Fumihiro Hommura

Randomized Phase II Trial Comparing Amrubicin With Topotecan in Patients With Previously Treated Small-Cell Lung Cancer: North Japan Lung Cancer Study Group Trial 0402

PURPOSE Amrubicin, a new anthracycline agent, and topotecan are both active for previously treated small-cell lung cancer (SCLC). No comparative study of these agents has been reported. This randomized phase II study was conducted to select amrubicin or topotecan for future evaluation. PATIENTS AND METHODS Patients with SCLC previously treated with platinum-containing chemotherapy were randomly assigned to receive amrubicin (40 mg/m(2) on days 1 through 3) or topotecan (1.0 mg/m(2) on days 1 through 5). Patients were stratified by Eastern Cooperative Oncology Group performance status (0, 1, or 2) and type of relapse (chemotherapy sensitive or refractory). The primary end point was overall response rate (ORR), and secondary end points were progression-free survival (PFS), overall survival, and toxicity profile. RESULTS From February 2004 to July 2007, 60 patients were enrolled, and 59 patients (36 patients with sensitive and 23 patients with refractory relapse) were assessable for efficacy and safety evaluation. Neutropenia was severe, and one treatment-related death owing to infection was observed in the amrubicin arm. ORRs were 38% (95% CI, 20% to 56%) for the amrubicin arm and 13% (95% CI, 1% to 25%) for the topotecan arm. In sensitive relapse, ORRs were 53% for the amrubicin arm and 21% for the topotecan arm. In refractory relapse, ORRs were 17% for the amrubicin arm and 0% for the topotecan arm. Median PFS was 3.5 months for patients in the amrubicin arm and 2.2 months for patients in the topotecan arm. Multivariate analysis revealed that amrubicin has more influence than topotecan on overall survival. CONCLUSION Amrubicin may be superior to topotecan with acceptable toxicity for previously treated patients with SCLC. Further evaluation of amrubicin for relapsed SCLC is warranted.

CD4+ T cells in cancer stroma, not CD8+ T cells in cancer cell nests, are associated with favorable prognosis in human non‐small cell lung cancers

We investigated intratumoral tumor‐infiltrating lymphocytes (TILs), including CD4+ and CD8+ T cells, in non‐small cell lung cancers (NSCLCs) and their relationships with clinicopathological variables and post‐operative survival. Tumor specimens from 178 NSCLCs were consecutively obtained by surgery at the Hokkaido University Medical Hospital between 1976 and 1994. CD8+ T cells, CD4+ T cells and Ki‐67/CD8+ T cells were visualized immunohistochemically, and counted within cancer cell nests and in cancer stroma. CD8+ T cells and CD4+ T cells were observed at higher frequencies within cancer cell nests in moderately and poorly differentiated tumors compared with well differentiated tumors (P<0.01), and in tumors with high Ki‐67 expression compared with low Ki‐67 expression (P<0.01), that showed severe cellular atypia and a higher growth rate. Patients with higher numbers of CD8+ T cells within cancer cell nests showed significantly shorter survival times compared to those with lower numbers of CD8+ T cells within cancer cell nests (5‐year survival rates, 47% and 60%, respectively; P=0.03). Moreover, patients with higher labeling index of Ki‐67/CD8+ T cells showed significantly shorter survival than those with lower labeling index of Ki‐67/CD8+ T cells within cancer cell nests (5‐year survival rates, 41% and 69%, respectively; P=0.02), and the labeling index of Ki‐67/CD8+ T cells within cancer cell nests was found to be a significant and independent unfavorable prognostic factor by multivariate analysis (P=0.01). On the other hand, higher numbers of CD4+ T cells in cancer stroma, but not within cancer cell nests, were correlated with longer survival times in patients with NSCLC (5‐year survival rates, 64% and 43%, respectively; P=0.04). CD4+ T cells in cancer stroma might reflect immune responses against cancer cells, while CD8+ T cells do not appear to work as effectors in tumor tissues of NSCLC. Moreover, the higher labeling index of Ki‐67/CD8+ T cells within cancer cell nests is a strong indicator of unfavorable clinical outcome.

