Yelena Novik

Topical TLR7 Agonist Imiquimod Can Induce Immune-Mediated Rejection of Skin Metastases in Patients with Breast Cancer

Purpose: Skin metastases of breast cancer remain a therapeutic challenge. Toll-like receptor 7 agonist imiquimod is an immune response modifier and can induce immune-mediated rejection of primary skin malignancies when topically applied. Here we tested the hypothesis that topical imiquimod stimulates local antitumor immunity and induces the regression of breast cancer skin metastases. Experimental Design: A prospective clinical trial was designed to evaluate the local tumor response rate of breast cancer skin metastases treated with topical imiquimod, applied 5 d/wk for 8 weeks. Safety and immunologic correlates were secondary objectives. Results: Ten patients were enrolled and completed the study. Imiquimod treatment was well tolerated, with only grade 1 to 2 transient local and systemic side effects consistent with imiquimods immunomodulatory effects. Two patients achieved a partial response [20%; 95% confidence interval (CI), 3%–56%]. Responders showed histologic tumor regression with evidence of an immune-mediated response, showed by changes in the tumor lymphocytic infiltrate and locally produced cytokines. Conclusion: Topical imiquimod is a beneficial treatment modality for breast cancer metastatic to skin/chest wall and is well tolerated. Importantly, imiquimod can promote a proimmunogenic tumor microenvironment in breast cancer. Preclinical data generated by our group suggest superior results with a combination of imiquimod and ionizing radiation and we are currently testing in patients whether the combination can further improve antitumor immune and clinical responses. Clin Cancer Res; 18(24); 6748–57. ©2012 AACR.

Therapeutic efficacy of theophylline in chronic lymphocytic leukemia.

Theophylline, a methylxanthine commonly used as a treatment for asthma, has been shown to induce apoptosis in chronic lymphocytic leukemia (CLL) cells bothin vitro andin vivo. We have treated three advanced CLL patients with theophylline, and seen responses in two. The clinical courses of the responders are presented, and the literature concerning theophylline as therapy for CLL is reviewed.

Results of a phase I–II study of adjuvant concurrent carboplatin and accelerated radiotherapy for triple negative breast cancer

ABSTRACT Purpose: To determine feasibility and explore the clinical efficacy of concurrent radiotherapy and carboplatin as adjuvant treatment of triple negative breast cancer (TNBC). Patients and Methods: Women with Stage I-II TNBC were treated after surgery in a phase I–II prospective trial [NCT01289353]. Weekly carboplatin (AUC = 2.0) was delivered for 6 weeks. Concurrent radiotherapy was delivered in the prone position during weeks 2–4, for a total dose of 40.5 Gy in 15 fractions to the breast, and 46.5 Gy in 17 fractions to the tumor bed. Adverse events (AE) were assessed weekly during treatment, once at 45–60 d, and every 6 mo thereafter, using the Common Terminology Criteria for AE (CTCAE) v3.0. Results: A total of 39 patients accrued and 36 received treatment. Eight patients (22%, exact 95% CI: 10%, 39%) developed grade 2 or greater acute radiation dermatitis. Overall, grade 2 AE were seen in nine and grade 3 in two patients. Twenty-three patients (64%) received additional adjuvant chemotherapy. With a median follow-up of 48 mo, 34/36 (94%) are alive and disease free. One patient died of pulmonary failure with possible but unproven breast cancer recurrence, and one patient died of pelvic malignancy. One patient recurred locally and is alive and disease free after surgical management. Brisk lymphocytic infiltrate was present pre-treatment in 39% of 18 patients with evaluable tumor. Conclusions: Adjuvant concurrent carboplatin and prone accelerated radiotherapy is a well-tolerated and promising treatment of early stage TNBC. The observed 3% compares favorably with the expected 30% recurrence rate within 1–4 y from treatment, warranting further studies.

