Palbociclib in combination with endocrine therapy versus capecitabine in hormonal receptor-positive, human epidermal growth factor 2-negative, aromatase inhibitor-resistant metastatic breast cancer: a phase III randomised controlled trial-PEARL

BACKGROUND

Palbociclib plus endocrine therapy (ET) is the standard treatment of hormone receptor-positive and human epidermal growth factor receptor 2-negative, metastatic breast cancer (MBC). However, its efficacy has not been compared with that of chemotherapy in a phase III trial.

PATIENTS AND METHODS

PEARL is a multicentre, phase III randomised study in which patients with aromatase inhibitor (AI)-resistant MBC were included in two consecutive cohorts. In cohort 1, patients were randomised 1 : 1 to palbociclib plus exemestane or capecitabine. On discovering new evidence about estrogen receptor-1 (ESR1) mutations inducing resistance to AIs, the trial was amended to include cohort 2, in which patients were randomised 1 : 1 between palbociclib plus fulvestrant and capecitabine. The stratification criteria were disease site, prior sensitivity to ET, prior chemotherapy for MBC, and country of origin. Co-primary endpoints were progression-free survival (PFS) in cohort 2 and in wild-type ESR1 patients (cohort 1 + cohort 2). ESR1 hotspot mutations were analysed in baseline circulating tumour DNA.

RESULTS

From March 2014 to July 2018, 296 and 305 patients were included in cohort 1 and cohort 2, respectively. Palbociclib plus ET was not superior to capecitabine in both cohort 2 [median PFS: 7.5 versus 10.0 months; adjusted hazard ratio (aHR): 1.13; 95% confidence interval (CI): 0.85-1.50] and wild-type ESR1 patients (median PFS: 8.0 versus 10.6 months; aHR: 1.11; 95% CI: 0.87-1.41). The most frequent grade 3-4 toxicities with palbociclib plus exemestane, palbociclib plus fulvestrant and capecitabine, respectively, were neutropenia (57.4%, 55.7% and 5.5%), hand/foot syndrome (0%, 0% and 23.5%), and diarrhoea (1.3%, 1.3% and 7.6%). Palbociclib plus ET offered better quality of life (aHR for time to deterioration of global health status: 0.67; 95% CI: 0.53-0.85).

CONCLUSIONS

There was no statistical superiority of palbociclib plus ET over capecitabine with respect to PFS in MBC patients resistant to AIs. Palbociclib plus ET showed a better safety profile and improved quality of life.

The variegated scallop, Mimachlamys varia, undergoes alterations in several of its metabolic pathways under short-term zinc exposure

The variegated scallop (Mimachlamys varia) is a filter feeder bivalve encountered in marine regions of the Atlantic coast. In particular, it is present in the La Rochelle marina (France), where it is used for the biomonitoring of marine pollution, due to its ability to strongly bioaccumulate pollutants. In this semi-closed environment, contamination generated by port activities leads to an accumulation of both organic and metal pollutants. Zinc is one of these pollutants, present at a dose of up to 150 μg.L^-1. This study investigated the effects of 48 h zinc exposure upon the metabolic profiles of Mimachlamys varia using UHPLC/QToF (ultra-high performance liquid chromatography-quadrupole time-of-flight) tandem mass spectrometry metabolomics. After acclimation in mesocosms recreating in situ conditions, both controls and exposed with Zn²⁺ (150 μg.L^-1) bivalves were dissected to recover the gills after 48 h and stored at -80 °C before metabolites extraction. UHPLC/QToF tandem mass spectrometry was performed to study metabolite composition of samples. Statistical analysis of results using multivariate techniques showed a good classification between control and exposed groups. Eleven identified metabolites were found to be down-modulated in exposed scallops. These variations could reflect potential zinc effects on several of the biological processes, such as energy metabolism, osmoregulation and defense against oxidative stress. Among the eleven metabolites highlighted, four were reported for the first time in an aquatic organism exposed to Zn. This study demonstrates once again the diversity of interactions between bivalves and metals and the complexity of the physiological response of marine bivalves to pollutants.

