Efficacy and safety of nilotinib in patients with KIT-mutated metastatic or inoperable melanoma: final results from the global, single-arm, phase II TEAM trial

Background

The single-arm, phase II Tasigna Efficacy in Advanced Melanoma (TEAM) trial evaluated the KIT-selective tyrosine kinase inhibitor nilotinib in patients with KIT-mutated advanced melanoma without prior KIT inhibitor treatment.

Patients and methods

Forty-two patients with KIT-mutated advanced melanoma were enrolled and treated with nilotinib 400 mg twice daily. TEAM originally included a comparator arm of dacarbazine (DTIC)-treated patients; the design was amended to a single-arm trial due to an observed low number of KIT-mutated melanomas. Thirteen patients were randomized to DTIC before the protocol amendment removing this study arm. The primary endpoint was objective response rate (ORR), determined according to Response Evaluation Criteria In Solid Tumors.

Results

ORR was 26.2% (n = 11/42; 95% CI, 13.9%–42.0%), sufficient to reject the null hypothesis (ORR ≤10%). All observed responses were partial responses (PRs; median response duration, 7.1 months). Twenty patients (47.6%) had stable disease and 10 (23.8%) had progressive disease; 1 (2.4%) response was unknown. Ten of the 11 responding patients had exon 11 mutations, four with an L576P mutation. The median progression-free survival and overall survival were 4.2 and 18.0 months, respectively. Three of the 13 patients on DTIC achieved a PR, and another patient had a PR following switch to nilotinib.

Conclusion

Nilotinib activity in patients with advanced KIT-mutated melanoma was similar to historical data from imatinib-treated patients. DTIC treatment showed potential activity, although the low patient number limits interpretation. Similar to previously reported results with imatinib, nilotinib showed greater activity among patients with an exon 11 mutation, including L576P, suggesting that nilotinib may be an effective treatment option for patients with specific KIT mutations.

Clinical Trial Registration

ClinicalTrials.gov, NCT01028222.

Phase III trial of low-level laser therapy to prevent induced oral mucositis in head and neck cancer patients submitted to concurrent chemoradiation

LBA5524

Background: Oral mucositis (OM) remains a limiting factor in in head and neck squamous cell carcinomas (HNSCC) patients (pts) treated with chemoradiation (CRT) leading to pain, dysphagia, and weight loss. Low-level laser therapy (LLLT) emerges as a promising, preventive therapy of CRT-induced OM. Yet, a definitive randomized trial supporting its use is lacking. This study was designed to assess the efficacy of LLLT in reducing the incidence and/or severity of OM. Methods: Assuming OM grade (G3) for placebo 0.4 (P0); LLLT 0.15 (P1) ; β=0.2; α=0.05, sample size was 94 pts. From Jun 2007 to Dec 2010, 47 LLLT and 47 placebo pts bearer of HNSCC of nasopharynx, oropharynx and hipopharynx entered a prospective, randomized, double blind, placebo-controlled, phase III trial. CRT consisted of conventional RT 70.2 Gy (1.8Gy/d, 5 times/wk) + concurrent cisplatin 100 mg/m2 every 3 wks. Main endpoints were OM incidence and severity, RT interruptions due to OM and pain intensity. The LLLT used daily was a diode InGaAlP (660nm-100mW-4J/cm²). OM evaluation was done by WHO and OMAS scale. Results: Mean age was 54.6 and 87.2% of pts were male. Primary site: oropharynx (74 pts), nasopharynx (9 pts), hypopharynx (11 pts). In the LLLT arm the incidence of OM G 3/4 was only 6.4% versus 48% in the placebo arm; HR of 0.13 (IC 95%, p<0.001). Besides in the LLLT arm 51% of pts did not have ulcers versus 17% in placebo arm (p<0.001). LLLT pts had less severe pain (p=0.012), used less narcotic analgesic, HR 0.33 (IC 95%, p<0.001) and required less gastrostomia, HR 0.037 (IC 95%, p= 0.005). No LLLT pts had RT interrupted due to OM. EORTC QLQ-C30 and its specific head and neck module QLQ-H&N35 were applied. Results clearly favored the LLLT arm. In QLQ-C30 benefit was seen in both physical and emotional functioning (p=0.037), fatigue (p=0.011), pain (p=0.043); and in QLQ-H&N35, pain (p=0.007), swallowing (p=0.001) and trouble with social eating (p=0.026). Conclusions: Our results indicate that upfront LLLT in HNSCC pts submitted to CRT is an effective tool in reducing G 3/4 OM, oral pain, use of narcotic and gastrostomia. QoL data supports the efficacy findings. Thereby LLLT should be the new standard of care in this setting.

