Improvements in Survival and Clinical Benefit With Gemcitabine as First-Line Therapy for Patients With Advanced Pancreas Cancer: A Randomized Trial

PURPOSE

Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer.

PATIENTS AND METHODS

One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival.

RESULTS

Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated.

CONCLUSION

This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Abstract BS2-2: Roles of epigenetic regulation in breast cancer development

Changes to the genomic DNA sequence, called mutations, are known to play a critical role in the development of cancer. However, increasing evidence indicates that epigenetic changes (heritable cellular changes in gene expression that do not involve alterations in the DNA sequence) also make important contributions to tumorigenesis. For example, promoter hypermethylation plays a major role in cancer through transcriptional silencing of critical growth regulators such as tumor suppressor genes. Other chromatin modifications, such as histone ubiquitination, methylation and acetylation, affect local chromatin structure and regulate gene transcription. Using genome-wide RNA interference screens, we are uncovering epigenetic modulators that play important roles in breast cancer development and progression. The results of these studies are expected to shed light on the role of epigenetic regulation in breast cancer, and suggest new therapeutic approaches.

Citation Format: Green MR. Roles of epigenetic regulation in breast cancer development. [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 BS2-2.

Mutation of chromatin modifiers; an emerging hallmark of germinal center B-cell lymphomas

Subtypes of non-Hodgkin's lymphomas align with different stages of B-cell development. Germinal center B-cell (GCB)-like diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL) and Burkitt's lymphoma (BL) each share molecular similarities with normal GCB cells. Recent next-generation sequencing studies have gained insight into the genetic etiology of these malignancies and revealed a high frequency of mutations within genes encoding proteins that modifying chromatin. These include activating and inactivating mutations of genes that perform post-translational modification of histones and organize chromatin structure. Here, we discuss the function of histone acetyltransferases (CREBBP, EP300), histone methyltransferases (KDM2C/D, EZH2) and regulators of higher order chromatin structure (HIST1H1C/D/E, ARID1A and SMARCA4) that have been reported to be mutated in ⩾5% of DLBCL, FL or BL. Mutations of these genes are an emerging hallmark of lymphomas with GCB-cell origins, and likely represent the next generation of therapeutic targets for these malignancies.

BSACI guideline for the diagnosis and management of cow's milk allergy

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.

A novel immunodeficiency disorder characterized by genetic amplification of interleukin 25

Many primary immunodeficiency disorders of differing etiologies have been well characterized, and much understanding of immunological processes has been gained by investigating the mechanisms of disease. Here, we have used a whole-genome approach, employing single-nucleotide polymorphism and gene expression microarrays, to provide insight into the molecular etiology of a novel immunodeficiency disorder. Using DNA copy number profiling, we define a hyperploid region on 14q11.2 in the immunodeficiency case associated with the interleukin (IL)-25 locus. This alteration was associated with significantly heightened expression of IL25 following T-cell activation. An associated dominant type 2 helper T cell bias in the immunodeficiency case provides a mechanistic explanation for recurrence of infections by pathogens met by Th1-driven responses. Furthermore, this highlights the capacity of IL25 to alter normal human immune responses.

Immediate impact of the FOLFIRINOX phase III data reported at the 2010 ASCO Annual Meeting on prescribing plans of American oncology physicians for patients with metastatic pancreas cancer (MPC)

286

Background: Since 2005 we at Xcenda, LLC have studied prescribing plans of American medical oncologists for first-line therapy in patients with MPC. In 2008 we reported the steady growth of prescribing plans for the gemcitabine-erlotinib (GE) combination from 23% in late 2005 to 46% in 2007. In 2007, gemcitabine (G) alone was the second most common regimen planned (27%) (Green MR. Proc GI ASCO 2008). No cytotoxic doublet consistently garnered >10% prescribing share in this clinical setting. At ASCO 2010 Conroy et al. (J Clin Oncol. 2010;28(15s): Abstract 4010) reported a survival advantage for the FOLFIRINOX regimen compared to package insert dose and schedule of G alone as first-line therapy in patients with MPC and excellent PS (0-1).

Methods: Between 7/31 and 8/28/2010 we again used our extensively tested, live research vehicle, NMCR Challenging Cases, to assess current prescribing plans of over 370 American medical oncologists for first-line therapy in a patient with metastatic pancreas cancer and either PS 1 or PS 2.

Results: The FOLFIRINOX data have produced an immediate change in the distribution of planned first-line prescribing with 18% share for the PS 1 scenario, largely substituted for previous use of GE for this setting (Table). In PS 2, plans for FOLFIRINOX are minimal with G alone followed by GE as the dominant selections.

Conclusions: The recently reported phase III FOLFIRINOX data are impacting first-line prescribing plans for patients with MPC. We will continue to quantitate physician-prescribing plans to more fully understand the additional impact the FOLFIRINOX data may have on overall chemotherapy management of these patients.

[Table: see text]

[Table: see text]

BRAF V600E mutation and the tumour suppressor IGFBP7 in atypical genital naevi

BACKGROUND

Atypical genital naevi (AGN) are naevi of special sites with atypical histological features that overlap with those of malignant melanoma. Activating BRAF mutations, identified in the majority of banal melanocytic naevi and cutaneous melanomas, are reportedly uncommon in naevomelanocytic proliferations in nonsun-exposed sites. We have recently shown that constitutive activation of the BRAF-MEK-ERK signalling pathway in oncogenic BRAF-positive naevi increases expression and secretion of IGFBP7, which induces senescence and apoptosis.

