Remote patient management of heart failure across the ejection fraction spectrum: A pre-specified analysis of the TIM-HF2 trial

AIMS

The benefit of non-invasive remote patient management (RPM) for patients with heart failure (HF) has been demonstrated. We evaluated the effect of left ventricular ejection fraction (LVEF) on treatment outcomes in the TIM-HF2 (Telemedical Interventional Management in Heart Failure II; NCT01878630) randomized trial.

METHODS AND RESULTS

TIM-HF2 was a prospective, randomized, multicentre trial investigating the effect of a structured RPM intervention versus usual care in patients who had been hospitalized for HF within 12 months before randomization. The primary endpoint was the percentage of days lost due to all-cause death or unplanned cardiovascular hospitalization. Key secondary endpoints were all-cause and cardiovascular mortality. Outcomes were assessed by LVEF in guideline-defined subgroups of ≤40% (HF with reduced EF [HFrEF]), 41-49% (HF with mildly reduced EF [HFmrEF]), and ≥50% (HF with preserved EF [HFpEF]). Out of 1538 participants, 818 (53%) had HFrEF, 224 (15%) had HFmrEF, and 496 (32%) had HFpEF. Within each LVEF subgroup, the primary endpoint was lower in the treatment group, i.e. the incidence rate ratio [IRR] remained below 1.0. Comparing intervention and control group, the percentage of days lost was 5.4% versus 7.6% for HFrEF (IRR 0.72, 95% confidence interval [CI] 0.54-0.97), 3.3% versus 5.9% for HFmrEF (IRR 0.85, 95% CI 0.48-1.50) and 4.7% versus 5.4% for HFpEF (IRR 0.93, 95% CI 0.64-1.36). No interaction between LVEF and the randomized group became apparent. All-cause and cardiovascular mortality were also reduced by RPM in each subgroup with hazard ratios <1.0 across the LVEF spectrum for both endpoints.

CONCLUSION

In the clinical set-up deployed in the TIM-HF2 trial, RPM appeared effective irrespective of the LVEF-based HF phenotype.

Binding Energy of Triplet Excitons in Nonfullerene Acceptors: The Effects of Fluorination and Chlorination

One strategy to improve the photovoltaic properties of nonfullerene acceptors (NFAs), employed in state-of-art organic solar cells, is the rational fluorination or chlorination of these molecules. Although this modification improves important acceptor properties, little is known about the effects on the triplet states. Here, we combine the polarizable continuum model with an optimally tuned range-separated hybrid functional to investigate this issue. We find that fluorination or chlorination of NFAs decreases the degree of the highest occupied molecular orbital-lowest unoccupied molecular orbital (HOMO-LUMO) overlap along these molecules. Consequently, the energy gap between T₁ and S₁ states, ΔE_ST = E_S1 - E_T1, also decreases. This effect reduces the binding energy of triplet excitons, which favors their dissociation into free charges. Furthermore, the reduction of ΔE_ST can contribute to mitigating the losses produced by the nonradiative deactivation of the T₁ excitons. Interestingly, although Cl has a lower electronegativity than F, chlorination is more effective to reduce ΔE_ST. Since the chlorination of NFAs is easier than fluorination, Cl substitution can be a useful approach to enhance solar energy harvesting using triplet excitons.

Is 24/7 remote patient management in heart failure necessary? Results of the telemedical emergency service used in the TIM-HF and in the TIM-HF2 trials

Aims

Telemedical emergency services for heart failure (HF) patients are usually provided during business hours. However, many emergencies occur outside of business hours. This study evaluates if a 24/7 telemedical emergency service is needed for the remote management of high‐risk HF patients.

Methods and results

The study included 1119 patients merged from the TIM‐HF and TIM‐HF2 trials [age 69 ± 11, 73% male, left ventricular ejection fraction 37% ± 13, 557 New York Heart Association (NYHA) II/562 NYHA III]. Patients received a 24/7 physician‐guided emergency service provided by the telemedical centre (TMC) in addition to remote management within business hours. During emergency calls, patient status, symptoms, electronic patient record, and instant telemonitoring data were evaluated by the TMC physician. Following diagnosis, patients were referred for hospital admission or instructed to stay at home. Apart from the TMC, patients could place a call to the public emergency service at any time.

Seven hundred sixty‐eight emergency calls were placed over 1383 patient years (0.56 calls/patient year). Five hundred twenty‐six calls (69%) occurred outside business hours. There were 146 (19%) emergency calls for worsening HF, 297 (39%) other cardiovascular, and 325 (42%) non‐cardiac causes, with a similar pattern inside and outside business hours. Of the 1119 patients, 417 (37%) placed at least one emergency call. Patients with NYHA Class III, higher N‐terminal prohormone of brain natriuretic peptide (>1.400 pg/mL) levels, ischaemic aetiology of HF, implanted defibrillator, and impaired renal function had a higher probability of placing emergency calls. During study follow‐up, patients who made an emergency call had a higher all‐cause mortality (22% vs. 11%, P = 0.007 in TIM‐HF; 16% vs. 4%, P < 0.001 in TIM‐HF2) and more unplanned hospitalizations (324 vs. 162, P < 0.001 in TIM‐HF; 545 vs. 180, P < 0.001 in TIM‐HF2). Of the total 1,211 unplanned hospital admissions, 492 (41%) were initiated by a patient emergency call.

Three hundred seventy‐nine calls (49%) were placed to the TMC, whereas 389 calls (51%) were made to the public emergency service. Three hundred twenty‐six (84%) of the calls to the public emergency service resulted in acute hospitalizations.

The TMC initiated 202 (53%) hospital admissions; 177 (47%) patients were advised to stay at home. All patients that remained at home were alive during a prespecified safety period of 7 days post‐call. Diagnoses made by the TMC physician were confirmed in 83% of cases by the hospital.

Conclusion

A telemedical emergency service for high‐risk HF patients is safe and should operate 24/7 to reduce unplanned hospitalizations. Emergency calls could be considered as a marker for higher morbidity and mortality.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A phase II feasibility study of palbociclib in combination with adjuvant endocrine therapy for hormone receptor-positive invasive breast carcinoma

BACKGROUND

The CDK4/6 inhibitor palbociclib prolongs progression-free survival in hormone receptor-positive/HER2-negative (HR+/HER2-) metastatic breast cancer when combined with endocrine therapy. This phase II trial was designed to determine the feasibility of adjuvant palbociclib and endocrine therapy for early breast cancer.

