherapy in patients with advanced gastric or esophageal-gastric junction adenocarcinoma

15128

Background: The aim of this study was to evaluate the activity and safety of 5-fluorouracil (5-FU) / leucovorin (LV) and irinotecan as first- or second-line treatment in patients with advanced gastric adenocarcinoma. Methods: Treatment consisted of irinotecan 80 mg/m2 intravenously (i.v.), followed by LV 200 mg/m2 (i.v.) and 5- FU 450 mg/m2 as an i.v. bolus. Treatment was administered weekly for 6 weeks, followed by a 2-week rest period. Results: Thirty-one patients (23 chemo-naïve, 8 chemo-exposed) were enrolled. The overall response rate was 22.6% and the disease control rate was 38.7%. Among the patients who received the regimen as first-line treatment, objective response rate was 30.4% and the disease control rate was 52.1%. However, progression of the disease was recorded in all the patients receiving the combination as second-line chemotherapy. The median time to disease progression (TTP) was 4 months and the median duration of survival was 7 months. The median TTP was 6 months for patients treated with first-line chemotherapy and 2.5 for those who received study treatment as second line. Furthermore, the median survival duration was 8 months and 6 months, respectively. The most frequent grade 4 toxicity was febrile neutropenia. Grade 3 or 4 non-hematological toxicities were rare. There were no treatment-related deaths. Conclusions: The combination of 5-FU/LV and irinotecan as first-line treatment was found to be well tolerated, with efficacy comparable to that of other regimens in advanced gastric cancer. Accordingly, this regimen can be regarded as one of first-line options, particularly in patients who can not tolerate aggressive chemotherapy.

No significant financial relationships to disclose.

Clinical and electrophysiological features of peripheral neuropathy induced by administration of cisplatin plus paclitaxel-based chemotherapy

The current prospective study sought to trace the incidence and severity of cisplatin plus paclitaxel (DDP+P)-induced neuropathy and to determine its clinical and electrophysiological pattern. Furthermore, it was attempted to describe its evolution by following up the course of peripheral neuropathy (PN) during chemotherapy as well as 3 months after its discontinuation. Thirteen adult patients scheduled to be treated with six courses of cumulative DDP+P-based regimens for a non-myeloid malignancy participated in this study. These patients were clinically and electrophysiologically monitored at baseline, during chemotherapy and 3 months after its discontinuation. The severity of PN was summarized by means of a modified PN score. Evidence of PN was disclosed in nine of the 13 patients (69.2%). The mean PN score for patients that manifested some grade of PN was 17.3 +/- 6.1 (range 9-28). All longitudinal comparisons concerning the motor conduction velocities (MCV) variables failed to reach significance. By contrast, comparisons of the mean changes at baseline and each of the follow-up studies revealed a significant decrease in all sensory action potentials examined. The follow-up evaluation performed 3 months after the discontinuation of chemotherapy showed that the DDP+P-induced neuropathy persists and progresses over time. Our results indicate that the majority of patients treated with a DDP+P-based regimen at full dose intensities would manifest an axonal, predominately sensory PN, of mild to moderate severity, which would persist for several months after the discontinuation of chemotherapy.

Efficacy of oxcarbazepine for prophylaxis against cumulative oxaliplatin-induced neuropathy

We conducted a randomized, open-label, controlled trial to assess the efficacy of oxcarbazepine for prophylaxis against oxaliplatin-induced peripheral neuropathy (OxIN). Thirty-two patients with colon cancer received 12 courses of the FOLFOX-4 regimen and were randomly assigned to receive oxcarbazepine (600 mg BID) or chemotherapy without oxcarbazepine. The incidence of OxIN was strikingly decreased in patients receiving oxcarbazepine (31.2% vs 75%). Oxcarbazepine may prevent OxIN symptoms. Further larger placebo-controlled trials are warranted to confirm our results.

Mitoxantrone plus gemcitabine in pretreated patients with metastatic breast cancer

Gemcitabine and mitoxantrone have both shown significant antitumor activity in patients with breast cancer. The aim of this study was to evaluate the efficacy and safety of this combination as second or third-line treatment in patients with metastatic breast cancer (MBC). Forty-six previously treated patients with MBC were enrolled from June 2000 to November 2002. Mean age was 56 years and ECOG performance status was < or =2. All patients received mitoxantrone 10 mg/m2, D8 and gemcitabine 1000 mg/m2, D1+8 every 21 days for 6 cycles. There were no complete responders. Objective response was observed in 12 patients (26%), 15 (33%) patients had stable disease, 15 (33%) had progressive disease and 4 (9%) were non-evaluable. At median follow-up of 27.8 months, overall survival was 13.3 months (range 0.6-33.8+) and the median time to disease progression (TTP) was 4.4 months (range 0.2-33.8). Toxicities (grade 3-4) were as follows: leukopenia 18 (39%), neutropenia 19 (41%), thrombocytopenia 4 (8.5%), anemia 6 (13%) and alopecia 1 (2%). Febrile neutropenia was recorded in 2 (4%) patients. There were no treatment related deaths. The authors conclude that the combination of mitoxantrone and gemcitabine is an effective regimen in pretreated patients with metastatic breast cancer. Toxicity was manageable.