OBJECTIVES

To ascertain the frequency of BRAF V600E mutations in AGN compared with banal naevi without atypia. An additional aim was to assess the expression of IGFBP7 in oncogenic BRAF-positive AGN.

METHODS

Genomic DNA was isolated per protocol from seven genital naevi without atypia and 13 AGN for BRAF genotyping. Immunohistochemical staining for IGFBP7 was performed on all cases.

RESULTS

The BRAF V600E mutation was identified in 43% of genital naevi without atypia and 23% of AGN (P = 0.61). In both groups, IGFBP7 expression was maintained in 67% of BRAF V600E-positive cases.

CONCLUSIONS

The prevalence of BRAF V600E in AGN suggests that ultraviolet exposure is not essential for generating the mutation. The BRAF V600E mutational status appears to be of limited diagnostic utility in distinguishing genital naevi that exhibit atypia from those that do not. Similar to oncogenic BRAF-positive common naevi without atypia, enhanced expression of the tumour suppressor IGFBP7 in oncogenic BRAF-positive AGN supports that they are biologically inert.

Clinical factors predictive of overall survival (OS) and the identification of prognostic groups in patients (pts) with unresectable stage III non-small cell lung cancer (NSCLC) treated with chemoradiotherapy on Cancer and Leukemia and Group B trial (CALGB) 39801

7535

Background: CALGB 39801 was designed to test whether treatment with induction chemotherapy and concurrent chemoradiotherapy (arm B) would improve OS in comparison to identical chemoradiotherapy alone (arm A), and demonstrated no significant benefit in OS for induction therapy. The objective of this analysis was to identify factors predictive of OS, and to use relevant factors to dichotomize pts into prognostic groups. Methods: Between July 1998 and May 2002, 331 pts were studied and included in a Cox proportional hazard regression analysis investigating previously identified prognostic factors: age (< 70 vs. ≥ 70 years), gender, race/ethnicity, hemoglobin (hgb) (< 13 vs. ≥13), performance status (PS) (0 vs.1), pretreatment weight loss (wt loss) (<5% vs. ≥ 5%), and treatment arm. Results: Cox regression analysis identified weight loss ≥ 5%, age ≥ 70, PS of 1, and hgb < 13 as predictive of worse survival (p<0.05), but not treatment arm (p=0.55). The median survival for pts with 0 (n=66), 1 (n=100), 2 (n=100), or ≥ 3 (n=65) risk factors were 24, 18, 10, and 8 months, respectively (p=0.0001). The pts were dichotomized into “poor prognosis” (PP) defined as ≥2 factors (n=165) and “good prognosis” (GP) defined as ≤ 1 factors (n=166). The hazard ratio (HR) for overall survival for the PP in comparison GP was 1.88 (95% CI, 1.49 to 2.37; p-value < 0.0001); the median survival times (MST) observed were 9 and 18 months, respectively (p<0.0001). The reasons for discontinuing treatment, and the rates of hematologic and non-hematologic adverse events were similar between the two groups. In the PP group the OS was similar between arms A (n=82) and B (n=83) (HR=0.97, 95% CI, 0.70 to 1.4; p=0.34); MST of 8.7 and 9.5 months, respectively. In the GP the OS was similar between arms A (n=79) and B (n=87) (HR=0.86, 95% CI, 0.63 to 1.1; p=0.87); MST of 19.3 and 17.6 months, respectively. Conclusions: Factors predictive of OS can be used to dichotomize pts into prognostic groups. Induction chemotherapy was not beneficial in either prognostic group.

No significant financial relationships to disclose.

Prescribing plans (PP) of American Oncologists for first-line therapy (Rx) for patients with stage III (wet)/IV non-small cell lung cancer (NSCLC) and PS 2: Overall selection and impact of gender and smoking status

e19046

Background: Selection of oral EGFR inhibitors or chemotherapy as 2nd line in patients with NSCLC may be influenced by patients’ performance status (PS), smoking status, gender; tumor histology; tolerance/response to 1st-line Rx; and patient expectations/desires. Methods: Between February ’07 and October ’08, we used a core case scenario of stage IV mucin positive adenocarcinoma (Adeno ca) of lung in a 68-year-old former smoker (FS; stopped 6 years ago) with PS 2, to study patient related variations in PP of almost 800 American medical oncologists during 10 live research events [393 MDs/5 events during 2008]. Impact of gender or/and smoking history on 1st-line Rx selection was assessed. Results: In 2007–08, 97%/97%% MDs planned anti-tumor Rx: 53%/63% combination; 44%/34% single agent. PP for 2008 is shown in the table . [2007 PP data for erlotinb use included]. PP for erlotinib in these 4 scenarios are stable over the 2007 - 08 testing interval. Impact of smoking status dominates over gender. For a female NS with Adeno ca /PS2, ≥2/3 of MDs plan erlotinib 1st-line. In the absence of testing results for EGFR expression by IHC, EGFR gene copy number by FISH, EGFR gene mutation testing, or kras mutation testing, our data show a direct correlation of patient “phenotype” and PP for erlotinib as 1st-line Rx, a setting not specifically an approved indications for this agent. The impact of recently reported progression free survival data from an Asian phase III trial (IPASS: gefitinib or chemotherapy or as 1st-line therapy in non or former light-smoking patients with lung adenoca) on future prescribing plans in this clinical setting will be of great interest. Conclusions: By our observations, smoking status dominates over gender in PP of oncologists when treating wet IIIB/IV Adeno ca of lung. Therefore we plan to continue to assess American oncologists’ PP for this NSCLC setting during 2009.