A phase 2 study of moderate dose interleukin-2 and granulocyte-macrophage colony-stimulating factor in patients with metastatic or unresectable renal cell carcinoma

Interleukin-2 (IL-2) has been shown to produce durable complete remission in patients with renal cell carcinoma (RCC). A phase 2 study was conducted to evaluate the potential therapeutic synergy as well as the toxic side effects of the concurrent administration of IL-2 and granulocyte-macrophage colony-stimulating factor (GM-CSF) in patients with advanced stage disease. Twenty-one patients with unresectable or metastatic RCC having an Eastern Oncology Cooperative Group performance status of 0 or 1 were enrolled. Six patients had received prior immunotherapy with interferon (IFN)-α, IFN-γ, and IL-12, whereas the remaining 15 subjects were previously untreated. Thirteen patients were assigned to a moderate-dose bolus of IL-2 at 72,000 IU/kg every 8 hours on days 1 through 5 and days 15 through 19, whereas 8 patients were given IL-2 as an intravenous continuous infusion at a dose of 5 MU/m2/d on days 1 through 5 and days 15 through 19. Subcutaneous GM-CSF at 125 μg/d on days 1 through 21 was administered concomitantly with IL-2. The median number of IL-2 bolus doses was 23 of a scheduled 28 (85%), whereas with the continuous infusion, 93% of planned IL-2 was given. All patients received 100% of GM-CSF doses. There were no complete or partial responses in this study. Of 13 patients treated in the bolus IL-2 arm, 10 had systemic progression of disease at 4 to 8 weeks, 1 developed metastasis in the brain at 4 weeks, and 2 had stable disease for 4 and 17 months. Among the 8 subjects treated with continuous infusion IL-2, 3 progressed with brain lesions at 3 to 8 weeks and 5 had stable disease at 6+, 7, 8+, 15+, and 17+ months. The median survival for the whole group was 10 months, with a range of 0.5 to 40+ months. There were no regimen-related deaths, and most of the observed toxicities were grade 1 and 2. Serious toxicities (grade 3 and 4) included anemia, atrial fibrillation, oliguria, abnormal liver function, and neurologic events like agitation or confusion. The combination of recombinant IL-2 and GM-CSF administered in the designed schedule and doses was not effective in patients with metastatic RCC and may even interfere with the therapeutic potential of moderate-dose IL-2 and increase its adverse events.

PTC299, a Novel Regulator of Tumor VEGF Expression, Is Well Tolerated and Achieves Target Plasma Concentrations: Dose-Ranging Results of a Phase 1b Study in Women with Metastatic Breast Cancer.

