Randomized phase-III study of low-dose cytarabine and etoposide + /- all-trans retinoic acid in older unfit patients with NPM1-mutated acute myeloid leukemia

The aim of this randomized clinical trial was to evaluate the impact of all-trans retinoic acid (ATRA) in combination with non-intensive chemotherapy in older unfit patients (> 60 years) with newly diagnosed NPM1-mutated acute myeloid leukemia. Patients were randomized (1:1) to low-dose chemotherapy with or without open-label ATRA 45 mg/m2, days 8-28; the dose of ATRA was reduced to 45 mg/m2, days 8-10 and 15 mg/m2, days 11-28 after 75 patients due to toxicity. Up to 6 cycles of cytarabine 20 mg/day s.c., bid, days 1-7 and etoposide 100 mg/day, p.o. or i.v., days 1-3 with (ATRA) or without ATRA (CONTROL) were intended. The primary endpoint was overall survival (OS). Between May 2011 and September 2016, 144 patients (median age, 77 years; range, 64-92 years) were randomized (72, CONTROL; 72, ATRA). Baseline characteristics were balanced between the two study arms. The median number of treatment cycles was 2 in ATRA and 2.5 in CONTROL. OS was significantly shorter in the ATRA compared to the CONTROL arm (p = 0.023; median OS: 5 months versus 9.2 months, 2-years OS rate: 7% versus 10%, respectively). Rates of CR/CRi were not different between treatment arms; infections were more common in ATRA beyond treatment cycle one. The addition of ATRA to low-dose cytarabine plus etoposide in an older, unfit patient population was not beneficial, but rather led to an inferior outcome.The clinical trial is registered at clinicaltrialsregister.eu (EudraCT Number: 2010-023409-37, first posted 14/12/2010).

Accurate detection of tumor-specific gene fusions reveals strongly immunogenic personal neo-antigens

Cancer-associated gene fusions are a potential source for highly immunogenic neoantigens, but the lack of computational tools for accurate, sensitive identification of personal gene fusions has limited their targeting in personalized cancer immunotherapy. Here we present EasyFuse, a machine learning computational pipeline for detecting cancer-specific gene fusions in transcriptome data obtained from human cancer samples. EasyFuse predicts personal gene fusions with high precision and sensitivity, outperforming previously described tools. By testing immunogenicity with autologous blood lymphocytes from patients with cancer, we detected pre-established CD4⁺ and CD8⁺ T cell responses for 10 of 21 (48%) and for 1 of 30 (3%) identified gene fusions, respectively. The high frequency of T cell responses detected in patients with cancer supports the relevance of individual gene fusions as neoantigens that might be targeted in personalized immunotherapies, especially for tumors with low mutation burden.

Percutaneous left atrial appendage closure reduces cost of care independent of the institutional cumulative caseload in patients with non-valvular atrial fibrillation

Background

Data on the impact of the cumulative percutaneous left atrial appendage closure (LAAC) caseload on cardiovascular outpatient and hospitalisation costs are limited.

Methods

The present single-institution analysis includes patients treated consecutively from the beginning of our LAAC experience in January 2012 until December 2016. Pre- and post-LAAC costs for hospitalisation and ambulatory visits were included.

Results

A total of 676 patients underwent percutaneous LAAC (using the Watchman device): 49 (2012), 78 (2013), 211 (2014), 210 (2015), and 129 (2016). LAAC procedural costs were stable over the years (overall median €9639; 2012: €9630; 2013: €10,003; 2014: €9841; 2015: €9394; 2016: €9530; p = 0.8) and there was no correlation between cumulative caseload and procedural costs (p = 0.9). Although annualised cardiovascular management costs after LAAC were lower than before LAAC (median difference between pre-LAAC and post-LAAC yearly costs: €727; 2012: €235; 2013: €1187; 2014: €716; 2015: €527; 2016: €1052; p = 0.5 among years analysed) from the beginning of the cumulative procedural experience, a significant reduction in costs was observed only from 2014 onwards. Institutional cumulative LAAC caseload and year of procedure were not related to the amount of reduction in the costs for cardiovascular care.