[Table: see text]

[Table: see text]

Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study

OBJECTIVES

To assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes (PEG+E) for the treatment of chronic constipation in children.

DESIGN

Randomised, double blind, placebo controlled crossover trial, with two 2-week treatment periods separated by a 2-week placebo washout.

SETTING

Six UK paediatric departments.

PARTICIPANTS

51 children (29 girls, 22 boys) aged 24 months to 11 years with chronic constipation (lasting > or =3 months), defined as < or =2 complete bowel movements per week and one of the following: pain on defaecation on 25% of days; > or =25% of bowel movements with straining; > or =25% of bowel movements with hard/lumpy stools. 47 children completed the double blind treatment.

MAIN OUTCOME MEASURES

Number of complete defaecations per week (primary efficacy variable), total number of complete and incomplete defaecations per week, pain on defaecation, straining on defaecation, faecal incontinence, stool consistency, global assessment of treatment, adverse events and physical examination.

RESULTS

The mean number of complete defaecations per week was significantly higher for children on PEG+E than on placebo (3.12 (SD 2.05) v 1.45 (SD 1.20), respectively; p<0.001). Further significant differences in favour of PEG+E were observed for total number of defaecations per week (p = 0.003), pain on defaecation (p = 0.041), straining on defaecation (p<0.001), stool consistency (p<0.001) and percentage of hard stools (p = 0.001). Treatment related adverse events (all mild or moderate) occurred in similar numbers of children on PEG+E (41%) and placebo during treatment (45%).

CONCLUSIONS

PEG+E is significantly more effective than placebo, and appears to be safe and well tolerated in the treatment of chronic constipation in children.

CALGB 30306: A phase II study of cisplatin (C), irinotecan (I) and bevacizumab (B) for untreated extensive stage small cell lung cancer (ES-SCLC)

7563

Background: VEGF is expressed in 80% of SCLC. Combining chemotherapy with B is effective in advanced non-small cell lung, breast and colon cancers. Methods: This was a phase II study of C 30 mg/m2 and I 65 mg/m2 days 1 and 8 plus B 15 mg/kg day 1 every 21 days for up to 6 cycles in patients with untreated ES-SCLC, PS 0–2, and adequate organ function. Eligibility required no significant bleeding, uncontrolled hypertension, brain mets or other risk factors for B therapy. An initial safety cohort of ten patients was closely followed for unexpected/severe toxicities. Pretreatment blood was collected for biomarker analysis. Statistical design: primary endpoint 12 mo survival rate > 57% (median survival ≥15 mo). Results: 72 pts were enrolled from 3/05–4/06 with one patient deemed ineligible due to diagnosis NSCLC. Demographics: 51% female; median age 62; PS 0–23%, 1–68%, 2–10%. There were no episodes of grade 3 or greater hemoptysis or other primary hemorrhagic episodes. One patient died after an embolic/thrombotic stroke bled secondarily. Other grade 3/4 toxicities included (%): anemia 5, neutropenia 23, platelets 10, hypertension 6, fatigue 12, diarrhea 17, nausea 11, bowel perforation 2, infection 14, all electrolyte 23, stroke 4, vascular access thrombosis 3. Deaths on therapy 3 (4%): pneumonitis 1, stroke 1, heart failure 1. Preliminary efficacy: CR 2 (3%), PR 42 (59%), SD 9 (13%), PD 1 (1%); ORR 62%; ORR excluding unevaluable (4%)/no data (18%): 80%; median progression free survival 7.0 mo (95% C.I. 6.2,8.0); median overall survival 10.6 mo (95% C.I. 8.5, 11.7); median follow-up 9.5 mo. Pretreatment VEGF/PDGF titers have been measured, reported to the CALGB statistics center, and will be analyzed in relation to response and survival outcomes. Conclusions: Although ES-SCLC often has bulky central disease there was no clinically significant hemoptysis. All patients will be at least 12 months from initiation of therapy by 5/07, and mature response and survival data will be presented.

No significant financial relationships to disclose.

Phase II randomized study of dose-dense docetaxel (Doc) and cisplatin (Cis) every two weeks with pegfilgrastim (Pfil) and darbepoetin alfa (Darb) with and without the chemoprotector BNP7787 in patients with advanced non-small cell lung cancer (NSCLC): CAL

