Abstract P6-20-03: Tumor epichaperome expression using 124I PU-H71 PET (PU-PET) as a biomarker of response for PU-H71 plus nab-paclitaxel in HER2 negative (HER2-) metastatic breast cancer (MBC)

Background: The epichaperome is a new cancer target required for tumor survival (Joshi et al. Nature Reviews Cancer 2018). PU-H71 is a synthetic, purine scaffold epichaperome inhibitor that binds to the ATP-binding site of HSP90 specifically when HSP90 is integrated into the epichaperome (Rodina et al. Nature 2016). It has demonstrated antitumor activity in multiple xenograft models. Furthermore, sequential administration of nab-paclitaxel and PU-H71 in TNBC xenograft models augmented epichaperome levels, and in turn resulted in super-synergistic drug action with ablation of xenografted tumors and cures in mice.

Methods: This is an open label phase1b study of PU-H71 + nab-paclitaxel in pts with HER2- MBC. Pts received nab-paclitaxel at a standard dose of 260mg/m2 IV Q 3weeks. PU-H71 was administered IV 6 hrs (+/-1 hr) post nab-paclitaxel Q3weeks in 2 escalating dose levels (225mg/m2 and 300 mg/m2). All pts underwent FDG PET/CT every 6 weeks. Additionally, patients had the option to enroll on a separate diagnostic PU-PET protocol to measure epichaperome expression prior to initiating treatment on the phase 1b study, wherein they received a single dose of up to 11mci of 124I-PU-H71 IV and underwent imaging at 3-4hrs and 20-24 hrs. Primary objective was to establish the MTD/RP2D of this regimen. Secondary objectives were to assess PK of PU-H71 + nab-paclitaxel and clinical efficacy. Exploratory analysis included correlation of epichaperome expression at baseline using PU-PET with tumor response.

Results: 12 patients (5 ER+/HER2- ; 7 TNBC) were enrolled (6 at 225mg/m2 of PU-H71 and 6 at 300mg/m2). Median Age: 54 yrs (range: 37-71). Median ECOG: 0. Median lines of therapy in the metastatic setting: 6 (range 1-11) including prior taxanes in 75% of pts. Most common toxicities included diarrhea G1 58%; G2 7%, G3 7%) that was easily managed with anti-diarrheal agents, G1 fatigue (25%), G1/2 peripheral neuropathy (17%), G1 hyperglycemia (67%), G1 increases in alk phos (58%), AST (50%) and ALT (42%). Hematological toxicities included G3 leukopenia (42%), G3/4 neutropenia (67%), G3 anemia (50%) and G2 thrombocytopenia (17%). There were no DLTs. 33% (4/12) had PR, 58% (7/12) achieved SD with only 1 PD at the time of first scan; 5 pts are currently ongoing including 2 TNBC pts with PR who have been on therapy > 7 months. PK data will be presented. 8/12 patients also underwent PU-PET at baseline. A higher tumor to muscle SUV ratio at 24 hrs on PU-PET predicted response and increased PU-H71 retention on PU-PET at 24 hrs correlated with a longer duration of response.

Conclusion: The RP2D of PU-H71 was 300mg/m2 with 260mg/m2 of nab-paclitaxel administered IV every 3 weeks. The regimen is well tolerated with promising clinical activity in this heavily pre-treated cohort. Tumor epichaperome expression at baseline using PU-PET has the potential to serve as a predictive biomarker of response. A Phase 2 trial of this combination along with baseline PU-PET is currently planned.

Citation Format: Jhaveri K, Dunphy M, Wang R, Comen E, Fornier M, Moynahan ME, Bromberg J, Ma W, Patil S, Taldone T, Rodina A, Sterlin V, Khoshi S, Lewis J, Norton L, Chiosis G, Modi S. Tumor epichaperome expression using 124I PU-H71 PET (PU-PET) as a biomarker of response for PU-H71 plus nab-paclitaxel in HER2 negative (HER2-) metastatic breast cancer (MBC) [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 P6-20-03.

Preoperative CEA, NSE, SCC, TPA and CYFRA 21.1 Serum Levels as Prognostic Indicators in Resected Non-Small Cell Lung Cancer

In 62 patients affected by resectable non-small cell lung cancer (NSCLC) submitted to radical surgery we evaluated the prognostic significance of CEA, NSE, SCC, TPA and CYFRA 21.1 serum levels at diagnosis, as well as the predictive ability of these tumor markers with respect to histological type and pathological stage. The group was composed of 56 male and 6 female patients; the median age was 62 years (range 29–73 years). Thirty-four patients had a histological diagnosis of adenocarcinoma and 28 of squamous cell carcinoma; with regard to pathological stage, 32 patients had stage I, 4 patients stage II and 23 patients stage IIIA disease. A good predictive ability with respect to histological type was obtained with SCC serum levels; as for pathological stage, TPA and CYFRA 21.1 were found to have moderate predictive ability. In this series of patients, at a median follow-up of 55 months after surgery, we found that both TPA and CYFRA 21.1 serum levels at diagnosis were reliable predictors of overall survival, high values of these markers being associated with a worse prognosis.

Abstract PD5-04: Ki67 changes and PEPI score in the LORELEI trial: A phase II randomized, double-blind study of neoadjuvant letrozole plus taselisib versus letrozole plus placebo in postmenopausal women with ER-positive/HER2-negative early-stage breast cancer

Background: Taselisib is an oral, potent, selective inhibitor of Class I PI3-kinase (PI3K) alpha, gamma, and delta isoforms with enhanced activity against PIK3CA mutant cancer cells. LORELEI trial demonstrated a significant improvement in ORR (objective response rate) centrally assessed by MRI with neoadjuvant taselisib plus letrozole compared to letrozole plus placebo in all randomized patients as well as in the PIK3CA mutant cohort (Saura et al, ESMO 2017).

