Kenichiro Kudo

Afatinib Prolongs Survival Compared with Gefitinib in an Epidermal Growth Factor Receptor-Driven Lung Cancer Model

An irreversible ErbB family blocker is expected to inhibit tumors with activating epidermal growth factor receptor (EGFR) mutations more strongly than reversible EGFR tyrosine kinase inhibitors and to overcome acquired resistance to the T790M secondary mutation. Eleven-week-old transgenic mice with Egfr exon 19 deletion mutation were treated with afatinib, gefitinib, or vehicle for 4 weeks. All mice were sacrificed at 15 weeks of age, and the number of superficial left lung tumors with a long axis exceeding 1 mm was counted. The afatinib-treated group had significantly fewer tumors than the vehicle group (P < 0.01) and tended to have fewer tumors than the gefitinib-treated group (P = 0.06). Pathologically, gefitinib-treated mice had clearer, more nodular tumors than afatinib-treated mice. Immunoblotting showed that afatinib suppressed not only pEGFR but also pHER2, and induced apoptosis for longer periods than gefitinib. Subsequently, when each drug was administered 5 days per week until death, afatinib significantly enhanced mouse survival compared with gefitinib (median survival time: 456 days vs. 376.5 days; log-rank test, P < 0.01). Finally, the combination of afatinib with bevacizumab was found to be superior to either drug alone in exon 19 deletion/T790M and L858R/T790M xenograft tumors. Overall, afatinib was more potent than gefitinib in tumors harboring an exon 19 deletion mutation, and the combination of afatinib with bevacizumab efficiently suppressed tumors harboring the T790M secondary mutation. Mol Cancer Ther; 12(5); 589–97. ©2013 AACR.

Reappraisal of Short-term Low-volume Hydration in Cisplatin-based Chemotherapy: Results of a Prospective Feasibility Study in Advanced Lung Cancer in the Okayama Lung Cancer Study Group Trial 1002

OBJECTIVE Cisplatin can induce severe renal toxicity. However, the degree and pattern of hydration that is most efficient at preventing it have scarcely been formally evaluated. We here performed a prospective feasibility study of cisplatin-based chemotherapy with short-term low-volume hydration in advanced lung cancer. METHODS Chemo-naïve patients with advanced lung cancer and reserving renal function who were suitable for cisplatin use (≥60 mg/m(2) on Day 1) were eligible for this study. Two-and-a-half-liter hydration within ∼4.5 h was investigated. The primary end point was the proportion of patients who underwent cisplatin-based chemotherapy without any Grade 2 or more renal toxicity in the first cycle. RESULTS A total of 46 patients were registered, all of whom were evaluable for renal toxicity. The median baseline creatinine score was 0.70 mg/dl and the median cisplatin dose on Day 1 was 80 mg/m(2). In the first cycle, none of the patients developed Grade 2 or more creatinine toxicity, which met the primary endpoint. Four patients (9%) had Grade 1 toxicity, with a median worst creatinine score of 1.19 mg/dl, but it disappeared rapidly. Creatinine toxicity was influenced by several clinical factors, including the performance status. Ten patients (22%) needed extra hydration during the first cycle, mainly due to gastrointestinal toxicity. However, all 10 were able to undergo further cycles of treatment. Thirty-two (86%) of the 37 patients who were assumed to be able to undergo further treatment at our institute received it in an outpatient setting. CONCLUSIONS This study demonstrated prospectively the feasibility of short-term low-volume hydration.

Impact of physical size on gefitinib efficacy in patients with non-small cell lung cancer harboring EGFR mutations.

Gefitinib is an essential drug for the treatment of non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene mutations. The approved dosage is 250 mg/body/day without adjustment for physical size such as body surface area (BSA), and the impact of physical size on the efficacy of gefitinib has not been evaluated. Here, we sought to clarify this issue using a retrospective cohort. We reviewed the medical records of patients with consecutive advanced NSCLC harboring EGFR mutations who underwent gefitinib monotherapy at Okayama University Hospital. In total, 101 patients were included in this study, and the median BSA in this cohort was 1.5 m(2). The median progression-free survival (PFS) of the patients with higher BSA (≥1.5 m(2)) was significantly worse than that of those with lower BSA (< 1.5 m(2)) (10.4 vs. 18.0 months; p = 0.019, log-rank test). Multivariate analysis also showed a significant impact of BSA on PFS (hazards ratio, 2.34; 95% confidence interval, 1.78-2.89; p = 0.002). By contrast, no significant association between BSA and PFS was observed in those undergoing cytotoxic chemotherapy (4.0 vs. 5.1 months; p = 0.989, log-rank test), suggesting that BSA is a predictive, rather than a prognostic, marker for gefitinib therapy in EGFR-mutated NSCLC. In conclusion, BSA affected PFS in patients with EGFR-mutated NSCLC who underwent gefitinib monotherapy, suggesting the need for appraisal of BSA-based dose adjustment, even for this molecular target-based therapy.

