Abstract P1-10-01: Defining the spectrum of germline variants among African American patients with triple negative breast cancer

Background: African American (AA) women are more likely to have breast cancer at a younger age and be diagnosed with triple negative breast cancer (TNBC), which is as yet unexplained. We examined results of multi-gene panel testing in AA women with TNBC tested at a large commercial laboratory to assess the utility of gene panels and findings in this group.

Methods: We assessed individuals who had clinical hereditary cancer testing with a multi-gene panel between September 2013 and May 2018. Women were included for analysis if they had a personal history of TNBC and self-identified as having any AA ancestry (n=3,268) or only Caucasian (CA) ancestry (n=8,953). Clinical data was collected from provider-completed test request forms. Comparisons were performed using descriptive statistics, t-tests (continuous variables), and chi-square tests (categorical variables) adjusting for multiple testing when necessary.

Results: In this cohort, AA women were significantly more likely than CA women to meet NCCN guidelines (97.5% vs. 96.6%, p=0.010) and significantly less likely to have an additional personal (16.2% vs. 21.8%, p<0.001) or family (79.3% vs. 86.3%, p<0.001) history of cancer. Overall, 11.5% of AA women were found to carry a pathogenic variant (PV) compared to 13.4% of CA women (p=0.004; Table 1). Compared to CA women, AA women with a PV were significantly younger at diagnosis (46.7 vs. 49.5 years of age; p<0.001). The prevalence of PVs in BRCA1, CHEK2 and the Lynch syndrome genes was higher in CA women, whereas the prevalence of BRCA2 PVs was higher in AA women. While the prevalence of PVs in individual genes was not significantly different according to ancestry after adjusting for multiple comparisons, AA women were significantly less likely to have a PV in any breast cancer-related gene compared to CA women (p=0.048). AA women were significantly more likely to have a Variant of Uncertain Significance (VUS; 35.6% vs. 20.9%; p<0.001) and to have >1 VUS (8.6% vs. 2.6%, p<0.001). Regardless of ancestry, patients diagnosed before age 40 were more likely to carry a PV (19.7% AA, 22.2% CA). However, the prevalence of PVs among patients diagnosed after age 60 was still striking (8.9% AA, 10.9% CA) and was similar to the PV prevalence among patients diagnosed between 40-60 (10.1% AA, 12.3% CA).

Conclusions: In the era of multi-gene panel testing, this large cohort of patients with TNBC supports the use of panel testing in AA women with TNBC regardless of age or additional personal/family history of cancer. While additional research to the rate and pathogenicity of VUS in AA women is needed, genetic counseling is necessary to explain the possibility and meaning of a VUS in this group.

Table 1.Distribution of PVs in BC-related genes according to ancestry AA WomenCA WomenGeneN (%)N (%)Any Breast Cancer-Related Gene347 (10.6)1104 (12.3)BRCA1132 (4.0)496 (5.5)BRCA297 (3.0)236 (2.6)ATM6 (0.2)25 (0.3)BARD119 (0.6)67 (0.7)BRIP120 (0.6)46 (0.5)CDH11 (<0.1)1 (<0.1)CHEK22 (0.1)33 (0.4)NBN2 (0.1)10 (0.1)PALB244 (1.3)138 (1.5)PTEN2 (0.1)4 (<0.1)RAD51C20 (0.6)41 (0.5)STK1101 (<0.1)TP532 (0.1)6 (0.1)Lynch Syndrome Genes10 (0.3)46 (0.5)Other Genes12 (0.4)24 (0.3)Multiple PVs6 (0.2)28 (0.3)Total (Any Gene)375 (11.5)1202 (13.4)

Citation Format: Pederson HJ, Heald B, Budd GT, Bernhisel R, Cummings S, Saam JR, Lancaster JM, Grobmyer SR, Eng C. Defining the spectrum of germline variants among African American patients with triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-10-01.

Abstract P5-21-26: T-DM1 activity in metastatic HER2-positive breast cancer patients who have received prior trastuzumab and pertuzumab: NSABP B-005

Background :

The pivotal phase III EMILIA trial reported a progression free survival (PFS) rate of 9.6 months and an objective response rate of 43% with T-DM1 in patients with HER2-positive metastatic breast cancer previously treated with trastuzumab and a taxane. However, there is very limited data on the efficacy of T-DM1 in patients who have received prior pertuzumab either neoadjuvantly or as first line therapy in the metastatic setting. The primary goal of this study was to assess the clinical efficacy (tumor response rates and median duration on therapy) of T-DM1 in patients previously treated with pertuzumab and trastuzumab.

Methods:

After IRB approval, a cancer data registry and electronic pharmacy database were utilized to identify breast cancer patients receiving treatment with T-DM1 at Cleveland Clinic and University of Pittsburgh. Patients that received trastuzumab and pertuzumab, in either the neoadjuvant or metastatic setting, with baseline and follow up imaging available for review were identified. Patient charts were reviewed to collect accurate information about the treatment sequencing and outcomes. RECIST version 1.1 was utilized for tumor assessment and patients with measurable disease and non measurable disease were included in the study.

Results:

We identified a total of 23 patients with a median age of 55 years that met the inclusion criteria. 69% percent of patients received T-DM1 as first line or second line therapy and 31% received it as third line or later. All patients had at least 1 measurable lesion. Best overall response showed rates of complete response, partial response and stable disease of 17%, 26% and 22% respectively. 35% patients progressed on first assessment after start of treatment. The median duration on therapy was 5.3 months (range 3 weeks to 33 months) with 43% of patients receiving T-DM1 for greater than 6 months.

Conclusion:

Our results were comparable to those reported by EMILIA trial. T-DM1 has reasonable clinical efficacy in patients who have received prior treatment with pertuzumab and trastuzumab with an overall response rate of 43% and median duration on therapy of 5.3 months.

Citation Format: Tiwari SR, Sussman T, Kota K, Moore HC, Montero AJ, Budd GT, Puhalha S, Abraham J. T-DM1 activity in metastatic HER2-positive breast cancer patients who have received prior trastuzumab and pertuzumab: NSABP B-005 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-26.

Abstract P2-12-04: Impact of institution of young women's breast cancer clinic on time to treatment and utilization of fertility, genetics and social work consultations in women under age 50 with new diagnosis of early stage breast cancer

Background: Genetic counseling and fertility resources are often underutilized in young women with early stage breast cancer (ESBC) due, in part, to concerns about treatment delays. At our institution, women newly diagnosed with ESBC typically see a breast surgeon, medical oncologist and radiation oncologist in a multidisciplinary clinic with additional cancer related subspecialist referrals occurring at those providers' discretion. We hypothesized that time to treatment (TTT) and utilization of fertility, genetics and social work consultations would improve after implementing a Young Women's Breast Cancer Clinic. As of January 1, 2015, all patients under age 50 seen at Cleveland Clinic for new diagnosis of ESBC were automatically offered scheduling of appointments with medical genetics, reproductive endocrinology and social work in addition to the usual multidisciplinary team.

Methods: Women under age 50 diagnosed with ESBC seen at Cleveland Clinic from 1/2014-12/2015 were identified using our tumor registry. Demographics, tumor pathology, clinical and treatment histories were obtained through medical chart review as per IRB approved protocol. Time from initial visit in our system to date of treatment initiation was calculated for all patients and compared between the 2014 (pre-intervention) and 2015 (post-intervention) cohorts as was time from diagnosis (biopsy date) to treatment initiation. Completed reproductive endocrinology, genetic counseling and social work consultations were documented. Welch two sample t-test was used to compare time to treatment between groups. Chi squared test was used to compare frequency of subspecialty consultations between groups.

Results: 207 young women with ESBC were identified over the 2 year period, 99 in 2014 and 108 in 2015. Median age was 45 in 2014 and 44 in 2015. Most were diagnosed outside of our hospital system, 58% in 2014 and 76% in 2015. The most common initial treatment was surgery with reconstruction (S+R) (54% and 50% for 2014 and 2015 respectively) followed by chemotherapy (23% and 27%) then surgery without reconstruction (S) (20% and 24%). Median TTT from first encounter was 30 days in 2014 and 28 days in 2015 (p=0.33) and was 36 days versus 33.5 days (p=0.23) when calculated from biopsy date. TTT in the S and S+R groups was 37 vs 28 days (p=0.84) and 36.5 vs 32 days, (p=0.21), respectively. Genetics, reproductive endocrinology and social work consults in 2014 vs 2015 were documented as 89% vs 94%, 4% vs 9% and 58 vs% 55% (p=0.22, 0.32, 0.77). For patients under age 40, 27% in 2014 and 30% in 2015 completed reproductive endocrinology consultations.

Conclusions: Offering upfront scheduling of breast cancer related subspecialty appointments for young women with newly diagnosed ESBC did not significantly improve overall TTT. There was a trend towards improved TTT in those receiving surgery with or without reconstruction as first treatment and no suggestion of delay in TTT. A modest numeric increase in completed genetic counseling and reproductive endocrinology consultations was not statistically significant, but may have been clinically meaningful for affected individuals.

Citation Format: Kruse ML, Raska P, Abraham J, Budd GT, Montero A, Grobmyer S, Moore H. Impact of institution of young women's breast cancer clinic on time to treatment and utilization of fertility, genetics and social work consultations in women under age 50 with new diagnosis of early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-12-04.

Abstract P5-14-07: Impact of time to treatment (TTT) on recurrence free survival in non metastatic invasive breast cancer

This abstract was withdrawn by the authors.