Methods: 334 postmenopausal women with newly diagnosed ER+/HER2-, untreated, Stage I-III operable breast cancer and evaluable tumor tissue for PIK3CA genotyping were randomized (1:1) to receive daily letrozole (2.5 mg) with either taselisib (4 mg on a 5 days on/ 2 days off schedule) or placebo for 16 weeks, followed by surgery. Tumor tissue collection was performed at baseline, week 3 (W3) and at surgery. Secondary objectives included, but were not restricted to, ORR assessed by MRI in patients with PIK3CA wild type (WT) tumors, ORR using alternative methods of tumor assessment (ultrasound, mammogram and clinical breast exam) in all patients and patients with PIK3CA mutant and WT tumors, central assessment of Ki67 at different timepoints (baseline, W3 and surgery), and the centrally derived PEPI score. Central Ki67 was assessed by two independent readers blinded to treatment arms and PIK3CA status (Vall D'Hebron Institute of Oncology, Barcelona).

Results: ORR by centrally assessed MRI was similar in the two treatment arms in patients with PIK3CA WT tumors (45.7 vs 40.4% for taselisib and placebo, respectively). ORR assessed by breast US was also significantly higher with taselisib compared to placebo in all randomized patients and in the PIK3CA mutant cohort. The highest concordance rate between MRI and other imaging modalities was found with breast ultrasound (53.7%). Centrally assessed Ki67 changes are reported in Table 1. Ki67 values decreased from baseline to W3 and from baseline to surgery in both treatment arms. No significant differences in the decrease of Ki67 values between treatment arms were detected. Unplanned analysis of Complete Cell Cycle Arrest (CCCA) at W3 was numerically higher with taselisib than with placebo in all randomized patients (49.6% vs 38.5%) and in the PIK3CA mutant cohort (60.9% vs 47.5%). Due to the variability in timing between the last dose of taselisib (median time 11 days; interquartile range 6-16 days) and tissue collection at surgery, considering the half-life of taselisib of approximately 40 hours, centrally derived PEPI score is not interpretable.

Ki67 proportional changes, %Taselisib + letrozolePlacebo + letrozoleBaseline to W3All patients-83.8-80.4PIK3CA mutant-84.5-79.1PIK3CA WT-82.8-81.1Baseline to surgeryAll patients-75.6-80.5PIK3CA mutant-71.9-79.9PIK3CA WT-78.2-81.2

Conclusion: Among the investigated alternative methods for assessing ORR, breast ultrasound performed similar to MRI. Decrease in the Ki67 values from baseline to W3 and to surgery were observed in both treatment arms. The time interval between taselisib cessation and tissue collection at surgery are being further investigated.

Clinical trial information: NCT02273973

Citation Format: de Azambuja E, Saura C, Nuciforo P, Frantal S, Oliveira M, Zardavas D, Jallitsch-Halper A, de la Pena L, Dubsky P, Lombard JM, Vuylsteke P, Castaneda Altamirano C, Sanchez C, Ballestrero A, Colleoni M, Santos Borges G, Ciruelos E, Bardia A, Fornier M, Boer K, Wilson TR, Stout TJ, Hsu JY, Shi Y, Piccart M, Baselga J, Gnant M. Ki67 changes and PEPI score in the LORELEI trial: A phase II randomized, double-blind study of neoadjuvant letrozole plus taselisib versus letrozole plus placebo in postmenopausal women with ER-positive/HER2-negative early-stage breast cancer [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 PD5-04.

A phase II study of ixabepilone and trastuzumab for metastatic HER2-positive breast cancer

BACKGROUND

A multicenter NCI-sponsored phase II study was conducted to analyze the safety and efficacy of the combination of ixabepilone with trastuzumab in patients with metastatic HER2-positive breast cancer.

PATIENTS AND METHODS

Two cohorts were enrolled: cohort 1 had received no prior chemotherapy or trastuzumab for metastatic disease and cohort 2 had received 1-2 prior trastuzumab-containing regimens for metastatic disease. Patients in both cohorts received ixabepilone 40 mg/m(2) as a 3-h infusion and trastuzumab on day 1 of a 21-day cycle. Tumor biomarkers that may predict response to trastuzumab were explored.

RESULTS

Thirty-nine women entered the study with 15 patients in cohort 1 and 24 patients in cohort 2. Across both cohorts, the overall RR was 44%, with a clinical benefit rate (CR + PR + SD for at least 24 weeks) of 56%. Treatment-related toxic effects included neuropathy (grade ≥2, 56%), leukopenia (grade ≥2, 26%), myalgias (grade ≥2, 21%), neutropenia (grade ≥2, 23%), and anemia (grade ≥2, 18%).

CONCLUSIONS

This represents the first study of the combination of ixabepilone with trastuzumab for the treatment of metastatic HER2-positive breast cancer. These results suggest that the combination has encouraging activity as first and subsequent line therapy for metastatic breast cancer.

Abstract P1-13-11: Adjuvant treatment of early-stage breast cancer with eribulin mesylate following dose-dense doxorubicin and cyclophosphamide: preliminary results from a phase 2, single-arm feasibility study

Background: Despite recent improvements in breast cancer outcomes, patients (pts) with high-risk, early-stage breast cancer continue to experience recurrences and death due to disease. Chemotherapy regimens with the ability to extend survival remain an important drug development goal. Eribulin mesylate has demonstrated antitumor activity and improved overall survival (OS) in pts with heavily pretreated, locally recurrent or metastatic breast cancer when compared to treatment of physician's choice. This study examines the feasibility of eribulin as adjuvant therapy following dose-dense (dd) doxorubicin (A) and cyclophosphamide (C) in patients with early-stage breast cancer.

Methods: Eligible pts have histologically confirmed, HER2-normal, stage I-III invasive breast cancer and adequate bone marrow, liver, and renal function. Treatment consists of dd AC (A 60mg/m2 IV; C 600mg/m2 IV) on Day 1 of each 14-day cycle x4 cycles, followed by eribulin mesylate 1.4mg/m2 IV over 2–5min on Days 1 and 8 every 21 days x4 cycles. Radiation/hormonal therapy were allowed per standard of care. The primary objective of feasibility is defined as the ability to complete 4 cycles of eribulin without a treatment-related dose delay (defined as >2 days) or reduction. Feasibility rates will be reported for pts with and without growth factor use. Secondary/exploratory endpoints include evaluation of the safety via NCI-CTCAEv4 of 4 cycles of AC followed by 4 cycles of eribulin, and 3-year disease-free survival and OS.

