Anya Litvak

Next-Generation Sequencing of Pulmonary Large Cell Neuroendocrine Carcinoma Reveals Small Cell Carcinoma–like and Non–Small Cell Carcinoma–like Subsets

Purpose: Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a highly aggressive neoplasm, whose biologic relationship to small cell lung carcinoma (SCLC) versus non-SCLC (NSCLC) remains unclear, contributing to uncertainty regarding optimal clinical management. To clarify these relationships, we analyzed genomic alterations in LCNEC compared with other major lung carcinoma types. Experimental Design: LCNEC (n = 45) tumor/normal pairs underwent targeted next-generation sequencing of 241 cancer genes by Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT) platform and comprehensive histologic, immunohistochemical, and clinical analysis. Genomic data were compared with MSK-IMPACT analysis of other lung carcinoma histologies (n = 242). Results: Commonly altered genes in LCNEC included TP53 (78%), RB1 (38%), STK11 (33%), KEAP1 (31%), and KRAS (22%). Genomic profiles segregated LCNEC into 2 major and 1 minor subsets: SCLC-like (n = 18), characterized by TP53+RB1 co-mutation/loss and other SCLC-type alterations, including MYCL amplification; NSCLC-like (n = 25), characterized by the lack of coaltered TP53+RB1 and nearly universal occurrence of NSCLC-type mutations (STK11, KRAS, and KEAP1); and carcinoid-like (n = 2), characterized by MEN1 mutations and low mutation burden. SCLC-like and NSCLC-like subsets revealed several clinicopathologic differences, including higher proliferative activity in SCLC-like tumors (P < 0.0001) and exclusive adenocarcinoma-type differentiation marker expression in NSCLC-like tumors (P = 0.005). While exhibiting predominant similarity with lung adenocarcinoma, NSCLC-like LCNEC harbored several distinctive genomic alterations, including more frequent mutations in NOTCH family genes (28%), implicated as key regulators of neuroendocrine differentiation. Conclusions: LCNEC is a biologically heterogeneous group of tumors, comprising distinct subsets with genomic signatures of SCLC, NSCLC (predominantly adenocarcinoma), and rarely, highly proliferative carcinoids. Recognition of these subsets may inform the classification and management of LCNEC patients. Clin Cancer Res; 22(14); 3618–29. ©2016 AACR.

Clinical Characteristics and Course of 63 Patients with BRAF Mutant Lung Cancers

Introduction: Mutant BRAF is a driver oncogene found in 2% of lung adenocarcinomas and represents a target for therapy. We examined the clinical characteristics and course of patients with lung adenocarcinomas harboring BRAF mutations. Methods: We identified patients with lung adenocarcinomas harboring BRAF mutations between 2009 and 2013 detected using a mass spectrometry–based polymerase chain reaction genotyping assay of hot-spot mutations involving codons corresponding to amino acids V600, D594, and G469 of BRAF. Patient characteristics and treatment outcomes were analyzed. Overall survival (OS) was compared with stage-matched patients with KRAS and EGFR mutant lung adenocarcinomas. Results: Sixty-three patients were diagnosed with BRAF mutant lung adenocarcinomas between 2009 and 2013 (V600, 36; non-V600, 27). The majority of patients with BRAF mutations were smokers (92%), although patients with V600 mutations were more likely to be light/never-smokers compared with patients with non-V600 mutations (42% versus 11%; p = 0.007). Of the 32 patients with early-stage disease, six (19%; 95% confidence interval 7%–36%) developed second primary lung cancers harboring KRAS mutations. Patients with advanced V600 mutant lung adenocarcinomas had a better survival from diagnosis compared with those with non-V600 mutant lung adenocarcinomas (3-year OS: 24% versus 0%; p < 0.001). Conclusions: This is the largest series of patients with BRAF mutant lung cancers described. Most patients were heavy smokers. Nineteen percent of patients with early-stage BRAF mutant lung cancers developed second primary lung cancers harboring KRAS mutations. Patients with advanced lung adenocarcinomas harboring V600 mutations have an improved OS compared with those with non-V600 mutations.