Abstract OT1-01-04: VENTANA (SOLTI-1501): Oral metronomic vinorelbine combined with endocrine therapy in luminal/HER2-negative early breast cancer: A window of opportunity trial

BACKGROUND

The CDK4/6 inhibitor palbociclib, in combination with endocrine therapy (ET), has been approved for patients (pts) with HR+/HER2- metastatic breast cancer (BC), suggesting that inhibition of the cell cycle in combination with ET is a strategy to keep exploring. In this context, vinorelbine (VNB) inhibits chromosome segregation during mitosis and blocks cells at G2/M. Interestingly, several metronomic schedules of VNB are being used in the clinical setting, a strategy that might not only affect cell-cycle but also aims to target tumor angiogenesis.

VENTANA is a “window-of-opportunity” trial designed to explore whether, similarly to CDK4/6 and mTOR inhibitors, oral metronomic VNB in combination with endocrine therapy induces a superior anti-proliferative effect than ET alone, as suggested by preclinical and clinical studies. We believe that a biological synergy of the combined treatment could open the door to include this treatment strategy in pts with BC as an alternative to CDK4/6 inhibitors.

METHODS

VENTANA is a phase 0 multicenter, three-arm, randomized clinical trial of oral metronomic VNB and letrozole (LET) versus either treatment alone in postmenopausal women with newly diagnosed, untreated HR+ and HER2-, stage I-III operable BC. Other eligibility criteria include primary tumor size ≥1 cm (cT1-3) and N0-1, ECOG PS 0-1 and evaluable diagnostic tumor sample. Pts are randomized (1:1:1) to receive LET 2.5mg daily, oral VNB 50mg 3 days a week, or LET 2.5mg daily and oral VNB 50mg 3 times a week. After 3 weeks of treatment, pts will undergo surgery, and both pre-treatment and post-treatment surgical samples will be analyzed for gene expression. Primary objective is to test if oral metronomic VNB and LET induce a superior anti-proliferative effect than either drug alone in pts with early BC defined as Luminal by PAM50. This will be evaluated by the expression of 11 proliferative genes contained in the PAM50 subtype predictor (BIRC5, CCNB1, CDC20, CDCA1, CEP55, KNTC2, MKI67, PTTG1, RRM2, TYMS and UBE2C) as surrogate signature biomarker of its anticancer activity.

VENTANA is a proof-of-concept study to describe the change in the expression of a proliferation-related gene signature in all 3 treatment arms. Changes in the proliferation signature will be determined by following formula: Mean suppression of proliferation signature score = 100 − [geometric mean (post treatment proliferation score / pre-treatment proliferation score · 100)]. By evaluating other BC-related gene signatures (560 genes), the antiangiogenic and immunogenic potential of the treatment arms will also be compared and genes regulated in a treatment-specific manner identified. All analyses will be performed within the different PAM50-defined subtypes (Luminal, Luminal A or Luminal B).

As the primary endpoint is continuous and there are no previous data to make assumptions about the degree of suppression of these genes, the sample size has not been determined by statistical calculations. A sample size of 20 pts per arm is considered appropriate to support our hypothesis. The targeted accrual of 60 pts will be enrolled in 10 sites across Spain (EudraCT Number 2015-004714-24).

Citation Format: Adamo B, Vidal M, Gomez Pardo P, Zaragoza K, Ciruelos E, Virizuela JA, Blanch Tormo S, Pérez-Fidalgo JA, Murillo L, Lopez-Gonzalez A, Amillano Parraga K, Martinez Jañez N, Gonzàlez Farré X, Prat A. VENTANA (SOLTI-1501): Oral metronomic vinorelbine combined with endocrine therapy in luminal/HER2-negative early breast cancer: A window of opportunity 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 OT1-01-04.