Results: As of 5/22/12, 46 of 80 planned pts have been treated; 38 pts have had ≥1 dose of eribulin and are evaluable for eribulin-related toxicity. Pt characteristics are as follows: median age 50 yrs (27–65 yrs); 100% female; ECOG of 0=81.6%; breast cancer stage at study entry: stg 1: 7.5%; stg 2: 72.5%, stg 3: 20%. Select treatment-related AEs are reported as total (all cycles) and eribulin-related events; many AEs overlapped during treatment (Table).

Molecular profiling of oral microbiota in jawbone samples of bisphosphonate-related osteonecrosis of the jaw

Oral Diseases (2012) 18, 602–612

Objective:  Infection has been hypothesized as a contributing factor to bisphosphonate (BP)‐related osteonecrosis of the jaw (BRONJ). The objective of this study was to determine the bacterial colonization of jawbone and identify the bacterial phylotypes associated with BRONJ.

Materials and methods:  Culture‐independent 16S rRNA gene‐based molecular techniques were used to determine and compare the total bacterial diversity in bone samples collected from 12 patients with cancer (six, BRONJ with history of BP; six, controls without BRONJ, no history of BP but have infection).

Results:  Denaturing gradient gel electrophoresis profile and Dice coefficient displayed a statistically significant clustering of profiles, indicating different bacterial population in BRONJ subjects and control. The top three genera ranked among the BRONJ group were Streptococcus (29%), Eubacterium (9%), and Pseudoramibacter (8%), while in the control group were Parvimonas (17%), Streptococcus (15%), and Fusobacterium (15%). H&E sections of BRONJ bone revealed layers of bacteria along the surfaces and often are packed into the scalloped edges of the bone.

Conclusion:  This study using limited sample size indicated that the jawbone associated with BRONJ was heavily colonized by specific oral bacteria and there were apparent differences between the microbiota of BRONJ and controls.

Bone Mineral Density (BMD) Changes at 1 Year in Postmenopausal Women Who Are Not Receiving Adjuvant Endocrine Therapy for Breast Cancer (BCA)

Background: Adjuvant therapy for breast cancer (BCA) may be associated with an increased risk for osteoporosis. This prospective, observational study evaluates BMD changes in postmenopausal women undergoing adjuvant chemotherapy (CTX) for early stage BCA, in the absence of endocrine therapy.Methods: Women who have been postmenopausal for at least 5 years, and who were recently diagnosed with Stage 0-III BCA were eligible to undergo serial BMD if adjuvant endocrine therapy was not recommended. Study BMDs were performed at baseline, 1 and 2 years. All patients (pts) were counseled on calcium, vitamin D and weight bearing exercise. This study was designed to assess serial changes in BMD in the individual and to compare changes in those treated with CTX to those who received no systemic therapy (observation). The study was closed prior to reaching target sample size due to slow accrual.Results: Sixteen pts enrolled. Eleven pts received CTX with a dose dense anthracycline and taxane containing regimen and 5 pts received no systemic adjuvant therapy. Twelve pts, median age 63 (range 52-80), have completed the 1 year assessment and are reported here. Two pts treated with CTX and 1 pt on observation were on bisphosphonates at study entry. Baseline BMD mean in gm/cm2 at the lumbar spine (LS) was 1.112 (range 0.807-1.389) and total hip (TH) was 0.989 (range 0.760-1.213). At 1 year, mean BMD at LS was 1.078 (range 0.767-1.347) and TH was 0.956 (range 0.753-1.210). For all 12 pts at 1 year, the individual BMD changes in LS & TH BMD ranged from 10% loss to 2% gain, with 8 of the 9 CTX treated pts losing 1-10% of BMD and the 3 pts on observation staying within 2% of baseline. The mean dosage of dexamethasone used during CTX by the 9 CTX pts was 230 mg (range 156-288mg). The 3 observation pts had no exposure to steroids during the parallel time period.Conclusions: This prospective, observational study supports the hypothesis that adjuvant CTX, and/or its supportive medications, may be associated with acute changes in BMD in postmenopausal women. Patient follow up continues.Funded by Susan G. Komen for the Cure POP0402593

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1066.

Safety of a novel capecitabine dosing schedule when combined with lapatinib in patients with HER2-positive metastatic breast cancer refractory to trastuzumab

1131

Background: Capecitabine (C) is active in breast cancer and is usually dosed for 14 days (d) followed by a 7d rest (14 - 7). We described a mathematical method which predicts the optimal schedule for C to be 7d followed by a 7d rest (7 - 7) (Norton et al, Amer Assn Can Res. 2005). The MTD of C(7 - 7) is 2,000mg BID (Traina et al, J Clin Oncol. April 2008). Lapatinib (L) improves time to progression when added to C(14 - 7) in patients (pts) with HER-2-positive (+) metastatic breast cancer (MBC) that progressed after trastuzumab (T). To optimize this effective combination, we are testing C(7 - 7) + L in a phase II trial. Methods: Eligible pts have measurable, HER-2(+) MBC that has progressed after T. HER-2(+)=IHC 3+ or FISH>2. Pts have normal LVEF by MUGA, ECOG performance status (PS) <2 and normal organ function. <3 prior chemotherapy (CRx) regimens are permitted. Prior fluoropyrimidine is excluded. Therapy (tx) consists of C (2,000 mg BID, 7 - 7) and L (1,250 mg, daily). Cycle length = 4 wk. Pts are evaluated for toxicity q4 weeks (wk), for response q12wk; LVEF by MUGA q12wk. Primary endpoint: response rate (RR). Secondary endpoints: toxicity, stable disease >6 months, PFS. Using a Simon optimal 2-stage design, with alpha = 10%, power = 90% to discriminate between RR 10% and 25%, 21 pts will be accrued to the first stage. If >2 pts respond, 29 additional pts will be enrolled. If >7/ 40 pts respond, then C(7 - 7) + L will be considered worthy of further study. Results: As of January 5, 2008, 6 pts are enrolled and evaluable. Median (med) age 64 yrs (42–71), med ECOG PS 1 (0–1), ER/PR(+) 3, HER-2(+) 6, sites of MBC: bone (2), viscera (4), soft tissue (5). Med baseline LVEF 62% (51–68%). Prior tx: Adjuvant: CRx (5), hormone tx (3), T (3); MBC: CRx (2), hormone tx (1), T (3). After a med of 3 cycles (1–4), there were no grade 3, 4, or 5 events. Tx-related toxicity is: Gr 2 fatigue (1); Gr 1 AST (4), diarrhea (3), ALT (2), vomiting (1), hand-foot (1), fatigue (1). No withdrawls due to reduced LVEF. Two pts evaluable for response: PR = 1, SD<6 mo = 1. Conclusions: Capecitabine (7 - 7) + lapatinib appears well tolerated compared to C(14 - 7)+L (Geyer et al). Additional safety and efficacy data is anticipated prior to this meeting.