Background: Current anti-angiogenic drugs interfere with the vascular endothelial growth factor (VEGF) signaling pathway. PTC299 is an orally delivered, small-molecule investigational drug designed to inhibit the expression of VEGF and other angiogenic cytokines within tumors. PTC299 also induces a parallel interruption of tumor cell division at the G1/S phase of the cell cycle, offering several potential mechanisms of action. In multiple models of human cancers grown as xenografts in mice, including breast cancer, single-agent PTC299 decreases tumor and plasma VEGF levels and results in significant tumor regression or delay of tumor growth. Data from Phase 1a testing in healthy volunteers supported initiation of this Phase 1b, 2-stage, open-label, dose-ranging, escalating-dose, safety, pharmacokinetic (PK), and pharmacodynamic study evaluating PTC299 monotherapy and PTC299 combination therapy with hormonal agents in adult women with metastatic breast cancer.Materials and Methods: In Stage 1, patients have received PTC299 monotherapy in repeated 6-week cycles, each comprising a 4-week course of PTC299 administered on a twice daily (BID) schedule, followed by a 2-week washout period. The study was designed to enroll 3 successive cohorts of 3 to 6 patients at progressively higher dose levels of 0.3 mg/kg/dose BID, 0.6 mg/kg/dose BID, or 1.2 mg/kg/dose BID, with treatment given until disease progression or unacceptable toxicity. Safety, PK, and antitumor activity have been assessed.Results: Stage 1 enrolled 9 subjects (3 at each dose level) with a median [range] of 53 [31-76] years old and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 (n=1) or 1 (n=8). Patients were extensively pretreated with hormonal (patient n=3), chemotherapy (n=9), and/or antiangiogenic agents (n=6). No dose-limiting toxicity was observed. Adverse events have generally been infrequent, low-grade, and do not appear to be PTC299-related. No hypertension, bleeding, thromboembolism, or proteinuria has been seen. Drug plasma concentrations have exceeded the maximally active plasma trough level identified in nude mouse xenograft models. Disease stabilization through multiple cycles (∼6 months and ∼4.5 months, respectively) has been observed in 2 subjects at the highest PTC299 dose level (1.2 mg/kg/dose BID). In these subjects, improvements in tumor-related markers of angiogenesis/inflammation have been observed.Discussion: PTC299 may offer safety, efficacy, and convenience advantages relative to current anti-angiogenic drugs. In Stage 1 of this Phase 1b study, PTC299 has been well tolerated, has achieved target plasma concentrations, and has shown suggestions of antitumor and pharmacodynamic activity. Accrual to Stage 2, in which subjects receive PTC299 combination therapy with hormonal agents, is ongoing.Supported by a translational breast cancer research grant award from the Congressionally Directed Medical Research Programs of the Department of Defense Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6092.

Phase II trial of RAD001 plus carboplatin in patients with triple-negative metastatic breast cancer.

293 Background: RAD001 is an oral mTOR inhibitor that has exhibited activity in breast cancer. Triple negative breast cancer cells are unable to repair double stranded DNA breaks and hence have sensitivity to platinum agents that cause interstrand cross-links. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in at least two different breast cancer cell lines (including ER/PR negative cell lines). We propose that combination RAD001 and carboplatin may have activity in triple-negative breast cancer. METHODS The primary objective of the study is to determine clinical benefit (complete remission; CR, partial remission; PR and stable disease; SD) and the toxicity of this combination in women with triple negative metastatic breast cancer who had received 0-3 prior chemotherapy regimens for metastatic disease. Prior carboplatin was allowed. Women with treated brain metastasis were eligible. Secondary objectives were to determine progression free survival. According to the original study plan, carboplatin AUC 6, was to be given intravenously every three weeks. 5 mg of RAD001 was to be given daily with a 3 patient run-in and then 10 mg daily if there were no dose-limiting toxicities. Due to a surprising amount of thrombocytopenia with this combination the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (and no plan to escalate to 10 mg). RESULTS Eleven patients of a planned 25 have been recruited thus far. Median age is 62. Median number of prior regimens is 1. Of the 6 patients assessable for response at this time, four have SD and two have had a PR. 1 SD was achieved in a patient progressing on prior carboplatin at study entry. Five of 7 patients assessable for toxicity had grade 3 or 4 thrombocytopenia and 2 patients had grade 3 neutropenia. All patients have had treatment held and/or dose reductions secondary to hematological toxicity. There have been no non-hematological grade 3 or 4 toxicities. CONCLUSIONS Clinical benefit was observed in all 6 evaluable patients. Dose limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. We continue to accrue study subjects at the amended dosing.

Efficacy of RAD001/carboplatin in triple-negative metastatic breast cancer: A phase II study.

