Jean-Charles Soria

Enterococcus hirae and Barnesiella intestinihominis Facilitate Cyclophosphamide-Induced Therapeutic Immunomodulatory Effects

The efficacy of the anti-cancer immunomodulatory agent cyclophosphamide (CTX) relies on intestinal bacteria. How and which relevant bacterial species are involved in tumor immunosurveillance, and their mechanism of action are unclear. Here, we identified two bacterial species, Enterococcus hirae and Barnesiella intestinihominis that are involved during CTX therapy. Whereas E.xa0hirae translocated from the small intestine to secondary lymphoid organs and increased the intratumoral CD8/Treg ratio, B.xa0intestinihominis accumulated in the colon and promoted the infiltration of IFN-γ-producing γδT cells in cancer lesions. The immune sensor, NOD2, limited CTX-induced cancer immunosurveillance and the bioactivity of these microbes. Finally, E.xa0hirae and B.xa0intestinihominis specific-memory Th1 cell immune responses selectively predicted longer progression-free survival in advanced lung and ovarian cancer patients treated with chemo-immunotherapy. Altogether, E.xa0hirae and B.xa0intestinihominis represent valuable oncomicrobiotics ameliorating the efficacy of the most common alkylating immunomodulatory compound.

Differential Expression of Biomarkers in Men and Women

Lung cancer is one of the most common cancers in the world. While historically, more men than women have died from lung cancer as a result of higher numbers of male smokers, the sex mortality ratio is now showing signs of narrowing. Tumors in women with lung cancer may be slightly different to those in men with lung cancer. This review focuses on biomarkers differentially expressed between female and male patients with lung cancer. There is variation in gene expression between men and women in some genes that encode carcinogen-metabolizing enzymes (CYP1A1, GSTM). Gastrin-releasing peptide (GRP), a bombesin-like peptide, is present in two actively transcribed alleles in women compared with men. Higher prevalence of infection with oncogenic variants human papilloma viruses (HPVs) HPV16 and HPV18 has been suggested in women. A higher frequency of G to T transversion was found in the p53 gene in lung tumors of women. KRAS mutation was found to be more frequent in women with resected non-small cell lung cancer (NSCLC) than in men with resected NSCLC. Epidermal growth factor receptor (EGFR) mutation is more frequently found in lung tumors from women, but the confounding effect of tobacco exposure may explain this difference. Lower levels of ERCC1 and BRCA1 have been reported in women with NSCLC. Lung tumors from women are more likely to express estrogen receptors than those from men. An in silico analysis of transcriptome datasets from lung cancer patients demonstrated that only seven genes (in at least two studies) had significantly different expression patterns in male versus female patients. All of these genes are localized on the sex chromosomes: one on chromosome X and six on chromosome Y. Many areas remain under debate and there are still significant gaps in our understanding, particularly how sex-linked factors relate to lung cancer risk, and to biological and clinical behaviors. Future research into lung cancer needs to address these gender differences more specifically.

Frequency and management of troponin I elevation in patients treated with molecular targeted therapies in phase I trials.

SummaryBackground Cardiotoxicity of Molecular Targeted Therapies (MTT) is poorly understood and is being investigated among patients with metastatic solid tumours. The frequency of cardiac events among patients receiving MTT has been evaluated in various ways, particularly troponin elevations. Patients and methods We prospectively evaluated cardiotoxicity among patients included in Phase 1 trials receiving molecular targeted therapies (MTT) for a metastatic solid tumour. At baseline, all patients were examined before the first cycle and monitored including a clinical examination, ECG and troponin I measurement. A trans-thoracic echocardiography was performed at baseline and before each cycle. Patients were enrolled in different trials investigating : an anti-VEGF monoclonal antibody, anti-VEGFR tyrosine kinase inhibitors, and a kinesin inhibitor. Results Among the 90 patients evaluated, 10 (11%) experienced chest pain and troponin I elevation (nu2009=u20092,20%) or asymptomatic troponin I elevation (nu2009=u20098, 80%) during follow-up. All patients were re-evaluated at the time of symptoms or troponin I elevation with trans-thoracic echocardiography, cardiac magnetic resonance and coronary angiography. All except one patient, had a normal LVEF during their re-evaluation. One patient exhibited ECG changes (T wave inversion). No QTc interval prolongation was found. On cardiac magnetic resonance, no late gadolinium myocardial enhancement was observed. All coronary angiographies were normal (no occlusion, or coronary stenosis >50%). All patients received beta blockers and aspirin. All Patients were re-challenged with the study drug and no cardiotoxicity was observed during follow up. Conclusion Troponin elevations are frequent among patients receiving molecular targeted therapies. Re-challenging these patients after a careful evaluation and under medical treatment seems to be possible. The mechanism underlying troponin elevations does not seem to be associated with coronary occlusion nor with toxic myocarditis.

