Giovanni Benedetti

Phase III Trial of Infusional Fluorouracil, Leucovorin, Oxaliplatin, and Irinotecan (FOLFOXIRI) Compared With Infusional Fluorouracil, Leucovorin, and Irinotecan (FOLFIRI) As First-Line Treatment for Metastatic Colorectal Cancer: The Gruppo Oncologico Nord Ovest

PURPOSE The Gruppo Oncologico Nord Ovest (GONO) conducted a phase III study comparing fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI [irinotecan 165 mg/m2 day 1, oxaliplatin 85 mg/m2 day 1, leucovorin 200 mg/m2 day 1, fluorouracil 3,200 mg/m2 48-hour continuous infusion starting on day 1, every 2 weeks]) with infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI). METHODS Selection criteria included unresectable metastatic colorectal cancer, age 18 to 75 years, and no prior chemotherapy for advanced disease. The primary end point was response rate (RR). RESULTS A total of 244 patients were randomly assigned. An increase of grade 2 to 3 peripheral neurotoxicity (0% v 19%; P < .001), and grade 3 to 4 neutropenia (28% v 50%; P < .001) were observed in the FOLFOXIRI arm. The incidence of febrile neutropenia (3% v 5%) and grade 3 to 4 diarrhea (12% v 20%) were not significantly different. Responses, as assessed by investigators, were, for FOLFIRI and FOLFOXIRI, respectively, complete, 6% and 8%; and partial, 35% and 58%, (RR, 41% v 66%; P = .0002). RR confirmed by an external panel was 34% versus 60% (P < .0001). The R0 secondary resection rate of metastases was greater in the FOLFOXIRI arm (6% v 15%; P = .033, among all 244 patients; and 12% v 36%; P = .017 among patients with liver metastases only). Progression-free survival (PFS) and overall survival (OS) were both significantly improved in the FOLFOXIRI arm (median PFS, 6.9 v 9.8 months; hazard ratio [HR], 0.63; P = .0006; median OS, 16.7 v 22.6 months; HR, 0.70; P = .032). CONCLUSION The FOLFOXIRI regimen improves RR, PFS, and OS compared with FOLFIRI, with an increased, but manageable, toxicity in patients with metastatic colorectal cancer with favorable prognostic characteristics. Further studies of FOLFOXIRI in combination with targeted agents and in the neoadjuvant setting are warranted.

Phase II study of gemcitabine–cisplatin–paclitaxel triplet as induction chemotherapy in inoperable, locally-advanced non-small cell lung cancer

PURPOSE Our objective was to determine the activity in terms of response rate, surgical resectability, and the tolerability of the new three-drug combination gemcitabine-cisplatin-paclitaxel (GCP) in unresectable stage IIIA(N2) and IIIB non-small cell lung cancer (NSCLC). PATIENT AND METHODS Forty-two chemo-naive patients with stage IIIA(N2)-IIIB NSCLC, median age of 59 years, Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, and the ability to tolerate pneumectomy, received gemcitabine (Gem) 1000 mg/m(2) IV days 1 and 8, cisplatin (CDDP) 50 mg/m(2) IV days 1 and 8, paclitaxel 125 mg/m(2) 1h infusion IV days 1 and 8, every 21 days for 3 cycles. After induction chemotherapy, patients were evaluated for surgery or definitive radiotherapy. RESULTS Grade 3-4 neutropenia was the main hematologic toxicity, occurring in 28% of patients. Grade 3-4 thrombocytopenia was observed in only 11% of cases. No neutropenic fever or bleeding episodes were recorded. Severe non-hematologic toxicity was uncommon. Thirty (71%, 95% CI: 57.2-84.7%) of the 42 eligible patients had objective responses (1 complete and 29 partial responses). After induction chemotherapy, 21 patients (50%) went to surgery. Complete resection was obtained in 16 patients (38%). Viable tumor was present in 18 of 21 resection specimens. In three cases only necrotic tumor cells were identified, for a pathological complete response of 7%. With a median follow-up of 13.9 months, median time to progression was 17.4 months, median survival 21.7 months and estimated 1-year survival 92%. CONCLUSIONS GCP combination is active and well tolerated in locally-advanced, non-resectable NSCLC. The activity profile, in terms of response and surgical resection rate, is comparable to that obtained with standard doublets.