[Table: see text]

Dose-dense (DD) doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (P) with trastuzumab (T) and lapatinib (L) in HER2/neu-positive breast cancer is not feasible due to excessive diarrhea: updated results

Abstract #2108

Background: DD q 2 weekly (w) AC → P + T x 1 year (y) has an acceptable safely profile w/ congestive heart failure (CHF) rate of 1/70 pts (Dang, JCO 2008). Lapatinib (L) is effective in HER2 (+) BC. We conducted a pilot study of dd AC → w P + T + L to determine its feasibility and cardiac safety.&#x2028; Methods: Enrolled pts had HER2 (+) BC; LVEF &gt; 50%. Rx consisted of AC at 60/600 mg/m2 x 4 q 2 w (w/ pegfilgrastim 6 mg day 2) → P at 80 mg/m2 x 12 q w + T x 1 y; L (1000 mg daily beginning w/ P + T and continued x 1 y). MUGA is obtained at baseline and at months (mo) 2, 6, 9, and 18. Rx is considered feasible if 1) &gt; 80% pts can complete the PTL phase without a dose delay or reduction and 2) the cardiac event rate (CHF or cardiac death) is &lt; 4%. Pts can remain on-Rx w/ one dose reduction of L (1000 mg → 750 mg) for a G 3 event or &lt; G 3 toxicity (unacceptable).&#x2028; Results: From March 2007 to April 2008, we enrolled 95 pts. Median (med) age was 45 years (range, 28-73). At a med follow-up of 7 months, 90 are evaluable. Of the 90 pts, 34 (37%) withdrew from study during the PTL phase; 29 for a 2nd event of G 3 or unacceptable &lt; G 3 toxicities (15 G 3 diarrhea, 4 G 1/2 diarrhea, 1 G 3 rash, 2 G 2 rash, 1 G 3 dyspnea and also had G 3 diarrhea, 1 G 3 ↑QTc also had G 3 diarrhea, 1 G 3 ↑ALT also had G 3 diarrhea, 1 G 3 paronychia, 1 G 3 pneumonitis, 1 asymptomatic LVEF ↓, 1 myocarditis) and 5 for other reasons (2 personal reason, 1 PCP pneumonia, 1 progression, 1 P hypersensitivity). Overall, 25/90 (27%) pts had G 3 diarrhea and 31/90 (34%) pts required a dose reduction of lapatinib. Med LVEF at baseline is 67% (N=95), at mo 2 is 68% (N=90), at mo 6 is 65% (N=53), and mo 9 is 65% (N=28). To date there are no patient drop-outs due to significant LVEF declines after dd AC; one patient dropped during PTL out due to an asymptomatic LVEF decline.&#x2028; Discussion: L at 1000 mg/day is not feasible combined w/ weekly P and T by protocol stipulation (&gt; 20% pts required L dose reduction) primarily due to excessive G 3 diarrhea. These results have led to the modification of Design 2 (Arm D) of ALTTO. We will report updated results.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2108.

Adjuvant (adj) bevacizumab (B) plus dose-dense (dd) doxorubicin/cyclophosphamide (AC) followed by nanoparticle albumin- bound paclitaxel (nab-p) in early stage breast cancer (BC) patients (pts): Cardiac safety

567

Background: Dose dense, q2 wk AC-paclitaxel (T) is superior to q3 wk therapy (Rx) (Citron, JCO 2003). The risk of congestive heart failure (CHF) with ddAC-T is not increased at <1%. In MBC, B improves PFS when added to T (Miller, SABCS 2005). It is unclear if doxorubicin plus B increases risk of CHF. Hence, we are testing the cardiac safety of ddAC-nab-p with concurrent B as adj therapy. Based upon the accepted cardiac event (CE) rate of ≤4% in trials with adj trastuzumab (an agent with known cardiac toxicity), we designed this study with similar monitoring & tolerability thresholds. The primary endpoint is cardiac safety, defined as discontinuation of B due to cardiac death from LV dysfunction or symptomatic CHF (dyspnea and LVEF<50%). Secondary endpoints: toxicity, disease-free & overall survival. Methods: Eligible pts have resected HER2(-) BC and normal LVEF. Rx consists of q2wk AC (60/600 mg/m2) ×4 then nab-p (260 mg/m2) x4 with pegfilgrastim on Day 2 plus B for one year (10mg/kg IV q2wk ×8 with chemoRx then B 15mg/kg q3wk); radiation & endocrine Rx per standard of care. MUGA obtained at baseline & mos. 2, 6, 9, 18. Pts with significant asymptomatic ↓LVEF during Rx may have B held per protocol. These pts are not counted as CEs but will have long-term cardiac monitoring. Accrual goal is 75 pts. If ≥3 CE (∼4.7%) or >1 cardiac death from LV dysfunction, B + ddAC-nab-p will not be considered safe. Results: 44 pts have enrolled, median (med) age 46.5 yrs (33–67). 28 pts have baseline & month 2 LVEF data: med baseline LVEF 68% (61–82), med LVEF at mo. 2 after ddAC+B 68% (53–75); 1 pt had an 18 point asymptomatic drop to 53% - B held but reinitiated in 4 wks with repeat LVEF 63%. 12 pts completed nab-p+B but none have reached the 6 mo. MUGA. Rx-related Gr 3/4 toxicity: neutropenia gr4 (6.8%), diarrhea gr3 (2.3%), hypertension gr3 (2.3%), neuropathy gr 3 (2.3%), fatigue gr 3 (2.3%), mucositis gr 3 (2.3%). 4 pts have withdrawn from study Rx, but only 1 due to toxicity including gr3 fatigue, mucositis & neuropathy. Conclusions: No LV dysfunction has been observed with B + ddAC-nab-p; this trial is on-going. Long-term follow-up and analysis of troponin, renin and circulating endothelial & tumor cells are planned.