Tumour growth rates and RECIST criteria in early drug development.

PURPOSEnThe evaluation of treatment efficacy with RECIST criteria does not take into account tumour growth dynamics. We notably investigated the impact of the pre-treatment tumour growth rate (GR) on the evaluation of treatment response.nnnPATIENTS AND METHODSnSeventy-six patients included in phase I clinical trials had scanographic evaluations before and after starting an experimental treatment. The GR was calculated for the pre-treatment period and for the experimental period (i.e. during the new treatment). Tumour response was evaluated per protocol at week 12 and at week 24 of the experimental period according to RECIST criteria. We studied the relation between pre-treatment and experimental GRs and RECIST tumour response.nnnRESULTSnOn average the tumour GR was decreased by 40% during the experimental period; compared to the pretreatment period (p=0.03). An increased growth rate (acceleration of GR during experimental treatment compared to pretreatment) was observed in 20 (38%) of the 53 patients considered as non-progressive at week 12 according to RECIST. Conversely a decreased GR was observed in 12 out of 23 (53%) patients classified as progressive according to RECIST. The variation in the GR between the pre-treatment and experimental period was not significantly correlated with response evaluated according to RECIST at week 12 or at week 24 (p=0.45 and 0.44, respectively).nnnCONCLUSIONSnRECIST evaluation of tumour response depends on the natural history of the tumours and poorly measures the impact of treatment on the kinetics of tumour growth. Integrating pre-treatment GR evaluations could substantially improve the assessment of treatment efficacy in drug development.

QT interval prolongation among patients treated with angiogenesis inhibitors.

Among toxicities associated with molecular targeted agents (MTA), cardiovascular toxicities remain largely unknown or underestimated. Their frequency is variable and dependent on the compound. A high incidence of hypertension, symptomatic or asymptomatic left ventricular systolic dysfunction, acute coronary syndrome, arterial and venous thrombosis has been observed in patients receiving MTA. One of the most threatening complications of angiogenic inhibitors (AI) could be QT prolongation with the risk of torsade de pointes (TdP) and sudden death. QT prolongation and torsade de pointes accounted for 29% of cardiac and non-cardiac post-marketing withdrawals. The assessment of the effects of drugs on cardiac repolarization is the subject of recent guidelines and recommendations. Regulatory agencies now require practically every new pharmaceutical compound to undergo a thorough investigation of its propensity to modify cardiac repolarization. To reduce the incidence of QT prolongation and torsade de pointes in patients receiving AI, cancer patients should be closely monitored while receiving AI.

A phase I, dose-escalation study of the Eg5-inhibitor EMD 534085 in patients with advanced solid tumors or lymphoma

