Adjuvant Subcutaneous Trastuzumab for HER2-Positive Early Breast Cancer: Subgroup Analyses of Safety and Active Medical Conditions by Body Weight in the SafeHer Phase III Study

BACKGROUND

This SafeHer subgroup analysis assessed the safety of fixed-dose subcutaneous trastuzumab (H SC) as an adjuvant therapy in HER2-positive early breast cancer (EBC) by body weight.

PATIENTS AND METHODS

Patients with HER2-positive EBC not previously treated with anti-HER2 therapy received H SC 600 mg (every 3 weeks for 18 cycles), with neoadjuvant or adjuvant chemotherapy or without adjuvant chemotherapy. Adverse events (AEs) were assessed throughout treatment and at final follow-up (28 ±5 days after last treatment). Subgroups were categorized by body weight, Asian origin, and chemotherapy administration. All analyses were descriptive.

RESULTS

Of 2,577 patients enrolled, 2,573 received ≥1 dose of study medication and were included in this safety analysis. Median body weight at baseline was 67.0 kg (range 33.6-150.0 kg). Any-grade AEs occurred in 88.7% (2,282/2,573) of the overall population, versus 87.1% (590/677) of the lowest bodyweight quartile (≤59 kg), 90.0% (561/623) of the highest quartile (>77 kg), and 86.5% (327/378) of the Asian population. Grade ≥3 AEs occurred in 23.2% (596/2,573) of the overall population, 17.9% (121/677) of the lowest bodyweight quartile, 26.8% (167/623) of the highest quartile, and 15.3% (58/378) of the Asian population. The highest bodyweight quartile had the highest incidence of medical conditions at baseline (highest quartile, 75.6%; lowest quartile, 56.1%).

CONCLUSION

These data support the use of fixed-dose H SC as an adjuvant therapy in HER2-positive EBC and confirm the comparable safety profile of H SC in patients with low body weight or of Asian origin versus the overall population in SafeHer. ClinicalTrials.gov: NCT01566721.

IMPLICATIONS FOR PRACTICE

The safety profile of fixed-dose subcutaneous trastuzumab (H SC) was comparable between patients in the lowest bodyweight subgroup and the overall patient population, and also between patients of Asian origin (of whom a higher proportion often fall within the lower bodyweight quartiles) and the overall population. The safety data from this SafeHer subgroup analysis therefore support the use of fixed-dose H SC 600 mg administered every 3 weeks as an adjuvant therapy for patients with HER2-positive early breast cancer across different bodyweight subgroups and in the Asian patient population.

Long-term trastuzumab (Herceptin®) treatment in a continuation study of patients with HER2-positive breast cancer or HER2-positive gastric cancer

BACKGROUND

Trastuzumab (Herceptin® [H]) is the standard of care for HER2-positive locally advanced/metastatic breast cancer and gastric/gastroesophageal junction (GEJ) cancer. However, there is a paucity of data available on long-term H treatment of patients. The Rollover Protocol (ROP) Study was conducted to report safety data for patients with HER2-positive locally advanced/metastatic breast and gastric/GEJ cancer who have received long-term H therapy (≥ 5 years and ≥ 3 years for breast and gastric/GEJ cancer, respectively).

METHODS

The ROP Study was a single-arm, multicenter, international continuation trial of H in patients who had previously completed a global Roche-sponsored trial with H therapy, had stable disease, and were receiving H at the end of the lead-in trial. Patients with chronic heart failure during the lead-in trial could be included following a risk-benefit analysis. The primary objectives were to provide H therapy to patients with HER2-overexpressing locally advanced/metastatic breast or gastric/GEJ cancer at the end of the lead-in study, and to follow the long-term outcomes and long-term overall safety in these patients.

RESULTS

Twenty-five of 69 patients enrolled in the ROP Study received long-term H therapy (19 breast cancer and 6 gastric/GEJ cancer). The median duration of H treatment for patients with breast cancer was 8 years 7 months, and 5 years 2 months for patients with gastric/GEJ cancer. The cardiac status of the patients remained stable over time, with no serious cardiac adverse events or marked changes in left ventricular ejection fraction (LVEF). The median overall worst LVEF measurement was 57.0%, and no patients experienced an LVEF of < 45% (range 47-63%). There were no serious adverse events related to study treatment.

CONCLUSIONS

These results suggest that H has an acceptable safety profile and was well tolerated in patients who received long-term H therapy (≥ 5 years and ≥ 3 years for breast and gastric/GEJ cancer, respectively). Further investigation and reporting of long-term H therapy would be valuable.

TRIAL REGISTRATION

This study was retrospectively registered on March 24, 2016 with Clinicaltrials.gov, number NCT02721641 .

HELOISE: Phase IIIb Randomized Multicenter Study Comparing Standard-of-Care and Higher-Dose Trastuzumab Regimens Combined With Chemotherapy as First-Line Therapy in Patients With Human Epidermal Growth Factor Receptor 2–Positive Metastatic Gastric or Gastroesophageal Junction Adenocarcinoma

Purpose

To compare standard-of-care (SoC) trastuzumab plus chemotherapy with higher-dose (HD) trastuzumab plus chemotherapy to investigate whether HD trastuzumab increases trastuzumab serum trough concentration (Ctrough) levels and increases overall survival (OS) in first-line human epidermal growth factor receptor 2–positive metastatic gastric or gastroesophageal junction adenocarcinoma.

