Clinical outcomes of immune checkpoint inhibitor diabetes mellitus at a comprehensive cancer center

Introduction: Immune checkpoint inhibitor-associated diabetes mellitus (ICI-DM) is a rare adverse event. In this study, we characterize clinical outcomes of patients with ICI-DM and evaluate survival impact of this complication on melanoma patients. Research design & methods: We conducted a retrospective review of 76 patients diagnosed with ICI-DM from April 2014 to December 2020. Results: 68% of patients presented in diabetic ketoacidosis, 16% had readmissions for hyperglycemia, and hypoglycemia occurred in 70% of patients after diagnosis. Development of ICI-DM did not impact overall survival or progression-free survival in melanoma patients. Conclusion: Development of ICI-DM is associated with long-term insulin dependence and pancreatic atrophy; the use of diabetes technology in this patient population can help improve glycemic control.

Histopathologic features predictive of metastasis and survival in 230 patients with cutaneous squamous cell carcinoma of the head and neck and non-head and neck locations: a single-center retrospective study

BACKGROUND

Staging systems for cutaneous squamous cell carcinoma (cSCC) produce inconsistent risk stratification.

OBJECTIVE

The aim of this study was to identify further prognostic parameters for better stratification.

METHODS

We retrospectively analysed the prognostic significance of clinicopathologic parameters of 230 patients who underwent primary excision of invasive cSCC of the head and neck (n = 115) and non-head and non-neck (n = 115) locations. In addition to known high-risk features, we analysed tumour nest shape, invasion pattern, lymphoid response pattern and tumour budding.

RESULTS

On multivariable analysis, lymphovascular invasion (LVI) and high tumour budding predicted worse disease-specific survival, and ulceration, LVI and high tumour budding predicted worse overall survival. Only ulceration was independently associated with risk of nodal metastasis.

CONCLUSION

High tumour budding, LVI and ulceration are independently associated with poor outcome in cSCC and may be used to refine cSCC prognostic stratification, which is crucial to optimize clinical decision and to identify patients who are more likely to benefit from more aggressive interventions or clinical trials.

Phase I/II study of the selective PI3Kβ inhibitor GSK2636771 in combination with pembrolizumab in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC) and PTEN loss

5052

Background: PTEN loss activates the PI3K/AKT signaling pathway, contributes to an immunosuppressive tumor microenvironment, resistance to androgen deprivation therapy and poor clinical outcome in pts with mCRPC. Treatment with anti-PD1 antibodies improves survival in many cancers, but efforts to harness its benefit in mCRPC have been unsuccessful. In preclinical PTEN loss models, selective PI3Kβ inhibitor enhanced survival and the frequency of intratumoral T cells. We hypothesized that the combination of PI3Kβ inhibitor and anti-PD-1 antibody is safe and promotes antitumor activity. To test this, we conducted a phase I/II study (NCT01458067) of PI3Kβ inh GSK2636771 and pembrolizumab in pts with solid tumors (including melanoma and mCRPC) with PTEN loss. We report the results from a cohort of pts with mCRPC and PTEN loss. Methods: The phase I primary objective was to determine the safety, tolerability, and recommended phase II dose (RP2D) of GSK2636771 + pembrolizumab using a 3+3 design. Pembrolizumab was given at 200 mg IV Q3W and dose escalation started at 300mg orally daily of GSK2636771 for 21 days cycle. The phase II primary objective was to evaluate the efficacy of the combination using RECIST 1.1. Secondary objectives were to evaluate PK and PD effects in tumor and blood. Tumoral PTEN loss was defined by loss of protein expression by IHC or by presence of an inactivating mutation identified by next-generation sequencing (NGS). Results: A total of 12 pts with mCRPC and PTEN loss were enrolled (2 pts in the dose escalation and 10 pts in the dose expansion cohorts). Median age was 67 years (range 55-80) and pts had a median of 4 lines of prior therapies with 83% of pts receiving prior taxane-based chemotherapy. The RP2D was identified at 200mg PO QD of GSK2636771 + pembrolizumab 200mg IV Q3W. Most treatment-related adverse events were grade (G) 1-2 with the most common being diarrhea (33%) and rash (42%). A total of 4 pts had G3 rash, including 2 pts with G3 immune-related bullous pemphigoid. Dose-limiting toxicities in pts with mCRPC included G3 hypophosphatemia and G3 rash. Treatment was discontinued because of G3 toxicity in 1 pt and 42% of pts required a dose reduction of GSK2636771. Among 11 evaluable pts at 200mg daily of GSK2636771, partial response (PR) was achieved in 2 pts (-56% and -59% as compared to baseline, per RECIST1.1), which was associated with ongoing progression free survival (PFS) > 12 months (24.1 and 13.6 months, respectively) and PSA > 50% reduction as compared to baseline. In addition, a pt with tumor reduction of 18% per RECIST1.1 has remained on treatment for 15.8 months. Conclusions: GSK2636771 plus pembrolizumab had an acceptable safety and tolerability profile. The combination showed promising preliminary antitumor activity and durable responses in a heavily pretreated population of pts with mCRPC. Clinical trial information: NCT01458067.

Lenalidomide: Based maintenance after autologous hematopoietic stem cell transplant for patients with high-risk multiple myeloma