Conclusion

LAAC led to cost-of-care savings from the beginning of our institutional procedural experience.

Dietary Inflammatory Index and Cross-Sectional Associations with Inflammation, Muscle Mass and Function in Healthy Old Adults

IMPORTANCE

Inflammaging is considered a driver of age-related loss of muscle mass and function (sarcopenia). As nutrition might play a role in this process, the Dietary Inflammatory Index® (DII) has been developed to quantify the inflammatory potential of an individual diet.

OBJECTIVES

We aimed to examine associations between the DII, inflammation, oxidative stress and sarcopenia-related parameters in healthy old compared to young adults.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included data of 79 community-dwelling, healthy old adults (65-85 years) and 59 young adults (18-35 years) who participated in a randomized controlled trial from April to December 2019.

MEASUREMENTS

The DII was computed with dietary data collected from 24-h recall interviews. Associations between the DII, inflammatory and oxidative stress markers as well as bioimpedance-derived body composition, handgrip strength and gait speed were determined with multiple linear regression analyses adjusted for age, sex, physical activity and insulin resistance.

RESULTS

Regression analyses revealed significant relationships between a higher interleukin (IL) 6 and IL-6:IL-10-ratio and higher percentage fat mass (%FM), waist-to-height-ratio (WHtR) as well as lower percentage skeletal muscle mass (%SMM) and gait speed exclusively in old adults. Subsequent analyses showed that IL-6 was associated with a pro-inflammatory diet as indicated by a higher DII, again exclusively in old adults (beta coefficient (β)= 0.027, standard error (SE) 0.013, p=0.037). While the DII was not related with handgrip strength or oxidative stress in neither old nor young adults, linear models confirmed that a higher DII was inversely associated with gait speed in old participants (β= -0.022, SE 0.006, p<0.001). Finally, a pro-inflammatory diet was significantly associated with higher %FM, WHtR and lower %SMM in both age groups.

CONCLUSION AND RELEVANCE

A pro-inflammatory diet reflected by the DII is associated with higher systemic inflammation, slower gait speed as well as lower muscle mass in old adults. Intervention studies are needed to examine whether anti-inflammatory dietary approaches can help to improve muscle mass and function and thus minimize the risk for sarcopenia in the long-term.

Proximate ferromagnetic state in the Kitaev model material α-RuCl3

α-RuCl₃ is a major candidate for the realization of the Kitaev quantum spin liquid, but its zigzag antiferromagnetic order at low temperatures indicates deviations from the Kitaev model. We have quantified the spin Hamiltonian of α-RuCl₃ by a resonant inelastic x-ray scattering study at the Ru L₃ absorption edge. In the paramagnetic state, the quasi-elastic intensity of magnetic excitations has a broad maximum around the zone center without any local maxima at the zigzag magnetic Bragg wavevectors. This finding implies that the zigzag order is fragile and readily destabilized by competing ferromagnetic correlations. The classical ground state of the experimentally determined Hamiltonian is actually ferromagnetic. The zigzag state is stabilized by quantum fluctuations, leaving ferromagnetism – along with the Kitaev spin liquid – as energetically proximate metastable states. The three closely competing states and their collective excitations hold the key to the theoretical understanding of the unusual properties of α-RuCl₃ in magnetic fields.

RuCl₃ has stood out as a prime candidate in the search for quantum spin liquids; however, its antiferromagnetic ordering at low temperature suggests deviations from typical QSL models. Here, using resonant inelastic x-ray scattering, the authors provide a comprehensive determination of the low energy effective Hamiltonian.