PATIENTS AND METHODS

Eligible patients with HR+/HER2- stage II-III breast cancer received 2 years of palbociclib at 125 mg daily, 3 weeks on/1 week off, with endocrine therapy. The primary end point was discontinuation from palbociclib due to toxicity, non-adherence, or events related to tolerability. A discontinuation rate of 48% or higher would indicate the treatment duration of 2 years was not feasible, and was evaluated under a binomial test using a one-sided α = 0.025.

RESULTS

Overall, 162 patients initiated palbociclib; over half had stage III disease (52%) and most received prior chemotherapy (80%). A total of 102 patients (63%) completed 2 years of palbociclib; 50 patients discontinued early for protocol-related reasons (31%, 95% CI 24% to 39%, P = 0.001), and 10 discontinued due to protocol-unrelated reasons. The cumulative incidence of protocol-related discontinuation was 21% (95% CI 14% to 27%) at 12 months from start of treatment. Rates of palbociclib-related toxicity were congruent with the metastatic experience, and there were no cases of febrile neutropenia. Ninety-one patients (56%) required at least one dose reduction.

CONCLUSION

Adjuvant palbociclib is feasible in early breast cancer, with a high proportion of patients able to complete 2 years of therapy. The safety profile in the adjuvant setting mirrors that observed in metastatic disease, with approximately half of the patients requiring dose-modification. As extended duration adjuvant palbociclib appears feasible and tolerable for most patients, randomized phase III trials are evaluating clinical benefit in this population.

CLINICALTRIALS.GOV REGISTRATION

NCT02040857.

High-density Mapping Guided Pulmonary Vein Isolation for Treatment of Atrial Fibrillation - Two-year clinical outcome of a single center experience

Pulmonary vein isolation (PVI) as interventional treatment for atrial fibrillation (AF) aims to eliminate arrhythmogenic triggers from the PVs. Improved signal detection facilitating a more robust electrical isolation might be associated with a better outcome. This retrospective cohort study compared PVI procedures using a novel high-density mapping system (HDM) with improved signal detection vs. age- and sex-matched PVIs using a conventional 3D mapping system (COM). Endpoints comprised freedom from AF and procedural parameters. In total, 108 patients (mean age 63.9 ± 11.2 years, 56.5% male, 50.9% paroxysmal AF) were included (n = 54 patients/group). Our analysis revealed that HDM was not superior regarding freedom from AF (mean follow-up of 494.7 ± 26.2 days), with one- and two-year AF recurrence rates of 38.9%/46.5% (HDM) and 38.9%/42.2% (COM), respectively. HDM was associated with reduction in fluoroscopy times (18.8 ± 10.6 vs. 29.8 ± 13.4 min; p < 0.01) and total radiation dose (866.0 ± 1003.3 vs. 1731.2 ± 1978.4 cGy; p < 0.01) compared to the COM group. HDM was equivalent but not superior to COM with respect to clinical outcome after PVI and resulted in reduced fluoroscopy time and radiation exposure. These results suggest that HDM-guided PVI is effective and safe for AF ablation. Potential benefits in comparison to conventional mapping systems, e.g. arrhythmia recurrence rates, have to be addressed in randomized trials.

[Guidelines of the German Respiratory Society for Diagnosis and Treatment of Adults Suffering from Acute, Subacute and Chronic Cough]

The present 2019 S2k consensus guideline of the German Respiratory Society was written - in contrast to the predecessor more general S3 guidelines from 2004 and 2010 - for pneumologists, since 2014 the German College of General Practitioners and Family Physicians (DEGAM) published his own cough guidelines.The guideline contains 48 recommendations agreed by consensus and 16 statements, which are explained in the background text in the following nine chapters: epidemiology, physiology, classification, acute, subacute or chronic cough, diagnostics and therapy; an extra chapter was dedicated to chronic idiopathic cough. Further emphasis of the guideline is the physiology of cough in anticipation of the introduction of new drugs, as well as detailed treatises on cough triggered by affections in the upper respiratory tract or by gastroesophageal reflux. The guideline should provide the pneumologist with the latest knowledge from neighboring disciplines required for diagnosis and therapy of cough. The clinical chapters also contain a short summary, practical recommendations and a bibliography of their own. Three new, simplified algorithms for acute, subacute and chronic cough round off the Diagnostics chapter.

Abstract GS3-02: PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib

Background: CDK4/6 inhibitors, such as palbociclib, are used to treat ER+ metastatic breast cancer in combination with endocrine therapy with trials ongoing in patients with primary disease. No biomarkers exist to identify those who do/do not benefit from added CDK4/6 inhibition. PALLET is an investigator-initiated/led phase II randomized trial collaboration between UK and NSABP investigators evaluating the biological and clinical effects of palbociclib with letrozole combination as neoadjuvant therapy.

Methods: Postmenopausal women with ER+ primary breast cancer and tumors &gt;2.0cm (ultrasound) were randomized to one of 4 treatment groups (3:2:2:2 ratio): Group A: letrozole (2.5mg/d) for 14 weeks; Group B: letrozole for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group C: palbociclib for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group D: letrozole + palbociclib for 14 weeks. Palbociclib was given 125mg/d PO on a 21 days on, 7 days off schedule. Post-14 week treatment was at the discretion of the treating clinician including letrozole until surgery. Core-cut biopsies were taken at baseline, 2 weeks and 14 weeks. Co-primary endpoints for letrozole alone vs palbociclib groups (Group A vs Groups B+C+D) were: (i) change in Ki67 (IHC) between baseline and 14 weeks (log-fold change, Mann-Whitney test); (ii) clinical response (ultrasound) after 14 weeks (4 group, ordinal, Mann-Whitney test). Complete cell-cycle arrest (CCCA) (Ki67≤2.7%) was analyzed using a logistic regression model adjusting for recruitment region. Pre-specified exploratory biomarkers included c-PARP (apoptosis).