HLA class I antigen expression is associated with a favorable prognosis in early stage non-small cell lung cancer

Human leukocyte antigen (HLA) class I displays a repertoire of endogenously processed peptides to CD8+ T lymphocytes. The present study assessed correlations between HLA class I expression, clinicopathologic factors, and tumor‐infiltrating immune cells in human non‐small cell lung cancers (NSCLC). Expression of HLA class I was assessed in 161 resected primary NSCLC by immunohistochemistry using EMR8–5, a novel monoclonal anti‐pan HLA class I heavy chain antibody. Expression of HLA class I was classified into three categories: strongly positive, weakly positive, or negative. Tumor‐infiltrating CD8+ lymphocytes and CD56+ natural killer cells within cancer nests and stroma were also counted. Expression of HLA class I was strongly positive in 50 tumors, weakly positive in 57 tumors, and negative in 54 tumors. Down‐regulation of HLA class I was significantly correlated with male sex, history of smoking, non‐adenocarcinoma histology, and moderate‐/low‐grade differentiation. The density of cancer nest‐infiltrating CD8+ cells in HLA class I‐negative tumors was significantly decreased compared to that in HLA class I strongly positive tumors (P < 0.01). Kaplan–Meier analysis revealed a significant favorable influence on overall survival for patients displaying tumors with strongly positive expression of HLA class I (P < 0.01). Multivariate analysis revealed down‐regulation of HLA class I as an independent factor of poor prognosis in pathological stage I patients, but not in late‐stage patients. These results suggest that down‐regulation of HLA class I expression in NSCLC is a marker of poor prognosis, and this may play a critical role in immune surveillance of patients with NSCLC. (Cancer Sci 2007; 98: 1424–1430)

Anti‐OX40 monoclonal antibody therapy in combination with radiotherapy results in therapeutic antitumor immunity to murine lung cancer

The therapeutic effect of agonistic anti‐OX40 (CD134) monoclonal antibody (mAb) in combination with radiotherapy was evaluated in a murine lung cancer model. After intradermal transplantation of ovalbumin (OVA)‐transfected Lewis lung carcinoma, C57BL/6 mice were irradiated locally with a single dose of 20 Gy in combination with an intratumoral injection of anti‐OX40 mAb at 50 µg on day 4 after transplantation, which is when the major axis of the inoculated tumor reached a diameter of 7–9 mm. On days 8, 11, and 14, the tumor‐bearing mice were further treated with the same dose of anti‐OX40 mAb. Anti‐OX40 mAb in combination with radiotherapy prolonged survival and provided greater efficacy than either single treatment against well‐established tumors. An in vivo depletion study suggested that therapeutic immunity was mainly CD8+ T‐cell dependent. OX40+CD8+ T cells were augmented in draining lymph nodes obtained from irradiated mice compared with those from non‐irradiated mice. OVA‐major histocompatibility complex tetramer+ CD8+ T cells had been strongly recruited to the draining lymph nodes obtained from mice treated with anti‐OX40 mAb in combination with radiotherapy, and strong antigen‐specific cytotoxicity was confirmed by a 51Cr‐release assay. Moreover, a tumor‐rechallenge model indicated that this combination therapy induced durable tumor immunity. Thus, anti‐OX40 mAb in combination with radiotherapy may potentially help the management of patients with lung cancer. (Cancer Sci 2008; 99: 361–367)

Cyclin D1 expression in non-small-cell lung cancers : its association with altered p53 expression, cell proliferation and clinical outcome