Abstract OT2-01-10: Pilot study of carboplatin, nab-paclitaxel and pembrolizumab for metastatic triple-negative breast cancer (ongoing clinical trial)

BACKGROUND. Triple-negative breast cancer (TNBC) is associated with an aggressive phenotype and decreased survival. TNBC is characterized by tumor-infiltrating lymphocytes (TIL) which predict for a better prognosis and likely reflect immune recognition of tumor-associated antigens by TIL. However, potent immune suppressive signals exist in the tumor microenvironment such as those mediated by PD-1 with its ligand, PD-L1. Therefore, to test the validity of decreasing PD-1/PD-L1-mediated immune suppression, a Phase Ib study of single-agent pembrolizumab in 32 patients with advanced TNBC showed a partial response of 16.1% and stable disease of 9.7%, thereby attesting to the effectiveness of single-agent pembrolizumab in these patients. Other studies have demonstrated that cytotoxic chemotherapy favorably modulates immunity against cancer and there is therefore a strong rationale to combine chemotherapy with an immune modulator such as pembrolizumab for the treatment of mTNBC.

TRIAL DESIGN. This is an investigator-initiated, industry-sponsored (Merck) pilot study of carboplatin (C), nab-paclitaxel (N) and pembrolizumab (P) in 30 patients with metastatic (m) TNBC. Eligible patients will receive 3 cycles of CNP, with each cycle consisting of C (AUC 6 on days 1 of a 21-day cycle), N (100 mg/m2 IV on days 1, 8 and 15 of a 21-day cycle), and P (200 mg IV on day 15 of each cycle). After completion of 3 cycles CNP, patients with responding or stable disease by RECIST 1.1 criteria will be eligible for additional cycle(s) of CNP.

ELIGIBILITY CRITERIA. Patients must have radiologically measurable mTNBC, an ECOG performance status of 0-1, must not have received more than 2 prior therapies for this disease, and must be willing to undergo a preliminary biopsy of a metastatic focus for research purposes. A second post-treatment biopsy will be encouraged but will not be mandated.

SPECIFIC AIMS. The primary objective is to determine overall response rate (ORR) in patients treated with CNP. The secondary objectives are to determine progression-free survival (PFS) and safety/tolerability of CNP. Correlative objectives include the identification of pathologic and genomic correlates of response to CNP.

STATISTICAL METHODS. Clinical response will be scored using RECIST 1.1 criteria. Under the proposed treatment, the expected clinical response is about 35%. With the precision of the 2-sided 95% confidence interval for the response rate set to 0.17 (the distance to the expected response rate of 35%), the sample size required for the study is 30 patients. The true response rate of therapy will be estimated based on the number of responses using a binomial distribution and its confidence intervals will be estimated using Wilson's method. The Kaplan-Meier method will be used to estimate PFS. Factors including pathologic and genomic correlates that predict survival outcomes will be identified by Cox model or extensions of the Cox model.

TARGET ACCRUAL. We plan to enroll 30 patients over 2 years, with the first patient expected to be enrolled in September 2016.

CONTACT INFORMATION. Joseph Baar, MD, PhD. Seidman Cancer Center of University Hospitals Case Medical Center. E-mail: joseph.baar@uhhospitals.org.

Citation Format: Baar J, Abraham J, Silverman P, Budd GT, Vinayak S, Varadan V, Moore H, Montero A, Fu P. Pilot study of carboplatin, nab-paclitaxel and pembrolizumab for metastatic triple-negative breast cancer (ongoing clinical trial) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-10.

Abstract OT1-01-02: Pilot trial of a type I polarized autologous dendritic cell vaccine incorporating tumor blood vessel antigen-derived peptides in patients with metastatic breast cancer

BACKGROUND. Cancer vaccines based on tumor-associated antigens are rarely curative in advanced cancer. This limitation relates to the heterogeneity of cancer due to defects in antigen presentation and altered immunophenotypes. Therefore, another method to promote anti-tumor immunity is to prime T cells against tumor-associated stromal cells. We have reported that IL-12 gene-therapy of established HLA-A2neg B16 melanomas in HLA-A2 transgenic (Tg) mice resulted in CD8+ T cell-mediated immunity against the host HLA-A2+ stromal cells within the tumor microenvironment (TME). We have also shown that vaccines based on a subset of tumor blood vessel antigen (TBVA)-derived peptides (DLK1310-318, EphA2883-891, HBB31-39, NRP1433-441, RGS55-13 and TEM1691-700) prevented HLA-A2neg MC38 tumor establishment and promoted the regression of melanomas in HLA-A2 Tg mice by CD8+ T cell targeting of HLA-A2+ pericytes and vascular endothelial cells in the TME.

TRIAL DESIGN. Based on this pre-clinical data, we are undertaking a Susan G. Komen-funded (IIR13261822; IND 15722) IRB-approved clinical trial of chemo-immunotherapy using the immunomodulatory drug gemcitabine (GEM) to suppress tumor infiltrating suppressor cells such as myeloid-derived suppressor cells (MDSC) and regulatory T cells (Tregs) with a dendritic cell (DC) vaccine pulsed with the above six HLA-A2-presented TBVA-derived peptides (DC-TBVA) in 30 HLA-A2+ patients with metastatic breast cancer (MBC). Eligible patients will first undergo leukapheresis for the generation of the DC-TBVA vaccine. Patients will then receive 3 cycles of GEM, 1000 mg/m2 IV on days 1 and 8 of a 21-day cycle for 3 cycles. Patients will then receive the DC-TBVA vaccine administered twice intradermally 7 days apart.

ELIGIBILITY CRITERIA. Patients must be HLA-A2+ and have radiologically measurable MBC, an ECOG performance status of 0-1 and not have any active immune disorders. Prior GEM therapy is acceptable as long as the last dose was ≥ 3 months from registration on this study. Patients may not be on steroids.

SPECIFIC AIMS. The 4 specific aims are to 1) assess the safety of GEM + αDC1-TBVA vaccination, 2) assess the clinical response of MBC to GEM + αDC1-TBVA vaccination, 3) determine the clinical efficacy of GEM + αDC1-TBVA vaccination in generating Tc1 immunity, and 4) correlate changes in MDSC and Tregs with the generation of anti-TBVA Tc1-cell immunity

STATISTICAL METHODS. Clinical response: if the response rate is less than 10%, then there is probability 0.05 or less of accepting the vaccine therapy; if the response rate is bigger than 32%, then the probability of rejecting the combination is less than 0.2. While the secondary goals of the study are exploratory, there is sufficient statistical power to identify moderate to large effects (i.e., there will be statistical power >.80 to detect changes from baseline in the different immune function parameters that are >0.6 standard deviations of the parameter.)

TARGET ACCRUAL. We will enroll 30 patients over 3 years, with the first patient expected to be enrolled in July 2015.

CONTACT INFORMATION. Joseph Baar, MD, PhD. Seidman Cancer Center. E-mail: joseph.baar@uhhospitals.org.

Citation Format: Baar J, Storkus W, Finke J, Butterfield L, Lazarus H, Reese J, Brufsky A, Downes K, Budd GT, Fu P. Pilot trial of a type I polarized autologous dendritic cell vaccine incorporating tumor blood vessel antigen-derived peptides in patients with metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-01-02.

Abstract P4-13-24: Impact of genomic medicine on clinical decision making in patients with advanced breast cancer at two academic medical centers

Background: A deeper molecular understanding of cancer biology has led to the development of therapies targeting driver mutations. Genomic profiling of tumors is commercially available and has become integrated into many clinical practices as part of a paradigm shift towards personalized care of cancer patients. The current impact of genomic profiling on clinical decision making for patients with advanced breast cancer is not well described.

Methods: Patients with metastatic breast cancer (mBC) who had tumors submitted for commercial genomic analysis from 2013-2015 were identified consecutively at two large academic cancer centers with genomic basket trials open for the majority of the collection period. Demographics, tumor pathology, clinical, and treatment histories were extracted through medical chart review as per an IRB approved protocol. Data from genomic analysis reports was extracted including number and type of mutations, FDA approved therapies and clinical trials available. Genomic analysis was determined to have impacted clinical decision making if the next line of therapy was influenced either by accrual to clinical trial, or a decision to prescribe an FDA-approved therapy. The most frequent somatic mutations and their relative frequencies were determined.

Results: A total of 82 patients with mBC who had undergone commercially available genomic testing were identified. The median age was 49 (range: 29-70). 42 patients (51%) had ER-positive HER2-negative disease, 33 (40%) had ER-negative HER2-negative disease, 4 (5%) had ER-negative HER2-positive disease and 3 (4%) had ER-positive HER2-positive disease. The median number of lines of therapy received prior to genomic profiling was 2 (range 0-15). Genomic analysis reports suggested that 61 (74%) of these patients had at least one FDA approved medication available for at least one somatic mutation, and 79 (96%) had at least one clinical trial available (39 (46%) in the same state, 11 (13%) in the same institution). Genomic testing influenced management in 8 patients (10%), with 6 patients (7%) experiencing a change in next line of therapy attributable to genomic information. In 74 patients (90%), genomic testing results did not affect clinical decision-making. The most frequently observed somatic mutations included: TP53, PI3KCA, MYC, CCDN1, FGF, ZNF703, GATA3, ARID1A, MCL1, PTEN, MYST3, and BRCA1.