7617

Background: We sought to explore the toxicity, feasibility, and response rate of dose-dense Doc and Cis with growth factor support without [A] and with [B] a novel chemoprotector in patients with NSCLC. Methods: Patients with measurable disease, stage IIIB (effusion) or IV, performance status (PS) 0–1, no prior chemotherapy, and adequate organ function were eligible. Treatment with Doc 75 mg/m2 ? Cis 75 mg/m2 both IV over 1 hr day 1 with Darb 200 mcg SC day 1 and Pfil 6 mg SC day 2 randomized to without/with BNP before Cis was repeated every other week (1 cycle = 2 weeks) for up to 6 cycles. Response was determined after 3 and 6 cycles. Because of anticipated neurotoxicity (NT), the primary statistical endpoint was to differentiate between grade =2 NT rates of 30% in [A] and 10% in [B]: 90% power, two-tailed p<0.10, 76 patients per arm. Feasibility was prospectively defined as febrile neutropenia in <10% of patients and =1 treatment delay per cycles 1–3 and 4–6 in <20% of patients. Objective response rates of >35% were required to merit further investigation. Results: Between 8/04 and 3/06, 160 patients were enrolled but 5 never started therapy and 4 were ineligible: male/female, 99/52; white/black/other, 126/23/2; median age 62 (range, 30–88); PS 0/1, 69/82; stage IIIB/IV 14/137; [A]/[B], 76/75 well balanced. Sensory/motor/either NT grade =2 occurred in 28/14/32% on [A] and 19/19/29% on [B]. The incidence of febrile neutropenia was 1%. Treatment was delayed in cycles 1–3/cycles 4–6 in 3/3 patients in [A] and 1/5 patients in [B]. Completion rates for 3/6 cycles were 87/51% in [A] and 84/52% in [B]. By intent to treat, complete/partial response rates were 4/46% in [A] and 3/47% in [B]. Median estimated overall/progression-free survival times are10/6 months in [A] and 11/6 months in [B]. Overall, grade 3+4 neutropenia and thrombocytopenia occurred in =10% and anemia in 12% of patients. Non-hematologic toxicity was mild. Six deaths were thought to be treatment related. Conclusions: This dose-dense treatment regimen is feasible, tolerable, and worthy of further investigation in NSCLC. BNP did not result in significant protection from NT.

No significant financial relationships to disclose.

CALGB 30206: Phase II study of induction cisplatin (P) and irinotecan (I) followed by combination carboplatin (C), etoposide (E), and thoracic radiotherapy for limited stage small cell lung cancer

7565

Background: We sought to determine the efficacy of using both irinotecan- and etoposide-containing regimens for patients with untreated LS-SCLC. Methods: Eligibility: measurable disease, performance status (PS) 0–2, no prior therapy, and adequate organ function. Treatment: Induction with P 30 mg/m2 and I 65 mg/m2 both IV day 1 and 8 q21 days ×2 cycles. Beginning day 43 daily chest irradiation (200 cGy/fraction) to 70 Gy concurrent with C AUC=5 IV day 1 and E 100 mg/m2 days 1–3 q 21 days x3 cycles (5 chemotherapy cycles total). Endpoints: Primary - to differentiate a 45% and 60% 2-year survival rate (>39 pts alive/75 pts; a=0.091, β=0.098); secondary-response rates to induction and overall therapy, overall and progression-free survival, and toxicity. Results: Characteristics: Between 11/03 and 9/05, 78 patients were enrolled (2 ineligible): male/female, 43/33; white/black, 74/2; median age 61 (range, 41–79); PS 0/1, 50/26; wt loss >5% in 10 (2 missing data). Two full induction cycles were delivered to 73 (96%) patients; all planned treatment was delivered to 50 pts (66%). Efficacy: To date, 41 (54%) pts have died before 2 yrs. P+I induction chemotherapy resulted in 4 (5 %) CR, 45 (59 %) PR; Overall RR 64% (95% CI 53–74%). Best response to therapy among 76 evaluable pts was 23 (30%) CR and 40 (53%) PR. The 95% CI for ORR is 73–90%. With median follow-up of 18 m, median PFS and OS are 12.6 m (95% CI 10.1–14.7) and 16.1 m (14.1–23.9). Toxicity: Frequent (>20%) grade 3/4 toxicities over all therapy in 77 patients were: neutropenia 25%/58%, hemoglobin 35%/1%, platelets 26%/26%. Maximum hematological toxicity was grade 3/4 in 16%/70% of patients. Maximum non-hematological toxicity was grade 3/4 in 47%/12% including: esophagitis in 27%/3% and dehydration in 21%/1%. No fatal toxicities. Conclusions: This treatment regimen, employing irinotecan doublet induction therapy followed by 70 Gy concurrent radiation and “standard” etoposide carboplatin has tolerable toxicity but did not produce a 2 year survival rate of >50%. New strategies for augmenting median and overall survival among patients with LS-SCLC are needed.

[Table: see text]

Accelerated conformal radiotherapy for stage I non-small cell lung cancer (NSCLC) in patients with pulmonary dysfunction: A CALGB phase I study