Abstract P3-15-02: A prospective, open label, non-comparative trial to determine the incidence of chemotherapy-induced nausea and vomiting associated with the docetaxel-cyclophosphamide regimen in early breast cancer patients. Results from the GEICAM 2009-02 study

Background: Docetaxel-Cyclophosphamide (TC) has become a common chemotherapy regimen for moderate-high risk Early Breast Cancer (EBC) patients. The incidence of chemotherapy induced nausea and vomiting (CINV) with TC together with an adequate standard anti-emetic therapy with 5-HT3 antagonist and corticosteroids are unknown. This study investigates the incidence of emesis control (complete response), defined as no vomiting (any grade of NCI CTCAE version 4.0) and no use of rescue treatment within 120 hours after the first cycle of TC. Secondary objective evaluates the efficacy of Aprepitant in non-responding patients.

Methods: EBC patients with no prior moderate-high risk CINV were included. Patients received Docetaxel 75 mg/m2 plus Cyclophosphamide 600 mg/m2 IV every three weeks. Antiemetic treatment consisted of oral Dexamethasone (D) 8 mg (at night) on day 0; oral D 8 mg x 3 (in the morning, 1 hour before chemotherapy and at night) plus 5-HT3 antagonists on day 1; and oral D 8 mg x 2 (in the morning and at night) on days 2 and 3. Non-responding patients (vomiting or need of rescue therapy in the first cycle) were offered participation in the efficacy phase (Aprepitant 125mg day 1 and 80 mg days 2 and 3 added to the standard antiemetic therapy in cycle 2). In addition to the standard NCI-CTCAE adverse event collection, a patient´s diary (from day 1 to 6) and the FLIE (Functional Living Index-Emesis questionnaire) were used. Assuming a 25% (+/- 6%) of patients resistant to standard antiemetic therapy, 212 patients were estimated.

Results: From May-11 to March-13, 212 EBC patients were included. Median age was 57 years (range 34-82), 29.3% were premenopausal. Twenty-seven patients were excluded from the main analysis because of major protocol violations (25) or consent withdrawal (2). Twenty-four patients (13%; IC95%: 8.2 – 17.8) did not respond to standard antiemetics and entered the efficacy phase with Aprepitant. From these 24 patients, 14 (56%; IC95%: 36.5 – 75.5) achieved a complete response on cycle 2. No adverse events related to Aprepitant were observed.

Conclusions: Proper use of standard antiemetic therapy for early breast cancer patients treated with TC provides a high control rate (87%). Among no responding patients, about half of them were rescued with Aprepitant. Identification of the non-responding patients could lead to a better antiemetic control with Aprepitant from the first cycle.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-15-02.

Docetaxel and carboplatin followed by sequential capecitabine as first line treatment in patients with locally advanced or metastatic breast cancer