Usefulness of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in Distinguishing Sarcoidosis from Recurrent Cancer in Patients with Lymphadenopathy after Surgery

OBJECTIVE Endobronchial ultrasound-guided transbronchial needle aspiration is a new minimally invasive test for investigating mediastinal and hilar lymphadenopathy. It is sometimes difficult to distinguish between a recurrent malignant lymph node and lymphadenopathy due to sarcoidosis in patients who develop lymphadenopathy after surgery for a malignant tumor. METHODS Between December 2009 and October 2012, we performed endobronchial ultrasound-guided transbronchial needle aspiration in 13 selected patients with a suspected recurrence in the mediastinum and/or hilum of the lung after surgical resection of a malignant tumor. We examined their medical records to obtain information on the diagnosis, the sizes of lymph nodes, the number of needle passes and other complications. RESULTS Definitive diagnoses were made using endobronchial ultrasound-guided transbronchial needle aspiration in 10 patients (three lung adenocarcinomas, one prostate carcinoma, one renal cell carcinoma, one neuroendocrine tumor and four sarcoidosis). Pathological specimens showing non-caseating granulomas led to the diagnosis of sarcoidosis in four patients; their previous malignancies had been papillary adenocarcinoma of the thyroid, carcinoma of the gingiva, thymoma and bladder cancer, but no recurrences were observed. The median of the longest diameter in 15 lymph nodes was 22 mm (range 13-35), and the median number of needle passes was two times (range 1-5) without severe complications. CONCLUSIONS Endobronchial ultrasound-guided transbronchial needle aspiration might be useful in differentiating between benign lymphadenopathy, including sarcoidosis, and cancer recurrence in patients with mediastinal or hilar lymphadenopathy after surgical resection of a malignant tumor.

Toxicity manifesting as cosmetic hair alterations during erlotinib treatment.

Erlotinib, an orally administered epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), has shown promising antitumor activity for non-small-cell lung cancer (NSCLC) as compared with the best supportive care [1]. It inhibits the intracellular phosphorylation of the tyrosine kinase domain associated with EGFR in cancer cells. This activity also occurs in tissues that normally express EGFR, such as the basal and suprabasal layers of the epidermis, sebaceous glands, and the outer root sheath of hair follicles [2], which results in papulopustules, pruitus, paronychia, xerosis, and telangiectasias. Recently, several researchers have independently reported cases with hair alterations as rarely occurring adverse events that were potentially induced by erlotinib treatment. However, it has never been investigated how rare these events are. In this report, we present our case series in a single institution that developed toxicity of cosmetic hair alterations during erlotinib treatment, and then focus on the frequency of these events. An 81-year-old woman, diagnosed with advanced pulmonary adenocarcinoma in December 2005 and treated with platinum-based chemotherapy, was admitted to our hospital in July 2008 due to progression of her disease. We treated her with erlotinib at a dose of 150 mg once daily, which achieved a partial response. The deletion of exon 19 in the EGFR gene was detected retrospectively using a specimen previously obtained by transbronchial biopsy. At fi rst, toxicity was mild and manageable with only a grade 2 cutaneous rash. However, around fi ve

A phase I trial of afatinib and bevacizumab in chemo-naïve patients with advanced non-small-cell lung cancer harboring EGFR mutations: Okayama Lung Cancer Study Group Trial 1404