Epidermal Growth Factor Receptor Exon 19 Deletions Predict Complete Regression of Multiple Intracranial Metastases in Two Cases of Non-small Cell Lung Cancer Treated with Erlotinib

To the Editor: The incidence of intracranial metastases in non-small cell lung cancer (NSCLC) is increasing as a result of both advances in neuroimaging and increased survival, and a synchronous presentation with the primary lung disease is not uncommon. Whole-brain radiation therapy (WBRT) can prolong the median survival by only 1 to 3 to 6 months, and chemotherapeutic regimens have response rates below 20%, with median survivals of 4 to 6.5 months.1 Recently, Caucasian patients treated with Gefitinib or Erlotinib have experienced unexpected activity against brain metastases, revealing the ability of small-molecule tyrosine kinase inhibitors (TKIs) to cross the blood brain barrier. Phase II trials using Gefitinib or Erlotinib for NSCLC harboring epidermal growth factor receptor (EGFR) mutations have recently shown a higher response rate for metastases to all sites, included multiple intracranial lesions.2 The Spanish Lung Cancer Group monitored a subgroup of chemotherapy-naive, EGFRmutated NSCLC patients with intracranial lesions who were treated with erlotinib: four complete responses and three partial responses were reported.3 Fekrazad et al.4 published a case of a nonsmoking native American woman who had a complete and continued regression of the brain metastases from a lung adenocarcinoma using Erlotinib, whereas WBRT had failed to control the same lesions. The primary lung tumor mass was partially controlled. However, these authors did not analyze EGFR mutations. Numerous studies have analyzed the prognostic and predictive significance of the mutational spectrum of EGFR. Murray et al.5 described an analytical database of 12,244 patients with 3381 somatic EGFR mutations They catalogued mainly the somatic mutational spectrum of exons 18–21 of EGFR, with 50% of the mutations being exon 19 deletions or deletional insertions. A clear association between EGFR mutations and a response to TKIs was confirmed, but no specific behavior regarding intracranial metastases was identified. Moreover, there is no specific analysis that correlates treatment with TKIs and the response at a particular disease site, although observations of this phenomenon are accumulating. Here, we report two cases of NSCLC in which the EGFR exon 19 deletion predicted complete regression of multiple intracranial metastases treated with Erlotinib. Case 1 was a 44-year-old, nonsmoking man who underwent total body computed tomography (CT) because he developed sudden right hemiplegia. A 2.7-cm tumor in the left lung with concomitant bilateral parenchymal metastases and synchronous multiple intracranial metastases (MIMs) ranging in size from 1 to 3.3 cm were found (Figure 1A). Adenocarcinoma of the lung was diagnosed after a transbronchial biopsy. The patient refused WBRT, and the cisplatin and etoposide chemotherapy was stopped at the second cycle because of an anaphylactic reaction. At that time, both the lung and intracranial lesions persisted unchanged, as shown by CT. A new sample of tumor tissue was obtained, and the molecular analysis identified the L747-P753 deletion of EGFR exon 19. Erlotinib 150 mg/d was administered orally with no clinically relevant side effects, except a mild skin rash. After 6 months, all of the intracranial lesions had disappeared, although a fibrotic image remained in the left lung on positron emission tomography-CT (Figures 1A, B). The patient died 15 months later from a relapse and disease progression. No data were available regarding a possible T790M EGFR gene mutation. Case 2 was a 48-year-old, Caucasian woman who smoked and presented with a lung neoplasm, synchronous metastases to the liver, spleen, and bones, and MIMs. Histologically, a transbronchial fine-needle aspiration showed large cell carcinoma of the lung. The patient was treated with four cycles of cisplatin plus fotemustine, followed by WBRT. Stable disease was obtained. However, 3 months later, disease progression was documented on CT scan, and the levels of the serological tumor markers CEA and CA-125 were 115 g/ml and 494 U/ml, respectively. Molecular analysis of a tumor sample showed an EGFR deletion in exon 19 (K745_E749del). Subsequently, the patient was given Erlotinib 150 mg/d orally beginning in February 2007. Four months later, the MIMs had disappeared completely, and the lung, bone, liver, and spleen metastases had regressed partially. The CEA and CA-125 fell to normal levels. The disease had remained stable at the last follow-up visit, after 24 months of Erlotinib treatment. These experiences confirm that intracranial NSCLC metastases can regress completely and for long time after treatment with Erlotinib in cases in which standard systemic chemotherapy and radiation therapy were useless. This is striking, because until now the central nervous system has been considered a sanctuary limiting the activity of all medical oncology strategies. Moreover, Erlotinib seems to be site specific for intracranial metastases harboring EGFR exon 19 deletions. Perspective studies in selected patients are needed to confirm these observations. In addition, it would Disclosure: None of the authors have any actual or potential conflict of interest including any financial, personal, or other relationships with other people or organizations within 3 years of beginning the work submitted that could inappropriately influence our work. Address for correspondence: Giovanni Benedetti, MD, U.O. Oncologia Ospedale di Macerata, via Santa Lucia 1, 62100 Macerata, Italy. Email: gbenedetti@asl9.marche.it The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, see: http://www.textcheck.com/certificate/j5LnTM. Copyright

