H. Lenz

Prognostic and predictive value of primary tumour side in patients with RAS wild-type metastatic colorectal cancer treated with chemotherapy and EGFR directed antibodies in six randomized trials

Background There is increasing evidence that metastatic colorectal cancer (mCRC) is a genetically heterogeneous disease and that tumours arising from different sides of the colon (left versus right) have different clinical outcomes. Furthermore, previous analyses comparing the activity of different classes of targeted agents in patients with KRAS wild-type (wt) or RAS wt mCRC suggest that primary tumour location (side), might be both prognostic and predictive for clinical outcome. Methods This retrospective analysis investigated the prognostic and predictive influence of the localization of the primary tumour in patients with unresectable RAS wt mCRC included in six randomized trials (CRYSTAL, FIRE-3, CALGB 80405, PRIME, PEAK and 20050181), comparing chemotherapy plus EGFR antibody therapy (experimental arm) with chemotherapy or chemotherapy and bevacizumab (control arms). Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS) and progression-free survival (PFS) for patients with left-sided versus right-sided tumours, and odds ratios (ORs) for objective response rate (ORR) were estimated by pooling individual study HRs/ORs. The predictive value was evaluated by pooling study interaction between treatment effect and tumour side. Results Primary tumour location and RAS mutation status were available for 2159 of the 5760 patients (37.5%) randomized across the 6 trials, 515 right-sided and 1644 left-sided. A significantly worse prognosis was observed for patients with right-sided tumours compared with those with left-sided tumours in both the pooled control and experimental arms for OS [HRs = 2.03 (95% CI: 1.69-2.42) and 1.38 (1.17-1.63), respectively], PFS [HRs = 1.59 (1.34-1.88) and 1.25 (1.06-1.47)], and ORR [ORs = 0.38 (0.28-0.50) and 0.56 (0.43-0.73)]. In terms of a predictive effect, a significant benefit for chemotherapy plus EGFR antibody therapy was observed in patients with left-sided tumours [HRs = 0.75 (0.67-0.84) and 0.78 (0.70-0.87) for OS and PFS, respectively] compared with no significant benefit for those with right-sided tumours [HRs = 1.12 (0.87-1.45) and 1.12 (0.87-1.44) for OS and PFS, respectively; P value for interaction <0.001 and 0.002, respectively]. For ORR, there was a trend (P value for interaction = 0.07) towards a greater benefit for chemotherapy plus EGFR antibody therapy in the patients with left-sided tumours [OR = 2.12 (1.77-2.55)] compared with those with right-sided tumours [OR = 1.47 (0.94-2.29)]. Exclusion of the unique phase II trial or the unique second-line trial had no impact on the results. The predictive effect on PFS may depend of the type of EGFR antibody therapy and on the presence or absence of bevacizumab in the control arm. Conclusion This pooled analysis showed a worse prognosis for OS, PFS and ORR for patients with right-sided tumours compared with those with left-sided tumours in patients with RAS wt mCRC and a predictive effect of tumour side, with a greater effect of chemotherapy plus EGFR antibody therapy compared with chemotherapy or chemotherapy and bevacizumab, the effect being greatest in patients with left-sided tumours. These predictive results should be interpreted with caution due to the retrospective nature of the analysis, which was carried out on subpopulations of patients included in these trials, and because none of these studies contemplated a full treatment sequence strategy.

Phase II trial of dasatinib for recurrent or metastatic c-KIT expressing adenoid cystic carcinoma and for nonadenoid cystic malignant salivary tumors