Effect of timing, technique and molecular features on brain control with local therapies in oncogene-driven lung cancer

BACKGROUND

The improved efficacy of tyrosine kinase inhibitors (TKI) mandates reappraisal of local therapy (LT) for brain metastases (BM) of oncogene-driven non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

This study included all epidermal growth factor receptor-mutated (EGFR⁺, n = 108) and anaplastic lymphoma kinase-rearranged (ALK⁺, n = 33) TKI-naive NSCLC patients diagnosed with BM in the Thoraxklinik Heidelberg between 2009 and 2019. Eighty-seven patients (62%) received early LT, while 54 (38%) received delayed (n = 34; 24%) or no LT (n = 20; 14%). LT comprised stereotactic (SRT; n = 40; 34%) or whole-brain radiotherapy (WBRT; n = 77; 66%), while neurosurgical resection was carried out in 19 cases.

RESULTS

Median overall survival (OS) was 49.1 months for ALK⁺ and 19.5 months for EGFR⁺ patients (P = 0.001), with similar median intracranial progression-free survival (icPFS) (15.7 versus 14.0 months, respectively; P = 0.80). Despite the larger and more symptomatic BM (P < 0.001) of patients undergoing early LT, these experienced longer icPFS [hazard ratio (HR) 0.52; P = 0.024], but not OS (HR 1.63; P = 0.12), regardless of the radiotherapy technique (SRT versus WBRT) and number of lesions. High-risk oncogene variants, i.e. non-del19 EGFR mutations and 'short' EML4-ALK fusions (mainly variant 3, E6:A20), were associated with earlier intracranial progression (HR 2.97; P = 0.001). The longer icPFS with early LT was also evident in separate analyses of the EGFR⁺ and ALK⁺ subsets.

CONCLUSIONS

Despite preferential use for cases with poor prognostic factors, early LT prolongs the icPFS, but not OS, in TKI-treated EGFR⁺/ALK⁺ NSCLC. Considering the lack of survival benefit, and the neurocognitive effects of WBRT, patients presenting with polytopic BM may benefit from delaying radiotherapy, or from radiosurgery of multiple or selected lesions. For SRT candidates, the improved tumor control with earlier radiotherapy should be weighed against the potential toxicity and the enhanced intracranial activity of newer TKI. High-risk EGFR/ALK variants are associated with earlier intracranial failure and identify patients who could benefit from more aggressive management.

SAT0046 MODIFIED DISEASE ACTIVITY SCORE AT 3 MONTHS IS A SIGNIFICANT PREDICTOR FOR RAPID RADIOGRAPHIC PROGRESSION AT 12 MONTHS COMPARED WITH OTHER MEASURES

Background:

Progressive rheumatoid arthritis (RA) is responsible for joint damage causing disabilities with no agreement on which disease measures best predict radiographic progression

Objectives:

We aimed to determine which disease activity measures including disease activity score (DAS), modified (M) DAS28 (CRP), clinical disease activity index (CDAI), and health assessment questionnaire disability index (HAQ-DI) best predict rapid radiographic progression (RRP) in early RA patients at baseline (BL) and 3 months.

Methods:

PREMIER data, a 2-year, multicenter, double-blind active comparator–controlled study with methotrexate (MTX) naïve RA patients and active disease <3 years, were used. Only patients in the MTX arm were analyzed. RRP was defined as change in modified total Sharp (mTSS) > 3.5 at month 12. Logistic regression analysis assessed impact of measures at BL and 3 months on RRP at 12 months. Best cut-off points of M-DAS28(CRP) was also estimated using area under the receiver operating characteristic curve.

Results:

149 patients were included: female (n=113; 75.8%), positive RF (n=127; 85.2%), mean (SD) age 52.9 (13.3) years, disease duration 0.8 (0.9) year, DAS28(CRP) 6.3 (0.9). After adjusting for potential confounders, only M-DAS28(CRP) at BL (adjOR=3.29; 95% CI: 1.70-6.36) and 3 months (adjOR=2.56; 95% CI: 1.43-4.56) strongly predicted RRP at 12 months. M-DAS28(CRP) 4.5 and 2.6 at BL and 3 months maximized sensitivity and specificity for prediction of RRP.