PRESENTATION OF NONSEMINOMATOUS GERM CELL TUMOR OF THE TESTIS WITH SYMPTOMATIC SOLITARY BONE METASTASIS. A CASE REPORT WITH REVIEW OF THE LITERATURE

Metastatic bone lesions are exceptional at diagnosis in germ cell tumors (GCTs). Bone involvement is usually a late event combined with synchronous metastasis in the retroperitoneal lymph nodes, lung and liver. Bone examination is not considered a standard procedure in the staging of GCTs, and this may contribute to underestimation of the real proportion of bone metastases. Here we report a case of nonseminomatous GCT of the testis with a synchronous, symptomatic, solitary pubic bone metastasis that was completely controlled by systemic chemotherapy and locoregional radiation therapy. Solitary bone metastases from GCTs seem to be chemosensitive and radiosensitive, but we do not know their prognostic value. We reviewed the literature where 3 similar cases have been reported. We propose individualized management for symptomatic GCT patients including bone scintigraphy and/or PET examination at diagnosis and a combined cytotoxic approach with chemotherapy and radiation therapy

Retinal metastasis regression with eribulin in a heavily pretreated breast cancer patient

The authors present the case of a heavily pretreated young woman with retinal and brain metastases from breast cancer who was successfully treated with eribulin. Eribulin was given at 1.1 mg/m(2) on day 1 and 8, every 3 weeks for a total of 12 courses. A significant reduction in the size of brain and retinal lesions was achieved after three cycles. The treatment was continued for 12 cycles, with a good profile of tolerability. In this clinical case, eribulin demonstrated to be active on brain and retinal metastases from breast cancer, although preclinical data showed limited ability to cross the blood-brain barrier.

Cardiotoxicity related to long-term trastuzumab therapy in metastatic breast cancer: the potential role of treatment duration and cardiac risk factors.

To the Editor: Since its approval, trastuzumab (Herceptin, F. Hoffmann-La Roche Ltd., Basel Switzerland) has dramatically improved outcomes of patients with Human Epidermal growth factor Receptor 2 (HER2+) metastatic breast cancer (MBC) and has ushered in a new era in clinical practice, providing innovative insights on long-term treatment (1–3). Indeed, several studies have shown that long-term HER2 suppression should be maintained in HER2+ MBC both beyond disease response(4,5) and progression (6,7). Therefore, a growing number of patients have been receiving longterm trastuzumab administration, as maintenance monotherapy or in combination with multiple lines of chemotherapy. However, over the last 10 years, trastuzumab cardiotoxicity, ranging from asymptomatic left ventricular dysfunction to congestive heart failure (1,8,9), has emerged as a critical concern. Differently than anthracycline, trastuzumab cardiotoxicity is neither dose-related nor cumulative and appears generally reversible (6). Its pathogenesis seems partly due to antibody-directed cellular cytotoxicity, to HER2 downregulation in cardiomyocites and, as recently demonstrated, to destabilization of mitochondrial membrane with Adenosin Triphosphate depletion and subsequent cardiomyocite contractile dysfunction (4). The large trastuzumab adjuvant trials, including the recent analysis of 2-year arm of HERA trial, showed a low incidence of Cardiac Events (CEs) during adjuvant trastuzumab and demonstrated that the cumulative incidence of CEs tends to plateau after treatment completion, thus suggesting that cardiotoxicity occurs early and mainly while on treatment (5,9). However, these data refer to patients strictly selected on the basis of cardiac risk factors and exposed to trastuzumab for a well-defined time. Conversely, in metastatic setting the cardiac safety of prolonged trastuzumab administration have yet to be clarified, despite an increasing number of patients having received trastuzumab for several years. Data on incidence, onset, and outcome of cardiotoxicity in MBC patients receiving long-term trastuzumb therapy are lacking. Notably, very few studies have weighed benefits and cardiac harms of prolonged trastuzumab therapies in a “real world” MBC population, in which comorbidities, previous treatments and general aging could represent heavy cardiac risk factors (7,10–12). To determine whether duration of trastuzumab and the presence of cardiac risk factors can affect the cardiac safety of trastuzumab in metastatic setting, we conducted a retrospective analysis of 62 HER2+ MBC patients treated with trastuzumab and at least one concomitant chemotherapy regimen at our Institution from December 2003 to June 2012. The median age was 52 years (range 29–76 years); the median cumulative time receiving trastuzumab resulted 29.5 months (range 3–99 months). Forty patients (64.5%) received trastuzumab without interruption from the diagnosis of MBC, for a median time of 29 months (range 3–99 months); in the remaining patients 1 or 2 interruptions were recorded with a median interruption time of 7 months (range 2–30 months). According to previous published data (9,10), we evaluated, in univariate and multivariate Cox regression analysis, the following variables as potential cardiac risk factors: age at start of trastuzumab, body mass index (BMI, <25 versus ≥25 kg/m), antihypertensive therapy, history of cardiac disease, diabetes, smoking, radiotherapy on the left chest wall, prior exposure to anthracyclines, baseline Left Ventricular Ejection Fraction (LVEF), continued/interrupted trastuzumab exposure and duration of concomitant exposure to chemotherapy and trastuzumab. In univariate analysis Address correspondence and reprint requests to: Barbara Pistilli, Oncology Unit, ASUR Marche 3, Macerata Hospital, Via S. Lucia, 1, Macerata 62100, Italy, or e-mail: barbara.pistilli@sanita.marche.it