BACKGROUND Adenoid cystic carcinoma (ACC) is a subtype of malignant salivary gland tumors (MSGT), in which 90% of cases express cKIT. Dasatinib is a potent and selective inhibitor of five oncogenic protein tyrosine kinases (PTKs)/kinase families including cKIT. We conducted a phase II study to determine the antitumor activity of dasatinib in ACC and non-ACC MSGT. PATIENTS AND METHODS In a two-stage design, patients with progressive, recurrent/metastatic ACC (+cKIT) and non-ACC MSGT (separate cohort) were treated with dasatinib 70 mg p.o. b.i.d. Response was assessed every 8 weeks using RECIST. RESULTS Of 54 patients: 40 ACC, 14 non-ACC (1, ineligible excluded); M:F = 28 : 26, median age 56 years (range 20-82 years), ECOG performance status 0 : 1 : 2 = 24 : 28 : 2, prior radiation: 44, prior chemotherapy: 21. The most frequent adverse events (AEs) (as % of patients, worst grade 2 or higher) were: fatigue (28%), nausea (19%), headache (15%), lymphopenia (7%), dyspnea (11%), alanine aminotransferase increased (7%), anorexia (7%), vomiting (7%), alkaline phosphatase increased (6%), diarrhea (6%), neutropenia (6%), and noncardiac chest pain (6%). No grade 4 AE occurred, 15 patients experienced a grade 3 AE, primarily dyspnea (5) and fatigue (4), and cardiac toxicity (1 prolonged QTc). Among ACC patients, best response to dasatinib: 1 patient (2.5%) had partial response, 20 patients (50%) had stable disease (SD) (3-14 months), 12 patients (30%) had PD, 2 withdrew, 3 discontinued therapy due to AE, and 2 died before cycle 2. Median progression-free survival was 4.8 months. Median overall survival was 14.5 months. For 14 assessable non-ACC patients, none had objective response, triggering early stopping rule. Seven had SD (range 1-7 months), 4 PD, 2 discontinued therapy due to AE, and 1 died before cycle 2. CONCLUSION Although there was only one objective response, dasatinib is well tolerated, with tumor stabilization achieved by 50% of ACC patients. Dasatinib demonstrated no activity in non-ACC MSGT.

Association of variants in genes encoding for macrophage-related functions with clinical outcome in patients with locoregional gastric cancer

BACKGROUND Nuclear factor-kappaB (NF-κB) and CCL2/CCR2 chemokine axis play a central role in tumor progression such as stimulation of angiogenesis, acceleration of tumor invasion and migration, and suppression of innate immunosurveillance in the macrophage-related functions. There have been few reports regarding association of the macrophage function-related genes with the clinical outcome in gastric cancer. We hypothesized that variants in genes encoding for NF-κB and CCL2/CCR2 axis may predict prognosis in gastric cancer and tested whether the functional single-nucleotide polymorphisms (SNPs) will be associated with clinical outcome in patients with gastric cancer across two independent groups. PATIENTS AND METHODS This study enrolled two cohorts which consisted of 160 Japanese patients and 104 US patients with locoregional gastric cancer. Genomic DNA was analyzed for association of 11 SNPs in NFKB1, RELA, CCL2, and CCR2 with clinical outcome using PCR-based direct DNA sequencing. RESULTS The univariable analysis showed four SNPs had significant association with clinical outcome in the Japanese cohort, NFKB1 rs230510 remained significant upon multivariable analysis. The patients with the A allele of the NFKB1 rs230510 had significantly longer overall survival (OS) compared with those with the T/T genotype in both the Japanese and US cohort in the univariable analysis. In contrast, genotypes with the T allele of CCL2 rs4586 were significantly associated with shorter OS compared with the C/C genotype in the US cohort [hazard ratio (HR) 2.43; P = 0.015] but longer OS in the Japanese cohort (HR 0.58; P = 0.021), resulting in the statistically significant opposite impact on OS (P = 0.001). CONCLUSIONS Our study provides the first evidence that the NFKB1 rs230510 and CCL2 rs4586 are significantly associated with the clinical outcome in patients with locoregional gastric cancer. These results also suggest that the genetic predisposition of the host may dictate the immune-related component of the tumor for progression in gastric cancer.

Genetic variants of DNA repair-related genes predict efficacy of TAS-102 in patients with refractory metastatic colorectal cancer.

Background Tri-phosphorylated trifluridine (FTD) incorporation into DNA is TAS-102s main anti-tumor action. We tested whether genetic polymorphisms in homologous recombination (HR) and cell cycle checkpoint pathway for DNA repair is associated with outcomes in refractory metastatic colorectal cancer (mCRC) patients treated with TAS-102. Patients and methods We analyzed genomic DNA extracted from 233 samples of three cohorts: an evaluation cohort of 52 patients receiving TAS-102, a validation cohort of 129 patients receiving TAS-102 and a control cohort of 52 patients receiving regorafenib. Single nucleotide polymorphisms of genes involved in HR (ATM, BRCA1, BRCA2, XRCC3, FANCD2, H2AX, RAD51) and cell cycle checkpoint (ATR, CHEK1, CHEK2, CDKN1A, TP53, CHE1, PIN1, PCNA) were analyzed by PCR-based direct sequencing. Results In univariate analysis for the evaluation cohort, patients with any G allele in ATM rs609429 had longer overall survival (OS) than those with the C/C variant (8.7 vs. 4.4 months, HR 0.37, 95% CI: 0.14-0.99, P = 0.022). Patients carrying any A allele in XRCC3 rs861539 had significantly longer progression-free survival (PFS) (3.8 vs. 2.3 months, HR 0.44, 95% CI: 0.21-0.92, P = 0.024) and OS (15.6 vs. 6.3 months, HR 0.25, 95% CI: 0.08-0.79, P = 0.012) than those with the G/G variant. In multivariable analysis, ATM rs609429 remained significant for OS (P = 0.020). In the validation cohort, patients having ATM rs609429 with any G allele showed longer OS and PFS; the G/A variant in XRCC3 rs861539 showed longer OS, though without statistical significance. Conclusion Genetic variants in the HR pathway may predict clinical outcome in mCRC patients receiving TAS-102.