Phase II Study of the GI-4000 KRAS Vaccine After Curative Therapy in Patients With Stage I-III Lung Adenocarcinoma Harboring a KRAS G12C, G12D, or G12V Mutation

INTRODUCTION Patients with early-stage lung cancer have a high risk of recurrence despite multimodality therapy. KRAS-mutant lung adenocarcinomas are the largest genetically defined subgroup, representing 25% of patients. GI-4000 is a heat-killed recombinant Saccharomyces cerevisiae yeast-derived vaccine expressing mutant KRAS proteins. The present phase II study assessed the feasibility, immunogenicity, and safety of the GI-4000 vaccine in patients with early-stage, KRAS-mutant lung cancer. MATERIALS AND METHODS Patients with stage I-III KRAS-mutant lung cancer who completed curative therapy were enrolled. The patients received the genotype matched GI-4000 vaccine for ≤ 3 years or until intolerance, disease recurrence, or death. The KRAS antigen T-cell response was assessed using the interferon-gamma enzyme-linked immunospot assay in peripheral blood mononuclear cells. The study was powered to detect an immune response in ≥ 25% of patients. RESULTS A total of 24 patients were enrolled over 28 months. No vaccine-related serious adverse events occurred. One patient withdrew consent because of pain at the injection site. The study met its primary endpoint, with 50% of patients developing an immune response to mutant KRAS. The median number of vaccinations received was 15 (range, 1-19). Ten patients experienced disease recurrence, and 6 died. Compared with the genotypically matched historical controls, the recurrence rates were equivalent but overall survival showed a favorable trend. CONCLUSION GI-4000 was well tolerated and immunogenic when used as consolidation therapy in patients with stage I-III KRAS-mutant lung cancer. The patterns of recurrence and death observed in the present study can be used to design a randomized study of GI-4000 with overall survival as the primary endpoint.

Clinical characteristics and outcomes for patients with thymic carcinoma: evaluation of Masaoka staging.

Background: Thymic carcinomas are rare cancers with limited data regarding outcomes, particularly for those patients with advanced disease. Methods: We identified patients with thymic carcinomas diagnosed between 1993 and 2012. Patient characteristics, recurrence-free survival (RFS), and overall survival (OS) were analyzed. Results: One hundred twenty-one patients with thymic carcinomas were identified. Higher Masaoka stage was associated with worse OS and RFS (5-year OS of 100%, 81%, 51%, 24%, and 17% for stage I, II, III, IVa, and IVb respectively, p < 0.001 and 5-year RFS of 80%, 28%, and 7% for stage I/II, III, and IV respectively, p < 0.001). Patients with stage IVb lymph node (LN) only disease had a better 5-year OS as compared with patients with distant metastasis (24% versus 7%, p = 0.025). Of the 61 patients with stage IVb disease, 22 of 29 patients (76%) with LN-only disease underwent curative intent resection versus 3 of 32 patients (9%) with distant metastasis. Twenty-two patients with LN involvement were treated with multimodality therapy. Three (14%) remain free of disease with long-term follow-up (range, 3.4+ years– to 6.8+ years). Conclusions: We describe the clinical features of a large series of patients with thymic carcinoma in North America. The Masaoka staging system effectively prognosticated OS and RFS. Patients with stage IVb LN-only disease had significantly better OS as compared with patients with distant metastasis with a subset of patients sustaining long-term RFS with multimodality therapy. If validated, these data would support a revised staging system with subclassification of stage IVb disease into two groups.