Patients and Methods

Patients with Eastern Cooperative Oncology Group performance status 2, no prior gastrectomy, and ≥ two metastatic sites were randomly assigned at a one-to-one ratio to loading-dose trastuzumab 8 mg/kg followed by SoC trastuzumab maintenance 6 mg/kg every 3 weeks or loading-dose trastuzumab 8 mg/kg followed by HD trastuzumab maintenance 10 mg/kg every 3 weeks until progression; treatment in each arm was combined with cisplatin 80 mg/m2 plus capecitabine 800 mg/m2 twice per day in cycles 1 to 6. The primary objective was HD trastuzumab OS superiority (all randomly assigned patients [full-analysis set]). Final results are from an interim analysis for futility (boundary hazard ratio [HR] ≥ 0.95) at 125 deaths.

Results

At clinical cutoff, 248 patients had been randomly assigned. A marked increase in mean trastuzumab Ctrough was observed after the first HD trastuzumab cycle versus SoC trastuzumab. In the full-analysis set, median OS was 12.5 months in the SoC trastuzumab arm and 10.6 months in the HD trastuzumab arm (stratified HR, 1.24; 95% CI, 0.86 to 1.78; P = .2401). Results were similar in the per-protocol set (cycle 1 trastuzumab Ctrough < 12 µg/mL). Safety was comparable between arms.

Conclusion

HD trastuzumab maintenance dosing was associated with higher trastuzumab concentrations, no increased efficacy, and no new safety signals. HELOISE confirms standard-dose trastuzumab (loading dose of 8 mg/kg followed by 6 mg/kg maintenance dose every 3 weeks) with chemotherapy as the SoC for first-line treatment of human epidermal growth factor receptor 2–positive metastatic gastric or gastroesophageal junction adenocarcinoma.

Abstract CT108: HELOISE: phase IIIB randomized multicenter study comparing two trastuzumab (H) dose regimens combined with chemotherapy (CT) as first-line (1L) therapy in patients (pts) with HER2-positive metastatic gastric/gastroesophageal junction adenocarcinoma (mGC/GEJC)

Background: CT (fluorouracil/platinum) + H is standard of care (SoC) for 1L HER2-positive mGC/GEJC based on the ToGA Phase 3 study. ToGA post hoc analyses showed that lowest H trough concentration (Cycle 1 Ctrough) quartile pts had shorter overall survival (OS) than pts in higher quartiles, and that they were enriched for poorer prognostic factors at baseline, e.g. ECOG 2, no prior gastrectomy, ?2 metastatic sites. HELOISE (NCT01450696) investigated whether higher dose H (HD H) + CT, when compared to SoC H + CT, improves OS in 1L HER2-positive mGC/GEJC.

Methods: Pts with the high risk features above were randomized 1:1 to loading dose H 8 mg/kg then SoC H maintenance 6 mg/kg every 3 weeks (q3w) or loading dose H 8 mg/kg then HD H maintenance 10 mg/kg q3w until progression; each arm combined with cisplatin 80 mg/m2 + capecitabine 800 mg/m2 in cycles 1-6. The primary objective was HD H OS superiority (target HR 0.75, all randomized pts); other objectives included pharmacokinetics (PK) and safety. Final results are from an interim analysis for futility at 125 OS events.

Results: 248 pts had been randomized at clinical cutoff, Feb 13, 2015. Baseline characteristics/demographics were balanced overall, with median ages 58.5 and 62.6 years in the SoC H and HD H arms, respectively; 23% of pts per arm were female. Safety was comparable between arms, with no difference in congestive heart failure (0% each). The OS futility boundary was crossed (HR 1.24 &gt; 0.95); safety, efficacy, and PK data are shown in the table. A marked increase in mean Ctrough was observed following the first HD H cycle vs SoC H. SoC H (8 mg/kg + 6 mg/kg) + CTHD H (8 mg/kg + 10 mg/kg) + CTPrimary tumorn=124n=124Gastric/GEJ, n (%)95 (76.6)/29 (23.4)101 (81.5)/23 (18.5)Treatmentn=124n=123Median H cycles/median capecitabine cycles/median cisplatin cycles, n6.5/6.0/6.06.0/6.0/5.0Safety, pts with ≥1:n=124n=123Any grade adverse event (AE), n (%)113 (91.1)112 (91.1)Serious AE (SAE)/SAE cardiac disorder, n (%)30 (24.2)/3 (2.4)35 (28.5)/4 (3.3)Efficacyn=124n=124OS events, n (%)58 (46.8%)67 (54.0%)Median OS, months12.510.6Stratified OS HR (95% CI)1.24 (0.86-1.78) Log-rank P=0.24Median PFS, months5.755.59Stratified PFS HR (95% CI)1.04 (0.76-1.40) Log-rank P=0.82PK: Mean Ctrough, μg/mL (% coefficient of variation)Cycle 1, 8 mg/kg loading H (n=101 and 99)17.1 (82.9)18.1 (100.1)Cycle 2, first dosing HD H (n=94 and 77)19.3 (45.7)35.6 (54.6)Cycle 7, steady-state H (n=51 and 44)31.4 (45.1)58.1 (47.5)

Conclusions: Although HD H maintenance dosing is associated with higher H concentrations in HELOISE, we observed no increased efficacy (OS, PFS) and no new safety signals. HELOISE confirms SoC H (8 mg/kg loading dose followed by H 6 mg/kg q3w maintenance doses) as SoC with CT for 1L treatment of HER2-positive mGC/GEJC.