No significant financial relationships to disclose.

Phase I study of a novel capecitabine schedule based on Norton-Simon mathematical modeling

1045

Background: We have previously described a mathematical method to optimize chemotherapy dose and schedule (Norton et al, AACR 2005). Capecitabine (C) has activity in breast cancer when conventionally dosed for 14 days (d) q3 weeks (14/7). However, the predicted optimal dosing schedule for C using our model is 7d followed by a 7d rest (biweekly, 7/7). We tested this hypothesis in a Phase I/II study described below. Methods: Eligible patients (pts) have measurable, metastatic breast cancer (MBC), ECOG performance status (PS) =2 and normal organ function. There is no limit to number of prior chemotherapy (CRx) regimens. Pts with prior fluoropyrimidine for MBC are excluded. HER2+ pts must not be candidates for trastuzumab. C is given in divided daily doses for 7d followed by a 7d rest. A standard “3+3” dose escalation scheme employs flat dosing which begins at 1,500mg BID and increases by 500mg/dose level. Primary endpoint is the maximum tolerated dose (MTD), defined as the highest dose for which the incidence of dose-limiting toxicity (DLT) is <33%. Results: 19 pts are now accrued; 17 pts have been treated, 2 withdrew prior to receiving C. Medians: age 47 y (range 34–62 y) and ECOG PS 0 (range 0–2). Sites of MBC: bone 8, viscera 16, soft tissue 11. ER/PR+ 11. HER2+ or unknown 2. Prior adjuvant tx: CRx 17, hormone tx 10. Six pts had adjuvant fluoropyrimidine-based tx. Three pts had 1 prior CRx for MBC; 12 pts received first-line hormone tx for MBC. Fifteen pts had prior anthracycline and taxane. Treatment-related toxicities after a median of 4 cycles (range 1–10) are shown in the table . The MTD has not been reached. Pts continue accrual to the 2500mg/2500mg dose level. Conclusions: Capecitabine 7/7 is well tolerated and allows for safe delivery of higher daily doses than routinely used in practice, as predicted by the mathematical model. Capecitabine 7/7 will be tested in a Phase II program at MSKCC in combination with targeted agents.

[Table: see text]

No significant financial relationships to disclose.

Updated cardiac safety results of dose-dense (DD) doxorubicin and cyclophosphamide (AC) followed by paclitaxel (T) with trastuzumab (H) in HER2/neu overexpressed/amplified breast cancer (BCA)

582

Background: DD q 2 weekly (w) AC → T is superior to conventionally scheduled (cs) AC → T and safe w/long follow-up (Hudis et al, SABCS 2005). With q 3 wk AC, adjuvant (adj) H is safe and effective (Romond et al and Perez et al, NEJM 2005). We therefore tested DD q 2 w AC → T + H × 1 year (y) as adj treatment (Rx) of patients (pts) with HER2/neu (+) BCA to determine cardiac safety. Based on the reported cardiac event (CE) rate of ≤ 4% in the randomized trials using cs chemotherapy (CRx) + H, we evaluated DD q 2 w AC → T + H with a 1° endpoint of cardiac safety defined as discontinuation (DC) of H due to 1) cardiac death or 2) congestive heart failure (CHF). The 2° endpoint is time to recurrence and overall survival. Methods: Pts with HER2/Neu IHC 3+ or FISH-amplified BCA were enrolled, regardless of tumor size or nodal status. Rx consisted of AC at 60/600 mg/m2 × 4 → T at 175 mg/m2 × 4 q 2 w w/pegfilgrastim 6 mg on d 2 + H × 1 y. Multi-gated radionuclide angiography scan (MUGA) is obtained at baseline and at months (mo) 2 (after AC × 4), 6 (after T × 4), 9, and 18. Pts w/baseline LVEF of ≥ 55% and w/o cardiac illnesses are eligible. Pts w/significant (sig) asymptomatic (asx) LVEF ↓ after DD AC based on mo 2 MUGA did not receive H, and pts w/sig asx LVEF ↓ during H had it DC’d. If the CE rate is > 4%, Rx is deemed not feasible. Results: From January 4, 2005 to November 1, 2005, 70 pts were enrolled. Median (med) age is 49 years (range, 27–72). Forty one of 70 pts (60%) had node (+) BC and 27/70 pts (40%) had (-) nodes. Med baseline LVEF is 68% (range, 55%-81%). As of January 9, 2005, all pts had mo 2 MUGA after DD AC and there is no sig LVEF ↓ and the med LVEF is 67% (range, 58%-79%). To date 39 pts had mo 6 MUGA w/med LVEF of 66% (range, 56%-75%) and one pt had a sig asx LVEF ↓ from baseline of 74% to 56%; H was DC’d. Twenty-three pts had mo 9 MUGA w/a med LVEF of 64% (range, 57%-69%). One patient had clinical CHF at mo 4 w/EF of 45% and improved sig w/cardiac medications. One had pneumonitis during radiation (RT). One had atrial fibrillation w/pericarditis after completion of RT. Discussion: DD AC → T + H appears to have an acceptable cardiac toxicity profile w/1/70 pts having a CE. Updated cardiac safety data will be presented.