Prognostic impact of radiology response and tumor volume among patients with locally advanced squamous cell carcinoma of the head and neck (LASCHNC) treated with concomitant chemoradiation

e17035

Background: There are no validated prognostic factors to predict response of chemo/RT in LASCHNC. Tumor volume as well as post-treatment CT radiology response have been studied in small retrospective series. An analysis of tumor volume and CT radiology response-score to endoscopic and pathologic responses as well as disease free survival was performed. Methods: In a single institution phase I-II study LASCHNC of oropharynx, hypopharynx and larynx were treated with concurrent radiation, cisplatin and erlotinib. 34 patients (pts) underwent a base line and post treatment CT (after 6 weeks), endoscopic evaluation and biopsy. Tumor volume was measured by multiplying the longest diameter by 0,523. (Cancer Res Clin Oncol. 2005), CT post-treatment changes score used as proposed by Pamejier et al., using a 3-point CT-score: 1 = expected post-treatment changes; 2 = focal mass with a maximal diameter of < 1 cm and/or asymmetric obliteration of laryngeal tissue planes; 3 = focal mass with a diameter of > 1 cm, or < 50% estimated tumor volume reduction. Results: Median tumor volume (mTV) was 21cm3 (0.3 to 178), median disease free survival (mDFS) in pts with tumor volume greater than mTV was 20.4 months and not reached in patients with tumor volume lower than mTV, log-rank 5.9, p = 0.015. The median tumor volume reduction by CT was 84% (-62 a 100%), 8pts were classified as score 1 (23.5%), 1pt score 2 (2.9%), 25pts score 3 (73%). There was a tendency for shorter DFS for those with a score 3, log-rank 3.05, p = 0.08. With a median follow-up of 24 months, 88% of score 1.2 are alive, versus 56% of score 3. Conclusions: There is a great variability in TV in LASCHNC, small tumor volumes were related to longer DFS and there is no correlation between tumor reduction and post-treatment CT score.

No significant financial relationships to disclose.

Phase II study of erlotinib combined with cisplatin and radiotherapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN)

6033

Background: Preclinical data indicates synergy of erlotinib with both cisplatin and radiotherapy (RT). We previously reported the phase I results with the dose of erlotinib defined as 150 mg/day. Methods: Patients (pts) with stages III and IV SCCHN were included. Treatment consisted of RT (70.2 Gy in 8 weeks), and cisplatin (C) (100mg/m2, q 21 days for 3 doses), both starting on Day 8. Erlotinib (E) was started on Day 1 and continued until the end of RT. Patients with N2/N3 disease were evaluated for elective neck dissection post RT. Results: Thirty one pts have been accrued to the study. Median age was 55 years (35–73), 13 pts had larynx carcinoma (stage III 9pts, IVA 3pts, IVB 1pts), 13pts oropharynx (stage III 2pts, IVA 8pts, IVB 3pts) and 5pts hypopharynx (stage III 1pt, IVA 4pts). Twenty five pts completed treatment and are evaluable for response and toxicity. Grade III or IV toxicity included: in-field dermatitis (14pts), nausea (13pts), mucositis (9pts), emesis (8pts), cutaneous infection (3pts), acneiform rash (7pts), fatigue (7pts), dysphagia (6pts), respiratory infection (4pts), neutropenia (1pt), diarrhea (1pt) and 1pt died due to sepsis. The dose of C was reduced in 4pts and withheld in 3pts; RT was delayed in 6 pts (median of 8 days). Twenty one pts (84%) required enteral feeding. Response was accessed by endoscopy with biopsy and CT/MRI scans. Twenty one pts (84%) had complete pathological response, 2 had residual disease and were submitted to salvage surgery, and 1 had disease progression. The median follow-up is 10.8 months. Five pts (23%) had a local relapse. Nineteen pts are disease-free (16 with organ preserved), 2 alive with disease, and 3 pts died due to disease progression. Conclusions: The combination of RT+C+E showed a high complete pathological response and acceptable toxicity, despite the high incidence of grade III/IV in-field dermatitis. These results encourage the design of a phase III trial. Final results will be presented at the meeting.