SummaryBackground The kinesin spindle protein Eg5 is involved in mitosis, and its inhibition promotes mitotic arrest. EMD 534085, a potent, reversible Eg5 inhibitor, demonstrated significant preclinical antitumor activity. Methods This first-in-man, single-center, open-label, phase I dose-escalation study (3u2009+u20093 design) investigated EMD 534085 safety, pharmacokinetics and antitumor activity in refractory solid tumors, Hodgkin’s lymphoma, or non-Hodgkin’s lymphoma. EMD 534085 (starting dose 2xa0mg/m2/day) was administered intravenously every 3xa0weeks. Doses were escalated in 100xa0% steps in successive cohorts of 3 patients until grade 2 toxicity occurred, followed by 50xa0% until the first dose-limiting toxicity (DLT) arose. If <2 of 6 patients experienced a DLT, doses were further increased by 25xa0%. Dose-escalation was stopped if a DLT occurred in ≥2 of 6 patients. Results Forty-four patients received EMD 534085. Median treatment duration was 43xa0days (range, 21–337). Thirty-eight patients (86xa0%) received ≥2xa0cycles. DLTs were grade 4 neutropenia (1 patient each at 108 and 135xa0mg/m2/day), and grade 3 acute coronary syndrome with troponin I elevation (1 patient at 135xa0mg/m2/day). The maximum tolerated dose (MTD) was 108xa0mg/m2/day. The most common treatment-related adverse events were asthenia (50xa0%) and neutropenia (32xa0%). EMD 534085 appeared to have linear pharmacokinetics. Increase in phospho-histone H3 positive cells in paired pre- and on-treatment biopsies showed evidence of target modulation. No complete or partial responses were observed. Best response was stable disease in 23 patients (52xa0%). Conclusions EMD 534085 appeared to be well tolerated; MTD was 108xa0mg/m2/day. Preliminary antitumor results suggested limited activity in monotherapy.

Phase I trials in oncology: a new era has started

The landscape of oncology drug development is currently undergoing fascinating revolutions and there is an urge to re-challenge many paradigms of early phase trials, which are currently becoming out-of-date. Needless to say, the advent of the first molecularly targeted therapies at the beginning of this millenary has opened this changing time, but this was only the wind before the tempest. Now, oncology faces the arrival of multiple new comers, including not only novel targeted therapies, but also active immune therapies, antibody-drug conjugates, and probably soon adoptive cell transfer using chimeric artificial T-cell receptors (CARs). Paradoxically, the need for rapid and efficient drug development has never been as significant, as illustrated by the advent of Food and Drug Administration (FDA) breakthrough designations based on phase I trials results, as well as FDA conditional approvals based on phase I and II data. As a result, phase I investigators are challenged by the need to conciliate efficiency with the implementation of novel drug development models for novel drugs that present unusual levels of activity and ad hoc specificities. Which recent trials have presented the most successful drug development model? Examples include the ALK/ROS inhibitors crizotinib (PF-02341066, Pfizer) and ceritinib (LDK378, Novartis), as well as the programmed death 1/programmed death-ligand 1 (PD-1/PD-L1) inhibitors nivolumab (BMS936558, Bristol-Myers Squibb), pembrolizumab (MK-3475, Merck) and MPDL3280A (Genentech-Roche). For the first two trials, thorough patient selection has been the key of success [1, 2]. In both studies, several thousands of patients were screened in order to eventually select 82 and 130 of them that fulfilled the eligibility criteria of presenting an ALK-rearranged disease (at least for non-small cell lung cancer patients). Interestingly, both phase I trials were amended to allow recruitment of hundreds of additional patients (n = 550 for crizotinib [3, 4] and n = 246 [3] for ceritinib). The impressive activity results