SummaryCyclin D1, like p16INK4 (p16) and retinoblastoma (RB) proteins, participates in the cell cycle control at the G1–S transition. We have previously demonstrated altered p16 and RB protein status in non-small-cell lung cancers (NSCLCs) and their potential synergistic effect with altered p53 protein on proliferative activity (Kinoshita et al (1996) Cancer Res 56: 5557–5562). In the present study, cyclin D1 expression was studied by immunohistochemistry in the same cohort of 111 resected NSCLCs as in our previous study, and the amount of the cyclin D1 gene was analysed by Southern blot analysis in 29 NSCLCs. Cyclin D1 expression was analysed in relation to the status of p53, p16 and RB proteins, and proliferative activity determined by the Ki-67 index. It was also analysed in relation to survival of 77 patients with NSCLCs which were potentially curatively resected between 1990 and 1995. We found that: (1) cyclin D1 was expressed in 13 (11.7%) of 111 NSCLCs; (2) the cyclin D1 gene was neither significantly amplified nor rearranged; (3) cyclin D1 expression significantly correlated with altered p53 protein expression (P = 0.04), whereas it did not correlate with p16 and RB protein status; (4) proliferative activity tended to be higher in cyclin D1-positive (+) tumours than in cyclin D1-negative (–) tumours, although this difference was not statistically significant (P = 0.08); and (5) patients with cyclin D1+ tumours survived longer than patients with cyclin D1– tumours (5-year survival rates, 89% and 64% respectively, by the Kaplan–Meier method; P = 0.045 by the log-rank test), and cyclin D1 expression tended to be a favourable prognostic factor (P = 0.08 in univariate analysis). These findings suggest the involvement of cyclin D1 in the development and progression of NSCLCs, their proliferative activity and clinical outcome of NSCLC patients.

Predictive value of expression of p16INK4A, retinoblastoma and p53 proteins for the prognosis of non-small-cell lung cancers.

The predictive value of expression of p16INK4A, retinoblastoma (Rb) and p53 proteins for prognosis was evaluated in 76 patients with non-small-cell lung cancers (NSCLCs) that were potentially curatively resected between 1990 and 1995, using the results of immunostaining analyses of these proteins as reported in our previous study (Kinoshita et al, 1996). Of these NSCLCs, 22 (29%) lacked p16 protein expression and eight (11%) Rb protein, while 30 (39%) showed positive (altered) p53 protein expression. Survival of patients with p16-negative tumours was not significantly different from that of patients with p16-positive tumours (5-year survival rates 67% and 72% respectively, P = 0.8), nor was survival of patients with Rb-negative tumours significantly different from that of patients with Rb-positive tumours (5-year survival rates 42% and 69% respectively, P = 0.9). Moreover, survival of patients with p16/Rb-negative (either p16- or Rb-negative) tumours was not significantly different from that of patients with p16/Rb-positive (both p16- and Rb-positive) tumours (5-year survival rates 67% and 68% respectively, P = 0.7). In contrast, survival of patients with p53-positive (altered) tumours tended to be shorter than that of patients with p53-negative (unaltered) tumours (5-year survival rates 56% and 78% respectively, P = 0.06). In univariate analysis of potential prognostic factors, p16, Rb and p16/Rb proteins were not significant prognostic factors in the present cohort of potentially curatively resected NSCLCs. Altered p53 protein status tended to be a negative prognostic factor (P = 0.06 by the univariate analysis). These results indicate that loss of p16 protein alone, or in combination with loss of Rb protein, does not predict the clinical outcome of patients with resected NSCLCs.

RCAS1 expression : a potential prognostic marker for adenocarcinomas of the lung

Objective: RCAS1 (receptor-binding cancer antigen expressed on SiSo cells) is a new tumor-associated antigen recognized by 22-1-1 monoclonal antibody. RCAS1 expressed on human cancer cells acts as a ligand for a putative receptor present on peripheral lymphocytes. RCAS1 has been shown to inhibit the in vitro growth of receptor-expressing cells and to induce apoptosis, which may contribute to the ability of tumor cells to evade host immune surveillance. In this study, we evaluated the prognostic significance of RCAS1 expression in primary lung adenocarcinomas. Methods: Immunohistochemical analysis was performed on tissue specimens surgically obtained from 102 patients with primary lung adenocarcinomas. Then, the association of RCAS1 expression with clinicopathological variables and prognosis of patients were analyzed. Results: Of 102 lung adenocarcinomas, positive RCAS1 expression was observed in 82 cases (80%). There was no correlation between RCAS1 expression and clinicopathological variables. In 70 potentially curatively resected lung adenocarcinomas, patients with RCAS1-positive tumors had a significantly shorter survival than those with RCAS1-negative tumors (p = 0.02), and RCAS1 expression was a significant and independent prognostic factor by multivariate analysis (p = 0.03). Conclusions: These results indicate that RCAS1 expression predicts prognosis in patients with lung adenocarcinomas, and this new antigen could be a novel tumor marker which reflects the clinical outcome of lung cancers.