Citation Format: Manish A. Shah, Ruihua Xu, Yung-Jue Bang, Paulo M. Hoff, Tianshu Liu, Luis A. Herraez-Baranda, Fan Xia, Amit Garg, Mona Shing, Josep Tabernero. HELOISE: phase IIIB randomized multicenter study comparing two trastuzumab (H) dose regimens combined with chemotherapy (CT) as first-line (1L) therapy in patients (pts) with HER2-positive metastatic gastric/gastroesophageal junction adenocarcinoma (mGC/GEJC). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT108.

Abstract OT3-01-13: MetaPHER: A phase IIIb multicenter, open-label, single-arm safety study of subcutaneous trastuzumab, in combination with pertuzumab and docetaxel in patients with HER2-positive advanced breast cancer

Background: In patients (pts) with HER2-positive metastatic breast cancer (BC), the phase III CLEOPATRA study (NCT00567190) demonstrated significant improvement in progression-free (PFS) and overall survival (OS) from first-line treatment with intravenous (IV) pertuzumab (PERJETA® [P IV]) plus trastuzumab (Herceptin® [H IV]) plus docetaxel (D IV). HannaH (NCT00950300), a phase III trial in pts with HER2-positive early BC demonstrated that fixed-dose trastuzumab subcutaneous (Herceptin® [H SC]) is non-inferior to weight-based H IV infusion in the co-primary endpoints of serum trough concentration and pathologic complete response, which was supported by the long-term efficacy endpoints of event-free survival (EFS) and OS. The safety profile of H SC was consistent with the known safety profile of H IV. H SC is comprised of 600 mg trastuzumab and recombinant human hyaluronidase (rHuPH20) as an excipient, allowing a significantly reduced administration time compared with H IV (5 mins versus 30–90 mins, respectively). The MetaPHER study is designed to investigate the safety and efficacy of H SC in combination with P IV and D IV in pts with HER2-positive advanced BC.

Trial design: MetaPHER is a phase IIIb multicenter, open-label, single-arm study, with eligible pts receiving H SC 600 mg/5 mL q3w, P IV (840 mg loading dose, then 420 mg at each subsequent cycle q3w), and D IV (at least 6 cycles at 75 mg/m2 q3w with possible escalation to 100 mg/m2 q3w; after Cycle 6, continuation of docetaxel is at the investigator's discretion). Study treatment is administered until disease progression, unacceptable toxicity, withdrawal of consent, death, or predefined study end, whichever occurs first. Pts will receive post-treatment follow-up for safety and survival.

Eligibility: Women aged ≥18 years with metastatic or locally recurrent HER2-positive BC, ECOG performance status 0 or 1, and a left ventricular ejection fraction ≥50% are eligible. Exclusion criteria include disease-free interval of &lt;6 months from completion of adjuvant or neoadjuvant non-hormonal treatment to disease recurrence; previous systemic non-hormonal therapy for metastatic or locally recurrent BC; history of persistent grade ≥2 hematological toxicity; current grade ≥3 peripheral neuropathy; or clinically significant cardiovascular disease.

Aims: The primary objective is to evaluate the safety and tolerability of H SC in combination with P IV and D IV in pts with HER2-positive advanced BC. Secondary endpoints include PFS, OS, objective response rate and incidence of anti-trastuzumab and anti-rHuPH20 antibody formation.

Statistical methods: Safety and efficacy results will be summarized descriptively to include all enrolled pts who received at least one dose of any study drug; the study is not designed for formal hypothesis testing. A sample size of 400 pts provides reasonable precision for the estimation of grade ≥3 AEs and cardiac AEs.

Accrual: MetaPHER is enrolling, FPI was May 2015, and target enrollment is 400 pts; clinicaltrials.gov ID: NCT02402712.

Contact information: For more information or to refer a patient, email global.rochegenentechtrials@roche.com or call 1-888-662-6728 (USA only).

Citation Format: Kümmel S, Crepelle-Fléchais A, Schlegel M, Hillenbach C, Swat A, Franz M, Girase P, Schneider A, Heinzmann D, Shing M. MetaPHER: A phase IIIb multicenter, open-label, single-arm safety study of subcutaneous trastuzumab, in combination with pertuzumab and docetaxel in patients with HER2-positive advanced 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 OT3-01-13.

Alpha-synuclein levels in blood plasma decline with healthy aging

There is unequivocal evidence that alpha-synuclein plays a pivotal pathophysiological role in neurodegenerative diseases, and in particular in synucleinopathies. These disorders present with a variable extent of cognitive impairment and alpha-synuclein is being explored as a biomarker in CSF, blood serum and plasma. Considering key events of aging that include proteostasis, alpha-synuclein may not only be useful as a marker for differential diagnosis but also for aging per se. To explore this hypothesis, we developed a highly specific ELISA to measure alpha-synuclein. In healthy males plasma alpha-synuclein levels correlated strongly with age, revealing much lower concentrations in older (avg. 58.1 years) compared to younger (avg. 27.6 years) individuals. This difference between the age groups was enhanced after acidification of the plasmas (p<0.0001), possibly reflecting a decrease of alpha-synuclein-antibody complexes or chaperone activity in older individuals. Our results support the concept that alpha-synuclein homeostasis may be impaired early on, possibly due to disturbance of the proteostasis network, a key component of healthy aging. Thus, alpha-synuclein may be a novel biomarker of aging, a factor that should be considered when analyzing its presence in biological specimens.