Variations in genes regulating tumor-associated macrophages (TAMs) to predict outcomes of bevacizumab-based treatment in patients with metastatic colorectal cancer: results from TRIBE and FIRE3 trials

BACKGROUND Tumor-associated macrophages (TAMs) with the M2-like phenotype are regulated by mainly NF-kB pathway including TBK1, which can influence tumor progression by secretion of proangiogenic factors such as vascular endothelial growth factor. The CCL2/CCR2 axis, histidine-rich glycoprotein (HRG), and placenta growth factor (PIGF) play a critical role in the polarization of M1/M2 phenotypes and the recruitment of TAMs to tumor microenvironment. We therefore hypothesized that variations in genes involved in regulating TAMs may predict clinical outcomes of bevacizumab treatment in patients with metastatic colorectal cancer (mCRC). PATIENTS AND METHODS We analyzed genomic DNA extracted from samples of patients receiving bevacizumab plus FOLFIRI as a first-line treatment using PCR-based direct sequencing. Twelve functional single-nucleotide polymorphisms in eight genes (CCL2, CCR2, HRG, PIGF, NFKB1, TBK1, CCL18, and IRF3) were tested for associations with clinical outcomes in a discovery cohort of 228 participants in TRIBE trial (NCT00719797), then validated in 248 KRAS exon2 (KRAS) wild-type participants in FIRE3 trial (NCT00433927). FIRE3-cetuximab cohort served as a negative control. RESULTS TBK1 rs7486100 was significantly associated with overall survival in 95 KRAS wild-type patients of TRIBE cohort in univariate analysis and had a strong trend in multivariable analysis; furthermore, the association of the T allele was observed for progression-free survival (PFS) in both univariate and multivariable analyses in FIRE3-bevacizumab but not cetuximab cohort. CCL2 rs4586, CCL18 rs14304, and IRF3 rs2304205 had univariate and multivariable correlations with PFS in KRAS mutant patients of the TRIBE cohort, whereas they had no correlations in KRAS wild-type patients of the TRIBE cohort. No association was seen in control cohort. CONCLUSIONS Our study demonstrates for the first time that variations in genes regulating TAMs-related functions are significantly associated with clinical outcomes in mCRC patients treated with bevacizumab-containing chemotherapy. These results also suggest that some TAM-related gene variations may predict outcomes of bevacizumab treatment in KRAS status-dependent manner.

Association of Cyclin D1 (CCND1) gene A870G polymorphism and clinical outcome of EGFR-positive metastatic colorectal cancer patients treated with epidermal growth factor receptor (EGFR) inhibitor cetuximab (C225)

3518 Background Cetuximab (C225) is a chimeric anti-EGFR monoclonal antibody with efficacy against EGFR-positive metastatic colorectal cancer. Recently, the link between EGFR signaling and the cell cycle has been identified. In vitro studies show blockade of EGFR by C225 can induce cell cycle arrest in the G1 phase which mediated by inhibition of interactions between cyclins and CDKs and increases expression of the cell cycle inhibitor p27KIP1. A frequent A870G polymorphism in the final codon of exon 4 of the Cyclin D1, leads gene alternatively spliced to produce two different mRNA transcripts [a] and [b] was also identified. In vivo studies have indicated this polymorphism can affect the prognosis of patients with different types of solid tumors. We hypothesized that CCND1 A870G polymorphism will predict clinical outcome in EGFR-positive metastatic colorectal cancer patients treated with EGFR inhibitor Cetuximab(C225). Methods Cyclin D1 A870G gene polymorphism was tested using PCR-RFLP method in genomic DNA extracted from peripheral blood from 39 metastatic colorectal cancer patients enrolled in a phase II EGFR inhibitor Cetuximab(C225) clinical trial. ResultsWe found a significant association between A870G polymorphism and overall survival of patients treated with Cetuximab(C225). With median follow-up 8.7 months (range 2.5, 11.7) and median survival time 4.8 months (95%C.I 2.7, 8.5), Patients with AA homozygous genotype survived a median time of 2.3 months (95%C.I 2.1, 5.7) compared with those have homozygous GG genotype 4.4 months (95%C.I 1.8, 9.8+) or heterozygous AG genotype 8.5 months(95%C.I 5.5, 11.7+), respectively (p<0.05, logrank test). ConclusionsThese data suggest that Cyclin D1 A870G polymorphism may be a potential prognostic molecular marker for clinical outcome of the EGFR-positive metastatic colorectal caner patients treated with third line EGFR inhibitor Cetuximab (C225). Prospective studies are needed to confirm these preliminary findings. [Table: see text].