7556

Background: The optimal treatment for medically inoperable stage I NSCLC has not been defined. Methods: CALGB 39904 is a prospective phase I study assessing accelerated once-daily radiotherapy for early stage NSCLC. The primary objectives were to define the maximally accelerated course of conformal radiotherapy; and to describe the short-term and long-term toxicity of therapy. Entry was limited to patients with clinical stage T1N0 and T2N0 NSCLC (< 4 cm) with pulmonary dysfunction (FEV1 <40% predicted, DLCO 45mmHg, V02 max <15m1/kg/min, O2 requirement). The nominal total radiotherapy dose was held constant at 70 Gy, while the number of daily fractions in each successive cohort was reduced (table). Results: The study was activated on 12/15/2000, and closed on 7/29/2005. Forty patients were accrued with 8 on each cohort. One patient on cohort 5 declined protocol treatment leaving 39 eligible patients. Patients were generally female (53%), white (83%), and ECOG performance status = 1 (67%). The median age was 74 (range 48 to 87), and the majority of the patients (73%) had T1N0M0 disease. Treatment was well tolerated without grade 4+ toxicity. There was one hematologic toxicity (lymphopenia) in cohort 2, and one non-hematologic toxicity each in cohort 3 (dyspnea) and cohort 4 (pain).The major repsonse rate was 74% (31% complete response, 43 % partial response), and 26% of patients had stable disease. After a median follow-up of 38.1 months, 21 patients remain alive. The actuarial median survival of all eligible patients is 38.5 months (95% confidence interval= 19.45 to NE). Conclusion: Accelerated conformal radiotherapy was well tolerated in a high-risk population with clinical stage I NSCLC. Outcomes are comparable to prospective reports of alternative therapies, including stereotactic body radiosurgery and limited resection,with less apparent severe toxicity. Further investigation of this approach is warranted.

No significant financial relationships to disclose.

[Table: see text]

Phase II trial of irinotecan/gemcitabine as second-line therapy for relapsed and refractory small-cell lung cancer: Cancer and Leukemia Group B Study 39902

BACKGROUND

This phase II study evaluated the efficacy and safety of the irinotecan/gemcitabine combination in patients with relapsed/refractory small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Patients with measurable tumor who had received one previous chemotherapy or chemotherapy/radiation regimen were eligible. Gemcitabine 1000 mg/m(2) was administered i.v. over 30 min followed immediately by irinotecan 100 mg/m(2) i.v. over 90 min, both on days 1 and 8 every 21 days. Patients were stratified based on response to initial treatment [i.e. primary sensitive disease with progression >or=3 months (group A), or refractory disease (group B)].

RESULTS

Seventy-three patients were enrolled but one never received treatment and one ineligible patient did not have SCLC. Median patient ages of the remaining patients were 61 and 63 years in groups A (n = 35) and B (n = 36), respectively, with performance status of 0 or 1 in 85% of 71 patients. Primary grade 3/4 toxic effects in groups A versus B were neutropenia (36% versus 43%), thrombocytopenia (36% versus 26%), nausea (12% versus 11%), vomiting (0 versus 11%), diarrhea (12% versus 9%), and pulmonary (12% versus 12%). Two patients had fatal events including pneumonitis (n = 1) and acute respiratory distress syndrome (n = 1). Responses occurred in 11 group A [two complete responses and nine partial responses (PRs)] and four group B (all PRs) patients, for response rates of 31% [95% confidence interval (CI) 17%, 49%) and 11% (95% CI 3%, 26%), respectively. Median survival and progression-free survival times were 7.1 (95% CI 6, 10.5) versus 3.5 (95% CI 3.1, 5.7) months, and 3.1 (95% CI 1.6, 5.3) versus 1.6 (95% CI 1.4, 2.8) months for group A versus B.

CONCLUSION

The irinotecan/gemcitabine combination is active and well tolerated as second-line therapy in SCLC patients. Additional studies are warranted as second-line therapy in patients who progressed 90 days or more after first-line therapy. However, the observed efficacy results in refractory SCLC patients indicate that this regimen should not be further explored in this population.

Defective maturation of dendritic cells in common variable immunodeficiency

Monocyte-derived dendritic cells (MdDCs) from many patients with common variable immunodeficiency (CVID) have been shown recently to have reduced expression of surface molecules associated with maturity. Using flow cytometry and confocal microscopy, we now show that this is due to a partial failure to fix Class II DR molecules on the surface during procedures that induce full maturation in vitro in cells from normal subjects. Major histocompatibility complex (MHC) class I, CD86 and CD83 expression were expressed normally, but CD40 was reduced. These abnormalities are unlikely to be due to prior in vivo exposure of monocytes to lipopolysaccharide (LPS), as addition of LPS to monocytes from normal subjects in vitro caused a different pattern of changes. CVID MdDCs retained Class II DR in the cytoplasm during maturation, showed increased internalization of cross-linked Class II DR surface molecules and were unable to polarize DR within a lipid raft at contact sites with autologous lymphocytes. These cells retained some features of monocytes, such as the ability to phagocytose large numbers of fixed yeast and fluorescent carboxylated microspheres and expression of surface CD14. These abnormalities, if reflected in vivo, could compromise antigen presentation and may be a fundamental defect in the mechanism of the antibody deficiency in a substantial subset of CVID patients.

Abraxane®, a novel Cremophor®-free, albumin-bound particle form of paclitaxel for the treatment of advanced non-small-cell lung cancer

BACKGROUND

Abraxane (ABI-007) is a novel 130-nm, albumin-bound (nab) particle form of paclitaxel designed to utilize endogenous albumin pathways to increase intratumor concentrations of the active drug. This multicenter phase II study was designed to evaluate the efficacy and safety of Abraxane 260 mg/m2 every 3 weeks in patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients with histologically confirmed, measurable NSCLC received Abraxane as first-line therapy.

RESULTS

Forty-three patients were enrolled. The overall response rate was 16%; the disease control rate was 49%. Median time to progression was 6 months, and median survival was 11 months. The probability of not having progressed by 1 year was 13%; the probability of surviving 1 year was 45%. No severe hypersensitivity reactions were reported despite the lack of premedication; 95% of patients were treated without dose reduction. Two patients (5%) discontinued therapy because of treatment-related toxicities (neuropathy, fatigue [1 each]). No grade 4 treatment-related toxicity occurred.