[Table: see text]

Serum HER-2/neu change predicts clinical outcome to trastuzumab-based therapy

500

Background: Trastuzumab monotherapy has a 34% objective response rate (ORR) in patients with HER-2/neu IHC 3+ or FISH-positive first-line metastatic breast cancer (C. Vogel et al, JCO 20:719–726, 2002). Predicting response and survival to trastuzumab-based therapy is an unsolved problem. The HER-2/neu extracellular domain (ECD) is released after cleavage by the ADAM metalloproteinases, and the remaining membrane-bound internal domain is constitutively activated. Trastuzumab inhibits cleavage of the HER-2/neu ECD. Methods: A pooled analysis of 7 trials of first-line trastuzumab therapy (with or without chemotherapy) with serial serum HER-2/neu levels were included. The FDA-approved HER-2/neu ELISA (Oncogene Science/Bayer HealthCare) was used to determine serum HER-2/neu levels. A pretreatment and post-treatment serum (16–120 days) from 307 patients was available. 236 patients had data on overall survival. Kaplan Meier Life table analysis was performed to compare duration of response (DRP), time to progression (TTP), and overall survival (OS). Results: The median decrease in serum HER-2/neu levels for all patients was 31.0% (Range: 98% decrease to 239% increase). Patients with > 20% decrease in HER-2/neu levels had a significantly higher objective response rate (ORR, complete + partial response) and longer DRP, TTP and OS. The results were similar regardless of the timing of the second serum draw (≤ 30 days vs. > 30 days) after the start of trastazumab. Conclusion: Patients with < 20% decrease in serum HER-2/neu levels have decreased benefit from trastuzumab therapy. Patients who do not have a significant decrease in serum HER-2/neu levels should be considered for additional HER-2/neu-targeted therapies.

[Table: see text]

[Table: see text]

Trastuzumab in combination with chemotherapy for the treatment of metastatic breast cancer

Metastatic breast carcinoma still remains an incurable condition. The relentless search for novel agents that might prove useful for management has evolved toward monoclonal antibodies, in part because of a rapidly expanding understanding of breast cancer biology. Trastuzumab (Herceptin; Genentech, Inc, South San Francisco, CA) is a recombinant humanized monoclonal antibody against the HER-2 receptor that has shown antitumor activity as a single agent in phase I and II trials of patients with metastatic breast cancer overexpressing HER-2. The observation of increased antitumor activity between trastuzumab and some chemotherapeutic agents in preclinical models has prompted its use in combination with several drugs. Of particular interest is the use of trastuzumab with paclitaxel. Two trials were presented at the 1999 meeting of the American Society of Clinical Oncology that evaluated this combination. One multicenter phase III trial showed clinical benefit and increased survival for patients with HER-2-overexpressing metastatic breast cancer treated with chemotherapy plus trastuzumab. A phase II trial, reviewed in this report, evaluated the efficacy and safety of weekly paclitaxel plus trastuzumab for patients with metastatic breast carcinoma, including those overexpressing and nonoverexpressing HER-2.

"Postpsychotic depression" and residual schizophrenia in a mental health hospital

Forty three patients, mean age 55.20 +/- 9.27 SD, affected by Schizophrenia Residual Type (DSM IV, RDC criteria) and treated with neuroleptic drugs for a mean of 25.42 years (+/- 4.12 SD) were included into the study. Clinical evaluation was cross-sectional assessed by BPRScale, SAPS, SANS, HRS-D, EPSE. ACS and MMSE. Seventy percent of patients presented a "postpsychotic depression" (42%, mild; 16%, moderate and 12% serious). "Postpsychotic depression" does not seem to be influenced by neuroleptics, but it seems to be a component of residual schizophrenia in patients with a long lasting permanence in a mental hospital.

Tumour markers CEA, NSE, SCC, TPA and CYFRA 21.1 in resectable non-small cell lung cancer

BACKGROUND

In the last few years, several prognostic factors have been investigated in order to identify among patients with completely resected non-small cell lung cancer (NSCLC) subsets at high risk of recurrence. In this context, the actual role of serum tumour markers is still unclear. The aim of this study was to evaluate the prognostic significance of preoperative CEA, NSE, SCC, TPA and CYFRA 21.1 serum levels in 62 patients submitted to radical surgery for non-small cell lung cancer (NSCLC). The predicting ability of these tumour markers with respect to histological type and pathological stage was also assessed.

PATIENTS AND METHODS

After informed consent was obtained, the preoperative serum concentrations of the tumour markers CEA, NSE, SCC, TPA and CYFRA 21.1 were measured by means of immunometric assays in 62 patients referred to our Institutions from January to December 1992. All patients had resectable, histologically proven NSCLC and were submitted to radical surgery. Overall survival (OS) was calculated as the time elapsed from surgery to the date of death or last clinical evaluation; the prognostic effect of the tumour markers was investigated by Cox multiple regression models.

RESULTS

Fifty-six patients were male and 6 female; median age was 62 years. Thirty-four patients had a histological diagnosis of adenocarcinoma and 28 of squamous cell carcinomas. With regard to pathological stage, 32 patients had stage I, 4 patients had stage II and 23 patients had stage IIIA disease. In this series of patients, at a median follow-up of 55 months after surgery, we found that both TPA and CYFRA 21.1 serum levels at the time of diagnosis were reliable predictors of overall survival high values of these markers being associated with worse prognosis.

CONCLUSIONS

Our findings suggest that in completely resected NSCLC, TPA and CYFRA 21.1 preoperative serum levels might provide a useful tool for stratifying subgroups of patients with different chances of disease recurrence after surgery.