e20024

Background: Maintenance therapy with single-agent lenalidomide (Len) after autologous hematopoietic stem cell transplantation (autoHCT) for multiple myeloma (MM) is associated with improved progression-free survival (PFS). However, patients with high-risk chromosomal abnormalities may need a more intense regimen. We hypothesized that adding another anti-myeloma drug to Len would lead to improved outcomes. Methods: We conducted a retrospective single-center chart review of adult MM patients with high risk cytogenetic abnormalities that received autoHCT between 2008-2018, followed by Len-based maintenance therapy. High risk cytogenetics were defined as del17p, t(4;14), t(14;16), 1q21 gain or amplification by fluorescence in situ hybridization. We divided patients into those who received either single-agent Len maintenance (Len-only) or Len-based combinations (Len-combo). We compared PFS, overall survival (OS), non-relapse mortality (NRM), day 100 and best post-transplant responses, and minimal residual disease (MRD) status between groups. We performed sensitivity analyses using inverse probability weights to correct for potential bias due to nonrandomization of the two groups. Results: A total of 231 patients with HRMM were included in our analysis, with a median age of 62.4 (range 33.5-79.9) years, and 55% were male. There were 153 patients in the Len-only group and 78 in the Len-combo group. Len-combo regimens were either doublets (Len with dexamethasone [dex: n = 10], elotuzumab [n = 28] or ixazomib [n = 14]) or triplets (Len with bortezomib/dex [n = 10], ixazomib/dex [n = 10] or carfilzomib/dex [n = 6]). More patients in the Len-combo group had >2 high risk cytogenetic abnormalities compared to the Len-only group (32% vs. 12%: p < 0.001). Busulfan + melphalan (Bu-Mel) conditioning was used in 12% vs. 18% in Len-only vs. Len-combo groups (p = 0.32). The final best response post-transplant of sCR/CR was 50% in the Len-only group vs. 54% in the Len-combo group (p = 0.72). Median follow up was 40.7 and 35.3 months, with Len-only and Len-combo, respectively. Median PFS and OS for all patients were 25.5 and 82.6 months, respectively. There was no significant difference in PFS (HR: 1.01, CI: 0.71-1.44, p = 0.94) or OS (HR: 0.84, CI: 0.49-1.43, p = 0.52) between groups. Similarly, there was no difference in outcomes between the groups whether they received conditioning with melphalan-only or Bu-Mel. However, for patients with HR cytogenetic abnormalities other than 1q+ there was a trend towards better PFS with Len-combo (HR 0.59, CI 0.32-1.09, p = 0.09), without a difference in OS (HR: 0.79, CI: 0.37-1.65, p = 0.53). Conclusions: In this single center retrospective analysis, intensification of post-transplant Len maintenance did not show an improvement in outcomes for HRMM patients. However, there was a trend towards improved PFS in patients with HR abnormalities other than 1q+.

Outcomes of BRAF mutant metastatic melanoma (MM) patients (pts) after cessation of targeted therapy (TT) with BRAF or BRAF/MEK inhibitor(i)

9564

Background: Since their introduction into the clinic a decade ago, BRAF and BRAF/MEKi have dramatically changed the outcomes of pts with BRAF mutant MM. While typically, these agents are administered until progression (PD), other reasons for stopping TT include unacceptable toxicity, complete response to treatment, or pt/physician decision or preference. The outcomes for MM pts that stop TT for reasons other than PD are largely unknown. Here we report the clinical features and outcomes of the largest cohort of MM pts who stopped TT for reasons other than PD to date. Methods: Under an institutionally approved database, we identified MM pts treated at the MD Anderson Cancer Center with BRAF±MEK inhibitors, and their records were reviewed to identify pts that stopped TT for reasons other than PD. Pts demographics, treatment information and clinical outcomes were recorded. Overall survival (OS) time was computed from three start dates (initial diagnosis, initial unresectable stage III melanoma, 1st dose of TT) to last known vital sign. Pts alive at the last follow-up date were censored. Time to recurrence was computed from date of 1st dose of TT to recurrence. Pts who did not experience disease recurrence were censored The Kaplan-Meier method was used to estimate OS and time to recurrence. Results: A total of 58 pts were identified, 32 (55%) were male. Most pts had a BRAF V600E (n = 49) or V600K (n = 6) mutation. At TT initiation median age was 59.5 years (range 29- 95), LDH was within normal range in 46 (85%), median number of prior systemic therapies was 1 (range 0-5), with 50% of pts receiving prior systemic therapy. Most (n = 33; 57%) pts were treated with single agent BRAFi (12 with dabrafenib, 11 vemurafenib). Among pts treated with combination TT (n = 25), most received dabrafenib with trametinib (n = 21; 84%). Median TT treatment duration was 9.5 months (range 0.03-80.5 months). Reasons for TT discontinuation were unacceptable toxicity (n = 29; 50%) and pt or physician decision/preference in responding patients (n = 23; 40%). At time of TT discontinuation, 48% of pts had achieved a complete response (CR), 28% a partial response (PR), and 22% stable disease (SD), 1 patient had unknown disease status. With standard follow-up, after stopping TT, 40 pts (69%) have recurred or experienced PD, with a median time to recurrence of 14.9 months (95% CI:7.8-26.3 months). At PD, 32 (76%) of pts had new metastatic sites. After PD 26 pts (63%) pts received BRAF/MEKi, 11 (44%) achieved a CR and 6 (24%) a PR, and 5 (20%) for a response rate of 88%; while 3 (12%) pt had PD as best response and 1 was unknown. For the full cohort, the median OS from time of 1st dose of TT was 6.4 years. Conclusions: Among MM pts who stopped TT for reasons other than PD, the majority of pts recurred, but most responded to re-introduction of TT. This information can help to inform discussion with pts regarding cessation of, or re-challenge with, TT.

Predictors of overall survival (OS) in patients (pts) with melanoma brain metastasis (MBM) in the modern era

9540

Background: The management and OS of pts with metastatic melanoma have improved due to new systemic therapies. However, relatively little is known about the use of these treatments (tx) and their association with OS in pts with MBMs. We reviewed a large cohort of MBM pts to assess how pt demographics, disease characteristics, and MBM tx impact OS in the current era. Methods: Under an institutional review board-approved protocol, retrospective data were curated and analyzed from pts diagnosed with, and received tx for, MBM from 2014 to 2018 at the MD Anderson Cancer Center (MDA). Pts diagnosed with uveal or mucosal melanoma or other cancers were excluded. Pt demographics; timing and features of initial melanoma dx; timing and features of initial MBM dx; prior, initial and subsequent tx; and OS were collected. OS was determined from MBM dx to last clinical follow-up (FU). Pts alive at last FU were censored. The Kaplan-Meier method and log-rank test were used to estimate OS and to assess univariate group differences, respectively. Multivariable (MV) associations of OS with variables of interest were investigated with Cox proportional hazards models. Initial treatment of MBM was assessed as a time-varying covariate. All statistical tests used a significance level of 5%. Results: A total of 401 MBM pts were identified. The median age at MBM dx was 61; 67% were male and 46% had a BRAF V600 mutation. At MBM diagnosis dx, most (70%) pts were asymptomatic; 70% had concurrent uncontrolled extracranial disease; 36% had elevated serum LDH. Prior tx included immunotherapy (IMT) for 39% and targeted therapy (TTX) for 17%. The median number of MBMs was 2; 31% had > 3 MBMs. Median largest MBM diameter was 1.0 cm, 9% had MBM > 3.0 cm, and 5% had concurrent leptomeningeal disease (LMD). Tx received after MBM dx included stereotactic radiosurgery (SRS; 53% as initial tx for MBM, 67% at any time after MBM dx), whole brain radiation therapy (WBRT; 16%, 35%), craniotomy (12%, 19%), IMT (37%, 74%), and/or TTX (22%, 40%). 31% received steroids during initial MBM tx. At a median FU of 13.4 (0.0 - 82.8) months (mos), the median OS was 15.1 mos, and 1- and 2-year OS rates were 56% and 40%. Notably, gender, time to MBM dx, and BRAF status were not associated with OS (univariate analysis). On MV analysis, clinical features associated with worse OS included increased age, increased primary tumor thickness, elevated LDH, > 3 MBMs, +LMD, +symptoms, and prior tx with IMT. Among tx used at any time after MBM dx, WBRT (HR 1.9, 95% CI 1.5-2.5) was associated with worse OS; SRS (HR 0.7, 95% CI 0.5-0.8) and IMT (HR 0.6, 95% CI 0.5-0.8) were associated with improved OS. Conclusions: In one of the largest cohorts of MBM pts described to date, OS has improved in MBM pts in the current era. Prognostic factors for OS include pt age, primary tumor and MBM features, prior tx, and tx for MBM. Additional analyses to assess the interaction of tx, disease features, and OS will be presented.