Results: 307 patients were recruited between 27 Feb 2015 and 08 Mar 2018; 103 were randomized to letrozole alone and 204 to letrozole + palbociclib. 279 (90.9%) patients were evaluable for 14 week clinical response. Clinical response was not significantly different between letrozole vs letrozole + palbociclib groups [(p=0.20; CR+PR 49.5% (46/93) vs 54.3% (101/186) and PD 5.4% (5/93) vs 3.2% (6/186)] nor was the small proportion of patients with pathological CR (1/87, 1.1% vs 6/180, 3.3%; p=0.43). 190 (61.9%) patients were evaluable for 14 week change in Ki67. The median log-fold change in Ki67 was greater with letrozole + palbociclib vs letrozole alone (-4.1 vs -2.2; p&lt;0.001) corresponding to a geometric mean change of -97.4% vs -88.5%. Similarly, a greater proportion of patients who received letrozole + palbociclib achieved CCCA (90% vs 59%, p&lt;0.001). 146 (47.6%) patients were evaluable for c-PARP and the log-fold change (suppression) was greater with letrozole + palbociclib vs letrozole alone (-0.80 vs -0.42; p=0.003) corresponding to a geometric mean change of -56.8% vs -31.4%. Other biomarkers of response / resistance are being evaluated. A higher proportion of patients had a grade ≥3 toxicity on letrozole + palbociclib than letrozole alone (49.8% vs 17.0%; p&lt;0.001) mainly due to asymptomatic neutropenia.

Conclusion: Adding palbociclib to letrozole markedly enhanced the suppression of malignant cell proliferation as assessed by Ki67 but did not substantially increase the clinical response of primary ER+ breast cancer over a 14-week period. Concurrent reductions in cell death may have reduced the speed of tumor shrinkage.

Citation Format: Dowsett M, Jacobs S, Johnston S, Bliss J, Wheatley D, Holcombe C, Stein R, McIntosh S, Barry P, Dolling D, Snowdon C, Perry S, Batten L, Dodson A, Martins V, Modi A, Cornman C, Puhalla S, Wolmark N, Julian T, Pogue-Geile K, Robidoux A, Provencher L, Boileau JF, Shalaby I, Thirlwell M, Fisher K, Huang Bartlett C, Koehler M, Osborne K, Rimawi M. PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib [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 GS3-02.

Abstract OT3-05-07: PATINA: A randomized open label phase III trial to evaluate the efficacy and safety of palbociclib + anti HER2 therapy + endocrine therapy vs anti HER2 therapy + endocrine therapy after induction treatment for hormone receptor positive, HER2 positive metastatic breast cancer

Background

Pre-clinical data and initial results from clinical studies point to the added benefit of CDK4/6 inhibition when combined with anti-HER2 tx. The current study is designed to evaluate the added benefit of palbociclib when given in combination with anti-HER2 and endocrine tx maintenance in the 1st†line setting of metastatic HER2+HR+ breast cancer.

Trial design

PATINA is an international, open-label, pivotal Phase III study. Primary objective is to demonstrate that the combination of palbociclib with anti-HER2 plus endocrine tx is superior to anti-HER2 plus endocrine tx in prolonging PFS. Sample size is 496 pts. The study starts after completion of 6-8 cycles of chemotherapy-containing anti-HER2 tx for metastatic breast cancer in the 1st line setting. Pts are eligible provided they are without evidence of disease progression by local assessment (i.e. CR, PR or SD). To account for the need for less intense tx regimens for a subset of pts diagnosed with HER2+ER+ disease, clinicians may recommend the combination of trastuzumab with either a taxane or vinorelbine prior to study initiation. Clinicians might also choose a non-pertuzumab option for pts previously treated with pertuzumab in the neo(adjuvant) setting. Secondary objectives include measures of tumor control (OR, CBR, DOR), OS, safety and QOL. The translational science main objective is to compare PFS estimates according to PIK3CA mutation status assessed by cfDNA analysis. Endocrine tx options are AI or fulvestrant. Premenopausal pts must receive ovarian suppression. The study has a 90% power to detect a hazard ratio of 0.667 in favor of the palbociclib arm. Pts approached to participate in AFT-38 will be asked to indicate on the informed consent forms whether remaining biospecimens and clinical data from the control arm of the study can be shared with the Mastering Breast Cancer (MBC) Initiative. The overarching purpose of the MBC is to create a mechanism for understanding the natural history of metastatic breast cancer by cataloguing longitudinally studied tumor-specific markers and treatment effects.

ClinicalTrials.gov Identifier: NCT02947685

Citation Format: Metzger-Filho O, Mandrekar S, Loibl S, Ciruelos E, Gianni L, Lim E, Miller K, Huang C, Koehler M, Francis P, Valagussa P, Goel S, Prat A, Goetz M, Loi S, Krop I, Carey L, Lanzillotti J, Winer E, Tripathy D, DeMichele A. PATINA: A randomized open label phase III trial to evaluate the efficacy and safety of palbociclib + anti HER2 therapy + endocrine therapy vs anti HER2 therapy + endocrine therapy after induction treatment for hormone receptor positive, HER2 positive metastatic 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 OT3-05-07.

Abstract OT3-05-08: PALLAS: PALbociclib CoLlaborative Adjuvant Study: A randomized phase 3 trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for HR+/HER2- early breast cancer

Background:

Cell cycle inhibition is a proven target for novel cancer therapeutics. Palbociclib (P) is an orally active inhibitor of CDK4/6, and arrests the cell cycle at the G1-S transition. P in combination with endocrine therapy (ET) has demonstrated efficacy in phase II and III randomized trials for patients with newly diagnosed and recurrent hormone receptor positive/HER2 negative (HR+/HER2-) metastatic breast cancer (MBC), and is approved in these settings. Given confirmed benefits of P and ET for MBC, the PALLAS study was designed to determine if the addition of P to adjuvant ET improves outcomes over ET alone in HR+/HER2- early breast cancer.

Trial Design:

PALLAS is an international open-label phase III trial randomizing (1:1) patients (pts) to 2 years of P (125 mg daily, 21 days on 7 days off in a 28-day cycle) combined with at least 5 years of provider choice ET (AI, tamoxifen, +/- LHRH agonist), versus ET alone. The primary objective of the study is to compare invasive disease-free survival (iDFS) for the combination of P and ET, versus ET alone. Secondary objectives include comparison of iDFS excluding cancer of non-breast origin, DRFS, LRRFS, OS, as well as safety. The principal objective of the translational investigations is to determine the predictive or prognostic utility of defined genomic subgroups with respect to iDFS and OS. Additional objectives include evaluation of cfDNA and tissue biomarkers predictive of benefit or resistance, pharmacogenomics, adherence, and patient-reported QOL. Eligible pts are pre- or post-menopausal women or men with stage II-III, HR+/HER2- breast cancer. Patients may have already initiated ET, but must be randomized within 12 months of diagnosis and 6 months of initiation of adjuvant ET. Trial sample size is 4600 pts and stage IIA pts will be capped at a total accrual of 1000 pts. Interim analyses for safety, futility/efficacy and sample size re-estimation are planned. PALLAS opened in 9/2015 and accrual is ongoing. Contact information: emayer@partners.org

Key words: palbociclib, CDK4/6 inhibition, HR+/HER2- early breast cancer, adjuvant endocrine therapy.