observed in these trials have triggered an accelerated approval by the FDA in August 2011 for crizotinib and in April 2014 for ceritinib, <5 years after the first patient was enrolled in the corresponding phase I study. This starkly contrasts with previous drug development schedules, which presented a time-lapse of ∼10 years between first-in-human studies and drug approval at the beginning of the century. Such successful stories strongly encourage the development of large-scale phase I trials enriched in molecularly selected patients—whenever a robust selection biomarker is available, thus implying the screening of several hundreds of patients and international collaborations. However, recent events have shadowed this impressive success of ceritinib. Indeed, despite the undisputable activity of the drug, uncertainties regarding the optimal dose and prandial conditions of administration were still unsolved at the end of that study [5, 6]. Although the drug was approved at the dose of 750 mg o.d., reviewers were concerned with the drug’s gastrointestinal (GI) tolerability and recommended investigating lower doses of 450 mg and 600 mg ceritinib taken with a meal, as a significant positive food effect was demonstrated for this drug and as this may improve the GI tolerability [6, 7]. How could have these issues been better addressed in phase I trials? One potential solution is the multiplication of expansion cohorts at doses below the maximum tolerated dose (MTD). In such design, dose levels that are known to be safe and at which pharmacodynamic parameters show a biological activity of the drug, can be expanded in parallel of the continuation of the dose escalation. This design, in which the patient could for example be its own control for food effect assessment in an expansion cohort, combines the advantage of collecting more data on PK data (including inter and intrapatient variability), as well as treating more patients when the drug is obviously active. This may help improving the ability of phase I trials of targeted agents to predict doses that will eventually be registered—as this ability has been reported to be poorer for targeted agents than for phase I trials evaluating conventional cytotoxic chemotherapies [8]. For immunotherapies, there is no doubt that the revolution is ongoing and that many drugs will flow through drug development processes to approval, considering the extremely promising levels of activity. One of the most recent examples of such successful drug development is the PD-L1 inhibitor MPDL3280A. Based on the results of the phase I trial only, this drug was granted a breakthrough therapy designation for urothelial bladder cancer. A large confirmatory phase II study has been mandated for confirmation (NCT02108652). However, the drug development model of immune therapies is often complex, as these agents challenge all previously established paradigms of cancer drug development even more deeply than targeted agents. As an illustration, after several phase I trials in monotherapy and combination, as well as phase II and phase III trials evaluating different schedules, it is still unclear what is the optimal dose of nivolumab to be administered [9–11]. Optimal patient selection is also a challenge, as there is no consensus on which technique, which antibody or which threshold should be used to assess PD-L1 positivity status. This obviously contrasts with a patient selection based on a specific mutation, as DNA sequencing is a robust and almost universal technique. If no consensus can be found soon on assessing PD-L1 positivity, this may become a worrying issue for a future large-scale administration of these drugs, as each compound currently has its own companion selection biomarker. More importantly, most phase I investigators ed ito ria ls editorials Annals of Oncology 26: 7–9, 2015 doi:10.1093/annonc/mdu513 Published online 30 October 2014