Conclusions: Genomic testing did not affect management in the vast majority of mBC patients treated at two major academic cancer centers. Furthermore, the most identified mutated genes found were not targetable. The real world clinical utility of genomic analysis remains limited in breast cancer but may influence clinical decision making in a minority of patients.

Citation Format: Kruse ML, Santa-Maria CA, Raska P, Swoboda A, Jain S, Sohal D, Moore H, Budd GT, Abraham J, Montero AJ. Impact of genomic medicine on clinical decision making in patients with advanced breast cancer at two academic medical centers. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-24.

Abstract P1-09-03: Socioeconomic characteristics of African American women with breast cancer

Background: Breast cancer is the most common cancer among African American (AA) women. Despite having a lower incidence of breast cancer compared to white women (124.4 compared to 127.9 per 100,000), AAs have a higher death rate (30.2 compared to 21.3 per 100,000). One explanation for this discrepancy is that breast cancer in AAs is often detected at a later stage compared to white women. We conducted this retrospective study to examine socioeconomic characteristics among AA women with breast cancer to see if there were factors associated with stage of diagnosis which may contribute to the known disparities. Methods: We identified all AA women diagnosed with any stage breast cancer from 2006-2014 within the Cleveland Clinic Cancer Data Warehouse and classified them into either early or late stage disease at time of diagnosis. Stages 0-II were classified as early and stages III-IV as late. We examined several variables at diagnosis including age, marital status, tobacco use, alcohol use, Medicaid insurance status, and breast cancer subtype which included HER-2 positive (HER+), hormone receptor positive/HER2 negative (HR+/HER-), and triple negative(TN). AA median income was obtained from US census data according to the zip code at diagnosis. We conducted univariate logistic regression for individual estimates and confidence intervals and multiple logistic regression and model selection to determine significant predictors of stage of diagnosis. Results: Of the 771 AA women identified, 108 (14%) were diagnosed at a late stage of disease with a median age of 59 years. Receptor status distribution was 12.4%, 31%, and 16.6% for HER+, HR+/HER-, and TN respectively for early stage, and 15.7%, 27%, and 25% for late stage. Among early stage 50% were current or previous smokers and 2.6% had Medicaid insurance compared to late stage patients where 63% were current or previous smokers and 9.2% had Medicaid insurance. Multiplicative effect estimates and 95% confidence intervals from univariate logistic regressions identified the following significant factors: tobacco use 1.48 [1.11-1.96] and Medicaid 3.73 [1.56-8.51] (p-values<0.01), and TNBC 1.67 [1.02-2.68] (p-value<0.05). In a stepwise model selection, only tobacco use and Medicaid were retained in the model, as well as age at diagnosis. Conclusions: There are socioeconomic differences among AA women with breast cancer. Only tobacco use, Medicaid insurance, and age at diagnosis were predictive of late stage in this study.

Citation Format: Winter A, Raska P, Ornstein M, Moore H, Montero A, Budd GT, Tullio K, Bailey J, Abraham J. Socioeconomic characteristics of African American women with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-09-03.

Abstract P4-11-04: Targeted vaccination against human a-lactalbumin may provide immunotherapy and immunoprevention of triple negative breast cancer

We have previously shown that a-lactalbumin vaccination mediates protection against the development of murine breast cancer in the absence of any detectable inflammatory changes in all normal non-lactating tissues examined. Based on these results, we have proposed that α-lactalbumin vaccination of healthy, cancer-free, adult women may provide safe and effective immunoprevention of breast cancer. Several issues have been raised over the past several years questioning the feasibility of applying this autoimmune strategy for breast cancer immunoprevention in the normal, healthy, cancer-free adult female population. These concerns have focused on whether adult women would be immunologically responsive to human α-lactalbumin, whether a history of lactation would create an insurmountable tolerance that would preclude generating effective immunity against α-lactalbumin, whether α-lactalbumin is immunologically available in human breast tumors, and whether expression of α-lactalbumin in normal non-breast tissues would predispose to systemic autoimmune complications. Here we provide an accumulation of several new findings that directly address these issues: 1) In vitro priming of peripheral blood mononuclear cells (PBMC) from normal healthy adult women results in frequencies of α-lactalbumin-specific interferon-gamma (IFNγ) producing T cells that are consistent with those mediating protection against breast tumor formation in mice; 2) Frequencies of IFNγ-producing T cells and the level of protection from the development of breast tumors are virtually identical whether vaccination occurs in parous mice with a history of lactation and breastfeeding or whether vaccination occurs in non-parous mice with no history of lactation; 3) ONCOMINE data base searches repeatedly show highly significant overexpression of α-lactalbumin in triple negative breast cancer (TNBC). This expression was confirmed experimentally using several methods including RT-PCR, Western blot analysis, and longitudinal visualization of α-lactalbumin gene expression during in vivo growth of human TNBC in immunodeficient mice. This in vivo visualization of α-lactalbumin gene expression was facilitated by measuring bioluminescence from growing human HCC1937 TNBC cells stably transfected with a lentivirus designed to regulate firefly luciferase expression under control of the human α-lactalbumin promoter; and 4) Evidence from the Human Protein Atlas indicates negative immunohistochemical staining for α-lactalbumin in 78 normal human tissues examined, thereby confirming the widely held view that α-lactalbumin expression in normal human tissues is confined exclusively to the lactating breast. Collectively, these findings indicate that normal, healthy, adult women are capable of mounting an immune response to human α-lactalbumin, that a history of lactation and breastfeeding has no impact on the induced immunity and the protection it provides against the development of breast cancer, and that α-lactalbumin vaccination may be most effective in providing therapy and immmunoprevention of TNBC, the most aggressive form of breast cancer and the most common variant occurring in women with BRCA1 mutations (supported by NIH R01 CA140350).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-11-04.

Uncertainty of (222)Rn concentrations in the usepa radiation and indoor environments National Laboratory Exposure Chamber

The U.S. Environmental Protection Agency (EPA) operates an environmentally controlled chamber for purposes of exposing various radon and decay product measurement equipment to known (222)Rn concentrations. Exposure durations range from 1 h to several months, and (222)Rn concentrations vary between 37 and 4,440 Bq m(-3). Radon concentrations are generated from Ra sources mounted on the chamber, but concentrations are continuously measured using equipment calibrated using (222)Rn generated from Ra laboratory standards made from a National Institute of Standards and Technology (NIST) Standard Reference Material (SRM) and verified through an aliquot measured by the NIST. The (222)Rn concentrations that are used to calibrate the equipment in the chamber are produced from bubbling a measured volume of air through the (226)Ra laboratory standard solution. This paper describes the process to derive an average chamber concentration during the exposure period. This includes the generation of laboratory (226)Ra standards from the original NIST SRM, (222)Rn emanation into a measured volume of air and transfer to Rocky Mountain Glassworks stainless steel scintillation cells to generate individual cell calibration factors, the calibration of larger mounted flow-through scintillation cells, and the reduction of cumulative chamber scintillation cell counts over various time periods. Each step is associated with an uncertainty based on measured and estimated factors, and each step adds an additional uncertainty to the cumulative total. The methods used follow guidance in the 1993 ISO Guide to the Expression of Uncertainty in Measurement and NIST Technical Note 1297. Chamber exposures of 96 h and (222)Rn concentrations between 150 and 2,700 Bq m(-3) are associated with a combined standard uncertainty of 4.1% (1 s). Ninety-six hour (96 h) exposures of lower (222)Rn concentrations of between 150 - 370 Bq m(-3) are associated with a combined standard uncertainty of 5%. Results indicate that there are measures that can be taken to reduce the estimated uncertainty slightly. The calculations used in this analysis have been incorporated into the computer code used to track chamber concentrations and exposures so that estimated uncertainties can be associated with each exposure.

Abstract PD02-04: Automated Quantitative RNA In Situ Hybridization for Resolution of Equivocal and Heterogeneous ERBB2 (HER2) Status in Invasive Breast Carcinoma

Background: Breast carcinomas that demonstrate a heterogeneous ERBB2 (HER2) status or equivocal results by both immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) present diagnostic challenges for which there is neither a standard methodology to achieve resolution in the clinical laboratory nor a uniform approach to management. We assessed the feasibility of using a novel automated and quantitative HER2 mRNA bright field in situ hybridization (ISH) assay capable of single molecule detection to determine HER2 status in invasive breast carcinomas that demonstrated significant tumor heterogeneity or failed to be resolved by standard IHC and FISH algorithmic testing.

Design: Formalin-fixed, paraffin-embedded (FFPE) breast carcinomas from a non-consecutive series of 163 patients were analyzed for HER2 mRNA using a fully automated bright field RNA ISH assay (RNAscope, Advanced Cell Diagnostics, Hayward, CA). Cases were assigned into either a training set (n = 34) or a validation set (n = 129) and analyzed by both Q-RT-PCR and RNAscope. automated image analysis was used to numerate the punctate signal dots per cell in RNAscope-stained slides. A HER2 mRNA score based on single-cell quantification by RNAscope was developed and correlated to HER2 FISH and HER2 mRNA Q-RT-PCR results. A simple cutoff value was derived using the training set and applied to the validation set.