Citation Format: Mayer E, DeMichele A, Gnant M, Barry W, Pfeiler G, Metzger O, Burstein H, Miller K, Rastogi P, Loibl S, Goulioti T, Zardavas D, Fesl C, Koehler M, Huang-Bartlett C, Huang X, Piccart M, Winer E, Wolff A. PALLAS: PALbociclib CoLlaborative Adjuvant Study: A randomized phase 3 trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for HR+/HER2- early 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 OT3-05-08.

Abstract P3-11-01: Treatment patterns for young women with HR+/HER2- metastatic breast cancer in the United States in the era of CDK 4/6 inhibitors

Background: NCCN guidelines recommend that premenopausal women with HR+/HER2- metastatic breast cancer (MBC) be rendered postmenopausal and then treated accordingly. After its approval in February 2015, the CDK4/6 inhibitor palbociclib (P), in combination with endocrine therapy (ET), has become a standard of care in the first-line or pretreated settings for women with HR+/HER2- MBC. Specialty pharmacy prescription data indicate that 12% of all women with HR+/HER2- MBC treated with P in the United States are younger than 50 years of age. We assessed the real world treatment patterns and outcomes before and after approval of P in women with HR+/HER2- MBC. We further sought to assess the impact of the NCCN guidelines for premenopausal women on treatment patterns and outcomes.

Methods: This retrospective cohort study utilized electronic health record (EHR) data from Flatiron Health (Fl) from 1/2012 through 4/2017 to evaluate patient characteristics and first-line ET treatment patterns among women with HR+/HER2- MBC prior to and after P approval. Menopausal status was defined by age (&lt; 50 vs &gt;50 yrs). Additional datasets of &gt; 13,000 pts with MBC in the Truven Health MarketScan and Optum Clinformatics claims and Humedica EHR databases will be included to represent a more comprehensive dataset and evaluate clinical outcomes.

Results and Discussion: Initial results include 4,537 pts in the FI database who initiated a first-line ET regimen. Overall, 30% of pts &lt; 50 yrs used P compared to 29% of women age &gt;50. Treatment patterns for initial endocrine therapy are shown in the table.

Initial Endocrine Therapy Women &lt;_50 yrs N (%) women &gt; 50 yrs N(%) cohort01.2012-01.201502.2015-04.2017Absolute Change01.2012-01.201502.2015-04.2017Absolute ChangeN (%)296 (%0273 (100%) 2062 (100%)1906 (100%) ET monotx +/- LHRH296 (100%)192 (70%)-30%2062 (100%)1345 (71%)-29%TAM108 (36%)75 (27%)-9%161 (8%)78 (4%)-4%AI139 (47%)80 (29%)-18%1326 (64%)866 (45%)-19%FUL49 (17%)37 (14%)-3%575 (28%)401 (21%)-7%ET + P +/- LHRHNA81 (30%)+30%NA561 (29%)+29%% of concurrent LHRH77 (26%)92 (34%)+8%20 (1%)28 (1%)0%

Decreased use of tamoxifen as 1st line ET was observed in pts &lt;_50 yrs over the observed time. 47% of young pts initiated endocrine based treatment with AI monotherapy in the pre-P era, consistent with the NCCN guidelines. About 26% (pre-P) and 34% (post-P) of pts ≤50 yrs initiated first ET with ovarian suppression in the analyzed treatment eras. The concurrent use of LHRH increased 8%.

Conclusions: The treatment paradigm for women with HR+/HER2- MBC has evolved over the last &gt;5 years. Consistent with NCCN guidelines, more young pts are receiving ovarian suppression as part of initial therapy, and pts regardless of age are receiving treatment with P. There has been a related decrease in use of tamoxifen for younger pts and overall. These data illustrate rapid incorporation of palbociclib into standard care for US pts with HR+/HER2- MBC. Further treatment patterns and therapy outcome data for these groups reflecting real world use ET regimens of over 17,000 pts in the combined cohort, will be reported.

Citation Format: Burstein HJ, Mayer EL, DeMichele A, Harnett J, Mardekian J, McRoy L, Huang Bartlett C, Koehler M, Fahed Rimawi M. Treatment patterns for young women with HR+/HER2- metastatic breast cancer in the United States in the era of CDK 4/6 inhibitors [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 P3-11-01.

Abstract PD5-06: Adjuvant palbociclib plus endocrine therapy for hormone receptor positive/HER2 negative breast cancer: A phase II feasibility study

Background:

The CDK4/6 inhibitor palbociclib (P) combined with endocrine therapy (ET) prolongs progression-free survival in previously untreated and treated hormone receptor positive/HER2 negative (HR+/HER2-) metastatic breast cancer (MBC). The most common toxicity with P is neutropenia, typically non-cumulative and uncomplicated. Given observed benefits of P in metastatic BC, this single arm phase II trial was designed to determine the feasibility and toxicity of combination adjuvant P and ET for HR+/HER2- early BC (EBC).

Methods:

Eligible patients (pts) had HR+/HER2- stage II (not T2N0)-III EBC, with prior completion of 3-24 mo of ET (either AI or tamoxifen) without significant adverse events (AE). Pts received P at 125 mg daily, 3 wk on/1 wk off in a 28d cycle, plus continuous ET, for planned duration 2 yrs. Pts were removed from study for toxicity, non-adherence, or other events related to tolerability; pts who recurred or completed 2 yrs of therapy were censored for the primary endpoint. The primary objective was to evaluate the treatment discontinuation rate at 2 yrs; a rate of &gt;50%, would indicated a non-feasible treatment duration (null hypothesis). Discontinuation rates at 2 yrs are estimated by Kaplan Meier with 95% confidence bands. A sample size of 160 pts provided 92% power to reject the null hypothesis using a one-sided alpha = 0.025 if the true rate of discontinuation is &lt;33.3%, and accounting for a censoring rate of up to 20% over the 2 yrs. Secondary endpoints include toxicity, adherence, QOL, and pharmacogenomics.