A phase I trial of the Hedgehog inhibitor, sonidegib (LDE225), in combination with etoposide and cisplatin for the initial treatment of extensive stage small cell lung cancer

OBJECTIVES The Hedgehog pathway has been implicated in small cell lung cancer (SCLC) tumor initiation and progression. Pharmacologic blockade of the key Hedgehog regulator, Smoothened, may inhibit these processes. We performed a phase I study to determine the maximum tolerated dose (MTD) of sonidegib (LDE225), a selective, oral Smoothened antagonist, in combination with etoposide/cisplatin in newly diagnosed patients with extensive stage SCLC. MATERIALS AND METHODS Patients received 4-6 21-day cycles of etoposide/cisplatin with daily sonidegib. Patients with response or stable disease were continued on sonidegib until disease progression or unacceptable toxicity. Two dose levels of sonidegib were planned: 400mg and 800mg daily, with 200mg daily de-escalation if necessary. Next generation sequencing was performed on available specimens. Circulating tumor cells (CTCs) were quantified at baseline and with disease evaluation. RESULTS Fifteen patients were enrolled. 800mg was established as the recommended phase II dose of sonidegib in combination with etoposide/cisplatin. Grade 3 or greater toxicities included: anemia (n=5), neutropenia (n=8), CPK elevation (n=2), fatigue (n=2), and nausea (n=2). Toxicity led to removal of one patient from study. Partial responses were confirmed in 79% (11/14; 95% CI: 49-95%). One patient with SOX2 amplification remains progression-free on maintenance sonidegib after 27 months. CTC count, at baseline, was associated with the presence of liver metastases and after 1 cycle of therapy, with overall survival. CONCLUSIONS Sonidegib 800mg daily was the MTD when administered with EP. Further genomic characterization of exceptional responders may reveal clinically relevant predictive biomarkers that could tailor use in patients most likely to benefit.

Radiogenomic evaluation of lung cancer — Are there imaging characteristics associated with lung adenocarcinomas harboring BRAF mutations?

INTRODUCTION We studied computed tomography (CT) features associated with BRAF mutated lung cancer. MATERIALS AND METHODS CT features of BRAF mutated lung cancers were compared to stage matched lesions without BRAF mutation. RESULTS 47 (25%) patients with BRAF mutation and 141 (75%) without BRAF mutation were included. BRAF lesions were most frequently solid 37 (84%), spiculated 22 (50%), and peripheral 37 (84%). No feature of the primary tumor was significantly different between BRAF and non-BRAF groups. BRAF patients were more likely than KRAS patients to have pleural metastases [5 (11%) vs 0 (0%), p=0.045]. CONCLUSION No feature of the primary tumor differentiates BRAF lesions from non-BRAF lesions.

From genotype to phenotype: Are there imaging characteristics associated with lung adenocarcinomas harboring RET and ROS1 rearrangements?

INTRODUCTION Recurrent gene rearrangements are important drivers of oncogenesis in non-small cell lung cancers. RET and ROS1 rearrangements are each found in 1-2% of lung adenocarcinomas and represent distinct molecular subsets. This study assessed the computed tomography (CT) imaging features of patients with RET- and ROS1-rearranged lung cancers. METHODS Eligible patients included pathologically-confirmed lung adenocarcinomas of any stage with a RET or ROS1 rearrangement via fluorescence in-situ hybridization or next-generation sequencing, and available pre-treatment baseline imaging for review. A cohort of EGFR-mutant lung cancers was identified as a control group. CT features assessed included location, consistency, contour, presence of cavitation, and calcification of the primary tumor. Presence of an effusion, lung metastases, adenopathy and extrathoracic disease were recorded. The Wilcoxon rank-sum/Kruskal-Wallis and Fishers exact tests were used to compare features between groups. RESULTS 73 patients with lung adenocarcinomas were identified: 17 (23%) with ROS1 fusions, 25 (34%) with RET fusions and 31 (43%) with EGFR mutations. ROS1-rearranged lung cancers were more likely to present as peripheral tumors in comparison to EGFR-mutant lung cancers (32% vs. 65%, p=0.04). RET-rearranged lung cancers did not significantly differ from EGFR-mutant lung cancers radiographically. The consistency of the primary lesion for RET and ROS fusions and EGFR mutations were most frequently solid and spiculated. CONCLUSIONS Lung adenocarcinomas with RET and ROS1 fusions share many radiographic features and those with ROS1 fusions are more likely to present as peripheral lesions in comparison to EGFR-mutant lung cancers.