Conclusion:

M-DAS28(CRP) was a stronger predictor at BL and 3 months for RRP compared with other disease activity measures. Removing tender joint count and patient global assessment from DAS28(CRP) improves prediction of RRP.

References:

[1] Breedveld FC, Weisman MH, Kavanaugh AF, Cohen SB, Pavelka K, van Vollenhoven R, et al. The PREMIER study: A multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. Arthritis and rheumatism. 2006;54(1):26-37.

Acknowledgments :

The authors wish to knowledge AbbVie Canada Inc. for providing patients data.

Disclosure of Interests:

Mohammad Movahedi Consultant of: Allergan, Deborah Weber: None declared, Pooneh Akhavan: None declared, Edward Keystone Grant/research support from: AbbVie; Amgen; Gilead Sciences, Inc; Lilly Pharmaceuticals; Merck; Pfizer Pharmaceuticals; PuraPharm; Sanofi, Consultant of: AbbVie; Amgen; AstraZeneca Pharma; Bristol-Myers Squibb Company; Celltrion; F. Hoffman-La Roche Ltd.; Genentech, Inc; Gilead Sciences, Inc.; Janssen, Inc; Lilly Pharmaceuticals; Merck; Myriad Autoimmune; Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis., Speakers bureau: AbbVie; Amgen; Bristol-Myers Squibb; Celltrion; F. Hoffman-La Roche Ltd, Janssen, Inc; Merck; Pfizer Pharmaceuticals; Sanofi-Genzyme; UCB

Lactose drives Enterococcus expansion to promote graft-versus-host disease

Disruption of intestinal microbial communities appears to underlie many human illnesses, but the mechanisms that promote this dysbiosis and its adverse consequences are poorly understood. In patients who received allogeneic hematopoietic cell transplantation (allo-HCT), we describe a high incidence of enterococcal expansion, which was associated with graft-versus-host disease (GVHD) and mortality. We found that Enterococcus also expands in the mouse gastrointestinal tract after allo-HCT and exacerbates disease severity in gnotobiotic models. Enterococcus growth is dependent on the disaccharide lactose, and dietary lactose depletion attenuates Enterococcus outgrowth and reduces the severity of GVHD in mice. Allo-HCT patients carrying lactose-nonabsorber genotypes showed compromised clearance of postantibiotic Enterococcus domination. We report lactose as a common nutrient that drives expansion of a commensal bacterium that exacerbates an intestinal and systemic inflammatory disease.

Time-Variable Exposure Experiments in Conjunction with Higher Tier Population and Effect Modeling to Assess the Risk of Chlorotoluron to Green Algae

An algae population model was applied to describe measured effects of pulsed exposure to chlorotoluron on populations of Pseudokirchneriella subcapitata in 2 laboratory flow-through chemostat tests with different exposure regimes. Both tests enabled evaluation of adverse effects on algae during the exposure and population recovery afterward. Impacts on population densities after chlorotoluron exposure were directly visible as biomass loss in the chemostats. Recovery was observed after each exposure peak. The test results indicate that P. subcapitata is unlikely to show an increased sensitivity to chlorotoluron after pulsed exposure. No altered response or adaptation of the algae to chlorotoluron was observed, with the exception of the last high peak in flow-through test 2. Therefore, an adaptation to the test substance cannot be excluded after long-term exposure. However, recovery to the steady-state level after this peak indicates that the growth rate (fitness) was not significantly reduced in the population with higher tolerance. No differences in chlorotoluron impact on the populations over time in terms of growth were detected. Model predictions agreed well with the measured data. The tests and modeling results validate the model to simulate population dynamics of P. subcapitata after pulsed exposure to chlorotoluron. Model predictions and extrapolations with different exposure patterns are considered reliable for chlorotoluron. The good reproducibility of the population behavior in the test systems supports this conclusion. An example modeled extrapolation of the experimental results to other (untested) exposure scenarios shows a potential approach to using the validated model as a supportive tool in risk assessment. Environ Toxicol Chem 2019;38:2520-2534. © 2019 SETAC.