Results: Evaluable HER2 results were obtained for 154 cases (94.5%) by RNAscope and 163 cases (100%) by Q-RT-PCR. In the training set, both FISH/IHC positive and negative cases were definitively separated by both Q-RT-PCR and RNAscope. HER2 mRNA dots per cell correlated strongly to FISH (Spearman r=0.77) and Q-RT-PCR (r = 0.81). Application of both methods to the validation set resulted in correct identification of 31/31 positive cases and 41/43 negative (overall concordance=97.3%) for both RNAscope and Q-RT-PCR. RNAscope showed a significant advantage over Q-RT-PCR in correctly identifying cases equivocal by FISH that were resolved by reflex IHC testing. RNAscope classified 7 of 26 (26.9%) FISH/IHC double equivocal cases as positives. In cases with HER2 protein heterogeneity, RNAscope showed a 100% concordance with FISH results, whereas Q-RT-PCR showed a 42.9% concordance.

Conclusion: RNAscope analysis of HER2 mRNA is an effective means to resolve HER2 status in double equivocal cases and cases that demonstrate heterogeneity. Automation and image analysis-based quantification minimize analytical and post-analytical variability. Quantification of single RNA transcripts in situ at single-cell level demonstrates superiority over qRTPCR and great potential in predictive biomarker analysis. Further studies of larger cohorts correlating clinical response with HER2 mRNA expression in situ are warranted.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD02-04.

P1-07-05: HER2 Status Resolution in FISH and IHC “Double Equivocal” Breast Carcinomas by Quantitative Real-Time PCR

Background: Clinical testing for HER2 amplification/over-expression is performed by immunohistochemistry (IHC) and/or fluorescence in situ hybridization (FISH) as outlined by the ASCO/CAP guidelines. Although these guidelines standardize testing and reporting, in a subset of patients, HER2 is equivocal by both IHC and FISH (“Double Equivocal”). These double equivocal patients represent a clinically problematic sub-group that currently lack standardized management guidelines. In this study, we utilize Quantitative Real-Time PCR (Q-RT-PCR) to resolve HER2 status in invasive breast cancer cases that could not be resolved via IHC and FISH testing.

Material and Methods: FISH for HER2 was performed on 2259 invasive breast carcinomas from 1/2008 to 12/2010. In accordance with ASCO/CAP, all equivocal HER2 FISH cases were reflex tested by IHC. In double equivocal cases, RNA extraction was performed following macro-dissection using High Pure RNA Paraffin Kit (Roche Applied Biosciences, Indianapolis, IN). Q-RT-PCR was carried out using TaqMan® RNA-to-CT™ 1-Step Kit with primers and probes for HER2, B2M, and GAPDH (Applied Biosystems, Foster City, CA). Q-RT-PCR results were expressed as the relative quantification of HER2 vs. two control genes, all normalized against calibrator RNA from the MCF7 cell line. Cut off for Q-RT-PCR HER2 overexpression was set using ROC curve analysis (MedCalc, Belgium).

Results: In our cohort of 2259 patients, 124 (5.5%) had an equivocal HER2 result by primary FISH testing. Reflex HER2 testing by IHC was unable to resolve the HER2 status in 35 (1.5%) patients. Detection of HER2 overexpression by Q-RT-PCR was validated using 50 FISH confirmed amplified and 50 non-amplified cases. Q-RT-PCR performed on these 2 control populations generated two non-overlapping populations and ROC curve analysis using a cut off value of 7.0 showed 100% sensitivity and specificity in detection of HER2 overexpression. Application of Q-RT-PCR in the double equivocal sub-group resulted in resolution of HER2 status in all cases, 8 HER2 positive (test value ranging from 7.12 - 15.37) and 14 HER2 negative (test value ranging from 1.05 - 6.92).

Conclusion: Application of Q-RT-PCR for HER2 represents a viable approach to resolve HER2 status in cases that fail classification by both FISH and IHC. Q-RT-PCR combines the precision and high sensitivity of real-time PCR with the morphological specificity of histological evaluation and ultimately allows definitive HER2 classification at the time of initial diagnosis. This knowledge of HER2 status at the time of diagnosis allows for comprehensive neoadjuvant treatment although, additional studies correlating response to anti-HER2 therapy and HER2 status by Q-RT-PCR are warranted.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-05.

Hypercalcemia caused by metastatic adamantinoma: response to radiotherapy

Purpose. To describe successful palliation of a patient with metastatic adamantinoma presenting with lung metastases and hypercalcemia resulting from a parathormone-like substance released from the tumor.

Methods and materials. The records of a patient with a history of a tibial adamantinoma who presented with symptoms of hypercalcemia 20 years after the original surgery, as well as the literature concerning hypercalcemia and adamantinoma were reviewed and summarized.

Results. After thorough review of the literature we found no prior reports of radiation being used for palliation of hypercalcemia associated with metastatic adamantinoma.We report rapid improvement in symptoms and normalization of serum calcium levels following a course of radiation therapy. The patient remains asymptomatic 15 months following radiotherapy despite a gradual return of elevated serum calcium levels.

Discussion. Radiation therapy should be considered as a palliative option for patients who are not surgical candidates presenting with medically refractory hypercalcemia.

Variants in the BRCA1/Fanconi-Anemia Repair Pathway and Taxane-Induced Neuropathy in SWOG S0221

Background: Taxane-induced peripheral neuropathy is a dose-limiting side effect that leads to suboptimal cancer treatment and diminished quality of life. The mode of taxane neurotoxicity is unclear, but may be through stabilization of microtubules and induction of spindle checkpoint, leading to cell cycle arrest at G2/M. Fanconi Anemia (FA) genes, including FANCD2, and FANCA, appear to be involved in G2/M phase checkpoint maintenance as well as spindle checkpoint in response to internal and external signals, such as taxane treatment. Thus, we hypothesized that variants in FA genes could impact severity of taxane-induced neuropathies.Methods: Using DNA extracted from blood collected from 893 breast cancer patients participating in a trial evaluating metronomic dosing of cyclophosphamide, doxorubicin and paclitaxel (S0221), we genotyped for single nucleotide polymorphisms (SNPs) that represent all of the variability across FANCA (44 SNPs) and FANCD2 (24 SNPs) in all race/ethnicity groups, as well as a panel of ancestry informative markers to control for potential population stratification, using Illumina GoldenGate platform. SNPs with minor allele frequency (MAF) less than 0.10 and those out of Hardy Weinberg Equilibrium (HWE) proportions (p<0.001) were removed from analyses. Ordinal regression was used to test for allelic and haplotypic association with grade 3 or 4 toxicities relative to 0, 1, and 2 toxicities, adjusting for age, genetic admixture index and treatment arm. To adjust for multiple testing, permutation analyses were performed on both single SNP and haplotype models.Results: Eighteen SNPs in FANCD2 and 38 SNPs in FANCA passed MAF and HWE proportion requirements. For FANCD2, 4 SNPs spanning 67.5 Kb (rs7648104, rs2272125 [coding SNP], rs6786638 and rs644215), were significantly associated with taxane-induced neuropathy (p<0.001) after controlling for multiple testing, with each SNP resulting in approximately a twofold increase in odds of severe taxane-induced neuropathy. Haplotype estimation showed that all 18 SNPs comprise a single haplotype. Two major (>1% frequency) haplotypes were found. The frequencies of the risk haplotype in cases (patients with grade 3 or 4 neuropathy) and controls (patients with ≤ grade 2 neuropathy) were 0.25 and 0.15, respectively. Ordinal regression analyses were highly significant (p<0.0005); patients with at least one copy of the risk haplotype had more than a twofold increased risk of grade 3 or 4 taxane-induced neuropathy (OR=2.2, 95% CI 1.44, 3.44). For FANCA, no SNPs or haplotypes were significantly associated with grade 3 or 4 neurotoxicity, either prior to or after correction for multiple testing.Conclusions: These results indicate that the Fanconi-Anemia pathway may be important for neurological sensitivity to taxanes, and that genotypic markers might be able to be used to identify patients at increased risk for severe taxane-induced neuropathy. Further studies will elucidate potential associations with survival outcomes.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2001.

Cyclophosphamide followed by fludarabine for untreated chronic lymphocytic leukemia: a phase II SWOG TRIAL 9706

B-cell chronic lymphocytic leukemia (CLL) accounts for 95% of chronic leukemia cases and 25% of all leukemia. Despite the prevalence of CLL, progress in its treatment has been only modest over the past three decades. Based upon the ability of fludarabine to produce high-grade remissions especially among patients with low initial tumor mass, and the ability of alkylators to reduce tumor mass, we hypothesized that sequential administration of a limited number of cycles of intermediate-dose cyclophosphamide followed by fludarabine could result in a larger percentage of patients with complete remissions (CRs). In all, 27 of the 49 eligible patients achieved overall responses of CR, unconfirmed complete remission (UCR), or PR, for a total response rate of 55% (95% confidence interval (CI) 40-69%). Considering the confounding medical issues of this patient population with advanced aggressive disease, the regimen was generally well tolerated. This study demonstrates that high-dose cyclophosphamide followed by fludarabine was relatively well tolerated in this group of advanced CLL patients. The study's criterion for testing whether the regimen is sufficiently effective to warrant further investigation was met: 14 (32%) of the first 44 eligible patients achieved CR or UCR.

Randomized Phase III Study of Docetaxel Compared With Paclitaxel in Metastatic Breast Cancer

Purpose

This randomized, controlled, multicenter, open-label, phase III study compared docetaxel versus paclitaxel in patients with advanced breast cancer that had progressed after an anthracycline-containing chemotherapy regimen.

Patients and Methods

Patients (n = 449) were randomly assigned to receive either docetaxel 100 mg/m2(n = 225) or paclitaxel 175 mg/m2(n = 224) on day 1, every 21 days until tumor progression, unacceptable toxicity, or withdrawal of consent.