OBJECTIVE In advanced epidermal growth factor receptor (EGFR)-mutant non-small-cell lung cancer (NSCLC), treatment with afatinib, a second-generation EGFR-tyrosine kinase inhibitor (TKI), confers a significant survival benefit over platinum-based chemotherapy. The first-generation EGFR-TKIs gefitinib and erlotinib in combination with bevacizumab have improved progression-free survival. We hypothesized that the combination of afatinib with bevacizumab would further improve efficacy, and conducted a phase I trial to test this hypothesis. MATERIALS AND METHODS Untreated patients with advanced EGFR-mutant NSCLC were enrolled. The primary endpoint was safety. Two doses of afatinib, 40mg/day (level 0) and 30mg/day (level -1), were evaluated in combination with 15mg/kg bevacizumab every 3 weeks. Optimal dosing was determined by dose-limiting toxicity (DLT), with the concentration at which ≤4 of 12 patients experienced toxicity considered the recommended dose. RESULTS Nineteen patients were enrolled (level 0:5, level -1:14). Three of the five patients at level 0 experienced a DLT, which indicated that this dose was unfeasible. Three patients at level -1 developed a DLT of grade 3 non-hematological toxicity, which was soon resolved. Grade 3 or worse adverse events were experienced by all five patients at dose level 0 (diarrhea in 2, skin rash in 1, hypoxia in 1, and paronychia in 1), and by three patients at level -1 (diarrhea in 2 and anorexia in 1). Among 16 evaluable patients, 1 had a complete response, 12 had partial responses, and 0 had progressive disease. CONCLUSION Afatinib plus bevacizumab (level -1) was well tolerated and showed evidence of favorable disease control. This combination therapy may represent a potent therapeutic option for patients with EGFR-mutant NSCLC.

Triplet therapy with afatinib, cetuximab, and bevacizumab induces deep remission in lung cancer cells harboring EGFR T790M in vivo

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have changed the treatment strategy for EGFR‐mutant lung cancers; however, resistance usually occurs due to a secondary mutation, T790M, in EGFR. Combination therapy using afatinib and cetuximab has had good results in lung tumors harboring EGFRT790M mutations in clinical trials. The effect of bevacizumab, an antivascular endothelial growth factor (VEGF) antibody, combined with EGFR‐TKIs has also been investigated. We hypothesized that the dose of afatinib and cetuximab could be reduced by combination with bevacizumab and that the triplet therapy may result in better tumor inhibition with tolerable toxicity. Using a xenograft mouse model with H1975‐harboring EGFRL858R+T790M and RPC‐9‐harboring EGFR19DEL+T790M, we tested the efficacy of the triplet therapy with a modified dose of afatinib, cetuximab, and bevacizumab, and compared this therapy to single and double therapies. Triplet therapy with afatinib, cetuximab, and bevacizumab induced pathological complete remission in xenograft tumors with H1975 and RPC‐9 cells versus tumors treated with single or double therapies. We saw no body weight loss in the mice. The triple therapy induced a significant reduction in CD31‐positive vascular endothelial cells and increased cleaved caspase‐3‐positive cells in the tumors. This suggests that one mechanism underlying the deep remission could be suppression of neovascularization and induction of apoptosis by intensive inhibition of driver oncoproteins and VEGF. These results highlight the potential of afatinib, cetuximab, and bevacizumab to induce deep remission in tumors harboring EGFRT790M mutations. Therefore, clinical trials of this combination therapy are warranted.

Centrally Located Squamous Cell Carcinoma of the Lung Mimicking Endobronchial Tuberculosis

Here we report a case of centrally located squamous cell carcinoma of the lung mimicking endobronchial tuberculosis. On the basis of the white light bronchoscopic (WLB) findings, bronchial tuberculosis was initially suspected. But transbronchial biopsy of the lesion revealed squamous cell carcinoma. Autofluorescence imaging bronchovideoscopy (AFI) showed the lesion area as magenta. After four cycles of chemotherapy, the magenta area was markedly shrunk on AFI. Performance of AFI might be useful for differentiating centrally located lung cancer from endobronchial tuberculosis.

