Bernardo Garicochea

Sorafenib in Combination With Capecitabine: An Oral Regimen for Patients With HER2-Negative Locally Advanced or Metastatic Breast Cancer

PURPOSE Sorafenib is a multikinase inhibitor with antiangiogenic/antiproliferative activity. A randomized, double-blind, placebo-controlled phase IIB trial assessed sorafenib with capecitabine for locally advanced or metastatic human epidermal growth factor receptor 2 (HER2) -negative breast cancer. PATIENTS AND METHODS Patients were randomly assigned to first- or second-line capecitabine 1,000 mg/m(2) orally twice a day for days 1 to 14 of every 21-day cycle with sorafenib 400 mg orally twice a day or placebo. The primary end point was progression-free survival (PFS). RESULTS In total, 229 patients were enrolled. The addition of sorafenib to capecitabine resulted in a significant improvement in PFS versus placebo (median, 6.4 v 4.1 months; hazard ratio [HR], 0.58; 95% CI, 0.41 to 0.81; P = .001) with sorafenib favored across subgroups, including first-line (HR, 0.50; 95% CI, 0.30 to 0.82) and second-line (HR, 0.65; 95% CI, 0.41 to 1.04) treatment. There was no significant improvement for overall survival (median, 22.2 v 20.9 months; HR, 0.86; 95% CI, 0.61 to 1.23; P = .42) and overall response (38% v 31%; P = .25). Toxicities (sorafenib v placebo) of any grade included rash (22% v 8%), diarrhea (58% v 30%), mucosal inflammation (33% v 21%), neutropenia (13% v 4%), hypertension (18% v 12%), and hand-foot skin reaction/hand- foot syndrome (HFSR/HFS; 90% v 66%); grade 3 to 4 toxicities were comparable between treatment arms except HFSR/HFS (44% v 14%). Reasons for discontinuation in the sorafenib and placebo arms included disease progression (63% v 82%, respectively), adverse events (20% v 9%, respectively), and death (0% v 1%, respectively). CONCLUSION Addition of sorafenib to capecitabine improved PFS in patients with HER2-negative advanced breast cancer. The dose of sorafenib used in this trial resulted in unacceptable toxicity for many patients. A phase III confirmatory trial has been initiated with a reduced sorafenib dose.

Reverse transcriptase-polymerase chain reaction analysis of cytokeratin 19 expression in the peripheral blood mononuclear cells of normal female blood donors.

BACKGROUND: Early detection of haematogenous dissemination of epithelial tumours afforded by the analysis of epithelial antigen expression in the peripheral blood mononuclear fraction (PBMN) and bone marrow may confer a worse prognosis to patients with carcinoma. Cytokeratin 19 is a protein normally expressed by epithelial cells including normal and malignant mammary cells. Previous studies have demonstrated that analysis of cytokeratin 19 expression by the reverse transcriptase-polymerase chain reaction (RT-PCR) can detect one epithelial cell in as many as 10(5)-10(7) haematopoetic cells. Despite its sensitivity concern has been voiced recently about the specificity of this technique owing to the detection of cytokeratin 19 expression in the PBMN of normal volunteers and the bone marrow of patients with haematological malignancies. AIMS: To assess the sensitivity and specificity of RT-PCR detection of cytokeratin 19 in PBMN of normal female blood donors. METHODS: Blood was taken from 52 normal female blood donors and PBMN separated through Fycol gradient centrifugation. Cytokeratin 19 was measured using a two step nested RT-PCR assay. RESULTS: No amplification was found in the first step for any of the samples studied, whereas in the second step amplification was observed in 10 of the 52 samples. Both steps could detect one MCF-7 cell (the cytokeratin 19 positive control) in 10(6) CEM (cytokeratin 19 negative control) cells. CONCLUSIONS: As both PCR steps are sensitive to the 10(-6) level, performing only the first amplification step may decrease the non-specificity of this method. Further studies are needed to define the specificity and sensitivity of this technique in blood and bone marrow specimens of women with breast cancer.