Abstract P2-06-05: Expression of the pluripotency transcription factor SOX2 in primary breast cancers (BCs): Correlation with clinicopathological features (CPfs) and recurrence

BACKGROUND SOX2 is one of the pluripotency transcription factors expressed by stem cells, which plays a central role in controlling the expression of genes implicated in embryonic development and stemness manteinance. Key regulators of embryonic stem cell (ESC) identity, such as NANOG, SOX2, OCT4 and GDF3 resulted overexpressed in a variety of solid tumors with a possible role in cancer progression and prognosis. SOX2 expression has mainly been reported in basal-like BC subtype, suggesting a role in conferring a less differentiated phenotype. In our analysis we evaluated a heterogenous group of BC tissues to determine whether the expression of ESC-regulating genes correlated with CPfs and recurrence. METHODS 140 primary invasive BC specimens were collected from 137 female patients who underwent surgery. mRNA expression for SOX2, OCT4, NANOG, GDF3 genes was assessed by RT-PCR. Immunoistochemistry (IHC) was performed for SOX2 with mouse monoclonal antibody (1:50, Y17, Santa Cruz Biotechnology, USA). Correlations with molecular subtypes, menopausal status, grading, ER, PR, ki67 (≤ 20% and > 20%), HER2, T-size and node status were evaluated by Fisher9s exact test and χ2 test. Association of ESC-genes, CPfs and DFS was estimated by univariate and multivariate Cox-regression analysis (p≤ 0.05). Survival analysis (DFS and OS) were calculated by Kaplan-Meier curves and compared by log-rank test. RESULTS In 117 samples assessable by RT-PCR the genes resulted expressed as follows: NANOG=52 (44.5%), SOX2=11 (9.4%), GDF3=9 (7.2%), OCT-4=0. Correlation of mRNA gene expression with CPfs was statistically significant between NANOG and grade 2, GDF3 and node-negative status, SOX2 and higher ki67 (p=0.019, p=0.029, p= 0.035, respectively). Six out of 11 SOX2+ tumors were HER2+ (data not statistically significant); in the remaining 5 samples the fluorescence in situ hybridization was performed but no HER2 amplification was detected. At univariate analysis of DFS, SOX2 expression (HR=2,36; p=0.002), ki67 (HR= 2,19; p=0,028), T-size >1 (HR=2,06; p=2.011), node-status (HR=2,21; p= 0.014); ER/PR(HR=0,58/HR=0,59, p=0.065/p=0.068) resulted statistically significant. At multivariate analysis, SOX2 (HR=2,99; 95% CI 1,41-6,30; p=0.004), node-status (HR=2,44; 95%CI 1,25-4,76; p=0.009) and T-size >1 (HR=1,77; 95% CI=0,99-3,13; p=0.051) were independently associated with increased risk of recurrence. An earlier recurrence was observed in SOX2+ patients (median 34.9 months; 95% CI: 7.5-62.2) than SOX2- patients (median: 60.3 months; 95% CI: 32.6-88.1) (p=0.017); OS resulted shorter in SOX2+ (68.2 months 95%CI: 63.7-151.4 vs 145.3 months 95% CI: 80.5-210.2) albeit not statistically significant (p=0.104). IHC analysis showed a positive score for SOX2 protein expression in all of 11 samples with SOX2 mRNA amplification; SOX2+ protein was not detected in 20 samples randomly selected among the tissues not expressing SOX2 mRNA. CONCLUSIONS Our analysis confirm that ESC-regulating genes correlate with specific CPfs (grading, node-status and ki67). Notably, SOX2 resulted to be an independent prognostic factor, as it was associated with a risk of recurrence increased by 3 times, irrespective of other CPfs. Citation Format: Barbara Pistilli, Giovanni Benedetti, Mauro Finicelli, Tiziana Squillaro, Andrea Marcellusi, Tommasina Biscotti, Alfredo Santinelli, Paola Mariani, Paolo Decembrini, Giancarlo Ciccioli, Luciano Latini, Antonio Giordano, Umberto Galderisi. Expression of the pluripotency transcription factor SOX2 in primary breast cancers (BCs): Correlation with clinicopathological features (CPfs) and recurrence [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-06-05.