EGFR Genotyping of Matched Urine, Plasma, and Tumor Tissue in Patients With Non–Small-Cell Lung Cancer Treated With Rociletinib, an EGFR Tyrosine Kinase Inhibitor

PurposeLiquid biopsies represent an attractive alternative to tissue biopsies, particularly rebiopsies, in determining patient eligibility for targeted therapies. Clinical utility of urine genotyping, however, has not been explored extensively. We evaluated epidermal growth factor receptor (EGFR) T790M detection in matched urine, plasma, and tissue and the clinical outcomes of patients with advanced non–small-cell lung cancer treated with rociletinib.MethodsTissue (n = 540), plasma (n = 482), and urine (n = 213) were collected from evaluable patients enrolled in TIGER-X, a phase I/II study. Genotyping was performed by therascreen EGFR testing in tissue, BEAMing in plasma, and a quantitative short footprint assay (Trovera) in urine, which was used to further examine discordant samples.ResultsPositive percent agreement with tissue T790M results was similar for urine (82%; 142 of 173) and plasma (81%; 313 of 387) genotyping. Urine and plasma together identified more patients who were T790M positive (92%) tha...

Predictive Versus Prognostic Value of Lung Adenocarcinoma Classification

TO THE EDITOR: Hung et al recently investigated the pattern of recurrence and the predictive value of the new International Association for the Study of Lung Cancer/American Thoracic Society/ European Respiratory Society histologic classification for lung adenocarcinoma in 573 patients who had been treated primarily by surgical resection. In this classification, nonmucinous invasive adenocarcinoma was classified into five categories on the basis of the presence of predominant histological patterns. The authors reported that among all 573 patients, those with micropapillary/solid predominant pattern adenocarcinoma had higher extrathoracic versus intrathoracic recurrence than patients with lepidic/acinar/papillary predominant pattern tumors. Micropapillary/solid predominant pattern had poorer overall survival (OS), freedom from recurrence, and disease-specific survival compared with lepidic/acinar/papillary predominant patients. Importantly, they reported that among 215 of 573 patients who received adjuvant chemotherapy, solid-predominant adenocarcinoma was also a significant predictive factor for OS (P .04) and tended to be significant for freedom from recurrence (P .08). The authors concluded that in lungadenocarcinoma,theInternationalAssociationfortheStudyofLung Cancer/American Thoracic Society/European Respiratory Society classification system has significant prognostic and predictive value regarding death and recurrence. Solid-predominant adenocarcinoma was also a significant predictor in patients undergoing adjuvant chemotherapy. It is generally accepted that prognostic markers are patient/tumor factors that affect patient outcome (usually survival) independently of treatment administered, whereas predictive markers are factors that predict response of the tumor to the treatment, either in terms of tumor shrinkage or survival benefit from the treatment. In patients with early-stage resectable non–small-cell lung cancer, the term “predictive” should be reserved for survival benefit from adjuvant chemotherapy. In the absence of a randomized trial with a notreatment control arm, a differential survival benefit from therapy cannot be determined, as the prognostic role of the marker may exert similar effects in both the treated and nontreated arms. This is the case in this report by Hung et al as shown clearly in Figures 1G to I, where OS and disease-specific survival were poorer for patients with solidpredominant compared with nonsolid histology, regardless of whether they received or did not receive adjuvant chemotherapy. In fact, nowhere in the manuscript or in the Data Supplement was significant interaction between chemotherapy and histologic subtype reported by comparing the hazard ratios for survival benefit in treated and nontreated patients in the two histologic groups, and by applying an interaction P value. Therefore, we believe the use of term “predictive” was inappropriate and misleading, and that this retrospective study was neither designed nor powered to be able to demonstrate significant treatment by histology interaction. Note: A reply to this Correspondence was not provided.

Abstract 927: Pretreatment and serial plasma assessments of EGFR mutations in NSCLC patients treated with rociletinib (CO-1686)

Background: EGFR mutation testing is required to identify patients who may respond to TKI therapy. However, tumor biopsies from NSCLC patients can pose challenges for molecular analyses due to inadequate sample material, the inability to biopsy patients due to poor health status or inaccessible lesions, and tumor heterogeneity. We examined the detection of EGFR mutations in circulating cell-free DNA (cfDNA) from plasma and the concordance of EGFR mutation status with contemporaneously matched tumor tissue in TIGER-X, a Phase 1/2 clinical study of rociletinib (CO-1686) in previously treated advanced NSCLC patients harboring EGFR mutations in their tumors. Rociletinib is an oral, potent, small-molecule irreversible tyrosine kinase inhibitor that selectively targets mutant forms of EGFR, including T790M, L858R and Del(19), while sparing wild-type EGFR. Methods: Pretreatment matched tumor tissue and plasma from 139 Stage IIIB/IV NSCLC patients enrolled in TIGER-X were evaluated for EGFR status. Tumor tissue was processed as FFPE and tested by allele-specific PCR. Plasma was tested as a two mL aliquot using BEAMing, a quantitative and sensitive detection technology based on digital PCR. Results: Using tissue as the reference, the positive percent agreement between tumor and BEAMing plasma test results was 86% (102/119) for activating mutations and 77% (78/101) for T790M. Four plasma samples of the 23 tumor T790M+/plasma T790M- cases were also tested by three independent plasma testing platforms with claimed analytical sensitivities of Conclusions: The BEAMing plasma test identified EGFR mutations detected in tumor with high sensitivity. In addition, plasma testing identified T790M+ patients that were determined T790M- by the tumor test, which may be in part explained by tumor heterogeneity and/or inadequate biopsy. These findings demonstrate that BEAMing can be a useful tool for the non-invasive assessment of EGFR mutations in NSCLC. Citation Format: Jonathan W. Goldman, Chris Karlovich, Elaina Mann, Lindsey Rolfe, Shannon Matheny, Darrin Despain, Philipp Angenendt, Claudia Stamm, Heather A. Wakelee, Jean-Charles Soria, Benjamin Solomon, D. R. Camidge, Rafal Dziadziuszko, Leora Horn, Shirish Gadgeel, Mitch Raponi, Andrew R. Allen, Lecia V. Sequist. Pretreatment and serial plasma assessments of EGFR mutations in NSCLC patients treated with rociletinib (CO-1686). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 927. doi:10.1158/1538-7445.AM2015-927