Results

In the intent-to-treat population, both the median overall survival (OS, 15.4 v 12.7 months; hazard ratio [HR], 1.41; 95% CI, 1.15 to 1.73; P = .03) and the median time to progression (TTP, 5.7 months v 3.6 months; HR, 1.64; 95% CI, 1.33 to 2.02; P < .0001) for docetaxel were significantly longer than for paclitaxel, and the overall response rate (ORR, 32% v 25%; P = .10) was higher for docetaxel. These results were confirmed by multivariate analyses. The incidence of treatment-related hematologic and nonhematologic toxicities was greater for docetaxel than for paclitaxel; however, quality-of-life scores were not statistically different between treatment groups over time.

Conclusion

Docetaxel was superior to paclitaxel in terms of OS and TTP. ORR was higher for docetaxel. Hematologic and nonhematologic toxicities occurred more frequently in the docetaxel group. The global quality-of-life scores were similar for both agents over time.

A phase I trial of weekly gemcitabine and subcutaneous interferon alpha in patients with refractory renal cell carcinoma

INTRODUCTION

Recombinant human interferon-a2b (rHuIFN-alpha2b) and Interleukin-2 have limited effectiveness in the treatment of metastatic renal cell carcinoma (MRCC). Gemcitabine (Gemzar) is also reported to have activity against MRCC, and recent in vitro, in nude mice xenografts, and human data suggests increased activity of gemcitabine (Gemzar) when combined with IFN-alpha2b.

PURPOSE

A phase I clinical trial utilizing gemcitabine (Gemzar and rHuIFN-alpha2b was conducted in patients with metastatic renal cell carcinoma.

METHODS

Treatment consisted of: gemcitabine (Gemzar) 600 mg/m2 I.V. weekly and rHuIFN-alpha2b 1.0 MU/m2 (dose level A) or 3.0MU/m2 S.C. (dose level B) three times a week for 6 weeks with a 2 weeks rest period.

RESULTS

Thirteen patients were entered into the trial and were evaluated. Dose limiting toxicity was predominantly hematologic, and was seen at dose level B. This included grade 3 anemia (1 patient), neutropenia (1 patient), and nausea (1 patient) and grade 4 neutropenia (1 patient). The maximal tolerated dose was gemcitabine (Gemzar) 600 mg/m2 I.V. weekly and rHuIFN-alpha2b 1.0 MU/m2 three times a week.

CONCLUSION

This combination of gemcitabine (Gemzar) and rHuIFN-alpha2b has significant hematologic toxicity despite low doses of each agent. Further investigation of this combination using this schedule is not recommended.

Phase I trial of capecitabine in combination with interferon alpha in patients with metastatic renal cancer: toxicity and pharmacokinetics

PURPOSE

The present study was designed to determine the toxicity and maximum tolerated doses of oral intermittent oral capecitabine and subcutaneous (s.c.) rHuIFNalpha2a in patients with metastatic renal cell carcinoma (RCC). The pharmacokinetics of capecitabine and its metabolites were also investigated.

METHODS

A total of 27 patients were treated at four dose levels of capecitabine (825 or 1000 mg/m2 twice daily orally, days 1-14, 22-36) and rHuIFNalpha2a (1.5 or 3.0 MU/m2 s.c. three times weekly). Unchanged capecitabine and its metabolites were analyzed in plasma using liquid chroatography/mass spectrometry in ten patients.

RESULTS

The toxicity of combined capecitabine and rHuIFNalpha2a was moderate. Patients experienced mild nausea/vomiting (70%) and diarrhea (63%). The hand-foot syndrome was seen in 67% of patients and was generally mild, as was hematologic toxicity. Dose-limiting toxicity included diarrhea, mucositis, neutropenia and the hand-foot syndrome. The dose level recommended for further trials included capecitabine 1000 mg/m2 twice daily and rHuIFNalpha2a 3.0 MU/m2 three times weekly. One patient had a partial response of a liver lesion (duration > 200 days). Pharmacokinetic parameters of capecitabine and its metabolites (5'-deoxy-5-fluorouridine, 5-fluorouracil and alpha-fluoro-beta-alanine) were similar to those reported by other authors. There was rapid conversion to 5'-deoxyuridine. The peak plasma concentrations of capecitabine occurred between 0.5 and 3.0 h.

CONCLUSIONS

The combination of capecitabine and rHuIFNalpha2a was well tolerated. The recommended dose levels for phase II trials are: rHuIFNalpha2a 3.0 MU/m2 s.c. three times weekly and oral capecitabine 1000 mg/m2 twice daily for 2 weeks. No evidence of an effect of rHuIFNalpha2a on the pharmacokinetics of capecitabine or its metabolites was apparent. A phase II trial in untreated patients with metastatic RCC is planned.

Delivering adjuvant chemotherapy to women with early-stage breast carcinoma: current patterns of care

BACKGROUND

Variations in practice patterns are markers for the quality of patient care in general medicine, but little is known about variation in care delivered to cancer patients. This study's purpose was to describe chemotherapy use, variations in chemotherapy delivery, and the incidence of complications in community practice settings.

METHODS

Data describing adjuvant chemotherapy for patients with early-stage breast carcinoma (ESBC) were collected from an ongoing Oncology Practice Pattern Study at 13 large managed care, academic, and community practices (1111 patients). Data collection included information about diagnoses and adjuvant chemotherapy treatments, laboratory results, supportive care, complications, and treatment modifications.

RESULTS

The median patient age was 50 years, and most patients had zero to three positive lymph nodes. Chemotherapy regimens consisting of cyclophosphamide, methotrexate, and 5-fluororacil (CMF) and of doxorubicin and cyclophosphamide (AC) accounted for 76% of the adjuvant therapies used. Overall, 30% of patients had delivered average relative dose intensities </= 85% of the referenced targets. Delivered summation dose intensities (SDIs) frequently were well below targeted SDIs. Neutropenia-related dose modifications occurred for 27.6% of patients and recurred with a 60.7% rate. AC was the regimen delivered with a dose intensity closest to the referenced target. However, patients who were treated with AC regimens and with regimens consisting of cyclophosphamide, doxorubicin, and 5-fluorouracil had significantly higher rates of chemotherapy-related complications compared with patients who were treated with CMF regimens in the most recent treatment years.

CONCLUSIONS

Adjuvant chemotherapy for patients with ESBC frequently is not administered as referenced in off-protocol community settings. Variation in the delivered SDI raises concerns about potential treatment outcomes and warrants strategies to identify patients who are at risk for complications early in therapy.

Breast tumor immunophenotype of BRCA1-mutation carriers is influenced by age at diagnosis

PURPOSE

Breast tumors of BRCA1 mutation carriers and those of early onset breast cancer cases share similar histological features, being generally high-grade, highly proliferative, aneuploid tumors that are predominantly estrogen- and progesterone-receptor negative. Because histological features of tumors of premenopausal women differ from those of tumors of older women, we sought to determine whether the immunophenotype of breast tumors of BRCA1 mutation carriers was influenced by age at diagnosis.

EXPERIMENTAL DESIGN

We examined 31 breast tumors from BRCA1 mutation carriers and compared them with 81 tumors of age-matched (plus or minus 5 years) breast cancer patients unselected for family history. Tumors were further matched for histology, grade, and size. Paraffin-embedded tumor tissues were examined for protein expression of estrogen receptor (ER), PR, Ki-67, cyclin D1, TP53, HER2, beta-catenin, and cyclin E using immunohistochemical approaches.

RESULTS

ER (P = 0.01), PR (P = 0.06), and cyclin D1 (P = 0.002) were less frequently expressed and Ki-67 (P = 0.01) and beta-catenin (P = 0.04) were more frequently expressed in tumors of BRCA1 mutation carriers than controls. After age stratification, we found a significant difference in the frequency of tumors of BRCA1 mutation carriers diagnosed before 50 years of age compared with age-matched controls that stained positive for ER (P = 0.01), PR (P = 0.03), Ki-67 (P = 0.008), cyclin D1 (P < 0.001), HER2 (P = 0.04), and beta-catenin (P = 0.05). However, no significant differences were observed in tumors of BRCA1 mutation carriers diagnosed at age 50 or older compared with age-matched controls.

CONCLUSIONS

These data suggest that age at diagnosis, possibly related to menopausal status, may be an important factor in the expression of specific proteins in breast tumors of BRCA1 mutation carriers.

Phase I and II trials of subcutaneously administered rIL-2, interferon alfa-2a, and fluorouracil in patients with metastatic renal carcinoma

PURPOSE

A phase I followed by a phase II trial utilizing rIL-2, IFN alpha, and 5-FU were conducted in patients with unresectable and/or metastatic renal cell carcinoma.

METHODS

Treatment consisted of: rIL-2 at 5.0 x 10(6) IU/m2 SQ on days 1-5 for 4 weeks, rHUIFN alpha-2a at 5.0 x 10(6) U/m2 SQ on days 1, 3, and 5 for 4 weeks, and 5-FU by IV bolus on days 1-5 during week 1. In the phase I study, patients were treated at varying doses of 5-FU: I-none, II-250 mg/m2, III-300, and IV 375. A phase II trial was then conducted utilizing the same schedule and maximum tolerated dose (MTD) for 5-FU.