Downregulation of TBXAS1 in an iron‐induced malignant mesothelioma model

Malignant mesothelioma is an aggressive and therapy‐resistant neoplasm arising from mesothelial cells. Evidence suggests that the major pathology associated with asbestos‐induced mesothelioma is local iron overload. In the present study, we induced iron‐induced mesothelioma in rats based on previous reports. Ten Wistar rats were given ferric saccharate and nitrilotriacetate i.p. for 5 days a week. Five of the ten rats exhibited widespread mesotheliomas in the peritoneum and tunica vaginalis. The tumor cells showed positive immunostaining for calretinin, wilms tumor‐1, podoplanin and the oxidative DNA marker 8‐hydroxy‐2′‐deoxyguanosine. In three of the five rats with mesothelioma, array‐based comparative genomic hybridization analysis identified a common chromosomal deletion mapped to the chromosomal 4q31 locus, which encompasses the TBXAS1 gene. Downregulation of the TBXAS1 gene was confirmed using quantitative PCR. TBXAS1 gene expression was also reduced in three of four human malignant pleural mesothelioma cell lines compared with normal bronchial epithelial cells. Immunohistochemistry revealed that TBXAS1 expression was weakly positive and positive in five and three out of eight human malignant mesothelioma samples, respectively. In conclusion, TBXAS1 gene expression was downregulated in rats with iron‐induced mesothelioma. The relationship between iron overload and TBXAS1 downregulation should be pursued further.

Abstract 1368: The impact of bevacizumab on combination low-dose afatinib and cetuximab therapy in lung cancer cells harboring activated EGFR mutations

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA Background. The combination of afatinib and cetuximab induced an unprecedented response in lung tumors harboring EGFR T790M in clinical trials (Cancer Discov. 2014). However, up to 20% of patients discontinued treatment due to adverse events, including skin rashes and diarrhea, and the median progression-free survival of the combination therapy was 4.7 months. There is clearly still room for improvement in the therapy. Bevacizumab, a key drug in lung cancer treatment, is thought to have a wide variety of effects, including anti-vascularization, normalization of tumor vasculature, and improved drug delivery. Thus, we hypothesized that the dosage of afatinib and cetuximab could be reduced by combining with bevacizumab, and that the triple therapy might produce better tumor inhibition with tolerable toxicity. Methods. Two lung cancer cell lines, H1975, with EGFR L858R and T790M, and RPC-9, with EGFR exon 19 deletion and T790M, were injected subcutaneously into nude mice as xenograft models. Mice were divided into four groups 10 days after tumor cell inoculation (vehicle, afatinib, afatinib + cetuximab, afatinib + cetuximab + bevcacizumab). Compared with previous reports (afatinib 25 mg/kg, 5 times/week, cetuximab 1 mg/mouse, every 3 days; J. Clin. Invest. 2009), the low dose of afatinib (10 mg/kg, 5 times/week; i.e., 60% less drug) or cetuximab (0.1 mg/mouse, once/week; i.e., 90% less drug) were administered to the mice for 1 month. Bevacizumab was injected at 2 mg/kg twice/week. Following the therapies, the mice were observed for 1 month without treatment. Results. Surprisingly, the triple therapy induced a pathological complete response (pCR) in H1975 and RPC-9 cell xenograft tumors; in contrast, the tumors treated with single or double therapy were inhibited only partially. Furthermore pCR was maintained during the observation period in the triple therapy group. There was no body weight loss in any group. Frozen tumors were obtained from RPC-9 xenograft models after 1 week treatment with each regimen. Expression levels of pEGFR, pAKT, and pERK were decreased in the triple therapy group. CD31-positive blood vessels and Ki-67-positive cells in tumors with triple therapy were reduced significantly versus the tumors in other groups. Cleaved caspase-3 expression in the tumors with triple therapy was positive in a higher number of tumor cells than in the other groups. Conclusions. We demonstrated that a low-dose of afatinib and cetuximab combined with bevacizumab induced pCR in EGFR T790M mutated cell xenograft tumors with no obvious adverse events. We suggest that the suppression of neovascularization and induction of apoptosis may play important roles in the triple therapy. Note: This abstract was not presented at the meeting. Citation Format: Kenichiro Kudo, Kadoaki Ohashi, Eiki Ichihara, Daisuke Minami, Hisao Kubo, Akiko Sato, Yuka Kato, Hideko Isozaki, Hiroe Kayatani, Tomoki Tamura, Mitsune Tanimoto, Katsuyuki Kiura. The impact of bevacizumab on combination low-dose afatinib and cetuximab therapy in lung cancer cells harboring activated EGFR mutations. [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 1368. doi:10.1158/1538-7445.AM2015-1368