Variations in genes involved in dormancy associated with outcome in patients with resected colorectal liver metastases

BACKGROUND Tumor dormancy has been described as a state of hibernation. Dormancy can be switched to proliferation by different pathways, which may play a critical role in tumor recurrence. In this study, we investigated genetic variations within genes involved in tumor dormancy and their association with recurrence and outcome in patients with colorectal liver metastases (CLM) who underwent neoadjuvant bevacizumab-based chemotherapy. PATIENTS AND METHODS Genomic DNA was extracted from resected CLM (FFPE) from 149 patients. Single-nucleotide polymorphisms (SNPs) in 14 genes associated with dormancy were analyzed by direct Sanger DNA sequencing and evaluated for response, recurrence-free survival (RFS), overall survival (OS) and recurrence patterns. RESULTS NME1 rs34214448 C>A was significantly associated with RFS in univariable analysis (P = 0.039) and with intrahepatic recurrence (P = 0.014). NOTCH3 rs1044009 T>C and CD44 rs8193 C>T showed a significant difference in 3-year OS rates (P = 0.004 and P = 0.042, respectively). With respect to radiological response, CD44 rs8193 C>T variant genotypes were associated with a significantly higher response rate (P = 0.033). Recursive partitioning analyses revealed that Dll4 rs12441495 C>G, NME1 rs34214448 C>A and NOTCH3 rs1044009 T>C were the dominant SNPs predicting histological response, RFS and OS, respectively. CONCLUSION Our data suggest that gene variations within genes involved in tumor dormancy pathways are associated with response and outcome in patients with resected CLM. These data may lead to new and more effective treatment strategies targeting tumor dormancy.

Pilot trial of 5-FU/oxaliplatin (CIFOX) for patients with metastatic colorectal cancer who progressed on 5-FU/LV/CPT-11 (IFL)

3773 Background: 5-FU/oxaliplatin is approved for the treatment of metastatic colorectal in patients who have progressed on IFL. In September 2001, we began accruing patients to a pilot trial combining 5-FU and oxaliplatin for patients who had progressed on IFL. The primary goal of the trial is to assess both the intratumoral gene expression and the genomic polymorphisms relationship to clinical outcome and toxicity. We are updating the previously reported results (Padmanabhan et al; Proc ASCO 2002). METHODS Patients received continuous infusion 5-FU 200 mg/m2/d for 10 weeks followed by a 2 week break and oxaliplatin 130 mg/m2 every 3 weeks (CIFOX). Response was assessed every 6 weeks. Chemotherapy was administered until progression of disease or intolerance. This study is designed to accrue 200 patients. RESULTS As of December 2003, 168 patients have been accrued; median age 60 years (range 25 - 87), 81 (48%) females, 87(52%) males; 27(16%) Asian, 7(4%) African American, 113(67%) Caucasian, 21(13%) Hispanic; 101(60%) colon cancer, 67(40%) rectal cancer; all patients had prior chemotherapy, 50 (30%) had prior radiation. Of the 149 evaluable patients, responses (by RECIST) were as follows: 23(15%) partial response, 71(48%) stable disease and 55(37%) progressive disease. The median number of cycles received was 4 (range 1-20). Grade 3-4 hematologic toxicity was reported in 4(3%) and 86(59%) had grade 3-4 non-hematologic toxicity. The most common grade 3-4 toxicities were gastrointestinal (diarrhea/vomiting/nausea/anorexia/stomatitis/pharyngitis), constitutional symptoms (fatigue), neurologic (neuropathy-sensory/neuropathy-motor), and pain (abdominal pain/cramping/headache). To date, 119 patients have progressed and 117 have died. The median overall survival is 9.0 (95% CI: 7.3, 10.0) months, median progression-free survival of is 4.0 (95% CI: 3.4, 4.6) months. CONCLUSIONS 5-FU/oxaliplatin (CIFOX) is an effective and well tolerated second line regimen for metastatic colorectal cancer. Assessment of the molecular correlates is ongoing. [Table: see text].