CONCLUSIONS

Abraxane 260 mg/m2 administered IV over 30 min without premedication was well tolerated. Significant tumor responses and prolonged disease control were documented in this group of patients with NSCLC. Exploration of higher doses of ABI-007 alone and in combination with other drugs active in NSCLC is warranted.

Chemoradiotherapy (CRT) and gefitinib (G) in stage III non-small cell lung cancer (NSCLC): A CALGB stratified phase II trial

7046

Background: G is a small molecule inhibitor of EGFR with activity in advanced NSCLC and preclinical evidence of being a radiosenitizer. Methods: Patients with stage III NSCLC were assigned to stratum 1 (PS 0–1>5% weight loss and/or PS 2) or stratum 2 (PS 0–1weight loss < 5%). Both strata received induction paclitaxel (P) 200 mg/m2 and carboplatin (C) AUC of 6 IV every three weeks for 2 cycles plus G 250 mg PO/day. G was removed 4/05 from induction therapy as stage IV studies showed no benefit from adding G to P and C. Stratum 1 then received RT 200 cGy for 33 fractions (total dose 6,600 cGy) and G 250 mg PO /day. Stratum 2 received the same RT with concurrent G 250 mg/day, and P 50 mg/m2 plus C AUC of 2 weekly for 7 doses. Maintenance G was started after all toxicities were grade ≤2. Results: Activation was 5/02 and administrative closure 5/04 due to results from SWOG S0023. 64 patients were accrued and 59 (20 stratum 1, 39 stratum 2) were eligible and analyzed: median age 67, male 74%, adeno 30%, squamous 45%, other 25%, IIIA 51%, IIIB 49%. There was no clear increase for acute high-grade infield toxicities compared to CRT alone (reported PASCO 2004). Best response for stratum 1 was PR 29% for induction (RR 29%, 95% CI 10%-56%) and CR 5%, PR 45% full treatment (RR 50%, 95% CI 27%-73%); for stratum 2 PR 13% for induction (RR 13%, 95% CI 3%-34%) and CR 5%, PR 76% full treatment (RR 81%, 95% CI 65%-92%). Stratum 1 “poor risk” median failure free survival (FFS) was 11.5 months (95% CI 5.6–21.2), one year survival 60% (95% CI 33%-79%) and median overall survival (OS) 19.0 months (95% CI 7.2–21.2). Stratum 2 “good risk” median FFS was 9.2 months (95% CI 6.7–12.0), one year survival 47% (95% CI 30%–63%) and median OS was 12.0 months (95% CI 8.5–18.6). EGFR and Ras mutation analysis on tumor biopsies (n = 50) will be presented. Conclusions: Small sample size prevented planned data analysis. Survival of “good risk” patients on stratum 2 (CRT + G) was disappointing. The promising survival of the small number of “poor risk” patients on stratum 1 (RT + G) justifies a follow-up phase II trial of induction chemotherapy followed by RT with a concurrent small molecule EGFR inhibitor.

[Table: see text]

Vatalanib (V) for patients with previously untreated advanced malignant mesothelioma (MM): A phase II study by the Cancer and Leukemia Group B (CALGB 30107)

7081

Background: Targeting both vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) may be an appropriate therapeutic strategy in MM. MM express VEGF, PDGF, and their receptors, suggesting autocrine growth-stimulating loops. VEGF inhibitors and PDGF inhibitors have in vitro activity in MM. In MM patients (pts), high VEGF levels correlate with poor outcome. Vatalanib inhibits VEGF and PDGF receptor tyrosine kinases. Methods: We conducted a phase II trial of V in pts with unresectable, histologically-confirmed MM, measurable disease, no prior therapy, ECOG performance status (PS) 0–1. Primary endpoint: 3-month (mo) progression-free survival (PFS). V 1250 mg, was given orally daily. CT scans were obtained Q6 weeks. Baseline serum VEGF, PDGF were determined. Results: 47 eligible pts (46 evaluable) enrolled at 19 sites from 7/03–11/04. Pt characteristics: male 92%, median age 75 (range 51–92; 64% were >70). Histology: epithelial 80%, sarcomatoid 11%, biphasic 9%. Site of origin: pleura 87%, peritoneum 6%, other 6%. PS 0/1: 21%/ 79%. 261 cycles were administered, median 3, range 1–32; 2 pts continue treatment. Grade 3/4 toxicities: neutropenia 2%, lymphopenia 2%, nausea/vomiting 15%/9%, increased ALT/AST 9%/6%, hypertension 2%, gastrointestinal bleed 2%. Partial response: 11% (5 pts), stable disease 66%. 3-mo PFS: 55% (95% CI: 40%, 68%), median PFS: 4.1 mo; median survival 10.0 mo. Median baseline serum levels in 40 pts: VEGF 425 pg/mL, PDGF 22754 pg/mL. There was no correlation between baseline VEGF or PDGF levels and response, PFS, or survival. Conclusions: The study did not achieve the protocol-specified 3-mo PFS of 75%. However, the objective response rate of 11% and median survival of 10 months are similar to other active single-agents for MM, which suggests that V may warrant further study in this disease.