Results:

Between 3/2014 and 11/2015, 162 pts initiated P; the majority had stage III EBC (52%) and received prior chemotherapy (63%). As of 05/2017, 120 (74%) have completed at least 1 yr of P + ET, and 50 (31%) have completed 2 yrs of P + ET. Early discontinuation of protocol treatment was reported for 59 pts (36%), including 49 events (30%) related to protocol-mandated (9%) and non-mandated (21%) tolerability. The cumulative rate of all discontinuations was 15.1% at 6 mos, 20.9% at 12 mos and 27.8% at 18 mos. Half of all non-mandated discontinuations occurred within the first 6 mos of initiation of therapy, and the rate decreased with greater provider and pt education. Median duration of pts still on treatment is 20 mos (inter-quartile range: 18 to 21 mos). The rate of grade 3/4 neutropenia was 77%, with 0 cases of febrile neutropenia. Other common all-grade P-related AE &gt; 20% included fatigue 65%, alopecia 25%, mucositis 24%, and anemia 24%. 32% of pts required one dose reduction, 16% required two. There have been 2 BC recurrence events and 1 chemotherapy-related AML. Updated data for the primary analysis of feasibility and tolerability, as well as pharmacogenomics, QOL, and adherence, will be presented.

Conclusions:

In this single arm phase II trial, the majority of pts have completed at least 1 year of adjuvant P + ET therapy, with no new toxicity signals. Non-protocol discontinuations have decreased with education. Updated results for the primary analysis will be presented. As in the MBC setting, extended duration palbociclib appears feasible and tolerable for most pts. The efficacy of 2 years of P and ET will be addressed by the phase III PALLAS trial (NCT NCT02513394).

Citation Format: Mayer EL, DeMichele AM, Guo H, Miller KD, Rugo HS, Schneider B, Waks AG, Come SE, Mulvey T, Huang Bartlett C, Koehler M, Barry W, Winer EP, Burstein HJ. Adjuvant palbociclib plus endocrine therapy for hormone receptor positive/HER2 negative breast cancer: A phase II feasibility study [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 PD5-06.

Electronic and structural properties of fluorene–thiophene copolymers as function of the composition ratio between the moieties: a theoretical study

Through theoretical analysis, we study relevant properties of some molecular structures formed by oligothiophenes (T) and dioctylfluorenes (F) units, like the exciton binding energy (E_b) and dipole moment, important for the efficiency of different kinds of optical and electronic devices.

Abstract P4-13-04: Upregulation of cell cycle pathway genes without loss of RB1 contributes to acquired resistance to single-agent treatment with palbociclib in breast cancer

Background: The oral cdk4/6 inhibitor, Palbociclib (Palbo), has been shown to prolong progression-free survival when combined with anti-estrogen therapy and have single-agent activity in metastatic breast cancer (MBC). Progressive disease (PD) on therapy does occur, however, and little is known about resistance mechanisms. Preclinical data have suggested that cell cycle gene expression changes are a potential mechanism of resistance. We performed comprehensive genomic analyses on serial tumor samples from an exceptional responder to single-agent Palbo to determine whether such changes occur in vivo.

Methods: Serial biopsies were obtained from a 67 year old patient with MBC treated on a phase II trial of single-agent Palbo at the University of Pennsylvania. Tissue was obtained from the primary lesion (1999, Stage 3, ER-/PR+/Her2+) and first recurrence (2005, contralateral breast, bone, lung; ER+/PR-/Her2+, treated with Herceptin/letrozole). At PD (2010), pt received single-agent P, 50 mg daily for 21 days each 28-day cycle, with PR for 33 months. A sample from metastatic skin lesion at PD on P (2013) was obtained. Next generation targeted sequencing was performed at Foundation Medicine using the Heme Panel. RNA was profiled using a 784-gene custom Nanostring array including cell cycle genes and ER pathway genes. Determination of pathway enrichment was performed using GSEA and the statistical significance of network neighborhood over-representation was calculated using cumulative hypergeometric distribution.

Results: There was no genetic evidence suggesting loss of RB1, or alterations in p16, cyclin D1, cdk4, PIK3CA or ESR1, and the genomic profile did not change between the primary and recurrent tissue samples. As expected, amplification of ERRB2 was present in all samples. In contrast, expression of cell cycle-regulated genes (PLK1, TOP2A, CDK1, BUB1, CDC20, CCNA2, CCNE2, CCNB1 BIRC5) increased more than two-fold at PD on Palbo compared to pre-Palbo, along with evidence of activation of the FOXM1 network.

Conclusion: Gene expression changes associated with cell cycle activation and FOXM1 activation may lead to acquired resistance to Palbociclib, despite wild-type RB1. These data demonstrate the importance of pre-/post-treatment biopsies and the feasibility of high-level genomic assessment in archival tissues to elucidate resistance mechanisms of novel therapies.

Citation Format: DeMichele A, Shih NNC, Koehler M, Huang Bartlett C, Jiang Y, Harwick J, Huang D, Zheng X, Clark AS, Colameco C, Feldman MD, Gallagher M, Goodman N, O'Dwyer P, Rejto P. Upregulation of cell cycle pathway genes without loss of RB1 contributes to acquired resistance to single-agent treatment with palbociclib in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-04.

Selective arterial Embolisation of Aneurysmal Bone Cysts of the Sacrum: a promising Alternative to Surgery

PURPOSE

The sacrum is a rare but unfavourable location for Aneurysmal Bone Cysts (ABCs), surgical procedures aiming to achieve local tumour control can be mutilating. Aim of this study was to evaluate whether selective arterial embolisation (AE) of ABC of the sacrum is an effective treatment and might be an alternative to surgical treatment options.

MATERIALS AND METHODS

Between 2007 and 2011 six patients (mean age 13.7 years, range 8 - 18 years) with an ABC of the sacrum were treated by AE. Follow-up was performed by MRI-scans as well as clinical examination (mean 36.5 months, range 14 - 56 months).

RESULTS

No treatment related complications have been observed. AE resulted in devascularisation of ABC and led to local tumour control in all patients. A partial consolidation was noticed in three patients. Pain relief was achieved in five of six patients, neurological deficits dissolved. In two patients more than one embolization was necessary. In one of these patients due to exacerbation of pain a surgical decompression was performed.