Bronchial and Thymic Carcinoid Tumors

Bronchial and thymic carcinoids are rare. We present epidemiologic data and potential risk factors. The approach to bronchial and thymic carcinoid patients is discussed, from the initial diagnosis and evaluations to treatment. These malignancies follow staging systems of their site of origin. Because bronchial and thymic carcinoids are rare, we use many treatment strategies that have been demonstrated in gastrointestinal and pancreatic neuroendocrine tumors. The lack of information regarding efficacy in bronchial and thymic carcinoids, as well as the scarcity of therapeutic options available, demands the importance of clinical trials that include these patients.

Successful perioperative use of prothrombin complex concentrate in the treatment of acquired factor X deficiency in the setting of systemic light-chain (AL) amyloidosis

To the Editor: This is the seventh in a series of short articles concerning iron deficiency and the role of intravenous iron. At a time when resources are scarce and restrictions on the use of erythropoiesis stimulating agents (ESAs) [1] have resulted in a significant increment in transfusions among patients with chemotherapy-induced anemia (CIA) [2], it remains puzzling why guidelines incorporating intravenous (IV) iron as a standard in CIA vary among the different governing bodies. To date, 12 of 12 prospective studies examining the role of intravenous iron as an adjunct to ESAs or as sole therapy have shown benefit. One negative trial which demonstrated no synergy in hemoglobin response or symptomatic improvement [3] resulted in changed conclusions after a re-analysis of the intention to treat population revealed those randomized to intravenous iron who actually received at least 80% of the planned dose enjoyed similar benefits seen in the previously published prospective trials [4]. Therefore, based on all prospective published evidence, co-administration of intravenous iron or intravenous iron alone improves responses to ESAs and hemoglobin respectively, in the treatment of CIA without appreciable clinically significant adverse events. Space does not permit an in-depth description of the trials. Interested readers are referred to two recent reviews [5,6]. Six studies encompassing 1,768 patients received ESAs plus or minus intravenous iron for CIA. All showed increments in hemoglobin response rates, decreased transfusions, decreased time to reach target hemoglobin and when examined, a decrease in ESA dose for similar benefits observed without intravenous iron. In one study in patients with lymphoproliferative disease not on chemotherapy, a positive hemosiderin stain on a bone marrow aspirate, the gold standard for iron repletion, was an entrance requirement [7]. As observed in the CIA studies, IV iron added to ESAs resulted in a significant improvement in response rate as well as an 11,000 unit per week reduction in ESA usage for a similar benefit. In another study, 127 subjects were examined, who underwent autologous bone marrow transplant [8]. IV iron when added to ESAs showed a significant benefit in hemoglobin response compared to ESA alone. A unique aspect of this trial was the five year follow-up of those enrolled. At that time there was no statistically significant difference in relapse rate or change in progression-free survival in the IV iron group compared to controls. Four studies evaluated the ability of intravenous iron without ESAs to decrease significant anemia progression or increase hemoglobin. While hemoglobin responses were smaller than in the trials examining the synergy between intravenous iron and ESAs, in all four trials, intravenous iron alone resulted in improved hemoglobin responses compared to no treatment. As was the case in the other trials, the benefits seen were independent of baseline iron parameters supporting the notion that intravenous iron is beneficial in CIA even if iron replete at commencement of therapy. In the largest of these trials, Steinmetz et al. examined 135 patients with CIA and noted a substantial increase in hemoglobin levels and stabilization to the 11–12 g/dl range without ESAs [9]. Intravenous iron may also have a salutary effect on the incidence of venous thromboembolism, the most clinically significant adverse event associated ESA therapy. In an animal model, Loo and Beguin showed a statistically significant reduction in platelet counts in rats given intravenous iron compared to controls [10], which in a post hoc exploratory analysis of CIA patients randomized to ESA alone or with IV iron translated to a reduction in thromboembolic events and platelet counts in patients given IV iron with ESAs compared to ESAs alone [11]. All of the above conclusions were supported by a large meta-analysis which searched 1,118 relevant trails of which 56 were included including two presented abstracts [6]. The meta-analysis did not take into account the recant of the one negative study with intravenous iron in CIA which would have strengthened the conclusions. ESAs were administered in all but two. Most included most solid tumors but one with lymphoproliferative diseases not on chemotherapy and another post-autologous bone marrow transplant. Irrespective of the method of intravenous iron administration, a clear improvement in response rates was observed. A statistically significant decrement in transfusions was also reported which applied to those who received IV iron alone or with ESAs. In conclusion, studies comprising thousands of patients demonstrate intravenous iron synergizes with ESAs for those being treated for CIA with improvements in hemoglobin responses, time to target, decreased red cell transfusion, improvement in quality of life parameters, and cost savings. Most importantly, these observations occurred without treatment related clinically significant toxicity. Intravenous iron as sole therapy for CIA promises to overcome a significant portion of the gap created by the 2007 CMS decision memo restricting ESA usage. Compared to the cost of ESAs, the cost of intravenous iron is negligible. Based on the preponderance of published evidence, failure to add intravenous iron to the standard treatment paradigm of CIA is suboptimal.