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Eicosanoid modulation in advanced non-small cell lung cancer (NSCLC): CALGB 30203

7025

Background: Increased expression of eicosanoids have been associated with adverse prognosis. Specific inhibitors of key enzymes of two eicosanoid pathways, COX-2 (celecoxib) and 5-LOX (zileuton) have been developed. In vitro, the addition of these inhibitors have demonstrated enhancement of cytotoxic chemotherapy. We hypothesized that the addition of eicosanoid inhibitors to standard chemotherapy of carboplatin (C) and gemcitabine (G) could improve outcome in advanced NSCLC. Methods: Patients (pts) with stage IIIb (pleural effusion)/stage IV NSCLC, PS 0–2, no prior therapy were eligible. All pts received up to six cycles of C AUC 5.5 d1 + G (1000 mg/m2) d1,8. Pts were randomized to three arms: A: Celecoxib (CEL) 400 mg po bid. B: Zileuton (Z) 600 mg qid po, C: CEL and Z at the same doses. CEL and Z were begun on the first day of therapy and continued until progression. In this randomized phase II trial, the objective was to demonstrate a 50% failure free survival (FFS) at 9 months. Serum and tissue samples were required. Results: Between 12/05/03 and 9/30/04, 140 pts were entered and 136 were eligible and treated (A: 44, B: 47, C: 45). M: 86, F: 50; PS 0,1,2 = 38,85,13. Toxicity was primarily hematologic with approximately 70% grade 3/4 toxicity on each arm. Response and survival with 95% CI (see table ). Arm C has superior FFS when compared to combined Arms A+B (p =.054, unstratified log rank test), however, this benefit decreases when adjusted for baseline PS (0 vs, 1,2) and stage (IIIB vs. IV) in a Cox model, p=.15, 2-sided Wald test. There was no difference in terms of OS (p=.96). Serum and tissue were submitted for >90%. Analysis of COX-2 and 5-LOX expression are pending. Conclusions: 1. The combination of C/G + eicosanoid modulators was well tolerated. 2. The trend towards improved FFS in Arm C is intriguing, however, did not achieve the primary endpoint. 3. Correlative studies which may be able to identify pts likely to benefit from this approach are in progress.

[Table: see text]

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CALGB 9761: A prospective analysis of IHC and PCR based detection of occult metastatic disease in stage I NSCLC

7030

Background: CALGB 9761 was a prospective trial of tumor and lymph node collection during planned surgical resection in patients with clinical stage I NSCLC. The primary objective was to determine if occult micrometastases (OM) detected by immunohistochemistry (IHC) or real time PCR of CEA in histologically negative lymph nodes is associated with poorer survival. Methods: 502 patients with clinical stage I NSCLC were accrued. 302 (60%) were eligible for analysis. 200 were ineligible due to postoperative stage change or change in diagnosis. At surgical resection samples of primary tumor and N2 and N1 lymph nodes were harvested. Lymph nodes were split in half, one half was sent for standard surgical pathologic analysis and the other half snap frozen and sent for IHC analysis using a polyclonal anticytokeratin antibody cocktail. Results: Of 302 eligible patients, 173 were T1N0 and 129 T2N0 by routine postoperative pathology. The median follow-up time for eligible patients is 5.25 years. Overall survival at 5 years is 63.22%. Median survival is not yet estimable. 14% of patients had IHC positive tissue in lymph nodes, a rate lower than expected compared to published single institution studies. Overall survival for this group at 5 years is 55.96% compared to 65.65% for the IHC negative group (p=0.38). The failure free survival at 5 years is 41.74% for the IHC positive group and 60.25% for the IHC negative group (p=0.16). RT-PCR data is currently being analyzed. Data on the first 50 patients analyzed demonstrated presence of CEA in nodal tissues and potential upstaging in approximately 50% of the patients. Conclusions: In a multi-institutional setting, IHC detection of OM by use of a polyclonal cytokeratin cocktail in stage I NSCLC has limited capacity to detect OM and poorly predicts recurrence and survival.

No significant financial relationships to disclose.

Adjuvant chemotherapy in stage IB non-small cell lung cancer (NSCLC): Update of Cancer and Leukemia Group B (CALGB) protocol 9633

7007

Background: In 2004, preliminary results of CALGB 9633 demonstrated statistically significant evidence that adjuvant chemotherapy with paclitaxel and carboplatin (PC) improved disease-free (DFS) and overall survival (OS) in resected stage IB NSCLC. Indeed, the study was closed early by the DSMB after a planned interim analysis demonstrated a p value for OS less than a prespecified stopping boundary. However, two larger trials, NCIC-JBR10 and ANITA, have shown significant OS advantages with adjuvant chemo, but failed to demonstrate improved survival in the stage IB subset. This report provides more mature data from CALGB 9633. Methods: InCALGB 9633, stage IB patients (pts) were randomized following resection to paclitaxel 200 mg/m2 and carboplatin AUC 6 q3wks ×4 cycles or to observation. While initially planned to accrue 500 pts, the accrual rate was <50% of expected. Because slow accrual allowed longer observation times for each pt, the accrual target was reduced to 384 pts. OS is the primary endpoint. The redesigned study had 80% power to detect a hazard ratio (HR) of 0.67 after 150 observed deaths using a 1-tailed logrank test conducted at the 0.05 level of significance. Results: Between 9/15/96 and 11/26/03, 344 pts were randomized. Median follow-up is 54 mo. Demographics and toxicity has been previously reported (JCO Sup, 22:621a, 2004). The current intent-to-treat analysis shows a significant improvement in DFS favoring adjuvant chemo (HR=0.74; 90% 2-sided CI: 0.57–0.96; p=0.027). There is a trend toward improvement in OS that is not significant (HR=0.80; 90% CI: 0.60–1.07; p=0.10). There is, however, a significant advantage in 3-yr survival (79% vs. 70%; p=0.045). Five-yr survival is not different (60% vs. 57%; p=0.32), although median follow-up is <5 yrs and CIs are wide. Continued follow-up is planned since only 131 of 150 deaths required for final analysis have been observed. Conclusions: This updated but “preliminary” analysis no longer shows a significant OS advantage for adjuvant chemotherapy in stage IB NSCLC. However, the re-designed study does not have adequate power to detect small differences in OS that may be clinically significant. Advantages in DFS and 3-yr survival support continued consideration of adjuvant PC in stage IB NSCLC.