108 Background: Triple-negative breast cancer cells are unable to repair double stranded DNA breaks and have sensitivity to platinum agents. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in breast cancer cell lines. RAD001 (oral mTOR inhibitor) and Carboplatin combination may have activity in triple-negative breast cancer. METHODS The primary objective is to estimate clinical benefit (complete remission (CR) + partial remission (PR) + stable disease (SD) lasting >6 months) and toxicity of the combination in triple negative metastatic breast cancer patients who have had 0-3 prior chemotherapy regimens. This design has > 80% power to test the null hypothesis i.e. clinical benefit rate is ≤ 10% vs. alternative hypothesis that clinical benefit rate is ≥ 30%. Prior carboplatin is allowed. Women with treated brain metastasis are eligible. Originally, carboplatin AUC 6 was to be administered every 3 weeks along with daily 5mg of RAD001 with a 3 patient run-in and then 10 mg daily. Due to a surprising amount of thrombocytopenia, the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (no escalation to 10 mg). RESULTS 23 out of 25 patients have been recruited. Median age is 59. Thus far, there have been 1 CR, 5 PRs, 8 SDs and 6 PDs. One SD was achieved in a patient progressing on single agent carboplatin at study entry. Median duration of response is 13 weeks (range: 6-74 weeks). 5 patients had grade 3/4 thrombocytopenia and 4 patients had grade 3 neutropenia (no febrile neutropenia). 13 patients had treatment held and/or dose reductions secondary to hematological toxicity. Since dosing amendment for carboplatin to AUC 4 the regimen has been well tolerated (only 1 patient with grade 3 neutropenia and thrombocytopenia). 1 patient had grade 3 dehydration. The estimated clinical benefit rate is 45% (95% C.I.: 23%, 67%). Median time to progression or death is 85 days from start of treatment. CONCLUSIONS Our study has met the primary end point of demonstrating clinical benefit in triple-negative metastatic breast cancer. Dose-limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. Patient accrual continues at the amended dosing.

Abstract S6-03: Randomized phase II trial of fulvestrant alone or in combination with bortezomib in hormone receptor-positive metastatic breast cancer resistant to aromatase inhibitors: A New York cancer consortium trial

Purpose: Fulvestrant (F) is a selective estrogen receptor downregulator (SERD) with activity in aromatase-inhibitor (AI) resistant estrogen receptor (ER)-positive metastatic breast cancer (MBC). In preclinical studies, the proteasome inhibitor bortezomib (B) enhances the antineoplastic effects of F, in part by promoting accumulation of large ER-aggregates that lead to cell death (Ishii et al. Clin Cancer Res 2011 17:2292). The objective of this study was to determine if the combination of F+B was more efficacious than F alone in MBC after AI progression. Patients and Methods: Postmenopausal women with ER-positive MBC who had progressive disease after prior AI therapy were eligible. They were randomized to F alone (500 mg IM days -15, 1, 15 in cycle 1, and day 1 of each subsequent cycle) or in combination with B (1.6 mg/m2 IV on days 1, 8, 15). The primary endpoint was progression free survival (PFS), measured from cycle 1, day 1 of starting F. A sample size of 118 was pre-specified in order to provide sufficient power to detect an improvement in median PFS from 5.4 to 9.0 months, and compare PFS rates after 6 and 12 months (1-sided alpha=0.10, beta=0.10). Patients with progression on F could cross over to the F+B combination. Results: Of 118 patients enrolled, 59 received F alone (arm A), 57 received F+B (arm B), and 2 assigned to arm B never initiated protocol therapy. There were no significant differences in patient characteristics between arms with regard to median age (57 vs. 59 years), ECOG performance status (0 and 1, 64% and 36%, respectively), prior chemotherapy for metastasis (25%), or liver metastases (37%), although patients in arm A had longer median interval between diagnosis and metastasis (49 vs. 28 months) and were more likely to present with metastasis (32% vs. 26%). Patients in arm B had more adverse events (all grades), including nausea (63% vs. 29%), diarrhea (47% vs. 8%), sensory neuropathy (46% vs. 29%), and limb edema (37% vs. 19%), although grade 3-4 events were uncommon, and only 11% discontinued B due to toxicity. At 12 months, the PFS proportion in Arm A and Arm B was 13.6% vs. 28.1%, respectively (P=0.03, 1-sided chi-square test) (95% CI for difference [14.5%] = -0.06%, 29.1%). Although median PFS was similar in the two arms (2.69 vs. 2.73 months, respectively), the hazard ratio for Arm B vs. Arm A (referent) was 0.73 (95% CI = 0.49, 1.09, P=0.06, 1-sided log rank test). Both results were significant at the pre-specified 1-sided 0.10 alpha level. Of 27 patients on arm A who crossed over to F+B at progression, 4 (15%) were progression-free for at least 24 weeks and had periods of disease control that were longer than when treated with F alone. Conclusion: Adding bortezomib to fulvestrant in AI-resistant ER-positive MBC enhances its effectiveness by delaying acquired fulvestrant resistance. These results support additional evaluation of proteasome inhibitors in combination with SERDs. Acknowledgement: Supported by contract N01-CM-62204 to the New York Cancer Consortium (P.I. J. Sparano) and grant P30 CA013330 (P.I. D. Goldman) from the National Institutes of Health, and by a grant from Millennium, Inc. Citation Format: Kerin B Adelson, Bhuvaneswari Ramaswamy, Joseph A Sparano, Paul J Christos, John J Wright, George Raptis, Miguel C Villalona, Cynthia X Ma, Dawn Hershman, Joseph Baar, Paula Klein, Tessa Cigler, G Thomas Budd, Yelena Novik, Antoinette R Tan, Susan Tannenbaum, Anupama Goel, Ellis Levine, Charles L Shapiro, Eleni Andreopoulou, Michael Naughton, Kevin Kalinsky, Samuel Waxman, Doris Germain. Randomized phase II trial of fulvestrant alone or in combination with bortezomib in hormone receptor-positive metastatic breast cancer resistant to aromatase inhibitors: A New York cancer consortium trial [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 S6-03.