Incidence, timing, and predictors of CNS metastasis in patients (Pts) with clinically localized cutaneous melanoma (CM)

9580

Background: Surveillance for CNS metastasis (mets) is not routinely performed in pts with clinically localized CM. Improved understanding of the incidence, timing and risk factors for the development of CNS metastasis in these pts may inform surveillance strategies. Methods: Under an IRB-approved protocol, demographics, tumor characteristics, and clinical events were collected for pts diagnosed from 1998 to 2019 with AJCC 8th edition stage I or II CM at MD Anderson Cancer Center. Dates of initial diagnosis, regional, distant non-CNS, and CNS mets were recorded. Symptoms and the extent of disease (brain, LMD, both) were recorded for pts with CNS mets. Cumulative incidence of distant mets (CNS and non-CNS) was determined using the competing risks method, including death; pts without CNS mets and alive at last follow-up were censored. Differences in cumulative incidence between groups were assessed using Gray’s test. Associations between measures of interest and cumulative incidence were determined using proportional subdistribution hazards regression models. All statistical tests used a significance level of 5%. Results: 5,179 Stage I-II CM pts were identified. At a median follow up of 82 (0.0-268.8) months, 703 (13.6%) pts were diagnosed with distant mets, including 355 (6.9%) with CNS mets. Cumulative incidence of CNS mets was 0%, 2%, and 5% at 1, 2, and 5 years, respectively. Among pts with distant mets, the first site of distant mets was CNS only for 29 (4%), non-CNS only for 557 (79%), and both for 116 (17%) pts. At initial diagnosis of CNS mets, 195 (55%) pts were asymptomatic, and 46 (13%) had no active extracranial disease. Median time to any distant met was longer for pts who were diagnosed with CNS mets [40.0 (1.9-238.0) months] vs pts diagnosed with non-CNS mets only [31.4 (1.1-185.7) months, p < 0.001]. On multivariable analysis, risk of CNS mets was significantly associated with primary tumor location of scalp [Hazard Ratio (HR) 3.4, 95% Confidence interval (CI) 1.9-5.9], head/neck (HR 3.3, 95% CI 2.0-5.3), or trunk (HR 2.3, 95% CI 1.5-3.5) (vs upper extremity); acral lentiginous melanoma subtype (HR 2.0, 95% CI 1.2-3.6) (vs superficial spreading); increased T category (T2 HR 1.5, 95% CI 1.1-2.2; T3 HR 1.9, 95% CI 1.2-3.0; T4 HR 2.1, 95% CI 1.1-3.8; vs T1), Clark level (CL) (CL4 HR 2.1, 95% CI 1.2-3.7 vs CL2), and mitotic rate (MR) (MR 5-9/mm2 HR 2.1, 95% CI 1.5-3.0; MR > 9/mm2 HR 2.0, 95% CI 1.3-3.0; vs MR 0-4/mm2). While high ( > 9/mm2) MR was associated with increased risk of CNS and non-CNS mets, intermediate (5-9/mm2) was associated with CNS mets only. Conclusions: Primary tumor location, tumor thickness, and MR were strongly associated with risk of CNS mets. MR rate was more strongly associated with risk of CNS than non-CNS mets. Validation in independent cohorts may provide evidence to support CNS surveillance strategies in select pts with stage I-II CM who are deemed high risk for CNS mets.

Neoadjuvant and adjuvant nivolumab (nivo) with anti-LAG3 antibody relatlimab (rela) for patients (pts) with resectable clinical stage III melanoma

9502

Background: Neoadjuvant therapy (NT) for pts with clinical stage III melanoma remains an active area of research interest. Recent NT trial data demonstrates that achieving a pathologic complete response (pCR) correlates with improved relapse-free (RFS) and overall survival (OS). Checkpoint inhibitor (CPI) NT with either high or low dose ipilimumab and nivolumab regimens produces a high pCR rate of 30-45% but with grade 3-4 toxicity rate of 20-90%. In metastatic melanoma (MM), the combination of nivo with rela (anti Lymphocyte Activation Gene-3 antibody) has demonstrated a favorable toxicity profile and responses in both CPI-naïve and refractory MM. We hypothesized that NT with nivo + rela will safely achieve high pCR rates and provide insights into mechanisms of response and resistance to this regimen. Methods: We conducted a multi-institutional, investigator-initiated single arm study (NCT02519322) enrolling pts with clinical stage III or oligometastatic stage IV melanoma with RECIST 1.1 measurable, surgically-resectable disease. Pts were enrolled at 2 sites and received nivo 480mg IV with rela 160mg IV on wks 1 and 5. Radiographic response (RECIST 1.1) was assessed after completion of NT; surgery was conducted at wk 9 and specimens were assessed for pathologic response per established criteria. Pts received up to 10 additional doses of nivo and rela after surgery, with scans every 3 mo to assess for recurrence. The primary study objective was determination of pCR rate. Secondary objectives included safety, radiographic response by RECIST 1.1, event-free survival (EFS), RFS, and OS analyses. Blood and tissue were collected at baseline, at day 15, day 28, and at surgery for correlative analyses. Results: A total of 30 pts (19 males, median age 60) were enrolled with clinical stage IIIB/IIIC/IIID/IV (M1a) in 18/8/2/2 pts, respectively. 29 pts underwent surgery; 1 pt developed distant metastatic disease while on NT. pCR rate was 59% and near pCR ( < 10% viable tumor) was 7% for a major pathologic response (MPR, pCR + near pCR) of 66%. 7% of pts achieved a pPR (10-50% viable tumor) and 27% pNR (≥50% viable tumor). RECIST ORR was 57%. With a median follow up of 16.2 mos, the 1 -year EFS was 90%, RFS was 93%, and OS was 95%. 1-year RFS for MPR was 100% compared to 80% for non-MPR pts (p = 0.016). There were no treatment related gr 3/4 AEs that arose during NT; 26% of pts had a gr 3/4 AE that began during adjuvant treatment. Conclusions: Neoadjuvant and adjuvant treatment with nivo and rela achieved high pCR and MPR rates with a favorable toxicity profile in the neoadjuvant and adjuvant settings. Pts with MPR had improved outcomes compared to non-MPR pts. Translational studies to discern mechanisms of response and resistance to this combination are underway. Clinical trial information: NCT02519322.