Altered serum IgG levels to α-synuclein in dementia with Lewy bodies and Alzheimer's disease

Natural self-reactive antibodies in the peripheral blood may play a considerable role in the control of potentially toxic proteins that may otherwise accumulate in the aging brain. The significance of serum antibodies reactive against α-synuclein is not well known. We explored serum IgG levels to monomeric α-synuclein in dementia with Lewy bodies (DLB) and Alzheimer’s disease (AD) with a novel and validated highly sensitive ELISA assay. Antibody levels revealed stark differences in patients compared to healthy subjects and were dependent on diagnosis, disease duration and age. Anti-α-synuclein IgG levels were increased in both patient groups, but in early DLB to a much greater extent than in AD. Increased antibody levels were most evident in younger patients, while with advanced age relatively low levels were observed, similar to healthy individuals, exhibiting stable antibody levels independent of age. Our data show the presence of differentially altered IgG levels against α-synuclein in DLB and AD, which may relate to a disturbed α-synuclein homeostasis triggered by the disease process. These observations may foster the development of novel, possibly preclinical biomarkers and immunotherapeutic strategies that target α-synuclein in neurodegenerative disease.

Immunohistochemistry and fluorescence in situ hybridization assessment of HER2 in clinical trials of adjuvant therapy for breast cancer (NCCTG N9831, BCIRG 006, and BCIRG 005)

A comprehensive, blinded, pathology evaluation of HER2 testing in HER2-positive/negative breast cancers was performed among three central laboratories. Immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) analyses were performed on 389 tumor blocks from three large adjuvant trials: N9831, BCIRG-006, and BCIRG-005. In 123 cases, multiple blocks were examined. HER2 status was defined according to FDA-approved guidelines and was independently re-assessed at each site. Discordant cases were adjudicated at an on-site, face-to-face meeting. Results across three independent pathologists were concordant by IHC in 351/381 (92 %) and FISH in 343/373 (92 %) blocks. Upon adjudication, consensus was reached on 16/30 and 18/30 of discordant IHC and FISH cases, respectively, resulting in overall concordance rates of 96 and 97 %. Among 155 HER2-negative blocks, HER2 status was confirmed in 153 (99 %). In the subset of 102 HER2-positive patients from N9831/BCIRG-006, primary blocks from discordant cases were selected, especially those with discordant test between local and central laboratories. HER2 status was confirmed in 73 (72 %) of these cases. Among 118 and 113 cases with IHC and FISH results and >1 block evaluable, block-to-block variability/heterogeneity in HER2 results was seen in 10 and 5 %, respectively. IHC−/FISH− was confirmed for 57/59 (97 %) primary blocks from N9831 (locally positive, but centrally negative); however, 5/22 (23 %) secondary blocks showed HER2 positivity. Among 53 N9831 patients with HER2-normal disease adjudicated as IHC−/FISH—(although locally positive), there was a non-statistically significant improvement in disease-free survival with concurrent trastuzumab compared to chemotherapy alone (adjusted hazard ratio 0.34; 95 % CI, 0.11–1.05; p = 0.06). There were similar agreements for IHC and FISH among pathologists (92 % each). Agreement was improved at adjudication (96 %). HER2 tumor heterogeneity appears to partially explain discordant results in cases initially tested as positive and subsequently called negative.

Abstract B49: GRN1005 phase I studies: Final results

Background: Treatment of brain tumors is an unmet medical need due to the inability of most anti-cancer agents to effectively cross the blood brain barrier (BBB). GRN1005 (formerly ANG1005) is a peptide-drug conjugate (PDC) consisting of three molecules of paclitaxel covalently linked to a proprietary 19-amino acid peptide (AngioPep-2) that targets the low-density lipoprotein receptor-related protein 1 (LRP-1), which is expressed on the surface of the BBB and on cells of various tumor types. Studies have shown that GRN1005 is capable of crossing the BBB by receptor-mediated transcytosis via LRP-1. Once in the brain, GRN1005 gains entry into tumor cells by binding to LRP-1 on the tumor cells.

Objectives: GRN1005 is investigated as therapy for patients (pts.) with intra-cranial tumors, including malignant glioma and brain metastases (mets), in 2 phase I studies. The primary objectives of the studies were to determine the maximum tolerated dose (MTD) and to examine the safety and tolerability profile of GRN1005. Secondary objectives included tumor response, pharmacokinetics, and immunogenicity.

Methods: Two phase I, multi-center, sequential cohort, dose escalation studies have been conducted with GRN1005 administered IV at doses from 30 to 700 mg/m2 once every 3 weeks (q3w); 1 cycle is q3w. Study ANG1005-CLN-01 (n = 63) was in pts. with primary brain tumors and Study ANG1005-CLN-02 (n=56) was in pts. with advanced solid tumors (breast, lung, others) in which most had brain mets.

Results: The phase I studies have been completed and GRN1005 at 650 mg/m2 q3w was identified as the MTD in each of the studies.