Clinical Trial Evidence of the Antitumor Activity of Topical Imiquimod for Breast Cancer Skin Metastases

TO THE EDITOR: Henriques et al recently published a case report demonstrating successful treatment of refractory breast cancer skin metastases with topical imiquimod added to systemic therapy. Application of imiquimod, a Toll-like receptor 7 agonist, resulted in partial regression of the skin metastases. The authors state in their introduction that a literature review only revealed a “single case report describing the use of topical imiquimod . . . to successfully treat breast cancer skin metastasis.” In 2012, we published a phase II trial of topical imiquimod in the treatment of breast cancer skin metastasis which included extensive correlative studies in tumor biopsies and blood. Imiquimod was applied five times per week as in the regimen approved for the treatment of superficial basal cell carcinoma and used in the previous case report of breast cancer. Similar to the report by Henriques et al, patients in the trial had the option to continue receiving a systemic regimen concurrently (if no previous response in skin was seen). The results of our prospective study showed that imiquimod treatment in women with heavily pretreated and refractory breast cancer skin metastases achieved a response rate of 20% (partial response in two of 10 patients). Changes in the tumor microenvironment of the responders were strongly suggestive of an immune-mediated response. We observed an induction of a Th1-polarized immune response as well as a reduction of a preexisting immunosuppressive milieu. Our results from a prospective trial demonstrate that imiquimod can be effective in patients with breast cancer that is metastatic to skin. However, the majority of tumors did not regress, which has important implications for future research. Combinatorial approaches should be tested to increase local response and to induce a more powerful antitumor immune response that is capable of controlling systemic metastases, as visceral disease ultimately causes the patient’s death. Preliminary evidence of systemic disease control has been observed in two patients from the imiquimod trial who experienced long-lasting complete remissions after immuno-endocrine therapy, accompanied by treatment-induced priming and boosting of tumor antigen–specific T cells, detectable ex vivo (manuscript submitted for publication). To inform clinical studies, our group and others have studied and identified synergistic combinations in murine models of mammary carcinoma. In the TSA murine model of breast cancer with cutaneous involvement, the combination of topical imiquimod and local radiotherapy induced complete regression of the treated lesions and improved systemic tumor control, leading to enhanced survival. Improved antitumor efficacy and prolonged survival was also observed in neu transgenic mice, in which topical imiquimod was combined with antibodies against interleukin-10. Clinical trials are ongoing to study these and other combinations (NCT01421017 and NCT00821964).