No significant financial relationships to disclose.

The impact of previous tracheostomy in patients with locally advanced squamous cell carcinoma of the larynx submitted to concurrent chemotherapy and radiation

6004

Background: The combination of chemotherapy and radiotherapy is a standard treatment for locally advanced larynx cancer. Patients presenting with previous tracheostomy due to aiway obstruction have a worse clinical outcome when submitted to a total laryngectomy or radiotherapy; the impact of previous tracheostomy is not clear in patients submitted to chemotherapy combined with radiation. Methods: A single-institutional study, patients with stage III and IV laryngeal carcinoma were prospectively selected from 2000 to 2003. Treatment consisted of Cisplatin 100 mg/m2 every three weeks for 3 cycles concurrent with radiotherapy to a total dose of 70.2 Gy. Prognostic factors like stage, age, performance status, chemotherapy completion, treatment response and previous tracheostomy were correlated on univariate and multivariate analysis with treatment response, progression-free and overall survival. Results: Forty-nine patients were selected, previous tracheostomy was performed in 12 (24,5%) before chemo/radiation therapy. Patients with tracheostomy had an inferior median overall cancer-specific survival (12 months versus 56 months), HR 2.37 (CI 95% 1.43–3.93) p=0.001, progression free-survival HR 2.8 (CI 95% 1.61–4.89) p<0.001 and lower rates of complete responses (40 versus 75%). The impact of previous tracheostomy was not altered when adjusted by number of chemotherapy cycles, tumor stage, performance status, age or treatment response. On a cox regression analysis for overall cancer-specific survival it was the strongest prognostic factor HR 7.75 (CI 95% 2.75–21.84) p<0.001. Conclusions: Previous tracheostomy is an independent negative prognostic factor for patients submitted to chemotherapy combined with radiation. Tracheostomty should be considered in the design of future studies and to select patients to different treatment strategies.

No significant financial relationships to disclose.

Retrospective analysis of patients with nonseminomatous testicular germ cell tumor and resection of postchemotherapy residual lung and mediastinal masses

15633

Background: Treatment of nonseminomatous testicular germ cell tumor (NSGCT) involves surgery of postchemotherapy (PC) residual masses. The resection of immature teratoma or viable cancer prolongs disease-free and overall survival. Discordance of histology among different sites of residual masses has been reported to occur in one-third of the patients and therefore, all identified masses must be removed. This study aims to evaluate the histology of residual masses in patients submitted to thoracic surgery for NSGCT and estimate time to progression after surgery and overall survival. Methods: Retrospective analysis of all patients with NSGCT and PC residual lung and mediastinal masses treated at the Brazilian National Cancer Institute between 1997 and 2006. Results: Of the 16 patients included, 10 patients had residual lung masses, 5 had both lung and mediastinal masses and 1 had mediastinal mass. Median age at diagnosis was 26.5 years. Embryonal carcinoma plus yolk sac tumor was the most frequent testicular histology (31%). Nine (56%) had stage IIIC disease and 7 (44%) were high-risk at the IGCCCG score. All patients received platinum-based chemotherapy (one had platinum-refractory disease). Of the 15 patients who had lung masses, 8 had bilateral disease. Histology of residual lung masses was necrosis in 8 patients (53%) and teratoma in 7 (47%). There was 100% concordance in the histology of bilateral lung masses. Ten patients (62%) had concomitant retroperitoneal masses. In only 3 of these patients (33%) there was concordance between retroperitoneal and lung histology. Median follow-up after surgery was 21.5 months. Five of the 16 patients (31%) had disease progression. One patient died (this patient had platinum-refractory disease). Median time to progression was 10 months and median overall survival was not reached. Conclusions: These data confirmed the small concordance between the histology of PC residual masses in the lung/ mediastinum and retroperitonium in NSGCT. There was concordance in the histology of bilateral lung masses. These findings suggest that all sites of residual masses should be resected and the presence of necrosis in residual lung masses indicates no need for contralateral resection.

No significant financial relationships to disclose.