Mutational analysis of N-RAS and GAP-related domain of the neurofibromatosis type 1 gene in chronic myelogenous leukemia

RAS mutations can be detected in a variable number of patients with myeloproliferative disorders such as myelodysplastic syndromes and acute myeloid leukemia, but are rare events in chronic myelogenous leukemia in chronic phase. However, there is good evidence supporting the involvement of RAS signalling pathway in CML and this could be due to alterations in RAS activity regulatory proteins. The neurofibromatosis (NF1) gene down-regulates the RAS signal transduction pathway through the inhibitory function of its GAP-related domain (GRD) on RAS protein. The loss or alteration of neurofibromin (the NF1 protein) may produce a disfunction similar to point mutations in the RAS gene resulting in the permanent stimulation of the RAS signal transduction pathway. Mutations involving the GRD region of the NF1 gene (GRD-NF1) have been described in a variety of tumors such as colon carcinoma and astrocytoma. Germline mutations and deletions in the NF1 gene, as seen in neurofibromatosis type 1, are also associated with certain myeloid disorders. In the present work, we sought to identify mutations in the codons 12/13 and 61 of RAS gene and in the Lys-1423 codon of GRD-NF1, which are well known hot spots in these genes, in a group of 36 adults and ten children with chronic myelogenous leukemia in chronic phase and blast crisis. Using the PCR-SSCP and the allele-specific restriction assay (ASRA) techniques, we were not able to observe any RAS or NF1 detectable mutation. These findings suggest that RAS and GRD-NF1 mutations are not involved either in chronic phase or in the progression to blast crisis in chronic myelogenous leukemia in adults and children.

The germline mutational landscape of BRCA1 and BRCA2 in Brazil

The detection of germline mutations in BRCA1 and BRCA2 is essential to the formulation of clinical management strategies, and in Brazil, there is limited access to these services, mainly due to the costs/availability of genetic testing. Aiming at the identification of recurrent mutations that could be included in a low-cost mutation panel, used as a first screening approach, we compiled the testing reports of 649 probands with pathogenic/likely pathogenic variants referred to 28 public and private health care centers distributed across 11 Brazilian States. Overall, 126 and 103 distinct mutations were identified in BRCA1 and BRCA2, respectively. Twenty-six novel variants were reported from both genes, and BRCA2 showed higher mutational heterogeneity. Some recurrent mutations were reported exclusively in certain geographic regions, suggesting a founder effect. Our findings confirm that there is significant molecular heterogeneity in these genes among Brazilian carriers, while also suggesting that this heterogeneity precludes the use of screening protocols that include recurrent mutation testing only. This is the first study to show that profiles of recurrent mutations may be unique to different Brazilian regions. These data should be explored in larger regional cohorts to determine if screening with a panel of recurrent mutations would be effective.

Abstract LB-055: Overall survival and safety experience from an expanded access program (EAP) of nivolumab (NIVO) for patients with advanced melanoma (MEL) who progressed after prior ipilimumab (IPI) treatment

Background: NIVO (anti-PD-1) was initially approved in the USA as a second-line treatment for MEL based on the results of the phase III CheckMate 037 trial, which enrolled patients (pts) who progressed after prior IPI (anti-CTLA-4) therapy. The results of this trial showed a significantly improved tumor response with NIVO vs. chemotherapy; at a minimum follow-up of 2 years, grade 3/4 treatment-related adverse events (AEs) were reported in 14% of NIVO-treated pts. We report initial overall survival (OS) and safety data from an ongoing EAP of NIVO monotherapy in MEL pts who progressed on IPI therapy (CheckMate 168). Participating countries are Brazil, Canada, the USA, and Argentina. Methods: In CheckMate 168 (NCT02142218), pts with stage III (unresectable) or stage IV MEL who progressed after prior IPI-containing therapy, with an ECOG performance status of 0 or 1, are eligible to receive NIVO 3 mg/kg Q2W for up to 24 months. Key exclusion criteria are active brain metastases, prior immune checkpoint inhibitor therapy other than anti-CTLA-4, and autoimmune disease. For the current analysis, the database lock occurred on November 1, 2016, and included 276 pts with at least 1 year of follow-up (total enrolled: 482). Results: Among the 276 pts included in the current analysis, MEL subtypes were cutaneous (70%), mucosal (8%), acral (5%), uveal (5%), and other or missing (12%). More than half of the pts (55%) had M1c disease (13% with treated brain metastases and 42% without), and 41% had elevated lactate dehydrogenase levels at baseline. Pts had received 1 (21%), 2 (42%) or ≥3 (37%) prior systemic therapies for MEL, which included prior BRAF inhibitor therapy in 24% of pts (in addition to IPI). In the EAP, pts received a median of 8 NIVO doses (range: 1-48), with a median duration of therapy of 3.8 months (range: 0.03-22.1). Median OS in the 276 pts was 14.6 months (95% CI: 11.8-21.2), with a 1-year OS rate of 55.8% (95% CI: 49.2-61.8). Treatment-related AEs of any grade were reported in 69% of pts, most commonly fatigue (24%), diarrhea (17%), nausea (13%), and pruritus (12%), and led to discontinuation of NIVO in 8% of pts. Treatment-related AEs of grade 3/4 occurred in 15% of pts, and led to discontinuation of NIVO in 4% of pts. Any-grade serious AEs related to NIVO treatment were reported in 8% of pts. One death (0.4%) was attributed to study drug (toxic encephalopathy). For treatment-related AEs of potential immunologic origin, those of any grade occurred most commonly in the skin (33%), gastrointestinal tract (18%), and endocrine systems (14%). Conclusions: The initial OS and safety experience from this EAP of NIVO after IPI therapy is consistent with clinical trial data, with no unexpected AEs. These findings suggest that NIVO clinical trial data can be generalized to the advanced melanoma population in a routine clinical practice setting. Citation Format: Milton Barros e Silva, Rafael Schmerling, Andreia Cristina de Melo, Sergio Azevedo, Bernardo Garicochea, Elaine McWhirter, Michael Smylie, Markus Gifoni, Carlos Henrique dos Anjos, Teresa Petrella, Matias Chacon, Martin Greco, Suresh Nair, Alexandre Avila, Sheena Demelo, Joel Jiang, Scott Ernst. Overall survival and safety experience from an expanded access program (EAP) of nivolumab (NIVO) for patients with advanced melanoma (MEL) who progressed after prior ipilimumab (IPI) treatment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr LB-055. doi:10.1158/1538-7445.AM2017-LB-055