Phase II Study of TRIplet combination Nivolumab (N) with Dabrafenib (D) and Trametinib (T) (TRIDeNT) in patients (pts) with PD-1 naïve or refractory BRAF-mutated metastatic melanoma (MM) with or without active brain metastases

9520

Background: Targeted therapies (TT) & immunotherapies (IMT) have improved survival for pts with BRAF V600 mutated stage IV MM, however many pts still progress and ultimately die from their disease. Preclinical data support the rationale for combining TT and IMT, but trials evaluating triplet combinations in IMT-naïve pts have reported mixed results. Notably, pts with untreated brain metastases (BM) were excluded from prior triplet trials and have a median PFS of 5.6 months when treated with TT. Further, there remains an unmet need for effective therapies for pts after IMT failure, as retrospective studies have reported short median PFS (5 mos) for TT in this setting. We hypothesized that N in combination with DT is safe and will demonstrate clinical activity in BRAF-mutated pts naïve or refractory to PD1 therapy and in pts with BM. Methods: We conducted a single arm phase II study (NCT02910700) of NDT in pts with BRAF-mutated, unresectable stg III or stg IV MM. Prior IMT was allowed, but prior BRAF/MEKi was not. Pts with untreated BM and asymptomatic or mildly symptomatic/requiring steroids were also allowed. Pts received 3mg/kg IV Q2wks of N (later amended to 480 mg IV Q4wks), 150mg PO BID of D and 2mg PO QD of T, all starting on Day 1. The primary objective was to determine safety and efficacy (ORR by RECIST 1.1). Monitoring for safety and futility using Bayesian stopping rules was performed. Longitudinal tissue and blood samples were collected to perform correlative analyses. Results: Following a 6 pt safety run-in with no observed DLTs, 27 pts were treated w NDT. 17 pts were PD1 refractory, 10 were PD-1 naïve. 10 of these 27 pts had a history or presence of BM, including active BM. Median follow up was 18.4 months (range 3.2-45.9). ORR in 26 evaluable pts was 92% (3 CR, 21 PR). Among the PD1 refractory pts evaluable for response (n = 16), ORR was 88% (2 CRs, 12 PR). All 10 evaluable PD-1 naïve pts achieved a response. 4 of 7 evaluable pts w BM achieved an intracranial response (57%), including 2 CRs. The median PFS for all pts was 8.5mos (8.5mos in PD1 naïve pts, 8.2mos in PD1 refractory pts). Median PFS for pts without BM was 8.5mos, 8.0 mos for those with BM. Median OS for all pts was not reached, and no statistically significantly difference in OS by PD1 exposure or presence of BM. 78% of pts experienced treatment related grade 3/4 AEs and 6 pts (22%) discontinued all 3 drugs due to toxicities. Conclusions: NDT at full doses of all 3 agents has a toxicity profile consistent with previously reported triplet combinations and shows promising clinical activity in pts with IMT refractory disease and with BM. There were no significant differences in outcomes between pts with and without BM. Translational studies to delineate predictors and mechanisms of response and resistance are ongoing. Clinical trial information: NCT02910700.

Implementation of a Novel Web-Based Lesion Selection Tool to Improve Acquisition of Tumor Biopsy Specimens

Introduction

For maximum utility of molecular characterization by next-generation sequencing (NGS) and better understanding of tumor microenvironment with immune correlates analysis, biopsy specimens must yield adequate tumor tissue, and sequential biopsy specimens should sample a consistent site. We developed a web-based lesion selection tool (LST) that enables management and tracking of the biopsy specimen collections.

Methods

Of 145 patients, the LST was used for 88 patients; the other 57 served as controls. We evaluated consistency of the lesion biopsied in longitudinal collections, number of cores obtained, and cores with adequate tumor cellularity for NGS. The Fisher exact test and Wilcoxon rank sum test were used to identify differences between the groups.

Results

The analysis included 30 of 88 (34%) patients in the LST group and 52 of 57 (91%) in the control group. The LST workflow ensured 100% consistency in the lesions biopsied compared with 75% in the control group in longitudinal collections and increased the proportion of patients in whom at least five cores were collected per biopsy.

Conclusions

The novel LST platform facilitates coordination, performance, and management of longitudinal biopsy specimens. Use of the LST enables sampling of the designated lesion consistently, which is likely to accurately inform us the effect of the treatment on tumor microenvironment and evolution of resistant pathways. Such studies are important translational component of any clinical trials and research as they guide the development of next line of therapy, which has significant effect on clinical utility. However, validation of this approach in a larger study is warranted.