Phase I/II study of erlotinib combined with cisplatin and radiotherapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN)

5575

Background: Erlotinib has single agent activity in SCCHN. Preclinical data indicates synergy with both cisplatin and radiotherapy (RT). Methods: This phase I/II study included patients (pts) with stages III and IV SCCHN. Pts received therapy with RT 70.2 Gy for 8 weeks and cisplatin (C) 100 mg/m2, 3 doses every 3 weeks, both starting on Day 8. Erlotinib (E) was started on Day 1 and continued until the end of RT. Phase I doses were escalated in cohorts of 3 pts/dose level: level 1–50 mg, level 2–100 mg and level 3–150 mg. In case of grade IV toxicity leading to RT interruption, 3 additional pts were included in the same dose level. Frozen tissue for molecular studies was collected before and after treatment. Results: Phase I was completed with 9 patients. No patient had RT interruption due to grade IV toxicity. Consequently 150 mg/day was established as the phase II dose. Twelve patients have been included in the phase II part of the trial. Final toxicity data is available for 13 patients (9 from phase I and 4 from phase II). Median age was 58 years, 10 pts had laryngeal carcinoma (stage III 4pts, IVA 3 pts, IVB 3 pts) and 3 oropharyngeal carcinoma (stage III 1pt, IVA 1pt, IVB 1 pt). The dose of C was reduced or held in 3 pts due to ototoxicity (2 pts) and neutropenia (1 pt). Other grade III or IV toxicity included dermatitis (8 pts), skin rash (3 pts), respiratory infection (2 pts), nausea (2 pts), neutropenia (2 pts), mucositis (2 pts) and cutaneous infection (1 pt). Response was accessed by direct visualization/biopsy and CT/MRI scans. Among the 13 patients who have completed treatment, 11 (84.6%) achieved complete pathological response, 1 had residual disease and 1 disease progression. Conclusions: This trial establishes the standard dose of erlotinib, 150 mg/day, as safe to be combined with full dose cisplatin and radiotherapy, in locally advanced SCCHN. Accrual for the phase II study is ongoing and additional response and toxicity data will be presented at the meeting.

No significant financial relationships to disclose.

XIAP mRNA levels but not XAF1 or XIAP/XAF1 mRNA levels predict pathological response in bladder cancer patients treated with neoadjuvant chemotherapy

20030

Background: The relation between apoptosis-related molecules and chemosensitivity has been extensively studied. In recent years, attention has shifted to a new family of inhibitor of apoptosis proteins (IAPs). XIAP (X- linked inhibitor of apoptosis) is the most versatile and potent member of the IAP family. To date, the overexpression of XIAP has been detected in various cancers. XAF1 (X-linked inhibitor of apoptosis associated factor 1) is a new protein identified for its ability to interact with XIAP. Neither XIAP nor XAF1 or XIAP/XAF1 mRNA expression have been studied in bladder cancer patients. Methods: The expression of XIAP and XAF1 mRNA was analyzed by a real time quantitative fluorogenic PCR method in a group of 17 patients with locally advanced bladder cancer treated with a combination of neoadjuvant Gemcitabine and Cisplatin. The prognostic significance of XIAP and XAF1 mRNA expression and the correlation with several clinicopathological variables was evaluated. Results: XIAP and XAF1 mRNA expression was detected in all 17 (100%) case samples. The levels of XIAP mRNA expression showed a moderate variation among samples. In contrast, XAF1 and XIAP/XAF1 mRNA levels showed significant variation among samples. Bivariate correlation analyses revealed a significant positive Spearman direct correlation coefficient between the XIAP expression and the pathological response. No significant correlation was found for XAF1 expression as well as for the XIAP/XAF1 ratio and clinical and pathological response. Conclusions: This is first study to address the role of XIAP, its negative regulator XAF1, and the XIAP/XAF1 ratio in bladder cancer patients. The positive correlation between the XIAP mRNA expression and the pathological response is in line with a previous study from our group in which a correlation was found between XIAP expression and survival. All these observations point to a complex role of XIAP in tumor biology. XAF1 mRNA expression in bladder carcinomas did not achieve significance as an independent predictive and prognostic factor in a bivariate analysis. Further studies are necessary in order to better assess a possible clinical value for XIAP and XAF1 as predictive and prognostic markers in cancer patients.

No significant financial relationships to disclose.