Angioimmunoblastic T-Cell Lymphoma: Clinical Aspects and Recent Advances in Biology and Therapy

Angioimmunoblastic T-cell lymphoma (AITL) comprehends 20% of the peripheral T-cell lymphomas (PTCL). Although rare, its clinical features may overlap with many other inflammatory, infectious or neoplastic disorders. Therefore, that patients are often diagnosed with advanced stage disease, which contributes for the disease´s dismal prognosis. The clinical presentation of AITL is frequently an assemblage of symptoms including generalized and painful lymphadenopathy, multiple cutaneous alterations, hypergammaglobulinemia, fever, loss of weight and significant autoimmune phenomena. Recent advances in AITL biology have implicated a cell with T-follicular helper phenotype as the origin of the disorder. This rare type of T lymphocyte has a peculiar capacity of interact with microenviroment, which results in an important production of cytokines, explaining the clinical findings of this type of lymphoma. In addition to its pathologic features, AITL can be distinguished from other T-cell lymphomas based on gene expression arrangement, suggesting that AITL has a unique biology. Moreover, somatic mutations in the epigenetic regulators DNMT3A, TET2, IDH2, and, especially, in the multifunctional RHOA GTPase gene, have emerged as very consistent genetic abnormalities in AITL. Considering its low incidence, the development of clinical trials in AITL is a challenging matter. Furthermore, the majority of data available originates from studies that contain other subtypes of PTCL, making prognosis analysis and treatment decision a tough work. In this review, we discuss the biological and clinical aspects of AITL and the alternatives for frontline treatment and the management of relapsed disease.

Familial Lymphoproliferative Malignancies and Tandem Duplication of NF1 Gene

Background. Neurofibromatosis type 1 is a genetic disorder caused by loss-of-function mutations in a tumor suppressor gene (NF1) which codifies the protein neurofibromin. The frequent genetic alterations that modify neurofibromin function are deletions and insertions. Duplications are rare and phenotype in patients bearing duplication of NF1 gene is thought to be restricted to developmental abnormalities, with no reference to cancer susceptibility in these patients. We evaluated a patient who presented with few clinical signs of neurofibromatosis type 1 and a conspicuous personal and familiar history of different types of cancer, especially lymphoproliferative malignancies. The coding region of the NF-1 gene was analyzed by real-time polymerase chain reaction and direct sequencing. Multiplex ligation-dependent probe amplification was performed to detect the number of mutant copies. The NF1 gene analysis showed the following alterations: mosaic duplication of NF1, TRAF4, and MYO1D. Fluorescence in situ hybridization using probes (RP5-1002G3 and RP5-92689) flanking NF1 gene in 17q11.2 and CEP17 for 17q11.11.1 was performed. There were three signals (RP5-1002G3conRP5-92689) in the interphases analyzed and two signals (RP5-1002G3conRP5-92689) in 93% of cells. These findings show a tandem duplication of 17q11.2. Conclusion. The case suggests the possibility that NF1 gene duplication may be associated with a phenotype characterized by lymphoproliferative disorders.