Abstract P2-11-11: Phase II trial of exemestane with immunomodulatory oral cyclophosphamide in metastatic hormone receptor (HR)-positive breast cancer: Prolonged progression-free survival (PFS) in patients with distinct T regulatory cell (Treg) profile

Background: Resistance to endocrine therapies in HR-positive breast cancer is a significant challenge. The steroidal aromatase inhibitor (AI) exemestane (EXE) has demonstrated short-term efficacy in metastatic HR-positive HER2-negative breast cancer (mHR + BC) that has progressed during treatment with a non-steroidal AI. Combination strategies have not shown a survival benefit. Immunotherapy represents a promising approach as it may increase durability of responses. Low dose cyclophosphamide (CTX) has demonstrated efficacy in combination with neoadjuvant letrozole in HR + BC, conceivably by enhancing anti-tumor immune responses. Here we investigated whether EXE combined with immunomodulatory CTX could provide durable responses in heavily pretreated patients and assessed immunological profiles (NCT01963481). Methods: Phase II trial of EXE (25mg PO daily) with CTX (50 mg PO daily) enrolled postmenopausal women (n=23) with mHR + BC who had progressed on prior endocrine therapy (including nonsteroidal AI, tamoxifen, and/or fulvestrant); prior chemotherapy was allowed. The primary endpoint was PFS (per RECIST 1.1) at 3 months; secondary endpoints were response rate, tolerability, and immune correlates. Detailed functional immune profiling of peripheral T cell subsets were performed by flow cytometry at baseline, 1, 3, 6, 9 & 12 months, with healthy donors available as controls. Results: All 23 patients have been enrolled, and 21 are evaluable for response. Median age was 54 (range 31-77), median prior lines of endocrine therapy was 2 (1-3) and chemotherapy was 1 (0-5). The majority (15/23) had visceral organ involvement. Combination treatment was well tolerated with one grade 3 urinary tract infection but no grade 4 or 5 toxicity. An objective response was observed in 19% of patients (4/21, 1 CR and 3 PR) and an additional 33% (7/21) had SD, resulting in a 3-month-PFS of 48.5% (95% CI, 30.5-77.1). Responses were durable in all patients, lasting =/> 9 months and included patients with liver metastases. Comparison of peripheral immune cell subsets of patients (n=16) at baseline to age/sex-matched healthy controls demonstrated an increased proportion of CD4 + memory T cells with central memory phenotype (CD45RO + CD27 + , p + CD45RO - FOXP3 + Helios + ) at baseline was significantly lower (p=0.003) in the non-progressor group compared to patients with progression. Remarkably, when these patient groups were compared for changes in T cell subsets during treatment, the proportion of both naive and memory Treg subsets increased from baseline to 3 months (p Conclusion: EXE and CTX had a favorable safety profile with evidence of clinical activity in patients with heavily pretreated mHR + BC, including durable responses in liver and bone. Correlative studies are ongoing to identify potential biomarkers of response or resistance to therapy. Citation Format: Kwa M, Novik Y, Oratz R, Jhaveri K, Wu J, Gu P, Meyers M, Muggia F, Bonakdar M, Abidoglu C, Kozhaya L, Li X, Joseph B, Iwano A, Friedman K, Goldberg JD, Unutmaz D, Adams S. Phase II trial of exemestane with immunomodulatory oral cyclophosphamide in metastatic hormone receptor (HR)-positive breast cancer: Prolonged progression-free survival (PFS) in patients with distinct T regulatory cell (Treg) profile. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-11.