A Phase II Study of Amrubicin as a Third-Line or Fourth-Line Chemotherapy for Patients With Non-Small Cell Lung Cancer: Hokkaido Lung Cancer Clinical Study Group Trial (HOT) 0901

Amrubicin, a third-generation synthetic anthracycline agent, has favorable clinical activity and acceptable toxicity for the treatment of patients with non-small cell lung cancer (NSCLC) and small cell lung cancer. We conducted this study to evaluate the efficacy and safety of amrubicin for advanced NSCLC patients as a third- or fourth-line therapy. Eligible patients had recurrent or refractory advanced NSCLC after second- or third-line therapy. Patients received amrubicin, 35 mg/m(2) i.v. on days 1-3 every 3 weeks. The primary endpoint was the disease control rate (DCR). Secondary endpoints were the overall survival (OS) time, progression-free survival (PFS) time, response rate, and toxicity profile. Of the 41 patients enrolled, 26 received amrubicin as a third-line and 15 received it as a fourth-line therapy. The median number of treatment cycles was two (range, 1-9). Objective responses were complete response (n = 0), partial response (n = 4), stable disease (n = 21), progressive disease (n = 15), and not evaluable (n = 1), resulting in a DCR of 61.0% (95% confidence interval, 46.0%-75.9%). The overall response rate was 9.8% (95% confidence interval, 0.6%-18.8%). The median PFS interval was 3.0 months, median OS time was 12.6 months, and 1-year survival rate was 53.7%. Grade 3 or 4 hematological toxicities were neutropenia (68%), anemia (12%), thrombocytopenia (12%), and febrile neutropenia (17%). Nonhematological toxicities were mild and reversible. No treatment-related deaths were observed. Amrubicin showed significant clinical activity with manageable toxicities as a third- or fourth-line therapy for patients with advanced NSCLC. This study provides relevant data for routine practice and future prospective trials evaluating third- or fourth-line treatment strategies for patients with advanced NSCLC.

Phase I study of amrubicin and vinorelbine in non-small cell lung cancer previously treated with platinum-based chemotherapy

BackgroundCombination chemotherapy comprising amrubicin and vinorelbine as a second-line therapy for advanced non-small cell lung cancer (NSCLC) has not been fully evaluated. To determine the maximum tolerated dose (MTD) and recommended dose (RD), the present phase I study examined patients with advanced NSCLC.MethodsThe subjects were nine patients with histologically confirmed advanced NSCLC, Eastern Cooperative Oncology Group performance status 0–1, prior platinum-based first-line chemotherapy, and measurable or evaluable lesions. Treatment consisted of five dose levels, with amrubicin 35–45 mg/m2 administered as a 5-min intravenous infusion on days 1–3 and vinorelbine 15–25 mg/m2 given as a 1-h intravenous infusion on days 1 and 8, every 3 weeks.ResultsAll patients had received carboplatin and paclitaxel as first-line therapy. Dose-limiting toxicity (DLT) was seen in two of six patients (febrile neutropenia and deep vein thrombosis ) at level 1, allowing us to conduct level 2. At level 2, all three patients experienced DLT (leucopenia ≥4 days in one patient; febrile neutropenia in three patients; and infection in two patients), and this level was determined as the MTD. Subsequently, level 1 (amrubicin 35 mg/m2 and vinorelbine 15 mg/m2) was defined as the RD. Responses in the nine patients included a partial response in one patient and stable disease in four patients.ConclusionAs second-line therapy, the RD of the combination of amrubicin and vinorelbine is 35 mg/m2 and 15 mg/m2, respectively. Further study should proceed to clarify the efficacy of this regimen.