Abstract #2155

Background: Anthracyclines and docetaxel (D) are the most active agents in metastatic breast cancer (BC). New regimens are being assesed to improve chemotherapy efficacy. D and carboplatin (C) has shown to be an active treatment in metastatic BC. Capecitabine (X) and D is also an active combination, despite the fact the toxicity profile needs to be improved. Sequential administration of D and X could lead to an improved toxicity profile compared with concomitant administration. We designed this study to evaluate activity and toxicity profile of treatment with D and C followed by sequential X in patients with locally advanced or metastatic BC.
 Methods: Patients with locally advanced or metastatic BC, at least one measurable lesion, age ≥ 18 years, ECOG PS ≤ 2, and adequate bone marrow and hepatic functions, were included in the study. Prior chemotherapy or radiotherapy for advanced disease was not allowed. Patients received 6 cycles of D 75 mg/m2 iv D1 and C AUC5 iv D1, every 21 days followed by 12 cycles of X 2000 mg/m2/day o.r. D1-14 in a 21 days course.
 Results: twenty patients have been analyzed. Median age was 55 years old (range 36-73), ECOG PS 0-1 94.4%; 90.0% of patients had infiltrating ductal carcinoma and 57.9% of patients had stage I-II at diagnosis. Main sites of metastatic disease were bone (35.0%), liver (25.0%) and lung (25.0%). Conservative surgery was performed in 35% of patients and mastectomy in 40%. Previous radiotherapy and chemotherapy was administered in 50.0% and 70.0% of patients, respectively. A total of 108 cycles of D and C (median 6, range 2-6) and 71 cycles of X (median 6, range 2-10) were administered. Median relative dose intensity was 96% for D and C and 95% for X. Over 17 evaluable patients for efficacy, 2 achieved complete response and 4 partial response; the ORR was 35.3% (95% CI:12.6-58.1). During D and C treatment, grade III/IV toxicities per patient were neutropenia (25.0%), leucopenia (10.0%), mucositis (5.0%), oedema (5.0%), febrile neutropenia (5.0%) and thrombophlebitis (5.0%). Most common grade II toxicities were nausea (20.0%), vomiting (15.0%) and asthenia (20.0%). During X treatment, grade III/IV toxicities per patient were neutropenia (7.1%) and hand-foot syndrome (7.1%). Main grade II toxicity was hand-foot syndrome (14.3%). Two patients finished treatment after 2 and 6 cycles of X due to diarrhea, oedema and anorexia, and hand-foot syndrome.
 Conclusion: In this preliminary analysis, D and C followed by sequential X seems to be an active and well-tolerated regimen as first line treatment in patients with locally advanced or metastatic BC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2155.

Multicenter phase II study of liposomal doxorubicin (M) and docetaxel (T) as neoadjuvant treatment in patients with stage II - III breast cancer

10662

Background: T and M is a very active chemotherapy regimen for breast cancer. M has been shown to be as effective as doxorubicin at same doses while reducing the cardiotoxicity and causing less myelosuppression. This study was designed to evaluate clinical and pathological response rate (RR) and toxicity after induction chemotherapy in patient with breast cancer. Methods: Patients with histological confirmation of breast cancer (stage II-III and inflammatory), age > 18 years, left ventricular eject fraction > 45% and adequate bone marrow, renal and hepatic function were included in the study. Prior systemic therapy or radiotherapy and surgery for breast cancer were not allowed. Treatment: T (75 mg/m2) iv and M (75 mg/m2) iv, every 21 days during 4 cycles, followed by surgery. Results: To date 59 patients have been enrolled; 50 were included in this interim analysis, with a median age of 52 years old (28–76), ECOG PS 0, 88.0%; ECOG PS 1, 12.0%; breast location: right, 52.0%; peri-postmenopausal status, 44.9%. Positive hormonal receptor status was 63.3%. Histology was ductal carcinoma in 84.0%. Patients received a total of 188 cycles (median 4, range 2–4). Median relative dose intensity was 99% for T and for M. Efficacy: Nine patients were non-evaluable (7 on treatment, 1 consent withdrawal and 1 lost of follow-up). Of 41 evaluable patients, 5 achieved complete response (CR) (12.2%), 26 partial response (PR)(63.4%), 9 stable disease (SD) (22.0%) and 1 progressive disease (PD) (2.4%), resulting in a clinical response rate (RR) of 75.6% (95% CI: 62.5–88.7%). Surgery was performed in 40 patients: six (15.0%) of them had pathological (p) CR, 25 (62.5%) pPR, 9 (22.5%) pSD resulting in a pathological RR of 77.5% (95% CI: 64.6–90.4%). Median of time to progression and overall survival has not been achieved yet. Hematological toxicities grades III/IV per patient were neutropenia (14%), thrombocytopenia (4%), leukopenia (2%), anemia (2%) and febrile neutropenia (12%). Non-hematological grade III/IV toxicities per patient were asthenia (6%), nausea / vomiting (4%) and infection (4%). Conclusions: T and M every 21 days during 4 cycles as induction chemotherapy in stage II and III breast cancer is an active and well tolerated treatment.

No significant financial relationships to disclose.