A phase I trial of erlotinib (E), cisplatin (C) and radiotherapy (RT) for patients with locally advanced squamous cell cervical cancer

13081

Background: Pre-clinical data indicates that inhibition of epidermal growth factor receptor (EGFR) potentiates the effect of RT. This phase I trial aims to determine the maximal tolerated dose (MTD) of erlotinib, an oral EGFR tyrosine kinase inhibitor, when administered concurrently with standard chemoradiation (CRT) for cervical cancer. Methods: In a modified Fibonacci design, two cohorts of three patients received escalating doses of E (50 mg/100 mg) one week before and combined with C (40 mg/m2, weekly, 5 cycles) and RT (external beam RT - 5040 cGy in 28 fractions, followed by 4 fractions/700 cGy/weekly of brachytherapy). Eligibility criteria included histologically proven squamous cell cervical carcinoma, stage III; no prior therapy; ECOG PS <3 and adequate end-organ functions. Patients were allowed four additional weeks of toxicity observation after CRT + E before proceeding to the next cohort. Frozen tissue for molecular studies was collected before treatment. Results: Considering the first two cohorts, patients presented median age 48 (36–59), stage IIIB (all patients). Median duration of treatment was 71 (70–104) days. Most common non-hematological toxicity were mild to moderate rash, fatigue, diarrhea (grade 3 in one patient), nausea and dysuria. Grade 3 leukopenia was observed in only one patient. Dose limiting toxicities have not been reported so far. Five patients had complete response and one patient had partial response (MRI). Of note, 5/6 patients reported clinical benefit (bleeding cessation) after one week on E alone. The third study cohort (E = 150 mg) is ongoing. Conclusions: This is the first report of a combination of erlotinib, cisplatin and pelvic RT. The addition of E to standard CRT does not appear to increase in-field or systemic toxicities. MTD has not been defined so far. Final results of the phase I will be presented at the meeting.

[Table: see text]

Phase II trial of gemcitabine and cisplatin as neoadjuvant chemotherapy for invasive bladder cancer: Preliminary results

14590

Background: Gemcitabine and cisplatin (GC) is an active and well tolerated combination in the treatment of metastatic bladder cancer (BC). Studies of neoadjuvant chemotherapy in BC suggest improved survival, especially for patients with complete pathologic response. We have prospectively analyzed the tolerability and efficacy of GC as neoadjuvant treatment of invasive BC. Methods: in this single-institution, one-stage phase II trial, patients (pts) with histologically verified muscle-invasive transitional cell carcinoma received 3 cycles of gemcitabine 1200 mg/m2 on days 1 and 8 with cisplatin 75 mg/m2 on day 1 prior to surgery. Radiologic response was evaluated with computed tomography and magnetic resonance imaging. Planned accrual was 35 pts. Primary endpoint was clinical and pathological response rate. Results: between Jun 2002 and Mar 2005, 22 pts (19 males) were enrolled. Accrual was poor due to a higher percentage of superficial tumors than expected. Median age was 61 years. All pts had Performance Status 0 or 1. Initial stage was II (T2) in 11 and III (T3–4) in 11 pts. Chemotherapy was well tolerated with infrequent grade III/ IV toxicity (nausea/ vomiting in 27%, neutropenia in 23% and neutropenic fever in 1 patient). Median follow-up is 26 months (6–40). Partial radiologic response rate was documented in 15 out of 19 assessable pts (79%). One patient was excluded due to renal toxicity in the first chemotherapy cycle and other had sarcomatoid carcinoma at definitive pathologic examination. By Dec 2005, 14 pts underwent radical cystectomy, 4 pts pelvic radiotherapy, 1 is waiting surgery and 1 had systemic progression before surgery. Nine out of 20 pts (45%) relapsed (8 systemic and 1 local) and 4 (20%) are dead (3 with confirmed disease progression). Complete pathologic response was observed in 3 pts (21.5% of 14) and local progression during chemotherapy in another 3 pts. Median estimated progression-free survival by Kaplan-Meier is 27 months (CI 95% 20.5–33.5) with median overall survival not reached. Conclusions: the combination of gemcitabine and cisplatin is effective and tolerable when used as neoadjuvant therapy in muscle-invasive bladder cancer. Longer follow-up is necessary to evaluate its impact in the overall survival of these pts.

[Table: see text]