RESULTS

Twenty patients were entered into the phase I trial. Dose-limiting toxicity included grade III nausea and vomiting, and one sudden cardiac death. The MTD for 5-FU was determined to be 300 mg/m2. In the phase II trial, a median of two cycles of therapy was administered to 25 evaluable patients. Toxicity was moderate and consisted primarily of fevers, chills, fatigue, nausea/vomiting, and anorexia. Grade IV thrombocytopenia, consistent with ITP, developed in one patient each on the phase I and phase II trial. Seven partial responses were seen among 25 patients treated in the phase II trial for a 28% (CI 12-49%) response rate.

CONCLUSIONS

The addition of 5-FU to rIL-2 and rHuIFN alpha-2a appears to increase the toxicity of this therapy. Randomized trials will be required to determine if efficacy is enhanced.

A phase II pharmacodynamic study of pyrazoloacridine in patients with metastatic colorectal cancer

PURPOSE

To perform a phase II trial of pyrazoloacridine (PZA), a novel DNA intercalator, in patients with metastatic colorectal carcinoma and no previous therapy.

METHODS

PZA was administered at a dose of 750 mg/m2 intravenously over 3 h every 21 days. Pharmacokinetic studies to determine PZA plasma concentrations were performed.

RESULTS

No responses were seen in 14 response-evaluable patients. Patients received a median of two cycles of PZA (range 1-6). Toxicity included neutropenia and neurologic side-effects, which were > or = grade III in 73% and 14%, respectively. High plasma concentrations of PZA (Cmax) correlated with low neutrophil counts (P = 0.04).

CONCLUSIONS

PZA is inactive at this dose and schedule in colorectal cancer, and produces moderately severe toxicity.

Leiomyosarcoma of the main renal artery treated by laparoscopic radical nephrectomy

Renal leiomyosarcomas are rare mesenchymal sarcomas. Although such tumors arising from the renal vein or kidney have been previously reported, we present the first case of a leiomyosarcoma arising from the main renal artery managed by laparoscopic radical nephrectomy.

Phase 1 trial of subcutaneous IL-6 in patients with refractory cancer: clinical and biologic effects

The authors evaluated the clinical and biologic effects of human recombinant interleukin-6 (rhIL-6) in patients with refractory cancer. A phase 1 trial using escalating doses of rhIL-6 (1-50 microg x kg(-1) x d(-1), Monday through Friday for 4 weeks) was performed in 30 patients. Toxicity was moderate and the maximum tolerated dose was determined to be 25 microg x kg(-1)x d(-1) based on cardiac and neurocortical toxicity in one patient each and thrombocytosis (platelets > 800,000/microL) in three patients. One patient with non-small-cell lung cancer had a partial response after three cycles of therapy. The biologic effects of rhIL-6 included anemia and dose-related thrombocytosis. Various proinflammatory activities were induced and included dose-related cyclical increases in peripheral blood monocytes and the CD14+/CD45RB+ +/- CD16C+ mononuclear cell populations. These increases were accompanied by increased levels of C-reactive protein, serum neopterin, and type I soluble tumor necrosis factor receptor. In contrast, rhIL-6 did not affect lymphocyte numbers or function (cytotoxicity, cytokine levels, immunoglobulin levels), with the possible exception of IL-2Ralpha mRNA induction in peripheral blood lymphocytes. rhIL-6 has pleiotropic proinflammatory actions in vivo and moderate toxicity when administered as long-term therapy.

Phase II trial of liposomal doxorubicin (Doxil) in advanced soft tissue sarcomas

PURPOSE

To assess the objective response rate, toxicity experienced, progression-free survival, and overall survival of patients with previously untreated advanced soft tissue sarcomas treated with a liposomal doxorubicin formulation (Doxil).

METHODS

Patients with metastatic or recurrent soft tissue sarcoma who had received no prior chemotherapy for advanced disease were treated with liposomal doxorubicin (Doxil) according to a two stage accrual design. Doxil was administered at 50 mg/m2 every 4 weeks. A total of 15 patients were treated and are evaluable for response and toxicity.

RESULTS

The male/female ratio was 7/8, the median age was 60 years (34-75) and the ECOG performance status was 0-1 in >90% of patients. Leiomyosarcoma (7/15) and malignant fibrous histiocytoma (2/15) were the most common histologic diagnoses. No objective responses were observed in the 15 evaluable patients. No lethal toxicity occurred. Grade 3-4 leukopenia or neutropenia were reported in 3/15 (20%) patients. Grade 3 mucositis or hand-foot syndrome occurred in 2/15 (13%) and 1/15 (7%) patients respectively and seemed more severe in older patients. The median time to progression was 1.9 months (range 0.9-6.2). Twelve patients have now died. The Kaplan-Meier estimate of median overall survival is 12.3 months. As called for in the study design, accrual was terminated because no responses were obtained in the first 15 patients.

CONCLUSION

Though well-tolerated, Doxil given according to this dose and schedule to patients with advanced soft tissue sarcoma had no significant therapeutic activity. A correlation between older age and skin/mucosal toxicity of Doxil is suggested in this study but needs confirmation. Future investigations of Doxil in soft tissue sarcomas should use a different schedule and dose.

Sulindac sulfone induced regression of rectal polyps in patients with familial adenomatous polyposis

Sulindac sulfone (Exisulind), a metabolite of the non-steroidal anti-inflammatory drug, sulindac, was evalauted for its effects on the development of rectal polyps in patients with familial adenomatous polyposis. Three cohorts of 6 patients each were given doses of 200, 300, or 400 mg Exisulind twice daily. Hepatotoxicity, shown by elevation in blood transaminase levels, was the dose-limiting toxicity and occurred at the 400 mg bid dose. Due to this toxicity, all patients treated with the 400 mg dose were subsequently reduced to the 200 mg dose level. Subsequently, 2 of the 6 patients were dose-escalated to 400 mg bid dose. The patients were treated with Exisulind for a period of six months. Sixteen of 18 patients had regression of small polyps (> or = 6 mm in diameter) characterized by a flattening of the polyps and a macular "halo" appearance. Histopathologic examination of the polyp biopsy specimens showed a marked increase in the proportion of mucin producing cells in the glands after treatment with Exisulind at all dose levels. Ki-67 staining, a measure of cell proliferation, was higher in the polyps than in normal mucosa. There was no significant change in the proliferation index between baseline and six month values in any of the groups treated with Exisulind or in normal tissues. The median apoptotic labeling index, as determined by the TUNEL technique, was higher in the polyps than in normal-appearing mucosa. Overall, there was no significant change in the apoptotic labeling index between base-line and 6 months in normal-appearing mucosa however, the index in polyps was increased. These results suggest that treatment of FAP patients with Exisulind for a period of six months may lead to regression of small polyps, and that the mechanisms of Exisulind--induced regression appear to be through stimulation of mucus differentiation and apoptosis in glandular epithelium.

Phase I trial of exisulind (sulindac sulfone, FGN-1) as a chemopreventive agent in patients with familial adenomatous polyposis

Exisulind (sulindac sulfone; FGN-1), a metabolite of sulindac without known effects on prostaglandin synthesis, can promote apoptosis and inhibit tumorigenesis in preclinical systems. We performed a Phase I trial of this compound in patients with familial adenomatous polyposis (FAP) to examine the tolerability and safety of this drug in the cancer chemoprevention setting. Six patients each were treated with exisulind at doses of 200, 300, and 400 mg p.o. twice a day. Reversible hepatic dysfunction was noted in four of six patients treated at the 400-mg p.o., twice-a-day dose level, but in only one to two of six patients treated at each of the lower dose levels. The serum half-life of exisulind was 6-9 h; little drug accumulation was noted over time. A nonsignificant trend toward increased apoptosis in polyps was noted at the maximum tolerated dose, but no decrease in polyp numbers or significant effects on cellular proliferation was noted. After treatment, polyps tended to display a "halo" appearance grossly and mucinous differentiation histologically. The maximum safe dose of exisulind is 300 mg p.o. twice a day in patients with subtotal colectomies. Reversible hepatic dysfunction limits further dose escalation. A decrease in polyp numbers could not be demonstrated, but the trend toward increased apoptosis at the MTD and the observation of mucinous change histologically suggest that further investigation of drugs of this class might be warranted.

Interferon-gamma and CXC chemokine induction by interleukin 12 in renal cell carcinoma

Interleukin 12 (IL-12) is known to play an important role in the development of an antitumor response. Its activity has been shown to be dependent upon the intermediate production of IFN-gamma and the influx into the tumor of CD8 lymphocytes. In a murine model, tumor regression induced by IL-12 treatment correlated with IFN-gamma, IP-10, and Mig expression in the tumor bed and was abrogated by antibodies to both chemokines. Here we examined the effects of rHuIL-12 on IFN-gamma and CXC chemokine gene expression in patients with renal cell carcinoma (RCC) in an attempt to determine whether a similar series of molecular events leading to IL-12-mediated tumor regression in mice is also detectable in humans. As in the murine RENCA model, cultured RCC cells themselves could be induced by IFN-gamma to synthesize IP-10 and Mig mRNA. Explanted RCC produced IFN-gamma and IP-10 mRNA in response to IL-12 treatment, which was consistent with the finding that biopsied RCC tumors from IL-12-treated patients also variably expressed augmented levels of those molecules after therapy. Although Mig mRNA was present in the majority of biopsied tumors prior to treatment, both the Mig and IP-10 chemokines as well as IFN-gamma were induced in the peripheral blood mononuclear cells of IL-12-treated patients. Skin biopsies of IL-12-treated patients also all synthesized IP-10 mRNA. This study demonstrates that recombinant human IL-12 therapy of patients with RCC has the potential to induce the expression of gene products within the tumor bed that may contribute to the development of a successful antitumor response.