Combination chemotherapy with docetaxel plus vinorelbine in metastatic breast cancer patients with prior exposure to anthracyclines

PURPOSE

To evaluate the anti-tumor activity and tolerance of docetaxel plus vinorelbine in metastatic breast cancer (MBC) patients previously treated with anthracyclines.

PATIENTS AND METHODS

Fifty patients with MBC were treated with docetaxel 75 mg/m2 (subsequently reduced to 60 mg/m2) plus vinorelbine 30 mg/m2 (subsequently reduced to 24 mg/m2). both on day 1, every 3 weeks, for a maximum of six cycles. All patients had previously received anthracyclines as adjuvant treatment (< 12 months disease-free interval) or first-line therapy for MBC. Thirty-seven patients had received at least one prior regimen for MBC. Twenty-five patients had prior high-dose chemotherapy with stem-cell rescue. Thirty patients had multiple metastatic sites. Liver and lung disease were the predominant metastatic site in 31 patients.

RESULTS

Forty-nine patients were assessable for response. Nineteen patients achieved a partial response and four a complete response (overall response rate, 46%; 95% confidence interval (95% CI): 32%-60%). Fourteen patients (28%) had stable disease on treatment. Median Kaplan-Meier estimated progression-free and duration of response times are 21 and 29 weeks. Median survival time is 47 weeks. Hematological dose-limiting toxicity, prompted a 20% dose reduction for both drugs after the first thirteen patients were treated. Neutropenia > or = grade 3 occurred in nineteen (34%) patients, neutropenic fever in 15 (7) courses, and mucositis > or = grade 3 in 6 (3%) courses.

CONCLUSIONS

The combination of docetaxel plus vinorelbine on day 1 every 3 weeks is feasible and active in MBC patients with prior anthracycline exposure. This regimen is safe, well-tolerated and convenient for the patients.

Effects of maternal chronic alcohol administration in the rat: lactation performance and pup's growth

A fostering/crossfostering analysis of the effects of maternal ethanol exposure on lactation performance and offspring growth was performed. Wistar rats were kept under one of the three experimental nutritional treatments: alcohol-treated (EG), pair-fed-treated (PFG) (as a nutritional control of alcohol-associated malnutrition), and control or normal diet (CG). Rats from the EG group were accustomed to increased amounts of ethanol (5% during the first week to 20% in the fourth week). The 20% ethanol level was maintained throughout three additional weeks and during gestational and lactational period. Daily food intake, fluid consumption, body weight and gestational parameters were studied in control (CG), pair-fed (PFG) and ethanol dams (EG). At birth, half the litters were fostered to other dams of the same treatment (GLG) and half were cross-fostered to dams of the opposite treatment (GG, LG). No cross-fostering analyses were performed on the pair-fed group. Offspring body weight was controlled throughout lactation. Liver, kidney and spleen weights as well as milk consumption were also studied at the end of lactation period. In dams, a significant reduction of body weight was described throughout the suckling period. No ethanol detrimental effects were observed on body weight at birth, but in spite of a normal birth weight, alcohol during lactation was responsible for a growth deficit. Milk consumption was significantly reduced in offspring exposed to ethanol during gestation and/or lactation. Curiously, prenatal alcohol exposure affects adversely the suckling behaviour in pups at the time of weaning. In our study, alcohol treatment and malnutrition affects liver and spleen weights. However, malnutrition decreases spleen weights more than alcohol treatment. In the case of the kidney weights the alcohol decreases kidney weight more than malnutrition. Collectively, the data from the present study show similar effects following pre/postnatal and postnatal alcohol exposure. The findings suggest that chronic alcohol administration during gestation and/or lactation adversely affects pup growth at weaning as indicated by its effect on milk consumption, pup and organ weight.