Randomized phase-II trial evaluating induction therapy with idarubicin and etoposide plus sequential or concurrent azacitidine and maintenance therapy with azacitidine

The aim of this randomized phase-II study was to evaluate the effect of substituting cytarabine by azacitidine in intensive induction therapy of patients with acute myeloid leukemia (AML). Patients were randomized to four induction schedules for two cycles: STANDARD (idarubicin, cytarabine, etoposide); and azacitidine given prior (PRIOR), concurrently (CONCURRENT), or after (AFTER) therapy with idarubicin and etoposide. Consolidation therapy consisted of allogeneic hematopoietic-cell transplantation or three courses of high-dose cytarabine followed by 2-year maintenance therapy with azacitidine in the azacitidine-arms. AML with CBFB-MYH11, RUNX1-RUNX1T1, mutated NPM1, and FLT3-ITD were excluded and accrued to genotype-specific trials. The primary end point was response to induction therapy. The statistical design was based on an optimal two-stage design applied for each arm separately. During the first stage, 104 patients (median age 62.6, range 18-82 years) were randomized; the study arms PRIOR and CONCURRENT were terminated early due to inefficacy. After randomization of 268 patients, all azacitidine-containing arms showed inferior response rates compared to STANDARD. Event-free and overall survival were significantly inferior in the azacitidine-containing arms compared to the standard arm (p < 0.001 and p = 0.03, respectively). The data from this trial do not support the substitution of cytarabine by azacitidine in intensive induction therapy.

Allogeneic donor split skin grafts for treatment of refractory ulcers in cutaneous chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation-a retrospective analysis on seven patients

Refractory skin ulcers due to severe chronic graft-versus-host disease (cGVHD) remain to be associated with significant morbidity and mortality.We performed an allogeneic donor skin transplantation in seven adult patients after allogeneic hematopoietic stem cell transplantation for cGVHD-associated refractory skin ulcers. While four patients received a split skin graft (SSG), in one patient, a full thickness skin graft for two small refractory ulcers of the ankle was performed, and one patient received in vitro expanded donor keratinocyte grafts derived from hair roots of the original unrelated donor. In one additional patient, a large deep fascial defect of the lower leg was covered with an autologous greater omentum free graft before coverage with an allogeneic SSG. An additional patient was treated with an autologous scrotal skin graft for a refractory ulcer associated with deep sclerosis of cGVHD after unrelated donor transplantation.All skin grafts engrafted and resulted in permanent coverage of the grafted ulcers without any signs of immunological mediated damage. In the patient receiving in vitro expanded keratinocyte grafts, two localized ulcers were permanently covered by donor skin while this approach failed to cover extensive circular ulcers of the lower legs.Allogeneic donor skin grafts are a valuable treatment option in refractory ulcers due to cGVHD but are restricted mainly to related donors while keratinocyte grafts from unrelated donors remain experimental. In male patients lacking a related donor, autologous scrotal skin graft may be an alternative option.

Intensification of ice nucleation observed in ocean ship emissions

Shipping contributes primary and secondary emission products to the atmospheric aerosol burden that have implications for climate, clouds, and air quality from regional to global scales. In this study we exam the potential impact of ship emissions with regards to ice nucleating particles. Particles that nucleate ice are known to directly affect precipitation and cloud microphysical properties. We have collected and analyzed particles for their ice nucleating capacity from a shipping channel outside a large Scandinavia port. We observe that ship plumes amplify the background levels of ice nucleating particles and discuss the larger scale implications. The measured ice nucleating particles suggest that the observed amplification is most likely important in regions with low levels of background particles. The Arctic, which as the sea ice pack declines is opening to transit and natural resource exploration and exploitation at an ever increasing rate, is highlighted as such a region.