At MTD, the dose-limiting toxicity (DLT) was neutropenia. The incidence of CTCAE Grade 4 neutropenia was 63% and was of short duration; febrile neutropenia occurred in 3 pts. (8%). Other AEs included peripheral neuropathy (5/38 [13%] Grade 2 and 3/38 [8%] Grade 3) and thrombocytopenia (25/38 [68%] Grades 1–3 and 1/38 [3%] Grade 4). There were 4 cases of Grade 3 infusion reactions at MTD (11%). Across all doses, the overall incidence of infusion reactions of any grade is 13% (15/119). No pre-medication was required with GRN1005 infusion in the phase I studies. Liver toxicity was not observed. There was no evidence of CNS toxicity as measured by neurocognitive testing and neurological examinations; and there was no evidence of anti-drug antibody production. Clinical activity in the phase I studies was observed with GRN1005 therapy in both studies. In Study ANG1005-CLN-01, 1 (6%; n=18) pt. achieved a partial response (PR) at MTD. Additionally, 1 pt. out of 3 in the 700 mg/m2 cohort achieved a complete response and 1 pt. out of 4 in the 420 mg/m2 cohort achieved a PR. In Study ANG1005-CLN-02, 4 of 20 (20%) pts. treated at MTD achieved an overall partial response (PR); some pts. had intra-cranial and extra-cranial lesion responses, despite prior taxane failures. A substudy showed GRN1005 and free paclitaxel concentrations in excised primary brain tumors.

Conclusions: In the GRN1005 phase I studies, single agent clinical activity was observed in pts. with primary brain tumors and in pts. with solid tumor brain metastases, including prior taxane failures; extra-cranial responses were observed along with intra-cranial responses. GRN1005's MTD is 650 mg/m2 q3w, and neutropenia was the DLT. Given the clinical activity and safety/tolerability observed in phase I, GRN1005 as therapy for pts. with intra-cranial tumors is being further investigated in phase 2 studies.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr B49.

Central nervous system metastases in patients with HER2-positive metastatic breast cancer: incidence, treatment, and survival in patients from registHER

PURPOSE

registHER is a prospective, observational study of 1,023 newly diagnosed HER2-positive metastatic breast cancer (MBC) patients.

EXPERIMENTAL DESIGN

Baseline characteristics of patients with and without central nervous system (CNS) metastases were compared; incidence, time to development, treatment, and survival after CNS metastases were assessed. Associations between treatment after CNS metastases and survival were evaluated.

RESULTS

Of the 1,012 patients who had confirmed HER2-positive tumors, 377 (37.3%) had CNS metastases. Compared with patients with no CNS metastases, those with CNS metastases were younger and more likely to have hormone receptor-negative disease and higher disease burden. Median time to CNS progression among patients without CNS disease at initial MBC diagnosis (n = 302) was 13.3 months. Treatment with trastuzumab, chemotherapy, or surgery after CNS diagnosis was each associated with a statistically significant improvement in median overall survival (OS) following diagnosis of CNS disease (unadjusted analysis: trastuzumab vs. no trastuzumab, 17.5 vs. 3.8 months; chemotherapy vs. no chemotherapy, 16.4 vs. 3.7 months; and surgery vs. no surgery, 20.3 vs. 11.3 months). Although treatment with radiotherapy seemed to prolong median OS (13.9 vs. 8.4 months), the difference was not significant (P = 0.134). Results of multivariable proportional hazards analyses confirmed the independent significant effects of trastuzumab and chemotherapy (HR = 0.33, P < 0.001; HR = 0.64, P = 0.002, respectively). The effects of surgery and radiotherapy did not reach statistical significance (P = 0.062 and P = 0.898, respectively).

CONCLUSIONS

For patients with HER2-positive MBC evaluated in registHER, the use of trastuzumab, chemotherapy, and surgery following CNS metastases were each associated with longer survival.

Survival by anatomic site, histologic type, and tumor stage in stomach and esophageal cancer patients from the U.S. SEER Cancer Registry

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Background: Data on the association of tumor characteristics and survival for stomach cancer (SC) and esophageal cancer (EC) patients (pts) are limited. The objective of this study was to describe survival in United States. SC and EC pts by anatomic site, histologic type, and tumor stage.

Methods: SC and EC pts were identified in the Surveillance, Epidemiology and End Results (SEER) Cancer Registry. SC was classified by anatomic site (cardia and non-cardia/other) and histologic type (intestinal, diffuse, other per Lauren criteria). EC was classified into anatomic site (middle/upper third, abdominal/lower third, overlapping lesions, NOS) and histologic type (adenocarcinoma (AC), squamous cell carcinoma (SQ), other). Frequency distribution and median survival were examined in these subgroups.

Results: From 2004-2006, >15,500 SC and > 9,800 EC cases were diagnosed. SC: (29% cardia) and (24% diffuse, 66% intestinal, 10% other). Compared with non-cardia/other pts, cardia pts tended to be male (77% vs 56%), white (88% vs 66%), intestinal type (77% vs 61%) and present with earlier stage disease (stage I-IIIa: 48% vs 42%). With the exception of stage I/II pts, survival was longer in cardia than non-cardia/other pts. The difference was most striking in stage IIIb/IV pts (7 months (mos) cardia vs 4 mos non-cardia/other). Compared to intestinal type, diffuse type tended to be younger (median age: 64 vs 72 yrs), more female (49% vs 34%), and present with more stage IIIb/IV disease (50% vs 39%). No difference in survival by histologic type was observed when accounting for stage. EC: (26% middle/upper, 58% lower, 5% overlapping, 11% NOS) and (57% AC, 34% SQ, 9% other). Among pts with AC histology 78% occurred in the lower third; in SQ most occurred in upper/middle third (56%). Compared to SQ, AC tended to be male (85% vs 63%), white (95% vs 67%), and present with stage IV disease (34% vs 25%). For all stages combined, survival was longer for AC pts (11 mos AC, 9 mos SQ, 4 mos other). This difference was most apparent among early stage (I-III) pts.