Phase I/II trial of human recombinant granulocyte-colony-stimulating factor (filgrastim) and escalating doses of cyclophosphamide, mitoxantrone, and 5-FU in the treatment of advanced breast cancer

PURPOSE

We performed a phase I/II dose-escalation trial of cyclophosphamide, mitoxantrone, and 5-fluorouracil (CNF) in combination with human recombinant granulocyte-colony-stimulating factor (G-CSF, filgrastim) in patients with advanced breast cancer. The objectives of this trial were (1) to gain experience with filgrastim given to patients with advanced breast cancer and receiving standard-dose CNF, and (2) to determine the maximum tolerated dose of CNF that could be given with filgrastim support by incremental dose escalation of two components of the CNF regimen, cyclophosphamide and mitoxantrone.

METHODS

Four patients who had received prior therapy for advanced disease received standard-dose CNF with filgrastim support. Sequentially enrolled patients who had received no prior chemotherapy for advanced disease were treated with standard-dose CNF without filgrastim (5 patients), standard-dose CNF with filgrastim (15 patients), or were entered into sequential cohorts of 3-6 patients to be treated with increasing doses of CNF with filgrastim support (29 patients).

RESULTS

The maximum tolerated doses that could be given with filgrastim support were 1500 mg/ml cyclophosphamide, 20 mg/m2 mitoxantrone, and 500 mg/m2 5-FU. Overall, 7 complete (14%) and 13 partial responses (26%) were observed. Despite the use of filgrastim, repeated cycles of CNF at doses of 2000 mg/m2 cyclophosphamide, 25 mg/m2 mitoxantrone, and 500 mg/m2 5-FU could not be given because of neutropenia and thrombopenia. Among 18 patients with bidimensionally measurable disease there were 3 complete (17%) and 5 partial (28%) responses. The median progression-free survival of all patients was 236 days (34 weeks).

CONCLUSION

The use of filgrastim allows CNF to be given at approximately twice the dose intensity of "standard"-dose CNF. Because nonhematopoietic toxicity was not dose-limiting, further dose escalation of this regimen might be possible with more effective hematopoietic support. The response rate and survival of patients treated in this study were within the range expected with standard-dose chemotherapy.

Phase II trial of circadian infusion floxuridine (FUDR) in hormone refractory metastatic prostate cancer

Circadian administration of chemotherapy has been reported to decrease toxicity and possibly enhance efficacy. Between March 1991 and December 1993, 18 evaluable patients with progressive, hormone-refractory metastatic prostate cancer were treated in this phase II trial of circadian infusion floxuridine (FUDR). The drug was delivered through a central venous catheter using a CADD-Plus computerized pump such that approximately 70% of the drug was administered between 3 and 9 p.m. and the rest (30%) was administered between 9 p.m. and 3 p.m. The dose of FUDR was 0.15 mg/kg/day x 14 days every 4 weeks. A total of 79 complete cycles was administered. Two of 18 evaluable patients (11.1%) had decreases in PSA lasting five and eight months. No objective responses or improvement in bone scans was noted. The major toxicity observed was diarrhea. Although circadian infusion FUDR is feasible and tolerable, it has limited activity in hormone refractory prostate cancer.

Mature results from a phase II trial of accelerated induction chemoradiotherapy and surgery for poor prognosis stage III non-small-cell lung cancer

Mature results are reported from a phase II trial of accelerated induction chemoradiotherapy and surgical resection for stage III non-small-cell lung cancer whose prognosis is poor. Surgically staged patients with poor prognosis stage III non-small-cell lung cancer were eligible for this study. Four-day continuous intravenous infusions of cisplatin 20 mg/m2/day, 5-fluorouracil 1,000 mg/m2/day, and etoposide 75 mg/m2/day were given concurrently with accelerated fractionation radiation therapy, 1.5 Gy twice a day, to a total dose of 27 Gy. Surgical resection followed in 4 weeks. Identical postoperative chemotherapy and concurrent radiation to a total dose of 40 to 63 Gy was subsequently given. Between February 1991 and June 1994, 42 eligible and evaluable patients, 23 with stage IIIA disease and 19 with stage IIIB disease, were entered in this trial. Treatment was well tolerated. The pathologic response rate was 40%. This response was complete in 5%. With a median follow-up of 54 months, the Kaplan-Meier 4-year survival estimate is 19%: 26% for stage IIIA and 11% for stage IIIB patients. Patients with a pathologic response, resectable disease, or pathologic downstaging to stage 0, I, or II had a better survival. The 4-year estimates of locoregional and distant disease control are 70% and 19%, respectively. It is concluded that although the ultimate role of concurrent chemoradiotherapy and surgery in stage III non-small-cell lung cancer must await the results of phase III clinical trials, survival and locoregional control in this study appear improved in comparison with historical experience. There is a subset of patients, able to undergo resection with pathologic downstaging, who have a projected survival equivalent to that of patients with more limited disease. Clinical or pathologic tools to identify these patients before treatment would be highly useful.

Approaches to managing carboplatin-induced thrombocytopenia: focus on the role of amifostine

Thrombocytopenia is a significant problem for patients receiving prolonged or aggressive chemotherapy for malignancy. For carboplatin, it is the predominant dose-limiting toxicity and it is cumulative in nature. A number of agents have been evaluated for efficacy in reducing the problem of thrombocytopenia. Some have proved valueless and have been discarded. Others (eg, recombinant thrombopoietin) are under current study, and one (interleukin-11 or oprelvekin) is now commercially available. In addition, the currently available cytoprotectant, amifostine (Ethyol; Alza Pharmaceuticals, Palo Alto, CA/US Bioscience, West Conshohocken, PA), has been shown to reduce the severity and duration of thrombocytopenia caused by carboplatin. Because of the short half-life of amifostine relative to that of carboplatin, multiple doses of amifostine have been administered in conjunction with carboplatin. The optimal dosing regimen with amifostine and carboplatin needs to be further evaluated in clinical studies. Future trials will also expand these observations to carboplatin-containing combination chemotherapy regimens and will further define the role of amifostine as a multilineage bone marrow protectant. The ability of amifostine to demonstrate multilineage bone marrow protection differentiates it from currently available growth factors and fulfills a medical need, including reducing the need for platelet transfusions and maintaining the desired chemotherapy dose intensity.

Intercomparison of radon and decay product measurements in an underground mine and EPA Radon Laboratory: a study organized by the IAEA International Radon Metrology Programme. International Atomic Energy Agency

The International Atomic Energy Agency (IAEA) in Vienna and the European Union (EU) in Bruxelles formed the "International Radon Metrology Programme" (IRMP, scientific secretary: F. Steinhäusler, University of Salzburg, Austria). The IRMP is designed to assess and foster the improvement of radon and decay product measurements that are made around the world. Within the framework of the IRMP, the U.S. Environmental Protection Agency Radiation and Indoor Environments National Laboratory (EPA) in Las Vegas, Nevada, organized jointly with the U.S. Bureau of Mines an international intercomparison exercise at a former uranium mine (Twilight Mine, Colorado) and the EPA Radon Laboratory. The main objective of this exercise was to compare radon and radon decay product instruments under both well-controlled as well as widely fluctuating exposure conditions. The laboratory exposures occurred under relatively steady radon and decay product conditions, with a moderate equilibrium ratio, while the conditions in the mine fluctuated greatly and the equilibrium ratio was low. An additional purpose of the exercise was to provide a forum for manufacturers and measurement organizations worldwide to exchange information and plan improvements in their operations and calibration programs. Altogether 19 organizations from seven countries intercomparing 32 different radon and radon decay product instruments participated in this exercise. This paper summarizes the results from the analysis of the experimental data obtained in the Bureau of Mines Twilight Mine in July of 1994, as well as the results from the EPA Radon laboratory in August of 1994.

Signal transduction abnormalities in T lymphocytes from patients with advanced renal carcinoma: clinical relevance and effects of cytokine therapy