Abstract A029: Biomarker analysis in HR+, HER2-, locally advanced, or metastatic breast cancer patients treated with buparlisib: results from BELLE-3

Background: Endocrine therapy resistance in hormone receptor-positive breast cancer often leads to activation of phosphoinositide 3-kinase (PI3K)/mammalian target of rapamycin pathway. In the BELLE-3 study the progression-free survival (PFS) improvement in buparlisib (BUP) vs placebo (PBO) arm was greater in patients (pts) with PIK3CA-mutant than PIK3CA-wildtype (Wt) tumors, based on circulating tumor DNA. In the current study we report the additional exploratory biomarker results from BELLE-3. Methods: The relationship between PFS and frequently mutated genes (PIK3CA, CCND1, ESR1 and 8q11.23 region) and pathways (PI3K and CDK pathways) was explored using NGS in tumor and pts were classified as altered (Alt) vs Wt. Genes and pathways with at least 10% frequency in both arms were carried forward to correlative analyses with PFS. In addition, ESR1 mutations were detected by BEAMing technology in baseline cell free DNA (cfDNA) for 167 pts. Results: NGS data were available for 185 pts and the NGS panel covered 500+ gene mutations, short insertions/deletion, copy number alterations, and translocations. PIK3CA was altered in 41% of pts and PI3K pathway was altered in 64% of pts. Benefit of BUP treatment was observed in PIK3CA altered pts, but did not extend to other alterations in the PI3K pathway. CCND1 was altered in 19% of pts and the CDK pathway was altered in 34% of pts and improved benefit of BUP was observed in altered pts in both the groups (HR = 0.31 and 0.38 respectively). Alterations in the 8q11.23 region (ZNF703, WHSC1L1 and FGFR1) were observed in 21% of pts with the benefit of BUP observed only among wildtype. In cfDNA, a higher treatment effect was observed in the ESR1 mutant subgroup (HR = 0.76 [Wt] and 0.27 [Alt]). Subgroup analyses of ESR1 mutations revealed a greater improvement in median PFS among pts with D538G mutation (BKM vs PBO = 8.25 vs 1.51; HR = 0.18) than among pts with Y537N/S/C mutation (BKM vs PBO = 4.17 vs 2.76; HR = 0.45). The PFS of different groups analyzed by NGS is mentioned in the table. Conclusions: A trend for stronger treatment effect was observed among pts with alterations in PIK3CA, CDK pathway, CCND1 (tumor), and ESR1 (ctDNA). The possibility of correlation among identified biomarkers is currently being explored. Table: Median PFSGroupTreatmentNEventsMedian PFS, moHR (95% CI)PIK3CAWtPBO34271.480.73 (0.46 - 1.16)BUP75602.83AltPBO23191.40.44 (0.25 - 0.79)BUP53344.11PI3K pathway (excluding PIK3CA Alt pts)WtPBO19171.450.51 (0.28 - 0.93)BUP47402.83Alt*PBO15104.671.1 (0.51 - 2.39)BUP28202.86CCND1WtPBO47371.480.61 (0.41 - 0.92)BUP103733.35AltPBO1091.430.31 (0.13 - 0.76)BUP25212.1CDK pathwayWtPBO40321.480.63 (0.4 - 0.98)BUP83583.42AltPBO17141.430.38 (0.19 - 0.75)BUP45362.68q11.23 regionWtPBO48391.450.49 (0.33 - 0.73)BUP98704.11AltPBO971.410.9 (0.38 - 2.13)BUP30241.48ESR1 mutation statusWtPBO29202.70.76 (0.43 - 1.31)BUP56372.8AltPBO23202.60.27 (0.14 - 0.51)BUP59246.0

* To assess the impact of genes in the PI3K pathway other than PIK3CA, the altered group includes patients who are PIK3CA wildtype but have an alteration in a different gene in the PI3K pathway.