Conclusions: Survival in SC and EC was associated with staging, anatomic and histologic subtypes. Quantifying this provides insights for the design and interpretation of clinical development programs.

[Table: see text]

Panitumumab monotherapy in patients with metastatic colorectal cancer and cetuximab infusion reactions: a series of four case reports

PURPOSE

Monoclonal antibodies against the epidermal growth factor receptor approved for treating metastatic colorectal cancer (mCRC) include cetuximab (a chimeric antibody) and panitumumab (a fully human antibody). Because these antibodies have differences in protein sequence, patients intolerant to one antibody might still tolerate the other. Four cases are presented from a US panitumumab compassionate-use program in which patients with mCRC who were intolerant to cetuximab received panitumumab.

PATIENTS AND METHODS

Eligible patients had failed previous fluoropyrimidine therapy with oxaliplatin- and irinotecan-containing chemotherapy, had cetuximab intolerance (ie, experienced an infusion reaction), and were unable to participate in a panitumumab clinical trial. For each patient, individual Federal Drug Administration-approved single-patient treatment use Investigational New Drug- and Institutional Review Board-approved protocols were used, informed consent was obtained, and data were collected independently by the investigator.

RESULTS

All 4 patients (2 men, 2 women) had received previous bevacizumab and premedications before cetuximab administration. In response to cetuximab, all 4 patients experienced Common Terminology Criteria for Adverse Events grade 3 or grade 4 infusion-reaction symptoms, which required acute therapy. Time from cetuximab discontinuation to panitumumab administration ranged from 8 days to 5 months. Panitumumab monotherapy was administered at approximately 6 mg/kg every 2 weeks. Two patients received premedications before panitumumab use. No physician reported any infusion reaction to panitumumab. One patient had stable disease, and 3 patients had disease progression.

CONCLUSION

Though this small case series provides evidence that patients with mCRC intolerant to cetuximab can receive subsequent panitumumab monotherapy without experiencing infusion reactions, additional clinical testing is needed to definitively examine this finding.

Embolic stroke and cardiac papillary fibroelastoma

Papillary fibroelastomas are rare, benign, primary cardiac tumors. They are, however, the most common primary tumor of the cardiac valves and may cause great morbidity risk from embolization. This paper reports the case of a healthy 34-year-old man who presented with symptoms of a right occipital embolic stroke. Transesophageal echocardiography revealed a papillary fibroelastoma on the anterior leaflet of the mitral valve. The papillary fibroelastoma was surgically excised and he has had no recurrent symptoms. This case illustrates the importance of obtaining a transesophageal echocardiogram to investigate a possible embolic source in patients with ischemic stroke.

Up-regulation of platelet-derived growth factor by peripheral-blood leukocytes during experimental allergic encephalomyelitis

In multiple sclerosis (MS) and its animal model, experimental allergic encephalomyelitis (EAE), clinical disease is associated with infiltration of the central nervous system (CNS) by immune cells. Subsequent remission with remyelination has been linked to an increased occurrence of oligodendrocyte progenitor (O2A) cells. Platelet-derived growth factor (PDGF) and fibroblast growth factor-2 (FGF-2) are key growth factors for O2A cells, yet little is known about their relevance in EAE and MS. We analyzed the expression of PDGF, FGF-2, and their receptors by peripheral-blood leukocytes (PBLs) and lymphocyte subsets during MBP-induced EAE. Strong up-regulation of PDGF, but not FGF-2, was observed in PBLs, with the highest expression after the disease maximum. T, NK, and NKT cells expressed PDGF, which is a novel observation because thus far only monocytes/macrophages have been reported to express PDGF. These results extend the idea that growth factors may contribute to improved CNS tissue repair, including PDGF, which is secreted by lesion-homing immune cells. The production of PDGF by lymphocytes may have potential therapeutic value when activating or modulating T-cell responses in demyelinating diseases.

Institutional experiences with panitumumab monotherapy in metastatic colorectal cancer (mCRC) patients (pts) intolerant to cetuximab