Update on the management of advanced breast cancer

Recent trials comparing single-agent vs combination therapy in metastatic breast cancer suggest that it may be time to reconsider the belief that combination chemotherapy is the gold standard of treatment. Based on the limited randomized trial data available to date, high-dose chemotherapy with stem-cell rescue should not be viewed as "state-of-the art" treatment for metastatic disease and should be used only in the context of clinical trials. Recent trials have explored the optimal dosing and scheduling of the taxanes, as well as the possible role of these agents in combination regimens. Capecitabine (Xeloda), a new oral fluoropyrimidine, appears to be comparable in efficacy to CMF (cyclophosphamide, methotrexate, and fluorouracil), and preclinical data suggest possible synergy between this agent and the taxanes. Other promising agents under study include liposome-encapsulated doxorubicin (TLCD-99), an immunoconjugate linking a chimeric human/mouse monoclonal antibody to doxorubicin molecules; MTA (LY231514), a multitargeted antifolate; and marimistat, a broad-spectrum matrix metalloproteinase inhibitor. Tamoxifen (Nolvadex) remains the most important hormonal agent, but new antiestrogens and selective estrogen receptor modulators (SERMs) may provide alternatives. The potential role of new aromatase inhibitors as first-line hormonal agents requires further study. Finally, the possible synergy between trastuzumab (Herceptin), a recombinant humanized monoclonal antibody to the HER-2/neu protein, and paclitaxel (Taxol) is being studied in two clinical trials.

5-year results of dose-intensive sequential adjuvant chemotherapy for women with high-risk node-positive breast cancer: A phase II study

PURPOSE

We conducted a phase II pilot study of dose-intensive adjuvant chemotherapy with doxorubicin followed sequentially by high-dose cyclophosphamide to determine the safety and feasibility of this dose-dense treatment and to estimate the disease-free and overall survival in breast cancer patients with four or more involved axillary lymph nodes.

PATIENTS AND METHODS

Seventy-three patients received adjuvant treatment with four cycles of doxorubicin 75 mg/m(2) as an intravenous bolus every 21 days, followed by three cycles of cyclophosphamide 3,000 mg/m(2) every 14 days with granulocyte colony-stimulating factor support.

RESULTS

Seventy-one patients were assessable, and all but two completed all planned chemotherapy. There was no treatment-related mortality. The most common toxicity was neutropenic fever, which occurred in 39% of patients. Median disease-free survival is 66 months (95% confidence interval, 34 to 98 months), and median overall survival has not yet been reached. At 5 years of follow-up, the disease-free survival is 51.7%, and overall survival is 60.0%. There is no long-term treatment-related toxicity, and no cases of acute myelogenous leukemia or myelodysplastic syndrome have been observed.

CONCLUSION

Our pilot study of doxorubicin followed by cyclophosphamide demonstrates the safety and feasibility of the sequential dose-dense plan. Long-term follow-up, although noncomparative, is promising. However, this regimen is associated with a higher incidence of toxicity (and also higher costs) than the standard dose and schedule of doxorubicin and cyclophosphamide, and therefore it should not be used as conventional therapy in the absence of demonstrated improvement of outcome. Randomized trials testing the dose-dense approach have been completed but not yet reported. Because the sequential plan can decrease overlapping toxicities, it is an appropriate platform for the addition of newer active agents, such as taxanes or monoclonal antibodies.

Depressive symptoms and schizophrenic relapses: the effect of four neuroleptic drugs

1. A prevalence of depressive symptomatology, ranging from 25% to 80% has been reported during the course of schizophrenia. 2. Depressive symptoms were assessed in 144 schizophrenic patients (DSM IV) during an acute exacerbation phase. 3. Depressive symptoms showed a prevalence ranging from 5.5% (severe clinical pictures) to 54.8 (mild clinical pictures). 4. The authors did not find a correlation between depressive symptoms per se and the presence of negative psychotic symptoms. Depression may be linked not so much to negative symptoms but to the psychotic state itself. 5. Depressive symptomatology concurrently occurred with schizophrenic relapses and improved together with the psychotic clinical picture, independently of the neuroleptic drug employed. Haloperidol, haloperidol decanoate and fluphenazine decanoate all showed a similar improvement of depressive symptoms. 6. L-sulpiride showed a trend to be most effective on depressive symptomatology in comparison to the other neuroleptics.

Long-term therapeutic efficacy and toxicity of recombinant interferon-alpha 2a in polycythaemia vera

We report on long-term therapeutic efficacy and toxicity of recombinant interferon-alpha 2a (rIFN-alpha) in a series of 38 patients with polycythaemia vera (PV). In all patients haematocrit was first brought into the normal range by venesection; rIFN-alpha was then begun at a starting weekly dose of 9,000,000 IU. Complete response (CR) was defined as persistence of normal haematocrit without venesection and partial response (PR) as >50% reduction of phlebotomy requirement. Eleven patients (28.9%) achieved CR and 8 (21.0%) PR. Median duration of treatment for all responsive patients was 40 months; 12 patients are still responsive and under treatment after 13, 15, 25, 35, 40, 41, 43, 49, 50, 51, 52 and 52 months of therapy with rIFN-alpha. In responsive patients, rIFN-alpha also normalized leucocyte counts, platelet counts and spleen enlargement; rIFN-alpha also relieved generalized pruritus in all 10 patients displaying this symptom. Early toxicity (flu-like syndrome) was observed in 23.6% and late toxicity (severe weakness) in 13.1% of patients, requiring rIFN-alpha treatment suspension in all cases. Progression to leukaemia was observed in none of the 10 patients treated only with rIFN-alpha and in one of the 12 who received alkylating agents before enrolment in this study. According to these data, rIFN-alpha seems to be an effective and safe treatment option for PV.