Safety results from phase I/II study of the PI3Kβ inhibitor GSK2636771 (G) in combination with pembrolizumab (P) in patients (pts) with PD-1 refractory metastatic melanoma (MM) and PTEN loss

e22000

Background: Checkpoint inhibitors (CPI) have improved survival and long-term disease control in 35-40% of pts with MM. Many pts derive no clinical benefit or progress after an initial response. Our group and others have shown that loss of the tumor suppressor protein PTEN occurs in multiple cancers, up to 30% of MM pts, activates the PI3K pathway, and correlates with decreased MM response rates to CPI and decreased T cell infiltrates. In PTEN-null MM preclinical models, inhibition of the PI3Kβ-subunit with GSK2636771 (G) was superior to pan-PI3K inhibitors, increased intratumoral T cell infiltration and the activity of CPI. To test our hypothesis that PI3Kβi reverses resistance to CPI, we are conducting a Phase I/II study (NCT03131908) combining G with P in PD-1 refractory pts with PTEN loss. Methods: The primary objective of Ph I portion is to determine the Maximum-Tolerated Dose (MTD) and Recommended Phase II Dose (RP2D) of G with P in PD-1 refractory pts (including melanoma, endometrial, TNBC, and prostate cancers) with PTEN loss. Pts receive P at 200mg IV q 3 wks. G starting dose level (DL1) was 300 mg PO qd for 21 days and escalated to 400 mg PO qd (DL2) using a 3+3 design. A dose level -1 (DL-1) (200 mg PO qd) was also included in the event of unacceptable toxicities at higher doses. Ph II will accrue 35 pts at the RP2D. This study is continuously monitored for toxicity and futility. The primary objectives of Ph II are safety, tolerability, and efficacy of the combination as defined by Objective Response Rate (ORR) by RECIST 1.1. Secondary Objectives include the PKs of G and PD effects in tumor tissue as measured by pathway inhibition and T cell trafficking into tumors. Results: 13 pts have been treated, 6 at the 300mg (DL1), 5 at 400mg (DL2), and 2 at 200 mg (DL-1). One DLT (grade 3 hypocalcemia) was observed at the 300mg dose. Two DLTs were observed in the 400mg cohort, one of which was AKI requiring dialysis and the other was a Gr 3 rash. Based on this experience and additional safety data from GSK regarding renal toxicity, DL-1 was declared RP2D at 200mg. 2 pts at the RP2D have passed the DLT evaluation period without toxicities. Conclusions: The combination of G and P is being explored at the RP2D of 200 mg. Renal toxicity precluded higher doses. No objective responses have been observed although 2 pts have experienced prolonged clinical benefit including a MM pt with 27% decrease in tumor burden. Through longitudinal biopsies, we aim to better understand the role PTEN loss plays when targeted in combination with CPI. Clinical trial information: NCT03131908.

Myeloablative fludarabine and busulfan regimen in myelofibrosis: Long term outcomes and analysis of prognostic factors

e19520

Background: Scoring systems, such as DIPSS-plus, prognosticate outcomes of myelofibrosis (MF) at diagnosis and at transplant. In this study, we evaluated the impact of individual components of these scoring systems, along with other factors previously reported to significantly prognosticate transplant outcomes in patients with MF. Methods: We identified 65 consecutive patients conditioned uniformly with Fludarabine(40 mg/m2X4days)/Busulfan(AUC-4000X4days) and ATG(MUD), tacroliumus and methotrexate for GVHD prophylaxis for allo-SCT during 2007-2019 at MD Anderson Cancer Center, USA. Associations between factors of interest and overall survival(OS), cumulative-incidence-of-relapse(relapse) and non-relapse mortality(NRM) were evaluated. Results: At transpant, median age was 61(range = 27-73) years; 42% were transfusion-dependent, 31% had secondary MF and 53% patients were intermediate2 and 42% were high-risk by DIPSS-plus. Forty percent of the 35 patients who had 28-gene panel tested had atleast one high-molecular-risk mutation, per MIPSS. Median follow-up for survivors was 35.6 months(range = 0.5-123). One-year and 5-year rates for OS were 78% and 51%, for relapse were 21% and 30%, and for NRM were 16% and 28%, respectively. Our multivariate analysis shows the following significant prognostic factors: HCT-CI > 3[hazard ratio(95% CI):5.63(1.48-21.27)p = 0.011], peripheral-blood blasts≥5%[5.98(1.33-26.89)p = 0.020] and prior splenectomy[6.41(1.83-22.47)p = 0.004] were associated with worse OS. Matched-unrelated donor[4.07 (1.38-12.08)p = 0.011) and mismatched-unrelated donor[7.36 (1.36-39.83)p = 0.021] versus matched-related donor as well as peripheral blasts≥5%[4.10(1.00-16.83)p = 0.05] were associated with worse NRM. Diagnosis to transplant duration > 12months[5.81(1.33-25.420)p = 0.020] was associated with higher relapse. Presence of 2 or more poor-risk mutations [6.39(1.35-30.21)p = 0.019] predicted higher relapse on univariate analysis and was not included in multivariate analysis(as data was available in 35 patients only). Conclusions: Of the IPSS-components used at diagnosis, only peripheral-blood blasts(at threshold ≥5%) was associated with worse outcome(OS and NRM). Unrelated-donor source was associated with higher NRM. Diagnosis to transplant duration > 12months predicted higher relapse. The effect of mutations needs to be validated in a bigger study.

Allogeneic stem cell transplantation (AlloSCT) for patients (pts) with lymphoma and chronic lymphocytic leukemia (CLL) following targeted small molecules inhibitors (SMIs)