Studies have demonstrated abnormalities of the CD3/T-cell antigen receptor (TCR) and pathways of signal transduction in T lymphocytes from animals and patients with advanced malignancy. Diminished expression of TCRzeta and p56(lck) that are associated with the TCR and reduced nuclear localization of RelA containing nuclear factor kappaB (NFkappaB) complexes have been noted. These defects have been described in T cells from patients with malignant melanoma, renal cell carcinoma (RCC), ovarian cancer, and colorectal cancer. Preliminary observations also indicate possible correlation with clinical variables such as stage in selected instances. To further characterize altered expression of TCRzeta, p56(lck), and impaired activation of NFkappaB, T lymphocytes were obtained from 65 patients with RCC, the majority of whom were receiving combination cytokine therapy [interleukin (IL)-2, IFN alpha-containing regimens] and 37 control individuals. In 29 of these patients, levels of TCRzeta and p56(lck) were determined by Western blots of T-cell lysates and semiquantitated using densitometry. Relative levels were then correlated with a series of clinical variables including response to therapy, performance status, survival, disease sites, age, and others. In another group of 28 patients (three individuals from the first group), the frequency of abnormal NFkappaB activation was studied using electrophoretic mobility shift assays after activation of T cells with phorbol myristate acetate/ionomycin or anti-CD3 monoclonal antibody. Changes in these signaling molecules during cytokine treatment were also investigated. TCRzeta and p56(lck) were detected in the peripheral blood T cells in 27 of 29 patients, and overall, reduced levels were noted visually in 12 of 29 (41%) and 13 of 29 (45%) individuals, respectively. When levels were semiquantitated using densitometry, significant decreases of TCRzeta (P = 0.029) and p56(lck) (P = 0.029) but not CD3epsilon (P = 0.131), compared with control levels, were found. In patients treated with IL-2/IFN alpha-based therapy, relative levels of TCRzeta increased significantly (P = 0.002) on day 15 of cycle one compared with the baseline. Correlations of TCRzeta or p56(lck) levels with response or disease variables, except for lower TCRzeta levels (P < 0.001) in the presence of bone metastases, were not found. Abnormal NFkappaB activation after stimulation with phorbol myristate acetate/ionomycin and/or anti-CD3 monoclonal antibody was found in 59% of patients (17 of 28) and was not accounted for by the advanced age of the study cohort. Activation of NFkappaB in peripheral blood T cells was inducible during cytokine therapy in four of six individuals who displayed impaired NFkappaB activity prior to therapy. Moreover, impaired activation of NFkappaB does not appear linked to a reduction of TCRzeta expression, because in five patients, normal TCRzeta levels were present although kappaB binding was not inducible. In the majority of patients with advanced RCC, peripheral blood T cells express TCRzeta and p56(lck), and in a subset, reduced levels of these TCRzeta associated molecules are seen that may increase during cytokine-based therapy. Abnormal activation of NFkappaB is also present in >50% of patients and may also revert to normal during IL-2/IFN alpha-based treatment. This alteration in NFkappaB activation occurred in the presence of normal expression of TCRzeta-associated signaling elements. The clinical significance of these findings remains unclear.

Phase I/II trial of all-trans retinoic acid and tamoxifen in patients with advanced breast cancer

Because tamoxifen and all-trans-retinoic acid (ATRA) have additive antitumor effects in preclinical systems, we performed a Phase I/II clinical trial of this combination in patients with advanced breast cancer. Patients with potentially hormone-responsive advanced breast cancer were enrolled. All received 20 mg of tamoxifen by mouth daily. Consecutive cohorts of 3-6 patients were treated on odd-numbered weeks with ATRA at doses of 70, 110, 150, 190, or 230 mg/m2/day. Twenty-six patients were entered in this trial; 25 were evaluable. A dose of 230 mg/m2 ATRA produced unacceptable headache and dermatological toxicity, but doses < or = 190 mg/m2 were tolerable. Two of 7 patients with measurable disease responded. Seven of 18 patients with evaluable, nonmeasurable disease achieved disease stability for more than 6 months. Plasma AUCs on day 1 of successive weeks of treatment were stable over time. A nonsignificant decrease in serum insulin-like growth factor I levels was noted during treatment, but this trend was similar to that observed in three "control" patients treated with tamoxifen alone. When given with daily tamoxifen, the maximum tolerated dose of ATRA that could be given on alternate weeks was 190 mg/m2/day. This schedule of ATRA resulted in repeated periods of exposure to potentially therapeutic concentrations of ATRA. Declines in the serum insulin-like growth factor I concentrations observed in patients treated with tamoxifen and ATRA were similar to those observed in patients treated with tamoxifen alone. Objective responses were observed, some in patients who had previously progressed while receiving tamoxifen, suggesting that further studies would be of interest.

Multicenter randomized clinical trial of goserelin versus surgical ovariectomy in premenopausal patients with receptor-positive metastatic breast cancer: an intergroup study

PURPOSE

To compare failure-free survival (FFS) and overall survival (OS) for patients with metastatic breast cancer treated with the gonadotropin-releasing hormone (GN-RH) agonist, goserelin versus surgical ovariectomy.

PATIENTS AND METHODS

Between August 1, 1987 and July 15, 1995 138 (136 eligible) premenopausal patients with estrogen receptor (ER)- and/or progesterone receptor (PgR)-positive metastatic breast cancer were entered by the Southwest Oncology Group (SWOG), North Central Cancer Treatment Group (NCCTG), and Eastern Cooperative Oncology Group (ECOG). Prior chemotherapy or hormone therapy for metastatic disease was not allowed. Patients were randomly assigned to goserelin (3.6 mg subcutaneously every 4 weeks; (n = 69) versus surgical ovariectomy (n = 67). The study was initially designed as an equivalence trial with 80% power to rule out a 50% improvement in survival due to ovariectomy. However, accrual was slow and the study was terminated early, which resulted in a final power of 60% for the alternative hypothesis of equal survival distributions.

RESULTS

FFS and OS were similar for goserelin and ovariectomy. The goserelin/ovariectomy death hazards ratio was .80 and the associated 95% confidence interval (CI) was .53 to 1.20. The test of 50% improvement in survival due to ovariectomy was rejected at P = .006. Goserelin lowered serum estradiol to postmenopausal levels. Hot flashes (75% v 46%) and tumor flare (16% v 3%) were more common with goserelin.

CONCLUSION

Goserelin and ovariectomy resulted in similar FFS and OS. We can rule out a moderate advantage for ovariectomy. Goserelin was safe and well tolerated.

Randomized trial of carboplatin plus amifostine versus carboplatin alone in patients with advanced solid tumors

BACKGROUND

To test the hypothesis that the cytoprotectant amifostine attenuates the thrombocytopenia produced by carboplatin, the authors performed a randomized trial comparing treatment with carboplatin alone versus the combination of amifostine and carboplatin.

METHODS

Patients with refractory or carboplatin-sensitive malignancies were randomized to receive either carboplatin, 500 mg/m2 alone or carboplatin, 500 mg/m2 in conjunction with 2 doses of amifostine of 910 mg/m2 each.

RESULTS

Fifty-five patients with a variety of malignancies were entered on this study. One patient withdrew from each arm prior to the administration of any therapy, leaving 30 evaluable patients treated with carboplatin alone and 23 treated with the combination of amifostine and carboplatin. For 82 cycles of therapy with amifostine plus carboplatin, the median platelet nadir was 127 x 10(9)/L while the median platelet nadir was 88 x 10(9)/L over the 80 courses of therapy with carboplatin alone (P = 0.023). The median platelet nadir after the first cycle of therapy was 144 x 10(9)/L for patients treated with amifostine plus carboplatin and 85 x 10(9)/L for patients treated with carboplatin alone (P = 0.24). The median survival for 9 patients with advanced nonsmall cell lung carcinoma treated with carboplatin alone was 39 weeks whereas the median survival for 12 such patients treated with amifostine plus carboplatin was 52 weeks (P = 0.116).

CONCLUSIONS

These data support the hypothesis that amifostine attenuates the myelosuppression of carboplatin. Additional studies of amifostine in combination with carboplatin-containing chemotherapy regimens are warranted.

Phase II trial of interleukin-2 and interferon-alpha in patients with renal cell carcinoma: clinical results and immunologic correlates of response

A phase II trial was conducted in patients with metastatic renal cell carcinoma, to assess the clinical efficacy and immunoregulatory effects of continuous-infusion recombinant interleukin-2 (rIL-2) (9.0 x 10(6) IU/m2/day on days 1-5, 8-12, 15-19, and 22-26) and subcutaneously administered recombinant human interferon-alpha 2b (rHuIFN alpha 2b) (10.0 x 10(6) U/m2/day TIW). Thirty-six patients with metastatic renal cell carcinoma, performance status of 0-1, and measurable disease who had not received prior rIL-2, rHuIFN alpha 2b, or chemotherapy were treated. Patients with CNS metastases, active infections, history of another malignancy within 3 years, and those requiring corticosteroids were ineligible. Cycles of rIL-2 and rHuIFN alpha 2b were administered in the outpatient department every 6-8 weeks in stable or responding patients until patient tolerance or a complete response were reached. Doses were modified for grade III or IV toxicity. Ancillary studies included three-color immunocytometric analysis of peripheral blood lymphocytes, repetitive tumor biopsies for immunohistologic analysis of infiltrating cells and proliferative responses of tumor infiltrating lymphocytes, and preliminary studies of changes in peripheral blood T-lymphocyte signal transduction molecules [T-cell receptor (TCR)-zeta, p56ick, p59fyn]. Thirty-six eligible patients were treated, with 6 of 36 patients (17%, 95% confidence interval 6-33%) responding (3 complete response, 3 partial response). In two of the partial responders, and in an additional three patients with either minimal tumor regression (one patient) or stable disease (two patients), surgical removal of residual disease was undertaken. The median survival of all patients was 14 months. The toxicity of this regimen was severe, but outpatient administration was possible in most instances. Immunoregulatory effects on T-cell subsets included increases in various CD3+ CD25+/- HLADr+/- subsets unrelated to response. Tumor biopsies before and/or during therapy were obtained in 17 patients, and no consistent alterations in the degree of T-lymphocyte or macrophage infiltrates could be detected. In a subset of patients, tumor infiltrating lymphocyte proliferative responses and levels of peripheral blood T-cell signal transduction molecules (TCR-zeta, p56lck, p59fyn) were investigated. Abnormalities were found in selected patients, which improved during rIL-2/rHuIFN alpha 2b therapy. This cytokine combination produces tumor regression in selected patients with metastatic renal cell carcinoma. Surrogate immunologic markers associated with response were not identified; however, preliminary studies demonstrate investigation of immune defects and their reversal with cytokine therapy is possible.