1463OPROSPECTIVE MOLECULAR EVALUATION OF SMALL CELL LUNG CANCER (SCLC) UTILIZING THE COMPREHENSIVE MUTATION ANALYSIS PROGRAM (MAP) AT MEMORIAL SLOAN KETTERING CANCER CENTER (MSKCC)

ABSTRACT Aim: Recent studies using next generation sequencing (NGS) on resected SCLC specimens have led to insights into the molecular heterogeneity of this disease. However, comprehensive, prospective molecular profiling of patients (pts) with advanced SCLC using the biopsy specimens available in clinical practice has not been performed. Methods: Utilizing an IRB-approved protocol, we prospectively are evaluating SCLC tumors (SCLC-MAP) of pts in active treatment. These biopsies are evaluated by: fluorescence in situ hybridization (FISH) for FGFR1 and MET copy number; point mutation genotyping for known oncogenes by a mass spectrometry based assay (Sequenom); and NGS with a panel of 300 cancer-related genes. We first tested the feasibility of this approach in a series of pts with SCLC identified retrospectively, with matched tumor and normal pairs, and performed NGS, confirming the findings by FISH. Results: In the feasibility cohort, 21 pts with SCLC had FFPE samples available. After histologic review and DNA extraction, 10 pts had adequate material for NGS. We observed recurrent mutations in RB1 (N=7) and TP53 (N=8) and amplifications of FGFR1 (N=2) and MET (N=1), using as little as 15 nanograms of DNA. FISH confirmed FGFR1 and MET amplification in the identified cases. Since 2/2013, SCLC pts undergoing active treatment, with sufficient archived tissue, are providing consent for SCLC-MAP. Thus far, 36 pt samples have been tested. Sequenom (N=32) identified an AKT1 E17 mutation (N=1) and a PIK3CA E542K mutation (N=1). NGS (N=25) has yielded the following: loss of RB1 (N=18 mutations; N=4 deletions); mutations in TP53 (N=24), MLL3 (N=9), and EPHA 5 (N=9); and amplifications of CDKN2C (N=5), MYCL1 (N=3), SOX2 (N=2), and FGFR1 (N=1, confirmed by FISH). 4 pts had insufficient material. Conclusions: Comprehensive molecular evaluation of SCLC is feasible on clinical specimens. Prospective collection of SCLC tumor samples and mutational analyses continue. Such analyses will allow us to characterize the molecular diversity of SCLC, identify pts who will be candidates for targeted therapies, and ascertain clinical characteristics. Funded, in part, by the Lung Cancer Research Foundation. Disclosure: All authors have declared no conflicts of interest.