A postgenomic approach to identification of Mycobacterium leprae-specific peptides as T-cell reagents

To identify Mycobacterium leprae-specific human T-cell epitopes, which could be used to distinguish exposure to M. leprae from exposure to Mycobacterium tuberculosis or to environmental mycobacteria or from immune responses following Mycobacterium bovis BCG vaccination, 15-mer synthetic peptides were synthesized based on data from the M. leprae genome, each peptide containing three or more predicted HLA-DR binding motifs. Eighty-one peptides from 33 genes were tested for their ability to induce T-cell responses, using peripheral blood mononuclear cells (PBMC) from tuberculoid leprosy patients (n = 59) and healthy leprosy contacts (n = 53) from Brazil, Ethiopia, Nepal, and Pakistan and 20 United Kingdom blood bank donors. Gamma interferon (IFN-gamma) secretion proved more sensitive for detection of PBMC responses to peptides than did lymphocyte proliferation. Many of the peptides giving the strongest responses in leprosy donors compared to subjects from the United Kingdom, where leprosy is not endemic, have identical, or almost identical, sequences in M. leprae and M. tuberculosis and would not be suitable as diagnostic tools. Most of the peptides recognized by United Kingdom donors showed promiscuous recognition by subjects expressing differing HLA-DR types. The majority of the novel T-cell epitopes identified came from proteins not previously recognized as immune targets, many of which are cytosolic enzymes. Fifteen of the tested peptides had > or =5 of 15 amino acid mismatches between the equivalent M. leprae and M. tuberculosis sequences; of these, eight gave specificities of > or =90% (percentage of United Kingdom donors who were nonresponders for IFN-gamma secretion), with sensitivities (percentage of responders) ranging from 19 to 47% for tuberculoid leprosy patients and 21 to 64% for healthy leprosy contacts. A pool of such peptides, formulated as a skin test reagent, could be used to monitor exposure to leprosy or as an aid to early diagnosis.

The first field trials of the chemically synthesized malaria vaccine SPf66: safety, immunogenicity and protectivity

This paper reports the results of the first field study performed to assess the safety, immunogenicity and protectivity of the synthetic malaria vaccine SPf66 directed against the asexual blood stages of Plasmodium falciparum. Clinical and laboratory tests were performed on all volunteers prior to and after each immunization, demonstrating that no detectable alteration was induced by the immunization process. The vaccines were grouped as high, intermediate or low responders according to their antibody titres directed against the SPf66 molecule. Two of the 185 (1.08%) SPf66-vaccinated and nine of the 214 (4.20%) placebo-vaccinated volunteers developed P. falciparum malaria. The efficacy of the vaccine was calculated as 82.3% against P. falciparum and 60.6% against Plasmodium vivax.

The frequency of local recurrence and microsatellites as a guide to reexcision margins for cutaneous malignant melanoma

A retrospective study was undertaken of local, regional, and distant recurrences in 346 patients with primary melanomas of tumor thickness less than 1.0 mm that were excised with margins of normal skin varying between 0.1 cm and 5.0 cm or more. Prospective histopathologic examination of 284 melanomas for the presence of microsatellites was also performed and their effect upon the frequency of local recurrence was studied. Margins of excision did not influence the frequency of local, regional, or distant metastases. Four recurrences of in situ superficial spreading melanoma occurred, however, when very narrow margins of excision (0.5 cm or less) were employed. Microsatellites were uncommon with tumors less than 3.0 mm in thickness (2.8% of all tumors of less than 3.0 mm in thickness, taken together), but relatively frequent in association with thicker tumors (37%). Melanomas with microsatellites were associated with a greater frequency of local clinical metastasis than those without (14% vs. 3%). Removal of more than 1.0 cm of normal skin around a melanoma of less than 1.0 mm in thickness does not further reduce rates of recurrence of any type. The use of margins of 0.5 cm or less for melanomas with a radial growth phase does appear to result in an increased frequency of local recurrence of the primary melanoma with an epidermal in situ component. These recurrences can be prevented by the removal of 1.0 cm of normal skin around such a melanoma. Microsatellites constitute a risk factor for local recurrence, but are a relatively uncommon phenomenon at tumor thickness less than 3.0 mm.