CONCLUSION

AE of sacral ABCs can serve as an effective and safe treatment option. Thus it might be an alternative to potentially harmful surgical procedures. In case of ongoing tumour growth or pain recurrence AE can be repeated. In case of treatment failure surgical interventions are still possible.

KEY POINTS

• transarterial embolisation enables local tumour control in sacral ABCs. • transarterial embolisation of sacral ABCs is a safe procedure. • in case of tumour progression repetitive embolisations are possible and effective.

Reperfusion by combined thrombolysis and mechanical thrombectomy in acute stroke: effect of collateralization, mismatch, and time to and grade of recanalization on clinical and tissue outcome

BACKGROUND AND PURPOSE

Our research focuses on interventional neuroradiology (stroke treatment including imaging methods) and general neuroimaging with an emphasis on functional MR imaging. Our aim was to determine the efficacy of revascularization (TIMI) of middle cerebral and/or carotid artery occlusion by means of mechanical recanalization techniques and to evaluate the impact of collateralization, mismatch in perfusion CT, time to revascularization, grade of revascularization on tissue, and clinical outcome in patients with acute ischemic stroke.

MATERIALS AND METHODS

Thirty-one patients with MCA and/or ICA occlusion were included. Ischemic stroke was diagnosed by NECT, CTA, and volume PCT for grading collateralization and mismatch. Time to recanalization was measured from the onset of stroke to the time point of DSA-proved mechanical recanalization. Tissue outcome was calculated by segmentation of infarct size between pre- and postinterventional CT and percentage mismatch lost. Clinical outcome was determined by the mRS.

RESULTS

Twenty-one of 31 patients (61.8%) presented with MCA and 10/31 patients (38.2%), with distal ICA occlusions. Sufficient recanalization (TIMI 2 and 3) was achieved in 23/31 (75%). Clinical evaluation revealed an mRS score of ≤2 in 25.5%. Age (r = 0.439, P = .038) and TIMI (r = 0.544, P = .002) showed the strongest correlation with clinical outcome. Time to recanalization, TIMI score, and mismatch were associated with a good tissue outcome in ANOVA.

CONCLUSIONS

Favorable outcome after mechanical recanalization of acute MCA and ICA occlusion depends on time to and grade of recanalization, mismatch, and collateralization. These results indicate that multimodal stroke imaging is helpful to guide therapy decisions and to indicate patients amenable for mechanical recanalization.

Cardiac safety of the lapatinib/letrozole combination as first-line therapy in patients (pts) with metastatic breast cancer (MBC)

1095

Background: Cardiotoxicity of traztuzumab therapy increases in pts pretreated with anthracyclines (A), radiotherapy to left breast, hypertension, or low baseline ejection fraction (EF). We report the cardiac safety profile of lapatinib, an oral, dual EGFR/HER-2 tyrosine kinase inhibitor, in a chemotherapy naïve or A-exposed pts with MBC. Methods: Women (n = 1286) with endocrine sensitive, previously untreated MBC received lapatinib and letrozole (L+L) or letrozole and placebo (L+P): 33% received previous A; 48% previous tamoxifen; <1% previous trastuzumab (T); <2% previous aromatase inhibitor. EF was evaluated by MUGA or echocardiogram at baseline, every 8 wk and at study withdrawal. Rate of cardiac events (NCI CTCAE grading), median time to onset, and duration of EF depression were assessed. Results: Cardiac events (CE; MEDRA terms: ejection fraction decreased, left ventricular dysfunction, ventricular dysfunction and cardiac failure) were infrequent in both arms. Grade 3/4 and 1/2 CE were reported in 0.9% and 4.0% of pts, respectively, in the L+L arm, and in 0.3% and 2.1%, respectively, in the L+P arm. The only symptomatic CE was a grade 4 event in the L+L arm. There was no apparent relationship between previous A exposure and CE frequency and severity. Median L exposure was 40 wk on L+L, 38 wk on L+P. Median time to onset and duration of EF decrease were 21.8 and 8.1 wk, respectively, on L+L, and 34.6 and 5.4 wk, respectively on L+ P. On the L+L arm, the dose was adjusted/interupted for 8 CE cases, discontinued for 6, and unchanged for 22. On the L+P arm, interuption of L was reported for 2 CE cases, discontinuation for 5, and in 7 CE events there was no change in therapy. Eight CE on L+L and 1 CE on L+P had not resolved as of the last report. Conclusions: This is the first long-term evaluation of lapatinib cardiac signals in a controlled trial in a trastuzumab-naïve MBC pt population. The frequency of cardiac events and degree of absolute EF decrease was low and occurred at similar rates in pts with or without anthracycline exposure. These encouraging cardiac safety data in first line metastatic BC study are promising for the ongoing study of lapatinib in patients with early HER-2+ BC treated on ALTTO trial.

[Table: see text]

Clinical benefit of lapatinib-based therapy in patients with HER2-positive breast tumors expressing p95HER2

1048

Background: Approximately 25% of HER2 overexpressing breast tumors express a truncated form of the receptor (p95HER2) that lacks the extracellular domain but retains kinase activity. p95HER2-positive tumors are associated with a worse prognosis and resistant to trastuzumab therapy. In preclinical models, lapatinib (L), a tyrosine kinase inhibitor of EGFR and HER2, is active in p95HER2 expressing tumors. The aim of this analysis was to test the hypothesis that benefit from L-based therapy is independent of p95HER2 expression in 2 clinical trials in patients (pts) with HER2-positive tumors treated with either L monotherapy (Study EGF20009 ) or L in combination with capecitabine (Study EGF100151). Methods: Pre-treatment tumor tissue from both trials (N=201) was analyzed for p95HER2 expression by immunofluorescence as previously described (Scaltriti M. et al, JNCI 2007). Expression of p95HER2 was correlated with clinical benefit rate (CBR: complete response [CR] + partial response [PR] + stable disease [SD] ≥ 24 weeks) and progression-free survival (PFS) using logistic regression and Cox-proportional hazard models. Results: 68/105 and an initial 72/96 tissue samples were evaluable for p95HER2 expression from studies EGF20009 and EGF100151, respectively. The Table summarizes the results from the L treated pts. The CBR and PFS in L treated pts were not significantly different between the p95HER2 subgroups. Expanded data for p95HER2 expression in additional EGF100151 tumor samples will be presented. Conclusions: L as a monotherapy or in combination with capecitabine has similar response activity in pts with p95HER2-positive and p95HER2-negative HER2-positive breast tumors.