Citation Format: Nadia Solovieff, Ying A. Wang, Banu Sankaran, Nicolas Scheuer, Mona El-Hashimy, Denis Weber, Dalila Sellami, Angelo Di Leo. Biomarker analysis in HR+, HER2-, locally advanced, or metastatic breast cancer patients treated with buparlisib: results from BELLE-3 [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A029.

Buparlisib plus fulvestrant in postmenopausal women with hormone-receptor-positive, HER2-negative, advanced breast cancer progressing on or after mTOR inhibition (BELLE-3): a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

Activation of the PI3K/AKT/mTOR pathway occurs frequently in breast cancer that is resistant to endocrine therapy. Approved mTOR inhibitors effectively inhibit cell growth and proliferation but elicit AKT phosphorylation via a feedback activation pathway, potentially leading to resistance to mTOR inhibitors. We evaluated the efficacy and safety of buparlisib plus fulvestrant in patients with advanced breast cancer who were pretreated with endocrine therapy and mTOR inhibitors.

METHODS

BELLE-3 was a randomised, double-blind, placebo-controlled, multicentre, phase 3 study. Postmenopausal women aged 18 years or older with histologically or cytologically confirmed hormone-receptor-positive, HER2-negative, locally advanced or metastatic breast cancer, who had relapsed on or after endocrine therapy and mTOR inhibitors, were recruited from 200 trial centres in 22 countries. Eligible patients were randomly assigned (2:1) via interactive response technology (block size of six) to receive oral buparlisib (100 mg per day) or matching placebo starting on day 1 of cycle 1, plus intramuscular fulvestrant (500 mg) on days 1 and 15 of cycle 1 and on day 1 of subsequent 28-day cycles. Randomisation was stratified by visceral disease status. The primary endpoint was progression-free survival by local investigator assessment as per the Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1 in the full analysis population (all randomised patients, by intention-to-treat). Safety was analysed in all patients who received at least one dose of treatment and at least one post-baseline safety assessment. This study is registered with ClinicalTrials.gov, number NCT01633060, and is ongoing but no longer enrolling patients.

FINDINGS

Between Jan 15, 2013, and March 31, 2016, 432 patients were randomly assigned to the buparlisib (n=289) or placebo (n=143) groups. Median progression-free survival was significantly longer in the buparlisib versus placebo group (3·9 months [95% CI 2·8-4·2] vs 1·8 months [1·5-2·8]; hazard ratio [HR] 0·67, 95% CI 0·53-0·84, one-sided p=0·00030). The most frequent grade 3-4 adverse events in the buparlisib versus placebo group were elevated alanine aminotransferase (63 [22%] of 288 patients vs four [3%] of 140), elevated aspartate aminotransferase (51 [18%] vs four [3%]), hyperglycaemia (35 [12%] vs none), hypertension (16 [6%] vs six [4%]), and fatigue (ten [3%] vs two [1%]). Serious adverse events were reported in 64 (22%) of 288 patients in the buparlisib group versus 23 (16%) of 140 in the placebo group; the most frequent serious adverse events (affecting ≥2% of patients) were elevated aspartate aminotransferase (six [2%] vs none), dyspnoea (six [2%] vs one [1%]), and pleural effusion (six [2%] vs none). On-treatment deaths occurred in ten (3%) of 288 patients in the buparlisib group and in six (4%) of 140 in the placebo group; most deaths were due to metastatic breast cancer, and two were considered treatment-related (cardiac failure [n=1] in the buparlisib group and unknown reason [n=1] in the placebo group).

INTERPRETATION

The safety profile of buparlisib plus fulvestrant does not support its further development in this setting. Nonetheless, the efficacy of buparlisib supports the rationale for the use of PI3K inhibitors plus endocrine therapy in patients with PIK3CA mutations.

FUNDING

Novartis Pharmaceuticals Corporation.