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Background: SMIs have improved outcomes in lymphoma/CLL. There is paucity of information about the safety and efficacy of alloSCT following SMIs. Methods: Data from 49 pts who received alloSCT between 2013-2018 at MDA and who have been previously treated with SMIs were retrospectively analyzed. Results: Histologies included CLL (n=31, 63%), mantle cell lymphoma (MCL) (n= 13, 27%), and follicular lymphoma (n= 5, 10%). Prior SMIs included ibrutinib [(n=46; 94%); 57% as ≥ 3rd line of therapy], venetoclax [(n=19, 39%); 68% as ≥ 3rd line of therapy], idelalisib (n=6, 12%). Ibrutinib was discontinued prior alloSCT in 31(67%) pts. due to refractoriness (n=25), or intolerance (n=6). Seven of 19 (37%) pts had venetoclax discontinued to due refractoriness (n=6) or intolerance (n=1). Risk factors for CLL pts at alloSCT included a prior Richter’s (n=14, 45%), unmutated IGHV (15/23, 65%), presence of del17p (n=23; 74%), and complex cytogenetics (n=15; 48%). In addition, 18/20 (90%) CLL pts had abnormal mutations: most frequent were TP53 (n=14; 78%), BTK (n=6; 33%), SF3B1 (n=4; 22%) and 8/18 (44%) pts had > 2 mutations. Risk factors for MCL pts included: Ki67≥ 30 % (n=10/12, 83%), blastoid histology (n=6, 46%). Median age was 51 years, and 9 (18%) pts had a HCT-CI >4. Median prior lines of therapies was 4. Median duration of SMI therapy was 4.6 months. At transplant 40 (82%) pts had sensitive and 9 (18%) had refractory disease. Conditioning was nonmyeloablative (BFR or FCR) in 62%, RIC in 20% and myeloablative in 18%. Most pts (61%) received matched unrelated or matched sibling donors (22%); 8 (16%) had an alternative donor. The median follow-up for survivors was 12.4 months (range, 1-41.6). OS and PFS at 1 year were 77% and 68%, respectively. The CI of acute grade 2-4 and 3-4 GVHD were 33% and 7%, respectively. CI of 1-year chronic GVHD was 19%. Disease refractoriness and acute 3-4 GVHD were predicators for inferior OS and PFS by MV analysis. Similar survival results were observed in pts with or without mutations. Fourteen pts died due to progression (n=9), infection (n=2), acute (n=2) or chronic GVHD (n=1). Conclusions: AlloSCT is an effective therapy in pts with lymphoma/CLL pretreated with SMI. Our results suggest that alloSCT can overcome high-risk mutations associated with exposure to SMIs. Prospective confirmation in a larger # of pts is needed.

Allogeneic stem cell transplantation (AlloSCT) for patients (pts) with acute leukemia following venetoclax-based therapy

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Background: BCL-2 inhibitor Ven has shown a promising benefit in pts with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). There is paucity of information about the safety and efficacy of alloSCT post Ven. Methods: We conducted a retrospective analysis of 35 AML/ALL pts who received alloSCT following Ven-based therapies between 2013-2018 at MDA. Results: Median age at alloSCT was 60 years and 15 (43%) pts had an age-adjusted HCT-CI score ≥ 4. Disease diagnosis – AML (n = 31; 89%), ALL (n = 4; 11%). Disease status at transplant was CR1 (n = 17; 49%), CR2/CR3 (n = 9; 26%) or refractory (n = 9; 26%). 20/26 (77%) CR pts were MRD-negative. Median # of prior therapies was 2 (range 1-7) and 4 (11%) pts had failed a prior alloSCT. AML pts were classified by ELN 2017 criteria to have favorable, intermediate and adverse risks in 16%, 23% and 61% respectively. Ven was provided in combination of hypomethylating agents (HMA) or other chemotherapies in 26 (74%) and 9 (26%) pts, respectively. Among pts treated with Ven + HMA, some also received IDH1/2 inhibitors (n = 7, 20%), FLT3 inhibitors (n = 4; 11%) or anti-PD1 (n = 3, 9%). Median duration of Ven-based treatment was 2 months (range 0.5- 4.6). Ven was discontinued in 6 (17%) pts due to adverse events (n = 4) or progression (n = 2); the remaining pts (83%) continued their Ven-therapy as a bridge to alloSCT. The median time from last Ven dose and transplant was 26 days. Conditioning regimens were melphalan-based reduced intensity (n = 26, 74%), or busulfan-based myeloablative regimens (n = 9; 26%). Donor source was matched -unrelated (n = 14, 40%), -related (n = 9; 26%) or haplo- (n = 12; 34%). GVHD prophylaxis consisted of tacrolimus with either PT-Cy in 25 (71%) pts or methotrexate in 10 (29%) pts. All pts engrafted (median day 30 donor cells = 100%). Median days to ANC > 500 and platelets > 20K was 15.5 and 22.5, respectively. With a median follow up of 5.7 months (range 0.7-15.4), the 1-year rates of OS, PFS, and NRM were 71%, 63% and 3% respectively. CI of acute grade 2-4 and 3-4 GVHD were 26% and 3% respectively. Four pts died: 3 because of disease relapse and 1 of infection. Conclusions: AlloSCT is a safe and feasible consolidation treatment option in acute leukemia pts who were pre- treated with Ven, without excessive risk of NRM or acute GVHD. Larger prospective studies are required to validate our observations.

Final Outcome of 223Ra-therapy and the Role of 18F-fluoride-PET in Response Evaluation in Metastatic Castration-resistant Prostate Cancer-A Single Institution Experience

BACKGROUND

223Ra was the first therapeutic alpha-emitting radionuclide registered for clinical practice. This radionuclide is targeting actively bone-forming cells, and it is approved for treating metastatic skeletal disease in prostate cancer. 18F-PET is used to detect skeletal metastatic disease based on osteoblastic activity. The aim of this study was to analyze, if 18F-PET can be used assessing the results of 223Ra therapy, and to report final median overall survival in a total of 773 therapy cycles.

METHODS

A 161 men with castration-resistant prostate cancer were included in a single institution study (Protocol#: PA14-0848) and they received a total of 773 223Ra therapy cycles.

RESULTS

The median overall survival (95% CI) was 12.4 (9.1, 16.1) months in patient population. Interim Na18F-PET imaging was applied in 14 patients at baseline, after 3 cycles and after 6 cycles. TLF10 (skeletal disease burden at SUV-values >10 on Na18F -PET) were calculated in all these PET studies, and there was no significant association between change in TLF10 after 3 cycles and TLF10 after 6 cycles (p=0.20).

CONCLUSION

From these results, we conclude that interim imaging does not help in assessing the final outcome of 223Ra therapy. The survival benefit of 223Ra therapy alone is more than a year in a high-risk group of advanced prostate cancer.

Abstract 5711: The impact of combination oral azacitidine (CC-486) + pembrolizumab (PEMBRO) on the immune infiltrate in metastatic melanoma (MM)

Introduction: Although immune checkpoint inhibitors have improved survival for many with MM, most pts do not respond and median PFS is only 6 months for single agent therapy. Cancers subvert the cellular epigenetic machinery to facilitate immune escape. Epigenetic mechanisms of resistance are potentially reversible by DNA hypomethylating agents (HMA). Based on preclinical models, we hypothesized that CC-486, an oral HMA, will enhance response to PEMBRO in PD-1 naïve pts and reverse resistance in anti-PD-1 refractory pts. The aim of this study is to determine the safety, efficacy, and characterize the pharmacodynamic impact of CC-486 + PEMBRO on immune infiltrates in pts with MM.