[Table: see text]

[Table: see text]

Progression-free survival (PFS) of patients with HER2-negative, estrogen-receptor (ER)-low metastatic breast cancer (MBC) with the addition of lapatinib to letrozole: Biomarker results of EGF30008

1018

Background: Lapatinib (Lap), an oral, dual inhibitor of EGFR/HER-2, is approved with capecitabine for treatment of HER-2+ MBC for recurrence after taxane, anthracycline, and trastuzumab-based therapy. Letrozole (Let) has activity in hormone-receptor positive (HR+) BC. It has been hypothesized that peptide growth factor signaling and hormone signaling pathways interact and dual targeting of these pathways results in therapeutic synergy. We report a blinded analysis of HER-2, ER, and progesterone receptor (PR) expression for patients (pts) with HR+ MBC at first diagnosis or post-adjuvant relapse and response to Lap + Let versus Let. Methods: 1286 pts were randomized 1:1 to 2.5 mg Let daily plus either 1500 mg Lap daily or placebo. The primary endpoint was PFS in HR+, HER-2+ MBC pts; secondary endpoints included PFS in the intent-to-treat population. Blinded, centralized commerical laboratory analysis of archived tumor tissue for HER-2 (IHC and/or FISH) and academic laboratory semi-quantitative analysis of ER/PR (IHC, H-score) was performed and correlated with clinical outcome. Results: In 219/1286 (17%) HER-2+ (FISH+ or IHC3+) pts, a significant improvement in median PFS was observed for Lap + Let versus Let (8.2 v 3.0 mos, HR = 0.71, 95% CI 0.53, 0.96, p = 0.019). No significant difference in median PFS was seen in 952 (74%) HER-2-negative pts (13.4 v 13.7 mos, HR = 0.90, 95% CI 0.77, 1.05, p = 0.188). 821/952 (86%) HER-2-negative pts had tissue available for quantitative ER and PR analysis. Analysis of ER and PR by quartile identified a subgroup of HER-2-negative pts that benefitted from adding Lap to Let. Pts with the lowest quartile of ER expression (H-score <160, n = 207) had a significant improvement in median PFS (13.6 mos v 6.6 mos, HR = 0.65, 95% CI 0.47, 0.9, p < 0.005). Pts with higher levels of ER did not significantly benefit from adding Lap to Let. Analysis of PR expression did not identfiy a subgroup that benefited from Lap. Conclusions: Pts with HER-2-negative, ER+ MBC and low ER expression may benefit from the addition of lap to let. Additional analyses of EGFR, other biomarkers, and prior hormone therapy will be presented.

[Table: see text]

Relevance of serum HER2 extracellular domain (sECD) in EGF30008, a study of letrozole ± lapatinib in patients (pts) with hormone-receptor positive (HR+) metastatic breast cancer (MBC)

1019

Background: Elevated baseline sECD (BsECD) correlates weakly with HER2 overexpression (HER2+). HR+ MBC. Lapatinib benefit was reported in pts with HER2+ tumors irrespective of BsECD status; BsECD status did not predict benefit for HER2- negative (HER2-ve) tumors. sECD levels and their predictive and prognostic value for progression-free survival (PFS) were further examined in a randomized, phase III trial of letrozole ± lapatinib. Methods: Pts (n=1286) with HR+ MBC were randomized to letrozole with placebo (P) or lapatinib (L). HER2 status was evaluated by FISH or IHC in archived tissue. sECD was measured by ELISA at baseline (n=1102 available samples), and every 4 wk. Pts were considered sECD+ if serum sECD was >15 ng/ml. Results: BsECD was positive in 14% (125/894) and 42% (87/208) of pts with HER2-ve and HER2+ tumors, respectively. Correlation between BsECD and FISH was weak but significant in HER2+ pts (R=0.35, p<0.0001) but not in HER2-ve pts (R=0.03, p=0.362). Unlike for HER2+ tumors, BsECD+ did not predict benefit in PFS from L in pts with HER2-ve tumors. HR: Hazard Ratio In pts with HER2- ve tumors, median ECD levels were stable in the P arm but increased slightly (4 ng/mL) in the L arm. In the HER2+ group, median levels in the P arm declined (3.5 ng/mL) but increased at 4 wk in L arm (3.4 ng/mL) and were stable thereafter. Conversion from sECD-ve to sECD+ was observed in both arms but did not correlate with outcome or provide predictive value. Data related to ECD status conversion will be reported. Conclusions: BsECD+ status correlates with HER2+ tumor status and may predict L benefit but BsECD+ status did not predict benefit in pts with HER2-ve tumors. On therapy changes in median sECD were small. Conversion from BsECD-ve to sECD+ did not predict L benefit and we could not confirm that evaluation of on treatment ECD status may help treatment decision.

[Table: see text]

[Table: see text]

A quality-adjusted time without symptoms or toxicity (Q-TWiST) analysis comparing lapatinib plus paclitaxel versus paclitaxel alone for first line metastatic breast cancer (MBC) in HER2+ patients

Abstract #4090

Background: Women with MBC received first line treatment with lapatinib and paclitaxel (L+P) or paclitaxel alone (P) in a phase III randomized, multicenter, double-blind, placebo-controlled study. In a sub-group analysis of HER2+ (ErbB2+) patients, time to tumor progression for L+P was significantly improved, with an emerging trend for survival benefit. The Q-TWiST method was used to examine overall quality-of-life adjusted survival experience comparing the trade-off between treatment toxicities and delayed progression in a subset of the randomized ITT population that overexpressed HER2.&#x2028; Methods: Survival curves for each treatment arm were partitioned into 3 health states: TOX (toxicity) - time with grade 3/4 adverse events (AEs) during progression-free survival time; TWiST (time without toxicity or disease progression) - remaining time prior to progression in which no serious AEs were experienced; REL (relapse) - time until death or end of follow-up following disease progression. The utility-weighted sum of the mean health state durations was derived to calculate a Q-TWiST score and treatment comparisons were made at varying combinations of the utility weights using a threshold utility analysis.&#x2028; Results: The ITT population included 579 subjects ages 23-87 of which 91 were HER2+ (n = 52 L+P, n = 39 P) based on FISH+ or IHC3+ irrespective of FISH (86 patients based on FISH+ or IHC3+ if FISH unknown; n = 49 L+P, n = 37 P). Overall median survival was 96 weeks after randomization based on data through 5FEB07. For the 91 patient cohort, using utility weights of 0.5 for both TOX and REL, i.e. counting 2 days of TOX or REL as 1 day of TWiST, resulted in a 9.4 week difference (p = 0.0459) in quality-adjusted survival favoring L+P. For the 86 patient cohort the difference was 8.5 weeks still favoring L+P (p = 0.1005). Q-TWiST differences between the arms (for 91 patient cohort) ranged from 5-13 weeks across utility weight combinations, with most tests providing a statistically significant advantage of L+P over P alone. Results from the sensitivity analysis using all grade AEs in the TOX state gave similar results.&#x2028; Conclusions: Among HER2+ patients, treatment with L+P resulted in more quality-adjusted survival than with P monotherapy. When utilities for periods of toxicity and relapse were valued at half the utility of TWiST, the Q-TWIST difference was around 9 weeks, approximately 10% of the 96 weeks median overall survival. These findings represent clinically important differences between treatment groups in quality-adjusted survival.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4090.