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Background: Two monoclonal antibodies (mAbs) targeting the epidermal growth factor receptor are approved for the treatment (tx) of advanced mCRC - panitumumab (Vectibix™), a fully human mAb, and cetuximab (Erbitux®), a chimeric mAb. Potential for cross-reactivity between these two mAbs with regard to infusion reactions (IR) has not been fully explored. Given the lack of sequence homology between the 2 agents and the fully human nature of panitumumab, it is hypothesized that pts intolerant to cetuximab due to IR could be tolerant to panitumumab. Methods: Single pt tx IND applications to administer panitumumab monotherapy in pts with advanced mCRC were approved by the FDA and local institutions as part of the Panitumumab Compassionate Use program. Eligibility also included previous tx with standard chemotherapy and intolerability to cetuximab, ie. CTCAE v3.0 grade 3 (severe) or grade 4 (life-threatening) IR. Results: Upon informed consent, 4 pts (2M/ 2F) were enrolled in 4 centers. Median (range) age was 62.5 (52, 64) years. 3 pts had colon cancer and 1 pt had rectal cancer. All had surgery and received prior 5-fluorouracil, leucovorin, irinotecan, oxaliplatin, bevacizumab, and cetuximab. One pt had a CTC grade 3 IR and 3 pts had a CTC grade 4 IR to cetuximab. IR symptoms included fever, wheezing, dyspnea, chest/back/abdominal pain, anxiety, hypotension, flushing, tachycardia, and tachypnea. Two IRs occurred within 10 minutes of the first cetuximab infusion. Cetuximab was discontinued and IR symptoms were treated with bronchodilators, diphenhydramine, epinephrine, methylprednisolone, oxygen, intravenous saline, and hospitalization. All pts received panitumumab. Data for pts 1, 2, and 3 are available: pt 1 received 1 infusion of panitumumab at 5 mg/kg Q2W with premedication (diphenhydramine and methylprednisolone); pts 2 and 3 received 7 and 2 panitumumab infusions, respectively, at 6 mg/kg Q2W without premedication. No pt had an IR to panitumumab. Pt 2 had stable disease; pts 1 and 3 died due to disease progression. Conclusions: Panitumumab monotherapy was tolerated without incidence of an IR in these cases of mCRC pts who are intolerant to cetuximab due to a severe or life-threatening IR. Additional data will be presented.

No significant financial relationships to disclose.

Efficacy and safety of high-dose cabergoline in Parkinson's disease

OBJECTIVES

To assess the efficacy and safety of high-dose (up to 20 mg/day) cabergoline in Parkinson's disease (PD) patients with motor fluctuations and/or dyskinesias.

MATERIALS AND METHODS

Thirty-four PD patients had cabergoline up-titrated and their levodopa (L-dopa) reduced over a maximum of 20 weeks, followed by at least 6 weeks steady cabergoline dosing. Primary endpoint was change in mean hyperkinesia intensity at the final visit (week 26).

RESULTS

Mean (+/- SD) cabergoline was increased from 6.43 +/- 2.66 to 12.78 +/- 5.67 mg/day and mean L-dopa reduced from 606.6 +/- 263.9 to 370.6 +/- 192.5 mg/day. A significant reduction (P < 0.001) in mean hyperkinesia intensity occurred from baseline (day 0) to week 26. Improvements in 'on with dyskinesias', mean dystonia intensity (P < 0.05), time spent in 'severe off' condition, severity of 'off' periods as well as clinical/patient global impression, and health-related quality of life were observed. Twenty-four drug-related adverse events were recorded of which four were regarded as serious.

CONCLUSION

High-dose cabergoline was well tolerated and provided significant improvements in the Parkinson symptomatology and a reduced requirement for L-dopa.

Computerized movement analysis and beta-CIT-SPECT in patients with restless legs syndrome

Considering the positive effect of dopaminergic treatment on Restless Legs Syndrome (RLS), it has been suggested that the cause of RLS may be linked to central dopaminergic dysfunction. As problems of alternating movements can result from a failure in the dopaminergic system, we used a movement analysis system to analyse this and in-parallel, performed [123I]beta-CIT-SPECT to investigate signs of dopaminergic dysfunction in patients with RLS. In 10 patients with idiopathic RLS, we conducted a three-dimensional computerized ultrasound-based movement analysis before a single dose of levodopa (L-dopa) was given and 90 minutes after the L-dopa challenge. In 6 of the 10 RLS patients, the striatal dopamine transporter system was studied with [123I]beta-CIT-SPECT. We did not observe any significant change in the movement pattern with the computerized movement analysis and no significant effect of L-dopa on the movement. We did not detect any significant differences between patients and normal controls regarding beta-CIT-signals in putamen or caudate nucleus, respectively. There was, however, a slight but significant change regarding the relative [123I]beta-CIT-SPECT binding in the putamen vs. the caudate nucleus. We conclude that the methods used could not detect any definite signs of changed central dopaminergic function in patients with RLS.

Three-dimensional computerized analysis of diadochokinetic movements of Parkinsonian patients

OBJECTIVES

Considering the rapid appearance of new pharmaceutical and surgical treatments for Parkinson's disease, a development of quantitative and objective methods for measuring treatment effects is highly warranted. The purpose of this study was to investigate the usability of a computerized movement analysis system in Parkinson's disease patients.

MATERIAL AND METHODS

We analysed the effect of L-dopa in a group of 14 patients with idiopathic Parkinson's disease and compared the results to those of 14 control persons. The results were compared to those achieved with the UPDRS, Hoehn & Yahr and Schwab & England Scales, as well as, to time-measured manual testing according to the CAPIT and CAPSIT-PD protocols.

RESULTS

We found that the computerized analysis results correlated well with the findings obtained with traditional scales and manual techniques, and that the computer-analysis had the advantage of delivering more exact and quantitative information not only concerning movement speed but also aspects of movement quality.

CONCLUSION

We conclude that this form of computerized movement analysis can have an important role in evaluating the effect of treatments, individualizing the therapy, as well as, for diagnostic procedures in patients with Parkinson symptomatology.