[Table: see text]

Combined modality trials of the Cancer and Leukemia Group B in stage III non-small-cell lung cancer: analysis of factors influencing survival and toxicity

BACKGROUND

Combined modality therapy (CMT) is the standard of care for patients with unresectable stage III non-small-cell lung cancer (NSCLC); however, insufficient data are available regarding prognostic factors in this disease setting.

PATIENTS AND METHODS

Six hundred and ninety-four patients included in five trials conducted by the Cancer and Leukemia Group B evaluating CMT in stage III NSCLC were included in this analysis. The primary objective was to identify factors that were predictors of survival and selected radiation-related toxicities using Cox regression models and logistic regression analysis.

RESULTS

The Cox model shows that performance status (PS) 1 [hazard ratio (HR) 1.24; 95% confidence interval (CI) 1.06-1.45; P=0.009] and thoracic radiation therapy (TRT) only (HR 1.58; 95% CI 1.22-2.05; P=0.001) predicted for poorer survival, while baseline hemoglobin >/=12 g/dl predicted for improved survival (HR 0.67; 95% CI 0.55-0.81; P </=0.0001). Multivariate logistic regression showed an increase of grade 3 + esophagitis among patients with PS 0 [odds ratio (OR) 1.7; 95% CI 1.1-2.7; P=0.029), >5% weight loss (OR 2.9; 95% CI 1.3-6.6; P=0.008) and patients receiving concurrent chemoradiation (OR 7.3; 95% CI 3.4-15.6; P=0.0001).

CONCLUSIONS

Baseline hemoglobin and PS, as well as the use of CMT, have the greatest effect on survival in unresectable stage III NSCLC. The use of concurrent chemoradiation increases the risk of esophagitis, which remains the primary radiation-related toxicity.

Randomized phase II trial of gemcitabine plus irinotecan or docetaxel in stage IIIB or stage IV NSCLC

BACKGROUND

To evaluate the activity and tolerability of gemcitabine plus irinotecan or docetaxel as first-line chemotherapy for advanced non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Eligible patients with chemotherapy-naïve stage IIIB or IV NSCLC were randomized to receive gemcitabine 1000 mg/m2 on days 1 and 8, plus either irinotecan 100 mg/m2 or docetaxel 40 mg/m2 on days 1 and 8. Treatment was administered every 3 weeks.

RESULTS

Of the 80 enrolled patients with stage IIIB or IV NSCLC, 78 were evaluable for activity and safety. Overall response rates, consisting of partial responses, were 12.8% [95% confidence interval (CI) 4% to 35%] for gemcitabine-irinotecan and 23.1% (95% CI 10% to 42%) for gemcitabine-docetaxel. Median overall survival was 7.95 months (95% CI 5.2-10.2) and 12.8 months (95% CI 7.9-17.1) for gemcitabine-irinotecan and gemcitabine-docetaxel, respectively. The corresponding estimated 1-year survivals were 23% and 51%, respectively. The 2-year survival rate in arm A (gemcitabine-irinotecan) is not currently estimable. The 2-year survival rate for arm B (gemcitabine-docetaxel) is 22% (95% CI 6% to 37%). Both combinations were well tolerated; the most common hematological toxicity was neutropenia, which occurred in 26% of patients in each treatment arm.

CONCLUSIONS

These results suggest that gemcitabine plus docetaxel or irinotecan is well tolerated in patients with chemotherapy-naïve advanced NSCLC. The survival data with the combination gemcitabine-docetaxel are promising. Gemcitabine-docetaxel combination therapy may be particularly useful for patients who have experienced toxicities with a platinum regimen or in patients who may be more susceptible to platinum-related toxicity.

The role of ATF/CREB family members in cell growth, survival and apoptosis

Programmed cell death is an integral part of the mechanisms regulating tissue homeostasis. Defects in the apoptotic signaling pathway are often associated with uncontrolled cell proliferation, high mutation rate and malignant transformation. Transcription factors, such as the mammalian ATF/CREB family of transcriptional regulators, have diverse functions in controlling cell proliferation and apoptosis. One particular ATF/CREB family member, ATFx, is an anti-apoptotic factor that plays an essential role in cell survival. Current observations indicate that one mechanism by which ATFx inhibits cell death and promotes cell survival is by disrupting signal transmission from activated "death receptors" to initiator caspases. A better understanding of ATFx function should provide new insight into the processes that control apoptotic cascades.