Experimental: NCT02816021 is an ongoing phase II study of CC-486 + PEMBRO in MM pts who are PD-1 naïve (Arm A) or who have progressed on prior PD-1 directed therapy (Arm B). Pts receive 300mg PO of CC-486 on days 1-14 and 200mg IV of PEMBRO q3 weeks. Serum and tumor biopsies are obtained at baseline, prior to cycles 3 and 5. Immune monitoring studies were performed by the Immunotherapy Platform at MD Anderson. Immune cell phenotyping by CyTOF was performed using 36 metal-conjugated antibodies targeting myeloid and T cell surface markers. FCS files were exported and manually gated for lymphocytes using FlowJo (version 10.1) and subjected to multidimensional phenographic analysis.

Results: Thirteen pts (Arm A, n=6; Arm B, n=7) have been enrolled. Two of the 3 pts remaining on study are PD-1 naïve and have received 13 and 8 cycles of CC-496 + PEMBRO with partial responses by RECIST1.1 at 6 months, respectively. One pt on Arm B remains on study with stable disease after 4 cycles. The combination was considered safe after a run-in phase (6 pts/arm treated without DLTs) and the study is open to full accrual. The most common grade 3/4 AEs were leukopenia , neutropenia, vomiting, and diarrhea (2 each) with 1 grade 5 AE unrelated to treatment (hepatic rupture/bleeding due to progressive disease). Serum and tumor biopsies from 6 pts (3 per Arm) were available for interim analysis, with additional samples in process. Of these 6 pts, 1 pt (PD-1 naïve) responded to therapy by RECIST1.1. We evaluated the blood and tumor samples by CyTOF. In the tumor samples, we observed an increase in frequency of T cells in 2 PD-1 naïve patients but did not observe similar changes in PD-1 refractory patients in this small cohort. Similar data was found with immunohistochemistry. These changes were not observed in the blood samples.

Conclusion: The regimen CC-486 + PEMBRO is not marrow suppressive and is well tolerated. Changes in the peripheral lymphocyte cell populations upon treatment are not necessarily concordant with changes occurring in the tumor. Analysis of collected samples is ongoing and will be presented at the meeting, and will help corroborate initial findings and yield further insight into the effect of this combination on the immune response.

Citation Format: Emily Z. Keung, Isabella C. Glitza, Elizabeth Burton, Rodabe N. Amaria, Sapna P. Patel, Adi Diab, Cassian Yee, Michael K. Wong, Wen-Jen Hwu, Patrick Hwu, Scott E. Woodman, Michael T. Tetzlaff, Nallely Trujillo-Conley, Denai R. Milton, Michael A. Davies, Kunal Rai, Irina Fernandez, Jorge M. Blando, Luis M. Vence, Padmanee Sharma, James P. Allison, Jennifer A. Wargo, Hussein Tawbi. The impact of combination oral azacitidine (CC-486) + pembrolizumab (PEMBRO) on the immune infiltrate in metastatic melanoma (MM) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5711.

Fludarabine with pharmacokinetically guided IV busulfan is superior to fixed-dose delivery in pretransplant conditioning of AML/MDS patients

We hypothesized that IV Busulfan (Bu) dosing could be safely intensified through pharmacokinetic (PK-) dose guidance to minimize the inter-patient variability in systemic exposure (SE) associated with body-sized dosing, and this should improve outcome of AML/MDS patients undergoing allogeneic stem cell transplantation (allo-HSCT). To test this hypothesis, we treated 218 patients (median age 50.7 years, male/female 50/50%) with fludarabine (Flu) 40 mg/m² once daily ×4, each dose followed by IV Bu, randomized to 130 mg/m² (N=107) or PK-guided to average daily SE, AUC of 6,000 µM-min (N=111), stratified for remission-status, and allo-grafting from HLA-matched donors. Toxicity and graft vs. host disease (GvHD) rates in the groups were similar; the risk of relapse or treatment-related mortality remained higher in the fixed-dose group throughout the 80-month observation period. Further, PK-guidance yielded safer disease-control, leading to improved overall and progression-free survival, most prominently in MDS-patients and in AML-patients not in remission at allo-HSCT. We conclude that AML/MDS patients receiving pretransplant conditioning treatment with our 4-day regimen may benefit significantly from PK-guided Bu-dosing. This could be considered an alternative to fixed dose delivery since it provides the benefit of precise dose delivery to a predetermined SE without increasing risk(s) of serious toxicity and/or GvHD.

Dual Roles of RNF2 in Melanoma Progression

Epigenetic regulators have emerged as critical factors governing the biology of cancer. Here, in the context of melanoma, we show that RNF2 is prognostic, exhibiting progression-correlated expression in human melanocytic neoplasms. Through a series of complementary gain-of-function and loss-of-function studies in mouse and human systems, we establish that RNF2 is oncogenic and prometastatic. Mechanistically, RNF2-mediated invasive behavior is dependent on its ability to monoubiquitinate H2AK119 at the promoter of LTBP2, resulting in silencing of this negative regulator of TGFβ signaling. In contrast, RNF2's oncogenic activity does not require its catalytic activity nor does it derive from its canonical gene repression function. Instead, RNF2 drives proliferation through direct transcriptional upregulation of the cell-cycle regulator CCND2. We further show that MEK1-mediated phosphorylation of RNF2 promotes recruitment of activating histone modifiers UTX and p300 to a subset of poised promoters, which activates gene expression. In summary, RNF2 regulates distinct biologic processes in the genesis and progression of melanoma via different molecular mechanisms.

SIGNIFICANCE

The role of epigenetic regulators in cancer progression is being increasingly appreciated. We show novel roles for RNF2 in melanoma tumorigenesis and metastasis, albeit via different mechanisms. Our findings support the notion that epigenetic regulators, such as RNF2, directly and functionally control powerful gene networks that are vital in multiple cancer processes.

Atomoxetine treatment of ADHD in children with comorbid Tourette syndrome

OBJECTIVE

This study examines changes in severity of tics and ADHD during atomoxetine treatment in ADHD patients with Tourette syndrome (TS).

METHOD

Subjects (7-17 years old) with ADHD (Diagnostic and Statistical Manual of Mental Disorders, DSM-IV) and TS were randomly assigned to double-blind treatment with placebo (n = 56) or atomoxetine (0.5-1.5 mg/kg/day, n = 61) for approximately 18 weeks.