Circulating tumor cell and endothelial cell data from a phase II evaluation of lapatinib and bevacizumab in HER2-overexpressing metastatic breast cancer

Abstract #3154

Background: Overexpression of both HER2 and VEGF is associated with worse outcome than overexpression of either receptor alone. In preclinical models, combination anti-HER2 and anti-VEGF therapy has been shown to be more effective than either treatment alone. Bevacizumab (B) plus trastuzumab and lapatinib (L) plus pazopanib have shown activity in patients (pts) with HER2+ MBC. We evaluated the combination of L+B in a phase 2 trial in HER2+ MBC pts. To explore new biomarkers of treatment effect, we measured circulating tumor cells (CTCs) with two different methods of CTC enumeration: CellSearch (Veridex LLC), and immunomagnetic enrichment followed by flow cytometry (IE/FC), as well as circulating endothelial cells (CECs) in pts receiving study treatment.&#x2028; Methods: This study evaluated L (1500 mg PO daily) plus B (10 mg/kg IV q2wk) in 50 HER2+ MBC pts. The primary endpoint is crude progression-free survival (PFS) at 12 wks. Serial evaluation of CTC and CEC was performed. Blood was obtained from consenting pts at baseline, weeks 2, 6 then every 12 weeks until end of study. CellSearch assay was performed as previously described using 7.5 cc blood in a CellSave tube and the CellSpotter analyzer. For IE/FC, 20 ml of blood was subjected to IE using anti-EpCAM ferrofluid, followed by FC for EpCAM, CD45, and nucleic acid content. CTC data were correlated with assay method and with best response. CECs were defined as CD34/31+, CD45-, or CD34/146+, CD45-, and were assayed by FC.&#x2028; Results: Enrollment to this study ended in March 2008 (n=52). Clinical data is presented at this meeting (Dickler et al). 47 patients have evaluable CTC and CEC data at baseline and/or first follow-up; 32 patients have response data. CTC determined by CellSearch or IE/FC showed significant correlation at baseline (R=0.58; P=0.012). CTC by CellSearch at first followup correlated with treatment response (P=0.01) with levels above 5 CTC/sample associated with progression; there was no correlation with baseline values. There were too few positive IE/FC values to evaluate correlation with outcome. The change in CEC/CD146 from baseline to first followup for is of borderline significance in this preliminary analysis (P=0.07) between PR (N=2, Mean Change Score/MCS=-4.345) and SD/PD (N=18, MCS=0.8); a decrease of CEC/CD146 from baseline to first followup suggests greater likelihood of response.&#x2028; Conclusions: L+B is an active regimen in pts with MBC. CTC measurements correlated between two separate methodologies, and for the CellSearch assay predicted response to therapy. A decrease in CEC from baseline to first followup correlated with response to this combined targeted therapy, consistent with our previous results with other B-based therapy. PFS and response correlations for the full study cohort will be presented.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3154.

A 6 gene molecular predictor of lapatinib related benefit: from cell line models to clinical trials

Abstract #58

Background: Identification of molecular predictors of response is an important aspect of individualized cancer treatment. Responses to lapatinib (L), an oral inhibitor of HER2 and EGFR, approved in combination with capecitabine for HER2+ metastatic breast cancer (MBC), were evaluated in a panel of BC cell lines. Computational approaches were used to identify transcripts that quantitatively associate with response to L in the cell line panel that were then tested in 2 clinical trials.&#x2028; Methods: The clinical utility of a 6-gene predictor was tested retrospectively using a branched-chain DNA assay in paraffin-embedded archival tumor tissue from patients (pts) with HER2 negative or untested MBC tumors enrolled in a phase III trial of paclitaxel (P) vs. P+L, and from pts with HER2 positive MBC enrolled in a L monotherapy trial. Expression of HER2 transcript using the branched-chain assay was compared with HER2 fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) status; discordant cases were analyzed. Response patterns for pts with HER2+ tumors and a computational model that predicts L sensitivity or resistance is described.&#x2028; Results: Ingenuity analysis of the mRNA predictors of response to L identified in the BC cell line panel revealed saturated gene networks with HER2 as a major node. The 6-gene predictor of response was comprised of 2 genes associated with sensitivity to L: HER2 and GRB7; 4 genes associated with resistance to L: CRK, ACOT9, FLJ31079, and DDX5. Expression results for the 6 genes and progression-free survival (PFS) data were available for 159 pts on L+P. Median PFS in the branched-chain HER2+ group was 32.9 wks vs. 22.4 wks in the HER2-negative group. The 6-gene predictor was used to predict response to L in the HER2+ pts. Comparison of PFS in the 24 “L sensitive” tumors vs. 25 “L resistant” tumors indicated that the predictor, derived from cell-line analyses, had the potential to predict clinical response to L in pts treated with L+P (HR=0.58; 95% CI=0.30-1.11; p=0.07). The 6-gene predictor was further tested in an independent L monotherapy study in pts with HER2 FISH+ MBC. Comparison of PFS in the 24 “L sensitive” tumors vs. 28 “ L resistant” tumors reconfirmed the potential of the 6-gene predictor to enrich for HER2+ pts most likely to experience clinical benefit from L (HR=0.40; 95% CI=0.19-0.84; p=0.015). Further testing is ongoing.&#x2028; Conclusions: This study suggests that molecular predictors of clinical response can be developed through an analysis of response from a collection of 50 BC cell lines. The identification of a L specific 6-gene assay is promising as a clinical predictor of benefit from L in pts with HER2+ BC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 58.