Soluble interleukin-2 receptors (sIL-2R) in Hodgkin's disease: outcome and clinical implications

The aim of this study was to assess the prognostic role of soluble interleukin-2 receptors (sIL-2R) in Hodgkin's disease (HD) both in the achievement of complete remission (CR) and in predicting disease relapse. Between August 1988 and June 1993 sIL-2R serum levels were measured in 174 untreated patients; in 137 of them evaluation was repeated at the end of treatment and in 132 also during the follow-up. Baseline sIL-2R levels (mean+/-standard error) were significantly higher in patients than in 65 healthy control subjects (1842+/-129 U ml(-1) vs 420+/-10 U ml(-10, P< 0.0001). At the end of treatment 135 out of 137 evaluated patients achieved complete response (CR) and their mean sIL-2R serum levels were significantly lower than those at diagnosis (635+/-19 U ml(-1) vs 1795+/-122 U ml(-1), P=0.0001). After a median follow-up of 5 years, sIL-2R remained low in 114 patients in continuous CR, while they increased in 9 out of 12 patients (75%) who relapsed. However, a temporary increase was also observed in six patients (5%) still in CR. Treatment outcome in terms of freedom from progression was linearly related to sIL-2R levels. Our study confirms that patients with untreated HD have increased baseline levels of sIL-2R compared with healthy subjects and that their pretreatment values may be an indication of disease outcome similar to other conventional prognostic factors, such as number of involved sites, presence of B symptoms and extranodal extent.

Polycythemia vera treated with recombinant interferon-alpha 2a: evidence of a selective effect on the malignant clone

We periodically analyzed bone-marrow cytogenetic features in 8 patients belonging to a series of 38 subjects with polycythemia vera (PV), all treated with recombinant interferon-alpha 2a (rIFN-alpha) at a weekly dose of 9,000,000 IU. Six out of these 8 patients never showed any chromosome alterations, while 2 displayed at diagnosis the presence of trisomy 8 in all bone-marrow metaphases. Interestingly enough, in these 2 patients rIFN-alpha treatment was able to induce not only complete hematological response but also the disappearance of trisomy 8, as shown by conventional cytogenetic investigation and fluorescence in situ hybridization performed on bone-marrow cells after 1 year of treatment. This finding indicates that, as previously shown in chronic myeloid leukemia, in PV rIFN-alpha can also eradicate the malignant clone by means of a selective effect on bone-marrow transformed cells.

Initial chemotherapy for primary resectable large-cell lymphoma of the stomach

BACKGROUND

We aimed to evaluate the safety and effectiveness of a conservative approach with short-term chemotherapy with or without consolidation radiotherapy in primary resectable large-cell gastric lymphoma in patients not requiring emergency surgery at presentation.

PATIENTS AND METHODS

Seventeen consecutive patients presenting with resectable primary large-cell lymphoma of the stomach not requiring immediate surgery were initially treated with chemotherapy with or without consolidation radiotherapy. Subtotal or total resection of the stomach was planned only as salvage treatment for those patients who failed locally, or as emergency surgery in instances of acute iatrogenic complications of treatment. Chemotherapy included four to six cycles of an anthracycline-containing regimen, and consolidation radiotherapy was planned on the entire stomach and surrounding lymph node areas for complete responders readily capable of compliance with a daily treatment schedule at our Institution.

RESULTS

None of the patients in the present series experienced acute iatrogenic morbidity or mortality from local complications. After a median follow-up of almost six years, two patients failing first-line chemotherapy have died of progressive lymphoma, while 15 patients are well and currently disease-free.

CONCLUSIONS

Up-front chemotherapy as initial treatment for primary gastric large-cell lymphoma appears to be a safe and effective treatment by which most patients can probably be spared surgical gastrectomy. Consolidation radiation therapy on the stomach can probably improve on the effectiveness of chemotherapy alone. More experience is needed to elucidate the prognostic factors, treatment-related long-term toxic effects and the feasibility of such a treatment administered outside of highly specialized institutions.

Activity of single agent vinorelbine in pretreated non-Hodgkin's lymphoma

BACKGROUND

To assess the activity of single agent vinorelbine in pretreated non Hodgkin's lymphoma.

PATIENTS AND METHODS

Twenty-three pretreated patients with non-Hodgkin's lymphoma (14 intermediate-high grade, nine low-grade) were treated with vinorelbine 30 mg/m2/week for six months or up to four doses after achieving CR.

RESULTS

Among 13 evaluable patients with intermediate-high grade lymphoma, three obtained CR and three PR, for an overall response rate of 46% (95% CI: 19%-75%). Median duration of response was six months. Otherwise, vinorelbine did not show any significant activity inn chemotherapy-refractory low-grade non-Hodgkin's lymphoma. Toxicity was acceptable, and the drug was well-tolerated even in elderly patients.

CONCLUSIONS

The good activity and tolerability of vinorelbine in relapsed intermediate-high grade lymphoma suggest its inclusion in first-line regimens, especially in elderly patients.

Chronic myeloid leukemia treated with busulfan

Interferon alpha is presently viewed as the first choice drug for treatment of chronic myeloid leukemia; however patients who are not eligible for this type of therapy are still treated with conventional chemotherapeutic agents as for instance hydroxyurea and/or busulfan. In a series of 23 patients with Philadelphia chromosome positive chronic myeloid leukemia who have been treated solely with busulfan, we have evaluated the relationship between total amount of drug required during the first 12 months of treatment and duration of the chronic phase. A statistically significant (p<0.005) inverse relationship between these two parameters was found, indicating that patients with low busulfan requirement during the first year of therapy have a better prognosis.

Fluorescence in situ hybridization (FISH) for evaluating residual disease in Philadelphia chromosome-positive chronic myeloid leukemia during interferon alpha therapy

Fluorescence in situ hybridization (FISH) is a quantitative technique which allows, by means of specific probes, to detect the t(9;22) translocation typical of chronic myeloid leukemia (CML) hematopoietic cells. We have evaluated FISH on interphase nuclei as a method for assessment of residual disease in bone marrow samples from 5 Philadelphia chromosome positive (Ph(+)) CML patients after 12 months therapy with interferon alpha; results were compared with findings obtained by conventional cytogenetics and by polymerase chain reaction (PCR). Our data indicate that FISH is more sensitive than cytogenetics for evaluation of residual disease, being positive in 1 out of 2 cases scored as Ph negative by cytogenetics, but is less sensitive than PCR which turned out to be positive in all patients. As additional advantage over conventional cytogenetics, FISH on interphase nuclei can be performed also on samples lacking metaphases or having poor chromosome spreading or unsatisfactory chromosome banding.