RESULTS

Atomoxetine subjects showed significantly greater improvement on ADHD symptom measures. Treatment was also associated with significantly greater reduction of tic severity on two of three measures. Significant increases were seen in mean pulse rate and rates of treatment-emergent nausea, decreased appetite, and decreased body weight. No other clinically relevant treatment differences were observed in any other vital sign, adverse event, laboratory parameter, or electrocardiographic measure.

CONCLUSION

Atomoxetine is efficacious for treatment of ADHD and its use appears well tolerated in ADHD patients with comorbid TS.

Atomoxetine treatment in children and adolescents with ADHD and comorbid tic disorders

OBJECTIVE

To test the hypothesis that atomoxetine does not significantly worsen tic severity relative to placebo in children and adolescents with attention deficit/hyperactivity disorder (ADHD) and comorbid tic disorders.

METHODS

Study subjects were 7 to 17 years old, met Diagnostic and Statistical Manual of Mental Disorders-IV criteria for ADHD, and had concurrent Tourette syndrome or chronic motor tic disorder. Patients were randomly assigned to double-blind treatment with placebo (n = 72) or atomoxetine (0.5 to 1.5 mg/kg/day, n = 76) for up to 18 weeks.

RESULTS

Atomoxetine treatment was associated with greater reduction of tic severity at endpoint relative to placebo, approaching significance on the Yale Global Tic Severity Scale total score (-5.5 +/- 6.9 vs -3.0 +/- 8.7, p = 0.063) and Tic Symptom Self-Report total score (-4.7 +/- 6.5 vs -2.9 +/- 5.2, p = 0.095) and achieving significance on the Clinical Global Impressions (CGI) tic/neurologic severity scale score (-0.7 +/- 1.2 vs -0.1 +/- 1.0, p = 0.002). Atomoxetine patients also showed greater improvement on the ADHD Rating Scale total score (-10.9 +/- 10.9 vs -4.9 +/- 10.3, p < 0.001) and CGI severity of ADHD/psychiatric symptoms scale score (-0.8 +/- 1.1 vs -0.3 +/- 1.0, p = 0.015). Discontinuation rates were not significantly different between treatment groups. Atomoxetine patients had greater increases in heart rate and decreases of body weight, and rates of treatment-emergent decreased appetite and nausea were higher. No other clinically relevant treatment differences were seen in any other vital sign, adverse event, or electrocardiographic or laboratory measures.

CONCLUSIONS

Atomoxetine did not exacerbate tic symptoms. Rather, there was some evidence of reduction in tic severity with a significant reduction of attention deficit/hyperactivity disorder symptoms. Atomoxetine treatment appeared safe and well tolerated.

Olanzapine versus divalproex in the treatment of acute mania

OBJECTIVE

The effects of olanzapine and divalproex for the treatment of mania were compared in a large randomized clinical trial.

METHOD

A 3-week, randomized, double-blind trial compared flexibly dosed olanzapine (5-20 mg/day) to divalproex (500-2500 mg/day in divided doses) for the treatment of patients hospitalized for acute bipolar manic or mixed episodes. The Young Mania Rating Scale and the Hamilton Depression Rating Scale were used to quantify manic and depressive symptoms, respectively. Safety was assessed with several measures.

RESULTS

The protocol defined baseline-to-endpoint improvement in the mean total score on the Young Mania Rating Scale as the primary outcome variable. The mean Young Mania Rating Scale score decreased by 13.4 for patients treated with olanzapine (N=125) and 10.4 for those treated with divalproex (N=123). A priori categorizations defined response and remission rates: 54.4% of olanzapine-treated patients responded (> or = 50% reduction in Young Mania Rating Scale score), compared to 42.3% of divalproex-treated patients; 47.2% of olanzapine-treated patients had remission of mania symptoms (endpoint Young Mania Rating Scale < or = 12), compared to 34.1% of divalproex-treated patients. The decrease in Hamilton depression scale score was similar in the two treatment groups. Completion rates for the 3-week study were similar in both groups. The most common treatment-emergent adverse events (incidence >10%) occurring more frequently during treatment with olanzapine were dry mouth, increased appetite, and somnolence. For divalproex, nausea was more frequently observed. The average weight gain with olanzapine treatment was 2.5 kg, compared to 0.9 kg with divalproex treatment.

CONCLUSIONS

The olanzapine treatment group had significantly greater mean improvement of mania ratings and a significantly greater proportion of patients achieving protocol-defined remission, compared with the divalproex treatment group. Significantly more weight gain and cases of dry mouth, increased appetite, and somnolence were reported with olanzapine, while more cases of nausea were reported with divalproex.

Effective resolution with olanzapine of acute presentation of behavioral agitation and positive psychotic symptoms in schizophrenia

Behavioral agitation and prominent positive psychotic symptoms often characterize the acute presentation of schizophrenia. The clinical treatment goal is a rapid control of these symptoms. The relative efficacy of olanzapine, a novel antipsychotic drug, was compared with that of the conventional antipsychotic drug haloperidol. A post hoc analysis conducted on a large multicenter, double-blind, 6-week study of acute-phase patients with DSM-III-R schizophrenia or schizophreniform or schizoaffective disorders treated with olanzapine (5-20 mg/day) or haloperidol (5-20 mg/day) assessed the treatment effects on agitation (Brief Psychiatric Rating Scale [BPRS] agitation score) and positive symptoms (BPRS positive symptom score). Overall, olanzapine-treated patients experienced significantly greater improvement in behavioral agitation than did haloperidol-treated patients (last observation carried forward [LOCF]; p < .0002). Both groups showed similar reductions in agitation scores during the first 3 weeks of therapy; olanzapine was associated with significantly greater improvements at weeks 4, 5, and 6 (observed cases [OC]). Similarly, patients with predominantly positive psychotic symptoms experienced significantly greater improvement in BPRS positive symptom scores with olanzapine compared with haloperidol (LOCF; p = .013). In olanzapine-treated patients, improvement in BPRS agitation and positive symptom scores was significantly greater at weeks 4, 5, and 6 (agitation scores, p < or = .01; positive symptom scores, p < .05) (OC). These data suggest that olanzapine may be considered a first-line treatment for the patient in an acute episode of schizophrenia.