Polymorphisms in IL-8 and the GSTP1 are associated with survival of metastatic colorectal cancer patients treated with CPT-11

3606 Background Irinotecan (CPT-11), an analogue of Camptothecins, demonstrates a broad spectrum of antitumor activity. Currently, there are no prognostic molecular markers for CPT-11 efficacy. Therefore, we investigated associations between polymorphisms in genes involved in CPT-11 metabolism (UGT1A1), chemoresistance (GSTP1), DNA repair (XPD, ERCC1, XRCC1, Werner 1074, and Werner 1367), and angiogenesis (IL-8 and COX-2) and survival of patients with metastatic colorectal cancer receiving CPT-11 based chemotherapy. In vivo studies show GSTP1 to detoxify chemotherapeutic agents by glutathione conjugation. In vivo and in vitro studies show IL-8 to possess angiogenic properties and its overexpression is associated with metastasis potential in colorectal cancer. Positional cloning studies identified Werner as the gene responsible for Werner Syndrome (WS), and cells from these patients have been shown to be particularly sensitive to Camptothecin. Methods The gene polymorphisms were tested using PCR-RFLP method on genomic DNA extracted from peripheral blood from metastatic colorectal cancer patients treated with CPT-11. Results 55 patients were collected; 31 males and 24 females; median age 55 (range 34-77) years. The response to CPT-11 was 40% (18/45, 1 pt was inevaluable, and 9 pts are still receiving treatment and were too early to be evaluated), with median survival of 22.9 (95% CI: 18.4, 29.3) months. The median time of follow-up and range was 15.4 (4.7-26.1) months. Individually, IL-8 and GSTP1 showed trends for overall survival (log rank p=0.07 and p=0.077, respectively). A combined analysis of these two genes showed patients carrying two favorable genotypes (homozygous Ile for GSTP1 and T allele for IL-8) had longer survival when compared with those patients carrying no favorable genotypes or only 1 favorable genotype (p=0.005). The Werner Loci polymorphisms also showed a trend for overall survival. Conclusion These data suggest that IL-8, GSTP1, and the Werner Loci polymorphisms may be potential prognostic molecular markers for clinical outcome of metastatic colorectal cancer patients treated with a CPT-11 regimen. [Table: see text].

Nintedanib for the treatment of patients with refractory metastatic colorectal cancer (LUME-Colon 1): a phase III, international, randomized, placebo-controlled study.

Abstract Background Angiogenesis is critical to colorectal cancer (CRC) growth and metastasis. Phase I/II studies have demonstrated the efficacy of nintedanib, a triple angiokinase inhibitor, in patients with metastatic CRC. This global, randomized, phase III study investigated the efficacy and safety of nintedanib in patients with refractory CRC after failure of standard therapies. Patients and methods Eligible patients (Eastern Cooperative Oncology Group performance status 0–1, with histologically/cytologically confirmed metastatic/locally advanced CRC adenocarcinoma unamenable to surgery and/or radiotherapy) were randomized 1 : 1 to receive nintedanib (200 mg twice daily) or placebo (twice daily), until disease progression or undue toxicity. Patients were stratified by previous regorafenib, time from onset of metastatic disease to randomization, and region. Co-primary end points were overall survival (OS) and progression-free survival (PFS) by central review. Secondary end points included objective tumor response and disease control by central review. Results From October 2014 to January 2016, 768 patients were randomized; 765 were treated (nintedanib n = 384; placebo n = 381). Median follow-up was 13.4 months (interquartile range 11.1–15.7). OS was not improved [median OS 6.4 months with nintedanib versus 6.0 months with placebo; hazard ratio (HR), 1.01; 95% confidence interval (CI), 0.86–1.19; P = 0.8659]. There was a significant but modest increase in PFS with nintedanib versus placebo (median PFS 1.5 versus 1.4 months, respectively; HR 0.58; 95% CI 0.49–0.69; P < 0.0001). There were no complete or partial responses. Adverse events (AEs) occurred in 97% of 384 nintedanib-treated patients and 93% of 381 placebo-treated patients. The most frequent grade ≥3 AEs were liver-related AEs (nintedanib 16%; placebo 8%) and fatigue (nintedanib 9%; placebo 6%). Conclusions The study failed to meet both co-primary end points. Nintedanib did not improve OS and was associated with a significant but modest increase in PFS versus placebo. Nintedanib was well tolerated. ClinicalTrials.gov number NCT02149108 (LUME-Colon 1).