Restless legs syndrome

Restless legs syndrome (RLS), first described in 1672 and given its name in 1945, is one of the most common sleep and movement disorders. Modern population-based studies demonstrate a prevalence between 5% and 15% in adult white populations. According to the diagnostic criteria, RLS is defined as an irresistable desire to move limbs, usually associated with paresthesias/dysesthesias and motor restlessness. The symptoms start or worsen at rest and improve with activity. Additionally, the symptoms worsen in the evenings and/or nights, which often results in disturbance of sleep with daytime tiredness. There is often a family history of RLS. Initially, the disease course is usually fluctuating and later may become continuous or chronic-progressive. The diagnosis is based on the patient history and is supported by a normal neurological examination. RLS is confirmed by the finding of periodic limb movements (PLM) in polysomnographic investigations and by a response to dopaminergic medication. A large number of studies have confirmed the effect of levodopa (L-dopa) in the treatment of RLS. A majority of the patients treated over a longer period of time with L-dopa, however, develop problems with an effect called augmentation, where the RLS symptoms begin appearing earlier during the day and involve new parts of the body with increasing severity. A large number of studies have now confirmed that dopamine agonists can also be effective in RLS therapy, and that this treatment seems to involve less risk for augmentation. This paper provides a general review of RLS with a focus on current treatment options.

Resting regional cerebral glucose metabolism in advanced Parkinson's disease studied in the off and on conditions with [(18)F]FDG-PET

Studies of resting regional cerebral glucose consumption (rCMRGlc) in nondemented patients with Parkinson's disease (PD) have produced conflicting results, reporting both reduced and normal metabolism in advanced disease and reduced or normal metabolism after dopaminergic therapy. To investigate these issues, [(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) was performed in 11 nondemented PD patients with advanced disease and 10 age-matched controls. PD patients were studied after withdrawal of all dopaminergic medication to produce a practically defined off condition, and a second time 1 hour after levodopa, resulting in a clinical on state. Dynamic PET scans and simultaneous arterialised venous blood samples of [(18)F] activity were obtained. A graphical approach was used to generate parametric images of rCMRGlc and statistical parametric mapping to localise significant metabolic changes in PD. Compared with controls, global rCMRGlc was reduced in the on but not in the off condition in PD. In both states, significant regional reductions of glucose uptake were found in the parietal, frontal, temporal cortex, and caudate nucleus. Reductions correlated with the severity of disability in frontal and temporal cortex. Direct comparison between on and off conditions revealed relatively greater reductions of uptake in the ventral/orbital frontal cortex and the thalamus during on. Results suggest that cortical and caudate hypometabolism are common in advanced PD and that caution is mandatory if [(18)F]FDG PET is being used to differentiate advanced PD from dementia and progressive supranuclear palsy where similar reductions are seen. Furthermore, in PD, administration of levodopa is associated with further hypometabolism in orbitofrontal cortex; an area known to be relevant for reversal learning where performance is typically impaired after dopaminergic treatment.

Bone marrow transplantation for chronic granulomatous disease: long-term follow-up and review of literature

Chronic granulomatous disease (CGD) is a heterogeneous group of disorders with defective respiratory burst activity in phagocytes which results in recurrent pyogenic infections. We report an 8-year-old boy with X-linked CGD who received an HLA-identical BMT from his sister. The nitroblue tetrazolium test returned to normal 3 months post transplant. Neutrophil engraftment has been stable for 7 years post BMT. Our patient was the eighth case of CGD successfully treated by BMT. Conditioning regimens in these patients have consisted mainly of BU and CY. We suggest that BMT is a safe and effective method of cure for patients with CGD. BMT should be considered for patients with HLA-identical siblings.

Assembly of the reovirus outer capsid requires mu 1/sigma 3 interactions which are prevented by misfolded sigma 3 protein in temperature-sensitive mutant tsG453

A temperature-sensitive reovirus mutant, tsG453, whose defect was mapped to major outer capsid protein sigma 3, makes core particles but fails to assemble the outer capsid around the core at non-permissive temperature. Previous studies that made use of electron cryo-microscopy and image reconstructions showed that mu 1, the other major outer capsid protein, but not sigma 3, interact extensively with the core capsid. Although wild-type sigma 3 and mu 1 interact with each other, immunocoprecipitation studies showed that mutant sigma 3 protein was incapable of interacting with mu 1 at the non-permissive temperature. In addition, restrictively-grown mutant sigma 3 protein could not be precipitated by some sigma 3-specific monoclonal antibodies. These observations suggest that in a wild-type infection, specific sigma 3 and mu 1 interactions result in changes in mu 1 conformation which are required to allow mu 1/sigma 3 complexes to condense onto the core capsid shell during outer capsid assembly, and that sigma 3 in non-permissive tsG453 infections is misfolded such that it cannot interact with mu 1.

Prostatic non-Hodgkin's lymphoma causing acute urinary retention in childhood

An 8-year-old boy presented with dysuria and acute retention of urine. Rectal examination showed a hard mass arising from the prostate. CT scan of the pelvis confirmed the presence of a large prostatic tumor causing bladder outflow obstruction. A provisional diagnosis of pelvic sarcoma was initially made. Biopsy of the tumor mass however, revealed non-Hodgkin's lymphoma of T-cell type. The tumor showed very good response to chemotherapy and the urinary obstruction significantly improved with a week after starting therapy.